Retained neonatal ureteral stent post-ureteric reimplantation: a 26-year saga

Abstract

Ureteral stents are an essential tool in modern day adult and paediatric urology. They are usually placed with the intention of removal or replacement after a specific time but may occasionally be forgotten or unintentionally retained. We present the case of a young man who presented with symptoms caused by a retained ureteric stent placed 26 years earlier during reconstructive ureteric surgery as an infant.

Background

Retained or forgotten ureteral stents can cause significant morbidity related to either irreversible renal injury or further necessary surgical intervention.¹ While this phenomenon is rare, it is entirely preventable. We report a highly unusual case of retained ureteral stent for over 26 years, placed during neonatal ureteric reimplantation and rediscovered in a symptomatic adult. This case highlights the need for effective communication between healthcare providers and patients as one factor which can help prevent retained stents.

Case presentation

A 26-year-old man presented to the emergency department with acute onset right flank pain. This was not associated with any urinary or constitutional symptoms. He reported having had similar self limiting episodes of pain 18 months prior. On examination, he was afebrile and tachycardic. He had a soft abdomen with marked right renal angle tenderness.

His prior medical history was remarkable for neonatal bilateral reflux disease and residual stage 2 chronic kidney disease (CKD). The patient was born with bilateral vesicoureteric reflux and megaureter, grade 4 on the right and grade 3 on the left. A neonatal vesicostomy was created at 12 months of age. This was closed with bilateral trigonal advancement ureteric reimplantation at age 18 months. In his childhood years, annual ultrasound and renogram monitoring confirmed a healthy right kidney with mild grade 1 reflux on the left side. These scans also demonstrated a relatively atrophic left kidney with 30% differential function at age 11 on nuclear medical imaging. Annual follow-up in adulthood with nephrologists showed stable CKD stage 2 with a baseline estimated glomerular filtration rate (eGFR) of 70. His last known imaging was an ultrasound 5 years prior to this presentation demonstrating an atrophic left kidney and mild hydronephrosis on the right. No further imaging was available and the patient denied any recent urological intervention and follow-up.

Investigations

Bedside urine dipstick showed microscopic haematuria with no leucocytes or nitrites. Blood tests revealed a mild acute on chronic renal injury with an eGFR of 63. CT demonstrated marked right hydroureteronephrosis with a tortuous right ureter to the level of the bladder. There was a radio-opaque foreign body extending from the proximal ureter to the right vesicoureteric junction suspicious for a ureteric stent (figure 1). There was no available documentation or records to confirm previous stent insertion and the patient’s mother was certain there had been no further surgical intervention following reimplantation surgery at age 18 months. The patient’s family could not recall if there was a stent placed at that time, or if one was ever removed. The most recent available ultrasound from 5 years prior was reviewed, and no foreign bodies were seen in the bladder images.

Figure 1.

Coronal non-contract CT slices showing right hydroureteronephrosis and a radio-opaque foreign body in the distal half of the ureter, later confirmed to be a forgotten stent.

Treatment

We elected to perform a rigid cystoscopy and primary ureteroscopy of the reimplanted right ureter under general anaesthetic. The neoureteric orifice was in a cross-trigonal position and ureteric access was achieved over dual glide wires with intraoperative fluoroscopic confirmation. Semirigid ureteroscopy to the right ureter found a retained mildly encrusted paediatric stent, presumably placed at time of childhood reimplantation (figure 2). The stent was removed successfully in its entirety, without resistance, using an NGage 1.7 Fr Stone Extractor basket (Cook Medical, Bloomington, IN, USA) (figure 3).

Figure 2.

Ureteroscopic images confirming the presence of a forgotten ureteral stent.

Figure 3.

The forgotten stent was removed in its entirety.

Outcome and follow-up

He recovered without complication and was discharged the next day without pain. At follow-up outpatient appointment 10 weeks postoperatively, he had no further symptoms and resolution of hydronephrosis on ultrasound.

Discussion

The forgotten ureteric stent is an entirely preventable problem, and one which can have devastating consequences.^1–3 There have been similar cases reported with stents left in situ for similar durations,⁴ although this is the first case documenting a forgotten stent for such a duration resulting from paediatric surgery. This case highlights the importance of accurate medical documentation and the importance of ensuring patients and their families have a full understanding of surgical procedures and the use of implantable devices such as stents. Strategies to prevent inadvertent retention of stents such as paper and electronic registries or records are commonly employed but remain fallible.² There was no documentation of stent placement in the available historic notes and the patient’s family were unaware of the stent placement. This case also raises the importance of the need for a holistic transition of care in patients with childhood or paediatric urological conditions who go on to be cared for by adult surgeons and physicians.

Learning points.

• Although rare, ureteral stents can be forgotten and present symptomatically in a delayed fashion.

• Clear documentation and communication with patients is critical and may reduce the risk of retained ureteral stents.

• Meticulous transition of care between paediatric and adult services may prevent such issues.