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ORIGINAL ARTICLE
Year : 2022  |  Volume : 27  |  Issue : 6  |  Page : 735-740
 

Complications and management of retained Double-J stents in children during the Coronavirus Disease-2019 pandemic


Department of Pediatric Surgery, Atal Bihari Vajpayee Institute of Medical Sciences, Dr. Ram Manohar Lohia Hospital, New Delhi, India

Date of Submission17-May-2022
Date of Decision15-Jul-2022
Date of Acceptance21-Aug-2022
Date of Web Publication11-Nov-2022

Correspondence Address:
Vijay Kumar Kundal
Department of Pediatric Surgery, Atal Bihari Vajpayee Institute of Medical Sciences, Dr. Ram Manohar Lohia Hospital, New Delhi-110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.jiaps_67_22

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   Abstract 


Background: Double-J (DJ) stents were commonly used for internal drainage after major reconstructive procedures or in cases of obstruction and ureteral injuries. They should be removed or changed within the stipulated time; otherwise, they can lead to various complications such as stent occlusion, migration, breakage, encrustation, stone formation at either end of the stent, and entanglement of the two stents if bilateral stenting was done. The present study focuses on the complications and the management due to delay in the removal of the DJ stents due to the coronavirus disease-2019 pandemic.
Materials and Methods: This is a cross-sectional study over a period of 9 months. Children <12 years were included in the study. The patients' demographic data, indication for DJ stenting, time gap between DJ stenting and removal, complication with delay in DJ stent removal, and its management were recorded. Indwelling duration for >4 months was considered a delay in removal. All patients were followed up for 3 months.
Results: A total of 10 patients were included in the study. Encrustation, proximal migration, distal migration, knotting of the stent, and entanglement of the bilateral stents in the bladder were observed. These complications were managed by various endourological procedures such as ureteroscopy, percutaneous nephroscopic, and cystoscopic removal. During follow-up, all patients were symptom-free.
Conclusion: Prolonged indwelling stents can cause various complications. Endourological procedures are an essential armamentarium for a pediatric surgeon to manage these complications. Proper patient counseling regarding indwelling stents and maintaining stent registry and sending automatic messages and e-mails to patients may prevent these complications.


Keywords: Double-J stents, complications, endourological procedures, management, pandemic


How to cite this article:
Divya G, Kundal VK, Shah S, Debnath PR, Meena AK, Sen A. Complications and management of retained Double-J stents in children during the Coronavirus Disease-2019 pandemic. J Indian Assoc Pediatr Surg 2022;27:735-40

How to cite this URL:
Divya G, Kundal VK, Shah S, Debnath PR, Meena AK, Sen A. Complications and management of retained Double-J stents in children during the Coronavirus Disease-2019 pandemic. J Indian Assoc Pediatr Surg [serial online] 2022 [cited 2022 Dec 7];27:735-40. Available from: https://www.jiaps.com/text.asp?2022/27/6/735/360970





   Introduction Top


Double-J (DJ) stents are mainly used for internal drainage of urine. These are used in cases of reconstructive urinary surgeries, intrinsic or extrinsic obstruction, and iatrogenic or traumatic ureteral injuries.[1] With the improvement in stent designs and material, there has been decreased patient discomfort which can be one of the reasons for prolonged indwelling stents. During the past 2 years due to the coronavirus disease-2019 (COVID-19) pandemic, many hospitals in the country were converted to COVID care centers either completely or partially. Only life-threatening surgeries were allowed to be performed at that time, due to the fear of the spread of COVID infection to normal patients, which is also one of the reasons for the delay in DJ stent removal. Prolonged indwelling duration of DJ stents can lead to various complications such as stent occlusion, migration, breakage, encrustation, stone formation at either of the stent and entanglement of the two stents if bilateral stenting was done.[2],[3] Knowledge and equipment regarding various endourological procedures are needed to manage these complications. The present study enlights the complications encountered due to retained stents during the pandemic and their management.


