Endourologic Management of Stent Retained Over 22 Years in Patient with Duplicated Collecting System

Abstract

Background: Retained and subsequently encrusted stents can lead to a number of complications, the most dire being deterioration of renal function. Limited literature exists concerning endourologic management of stents retained for extreme durations and few that concerns patients with abnormal renal anatomy.

Case Presentation: A 70-year-old man with history of Crohn's disease and partially duplicated collecting system presented with rising creatinine and was found to have bilateral retained Double-J stents, originally placed before small bowel resection 22 years prior. The patient underwent staged bilateral percutaneous nephrolithotomy with ultimate effective removal of both stents. The patient has had subsequent improvement in renal function and has not required dialysis.

Conclusion: Removal of ureteral stents in a timely manner is paramount to prevent long-term retention and complication, but when required retained stents can be safely managed with a well-planned endourologic approach, even if significant deterioration in renal function has occurred.

Introduction and Background

Ureteral stents have long played a role in management of ureteral obstruction. Although it is common to use stents in treatment of chronic obstruction, individual stents are only designed to be left in place for a short period of time, days to months at the longest. Stents retained for longer periods of time are at higher risk for complications, including encrustation, stone formation, infection, migration, and stent fragmentation as well as patient discomfort from ureteral tissue irritation.

In this report, we describe an instance of bilateral retained stents for more than a 22-year period in a patient with partially duplicated collecting system that required two-stage endoscopic removal.

Case Presentation

The patient is a 70-year-old Caucasian man with a history of Crohn's disease and right-sided partially duplicated collecting system that underwent a small bowel resection with antecedent intraoperative bilateral Double-J stent placement in 1997. His postoperative course after bowel resection was complicated by infection, requiring prolonged hospitalization. The patient did not remember being told that stents were placed. He states he had no reason to suspect he had stents as his surgery had been a bowel surgery and he had no urinary symptoms. He presented more recently for evaluation of microscopic hematuria. Cystoscopy revealed significant bladder stone burden as well as what appeared to be a retained stent in the left ureter. CT confirmed bilateral stents with extensive calcifications affecting the bladder curls bilaterally, which were each encased in a 32 × 32 × 10 mm stone, as well as the length of the ureter bilaterally, where the diameter of encrustation ranged from 3 to 5 mm (Fig. 1). On the right side there was a partial duplication with the ureters merging ∼3 cm distal to the lower moiety. The proximal curl of the stent rested at the junction of the two ureters, with encrustation extending beyond the stent into both proximal ureters, ∼30 mm long and 7 mm in diameter (Figs. 2 and 3). On the left there was complete duplication with the stent in the ureter to the lower moiety, and the proximal curl was folded on itself and incased in encrustation 10 mm in diameter (Fig. 4). Creatinine was 3.7, with estimated glomerular filtration rate of 13. Two years prior, creatinine had been 1.2. Renal scan showed bilateral decreased cortical uptake and split function of 27% on the right and 73% on the left. He was referred to our care in January of 2019 for surgical evaluation and was scheduled for cystolithotripsy and bilateral percutaneous nephrolithotomy (PCNL). The patient gave permission for distribution of clinical history and images.

FIG. 1.

CT of abdomen/pelvis showing bilateral retained stents.

FIG. 2.

Large burden of encrustation on proximal aspect of stents bilaterally.

FIG. 3.

Fluoroscopic image showing large burden of encrustation on proximal aspect of left retained stent in duplicated collecting system.

FIG. 4.

CT showing L-duplicated collecting system.

Intervention

Initial approach

Cystolithotripsy was performed in the dorsal lithotomy position with an offset laparoscope and a Trilogy lithotripter (Boston Scientific, USA) to remove the encrusted distal ends of both stents. Stone was dense and lithotripsy progress was slow.

Semirigid ureteroscopy was performed in the right ureter, and the distal most 3 cm was able slowly and tediously to be cleared of stone. Further advancement was limited because of a combination of a tight ureter and large trilobar prostate. The same combination prevented entry into the left ureter. The distal curls were cut off the stents with laser and removed with a grasper. A 5F open-ended catheters were placed in each ureter.

The patient was then repositioned into the prone position. Fluoroscopy-guided access was obtained into the lower pole of the left kidney. The encrustation of the renal curl was fractured using the Trilogy lithotripter. A rigid grasper was used to carefully and incrementally pull the stent up into the renal pelvis. There again the lithotripter was used to fragment encrustations off the stent. This process proved time consuming, but ultimately it was removed with a stent grasper. Given the extensive amount of stent encrustation pulled out of the ureter, a decision was made to replace a stent. A nephrostomy tube was placed as well.