   Materials and Methods Top


This is a cross-sectional study done over 9 months from January 2021 to September 2021. Indwelling DJ stents for >4 months were considered delay in the removal of DJ stents or retained stents. Children <12 years were included in the study. The patients' demographic data, indication for DJ stenting, time gap between stenting and removal, and complications with delay in DJ stent removal and its management were recorded. Data regarding the educational background and socioeconomic status were also noted. Preoperative urine culture and renal function tests were done in all patients. X-ray kidney, ureter, and bladder region was done on the day of the surgery to localize the final position of the DJ stent. The follow-up period was 3 months after the successful removal of difficult DJ stents.


   Results Top


During the study period out of 64 DJ stent removals, 10 patients had complications due to prolonged indwelling of DJ stents. The mean age of presentation was 8.5 years. A male-to-female ratio was 7:3. Data regarding the patients' age, gender, primary procedure after which DJ stenting was done, duration of the indwelling DJ stent, complication associated with DJ stent, and the management procedures were enumerated in [Table 1]. The longest duration of indwelling stent was 15 months and the shortest was 4 months with a mean duration of 8.7 months. Only one patient had intermittent pain abdomen, for which antibiotics and analgesics were prescribed by the local practitioner and the remaining other patients were asymptomatic before the removal of the stents. Preoperative urine culture was sterile in all patients. Renal function tests were normal in all the patients. Among the 10 patients, five patients were referred from other hospitals. The postoperative period was uneventful in all the patients and during follow-up all of them were symptom-free.
Table 1: Complications due to retained double-J stents and their management

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   Discussion Top


In our institute, we prefer temporary internal drainage with DJ stenting after procedures such as pyeloplasty, pyelolithotomy, percutaneous nephrolithotomy (PCNL), and ureteric injuries (iatrogenic or traumatic), although it is completely based on surgeons' discretion. In general, these DJ stents are removed 4–6 weeks after their insertion. In the current study, the removal of the DJ stents after 4 months was considered delay in removal. Delay in removal can cause various complications such as proximal or distal migration of the stent, stent occlusion and hydronephrosis, breakage, encrustation, and stone formation either at the upper end or at the lower end, urinary tract infection (UTI), hematuria, and bladder erosion.[4]

In the present study, the most frequent complication was encrustation. According to El-Faqih et al. rate of encrustation was 9.2% if the DJ stent was kept for <6 weeks and it is 76.3% if the stent was left for up to 12 weeks. This implies that, as the indwelling duration is prolonged, the rate of encrustation increases.[5] Indwelling duration of 2–4 months is considered safe according to various authors.[2],[3],[6],[7] The majority (70%) of the patients in our study were from poor socioeconomic backgrounds with low education status. Poor compliance is the most important predisposing factor. Other risk factors include frequent UTI, stent material like polyurethane (silicon stents are more resistant to encrustation compared to polyurethane), history of urolithiasis (calcium oxalate monohydrate stones), and congenital urinary tract obstruction.[8],[9] Improper placement of the stents, inadequate length of the stent, and ureteral peristalsis can cause migration of the stents.[10] Retained stents may become hard and lose tensile strength causing breakage.[11] Aihole et al. reported a case of forgotten DJ stent after right-sided pyeloplasty causing symptomatic pyonephrosis and poor renal function which led to nephrectomy.[12]

During the COVID-19 pandemic, our public health institution was converted into a COVID care center. Only emergency and life-threatening surgeries were allowed to be performed at that time. Due to the shortage of oxygen supply and for better utilization of limited resources, only emergency and life-threatening surgeries were being performed during the pandemic. Transportation facilities were also hampered due to the nationwide lockdown, hence reaching the hospital was also difficult for the patients.[13] One more reason could be, that patients avoiding to visit the hospital due to the fear of contracting the COVID infection, especially in asymptomatic individuals.

In our series, we had 10 patients with complicated DJ stents, for which different endourological procedures were employed to manage these complications. Five patients were referred from other hospitals. Stents were left in situ for a mean of 8.7 months. Out of the 10 patients, DJ stenting was done during pyeloplasty in 5 (n = 5, 50%) patients, after pyelolithotomy in 4 (40%) patients, and in one case of the nonfunctioning kidney (10%). In the present study, encrustation [Figure 1] was the most common complication (n = 5, 50%). Associated with encrustation, stone formation at the upper end was observed in one patient with the previous history of urolithiasis. One patient with encrusted stent had a nonfunctioning kidney which is symptomatic, hence nephroureterectomy and stent removal were done. In another patient, the upper-end coil of the encrusted stent was impacted at the infundibulopelvic angle, which was uncoiled ureteroscopically and then removed. Knotting at the upper end of the stent was observed in one patient. Proximal migration [Figure 2]c (into the ureter – two cases, into the renal pelvis – one case) was observed in 3 (38%) cases and distal migration [Figure 2]d was noticed in 1 (12%) patient. Entanglement of bilateral DJ stents in the bladder was noted in one patient.
Figure 1: Encrusted DJ stent. DJ: Double J

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Figure 2: (a) X-ray showing excessive coiling at the upper end of DJ (b) Exteriorized distal end in the case of the knot at the upper end (c) Proximal migration of DJ stent into the ureter in a case of crossed ectopia on the left side with PUJO (distal end of the stent not visualized in the bladder on cystoscopy) (d) Distal migration of the stent. DJ: Double J, PUJO: Pelviureteric junction obstruction

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Routinely, DJ stents are removed cystoscopically, but the removal of the complicated DJ stents needs several endourological techniques such as ureteroscopy (URS), PCNL, and percutaneous cystolithotomy (PCCL) or multimodel approach. Failed endourological procedures may need open surgery for the removal of complicated stents. We have managed these complicated stents by different endourological procedures such as cystoscopy, URS, PCNL, and PCCL. Several authors signified the importance of these endourological techniques for the removal of complicated DJ stents.[14],[15]

In the first case, encrustation of DJ stent with stone formation at the upper end was managed by PCNL. Dakkak et al. managed encrusted ureteral stents by different endourological procedures such as PCNL and ureterorenoscopy and recommended minimally invasive approach as the first-line therapy.[16] In the second case, proximal migration of the stent into the renal pelvis was managed by percutaneous nephroscopic removal. In the third and fourth cases, proximal migration into the ureter [Figure 2]c was dealt by ureteroscopic removal. Jayasimha et al. managed proximally migrated stents either by antegrade nephroscopic retrieval or retrograde ureteroscopic retrieval.[17] In the fifth case, upper end of the encrusted DJ stent was impacted at the infundibulopelvic angle, and uncoiling and removal were done by ureterorenoscopy. In the sixth case, distally migrated stent was removed cystoscopically [Figure 2]d. In the seventh case, encrusted DJ stent was removed by cystourethroscopy with gentle traction. Entangled bilateral stents in the bladder in the eighth case were removed by percutaneous cystoscopy. In the ninth and tenth cases, stents were removed in two parts. In case nine, DJ stenting on the right side was done in another institution, and the patient presented to us after 15 months, on evaluation child was diagnosed with a case of nonfunctioning kidney on the right side which is symptomatic. The child planned for the right nephroureterectomy and DJ stent removal. During nephroureterectomy, the stent was found to be heavily encrusted and is removed in two parts. The stent along with the ureter was divided as low as possible and the proximal part was removed. Distal part was attempted to be removed by cystoscopy but it was failed and hence it was removed by PCCL. In the tenth case, during the cystoscopic removal of the encrusted stent, there was resistance after exteriorizing the coil at the lower end [Figure 2]b, hence it was divided proximal to it and knotted upper end of the stent was removed by PCNL. Knotting of ureteric stents is a rare entity and approximately 30 case reports were published in the adult literature till 2020.[18],[19],[20] Excess length at either end of the stent [Figure 2]a is the main risk factor for knotting.[20] Knotting at the proximal end is more common and distal end knotting was reported by Das and Wickham.[21] The first case of ureteric stent knotting in pediatric patient was reported by Corbett and Dickson in a 4-year-old male child in 2015, and he concluded that knotting must be considered if resistance is encountered during the stent removal.[22] Various techniques used to remove the knotted stents include simple traction, URS, and percutaneous removal. Flowchart was given in [Figure 3] showing various complications and their management options. Ureteral or urethral trauma and avulsion are the possible complications if undue traction is applied during the removal of stents. Endoscopy at the end of the procedure can identify these complications. No procedure-related complications were seen in our patients and were asymptomatic during the follow-up. If there is partial ureteric injury, it can be managed by inserting a new stent; if there is complete ureteric injury without segmental loss it can be managed by primary anastomosis over a DJ stent and if there is segmental loss it can be managed by temporary diversion with definitive procedure planned at a later date or definitive procedures such as ureterocalycostomy, ureteric reimplantation, ureteroureterostomy, and ileal conduit.[23]
Figure 3: Flow chart showing different complications of DJ stents and their management options. DJ: Double J, PCCL: Percutaneous cystolithotomy, PCNL: Percutaneous nephrolithotomy, URS: Ureteroscopy, PCN: Percutaneous nephrostomy