Fluoroscopy access was obtained to the lower pole moiety on the right. A combination of lithotripter and holmium laser (Lumenis) was used to clear the encrustation in the lower pole ureter down to the confluence of the ureters where the stent was encountered. Flexible laparoscopes could from there only make minimal movement down the common ureter or up toward the upper moiety. Thus, the stent could not be grasped and removed.

At this point, overall case duration had exceeded 5 hours. After unsuccessful attempts to enter the upper pole, the decision was made with anesthesia to place a nephrostomy tube and return at a later date for conclusion of the right-sided stent.

Interventional radiology was able to obtain percutaneous access into the right upper moiety on a later date. The access was dilated and a combination of lithotripter and laser was used to get down to the confluence where the stent was identified. Tedious lasering ∼3–4 cm alongside the length of the stent was carried out and ultimately the stent became loose enough that it could be grabbed with basket and removed. A right stent was placed and the left nephrostomy tube was removed. Of note, all stents removed during the duration of the procedure were relatively intact and not brittle, requiring laser to break.

The patient was discharged home the day after the second procedure. On discharge, the patient's creatinine was 4.0. On nephrology follow-up 9 months postoperation, the patient's creatinine had plateaued at 3.7, there was minimal function in his right kidney, and he had mild anemia related to his chronic kidney disease. He did not require dialysis and was otherwise well. His stents have been removed.

Discussion

Complications of retained stents are well recorded though it is rare, if not unprecedented, to have to manage the sequelae from over two decades of stent retention. Series that explore approaches to retained stent removal typically look at patients with 1.5–2 years of retention, whereas single case reports describe removal after anywhere from 3 to 12 years.¹

Patient discomfort is the most common side effect of stent placement. It is interesting that this patient did not experience voiding symptoms or pain over the course of his stent retention, as >80% of patients do.² It is possible that he did initially, and they faded over time, or that he became accustomed to them. Had he had these symptoms or not adapted to them, it is unlikely that he would have waited so long to return to care.

Specific approaches to removal of encrusted stents are numerous, but there is a general algorithm of escalation that can be followed. Initial imaging is important to determine approximate stone burden. Stents with less encrustation have been effectively removed with extracorporeal shockwave lithotripsy before cystoscopy. Ureteroscopy with laser lithotripsy is the next step, and with stone burden >2 cm, PCNL is generally required. Multiple surgeries are often required, and open approaches are reserved for patients who have failed endoscopic management.^3,4 The approach taken here was dictated by two factors: a high degree of stent encrustation and stone burden and the patient's unique anatomy.

Stent encrustation is common occurrence in urology. It has been shown that in patients who are treated with stents for urolithiasis, 9.2% of stents removed before 6 weeks are encrusted, as compared with 47.5% between 6 and 12 weeks and 76.3% after 12 weeks.²

Some data have suggested that the burden on the proximal curl is most closely associated with the need for multiple surgeries, as proved to be the case here.¹

This case was also made more difficult by the patient's partially duplicated collecting system. The problems associated with duplicated or partially duplicated systems are well known, although the trouble they cause with stent management has not been thoroughly described. The problem here, access to an upper moiety, should be solvable with a well-planned PCNL in addition to cystolithotripsy and ureteroscopy. In this case, however, the severe encrustation of the stent, as well as the position of the upper moiety in relation to the patient's liver, necessitated an additional point of access. Even with the supplemental IR access, removing the remaining stent from the upper pole was tedious.

On a systemic scale, this case calls into question the efficacy, and acquired liability, of relying on patients to return for follow-up stent removal. Stent registry systems alert providers to stents overdue for removal. This has been broadly implemented in some institutions, including our own and would certainly be beneficial for older patients who are not bothered by stents, as was seen in this case.

Conclusion

Retained and encrusted ureteral stents have the potential to cause a high degree of morbidity for patients effected and can ultimately lead to deterioration of renal function. Follow-up systems, such as stent registries, have the potential to reduce such events and should be encouraged. Duplicated collecting systems can serve to complicate the removal of severely encrusted stents, but with thoughtful planning and patient approach, endoscopic management should still be possible.

Abbreviation Used

CT

computed tomography

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Cite this article as: Daly WC, Ingimarsson JP (2020) Endourologic management of stent retained over 22 years in patient with duplicated collecting system, Journal of Endourology Case Reports 6:4, 377–379, DOI: 10.1089/cren.2020.0032.