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The complications related to DJ stents can be prevented by selecting adequate length of the DJ stent, ensuring proper coiling at the upper and lower end, adequate hydration, proper counseling of the parents regarding the stents and their complications, maintaining a stent registry, and to send automatic e-mails or messages to remind about the DJ stent removal or change. The feasibility of computer-based stent registry was evaluated by Modi et al.[24] The role of stent registry in the management of forgotten stents to prevent morbidity was reported by Patil et al.[25] The multimodel endourological approach is the preferred method and techniques such as cystoscopy, URS, PCNL, and PCCL are essential armamentarium for pediatric surgeons to manage these complications.


   Conclusion Top


Usage of DJ stents is inevitable in pediatric urology practice and henceforth its complications. Proper patient counseling and maintaining a stent registry may decrease these complications. Timely removal of DJ stents should be done. Rather than considering it an elective procedure DJ stent removal should be done on an emergency or semi-emergency basis. Knowledge regarding these complications and the endourological techniques to manage these complications are essential for pediatric surgeons and pediatric urologists.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Borboroglu PG, Kane CJ. Current management of severely encrusted ureteral stents with a large associated stone burden. J Urol 2000;164:648-50.  Back to cited text no. 1
    
2.
Monga M, Klein E, Castañeda-Zúñiga WR, Thomas R. The forgotten indwelling ureteral stent: A urological dilemma. J Urol 1995;153:1817-9.  Back to cited text no. 2
    
3.
Mohan-Pillai K, Keeley FX Jr., Moussa SA, Smith G, Tolley DA. Endourological management of severely encrusted ureteral stents. J Endourol 1999;13:377-9.  Back to cited text no. 3
    
4.
Nerli RB, Magdum PV, Sharma V, Guntaka AK, Hiremath MB, Ghagane S. Forgotten/retained double J ureteric stents: A source of severe morbidity in children. Afr J Paediatr Surg 2016;13:32-5.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
El-Faqih SR, Shamsuddin AB, Chakrabarti A, Atassi R, Kardar AH, Osman MK, et al. Polyurethane internal ureteral stents in treatment of stone patients: Morbidity related to indwelling times. J Urol 1991;146:1487-91.  Back to cited text no. 5
    
6.
Somers WJ. Management of forgotten or retained indwelling ureteral stents. Urology 1996;47:431-5.  Back to cited text no. 6
    
7.
Kawahara T, Ito H, Terao H, Yoshida M, Matsuzaki J. Ureteral stent encrustation, incrustation, and coloring: Morbidity related to indwelling times. J Endourol 2012;26:178-82.  Back to cited text no. 7
    
8.
Singh I, Gupta NP, Hemal AK, Aron M, Seth A, Dogra PN. Severely encrusted polyurethane ureteral stents: Management and analysis of potential risk factors. Urology 2001;58:526-31.  Back to cited text no. 8
    
9.
Bouzidi H, Traxer O, Doré B, Amiel J, Hadjadj H, Conort P, et al. Characteristics of encrustation of ureteric stents in patients with urinary stones. Prog Urol 2008;18:230-7.  Back to cited text no. 9
    
10.
Singh I. Indwelling JJ ureteral stents – A current perspective and review of literature. Indian J Surg 2003;65:405-12.  Back to cited text no. 10
    
11.
Mursi K, Fayad A, Ghoneim I, El-Ghamrawy H. Stones on a forgotten double-J stent: A case report of multiple stones casting a multi-fractured ureteral stent. Afr J Urol 2005;11:247-9.  Back to cited text no. 11
    
12.
Aihole JS, Muniyappa NB, Javaregouda D, Jadhav V. Forgotten JJ stent: A rare case report. Pediatr Urol Case Rep 2015;2:6-10.  Back to cited text no. 12
    
13.
Pal R, Yadav U. COVID-19 pandemic in India: Present scenario and a steep climb ahead. J Prim Care Community Health 2020;11:1-4.  Back to cited text no. 13
    
14.
Bukkapatnam R, Seigne J, Helal M. 1-step removal of encrusted retained ureteral stents. J Urol 2003;170:1111-4.  Back to cited text no. 14
    
15.
Murthy KV, Reddy SJ, Prasad DV. Endourological management of forgotten encrusted ureteral stents. Int Braz J Urol 2010;36:420-9.  Back to cited text no. 15
    
16.
Dakkak Y, Janane A, Ould-Ismail T, Ghadouane M, Ameur A, Abbar M. Management of encrusted ureteral stents. Afr J Urol 2012;18:131-4.  Back to cited text no. 16
    
17.
Jayasimha S, Nagasubramanian S, Jayanth ES, Muthukrishna Pandian R, Chandrasingh J, Kumar S. Management of proximal migration of double-J stents after anderson-hynes pyeloplasty in children. J Pediatr Urol 2021;17:399.e1-399.e7.  Back to cited text no. 17
    
18.
Flam TA, Thiounn N, Gerbaud PF, Zerbib M, Debré B. Knotting of a double pigtail stent within the ureter: An initial report. J Urol 1995;154:1858-9.  Back to cited text no. 18
    
19.
Sighinolfi MC, De Stefani S, Micali S, Mofferdin A, Baisi B, Celia A, et al. A knotted multi-length ureteral stent: A rare complication. Urol Res 2005;33:70-1.  Back to cited text no. 19
    
20.
Picozzi S, Carmignani L. A knotted ureteral stent: A case report and review of the literature. Urol Ann 2010;2:80-2.  Back to cited text no. 20
[PUBMED]  [Full text]  
21.
Das G, Wickham JE. Knotted ureteric stent: An unusual urological complication. J R Coll Surg Edinb 1990;35:190.  Back to cited text no. 21
    
22.
Corbett HJ, Dickson AP. Knotting of a ureteric stent in a child. Int Urol Nephrol 2005;37:493-4.  Back to cited text no. 22
    
23.
Tang K, Sun F, Tian Y, Zhao Y. Management of full-length complete ureteral avulsion. Int Braz J Urol 2016;42:160-4.  Back to cited text no. 23
    
24.
Modi J, Nagarajan R, Kumar S. Re: Sabharwal S, Macaden AR, Abrol N, Mukha RP, Kekre NS. A novel computer based stent registry to prevent retained stents: Will patient directed automated short message service and letter generator help? Indian J Urol 2014;30:150-2.  Back to cited text no. 24
    
25.
Patil SM, Magdum PV, Shete JS, Nerli RB, Hiremath MB. Forgotten DJ stent – A source of morbidity: Is stent registry a need of the hour? Int J Recent Sci Res 2015;6:2674-6.  Back to cited text no. 25
    


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