[PP-242]
Removal of Forgotten Incrustated Double J Stent with Ureteroscopy and ESWL Combination After 18 Months
İsmail Selvi, Halil Başar, Halil Çağrı Aybal, Onur KekilliINTRODUCTION-AIM: Double J stents(DJS),which are forgotten can lead to adverse effects such as flank pain,pyelonephritis,stent migration,encrustation,calcification,disintegration into multiple kidney,ureter,bladder stones,hydronephrosis,renal failure,sepsis.It is recommended to be removed within 3 months.In literature, "long time stenting" is defined as time that longer than 12 months.
Ureteral reactions such as epithelial hyperplasia, edema, mucosal dysplasia causes crystalloid aggregation in the presence of alkaline urine,urinary tract infections calcium phosphate and struvite deposits.We presented a case of forgotten incrustated DJS,which was removed with ureteroscopy and ESWL combination after 18 months.
CASE: A 58-year-old male patient presented with left flank pain and dysuria.Direct urinary system graphy(DUSG) demonstrated DJS with one piece in left ureter.He didn’t know about DJS.18 months ago, due to metastatic rectosigmoid carcinoma,patient was performed low anterior resection+ metastasectomy to liver+partial cystectomy,then adjuvant chemotherapy was initiated. But he didn’t follow his control visits.Abdominal tomography revealed a DJS,extending from left renal pelvis into the bladder throughout the entire ureter.Multiple sequential calculations of 21x11 mm in size in all segments of DJS and dilatation in left kidney were seen(Figure1A-B).Complete urine examination was normal and creatinin was 4,18. Cystoscopy revealed calcification on the bladder part of DJS(Figure1C).Calculi were fragmented with pneumatic lithotripsy.Left ureter was entered with ureteroscopy.On ureteral segment,calculi around DJS were fragmented with laser lithotripter. Calculi in proximal part of DJS could not be intervened and DJS could not be removed. On the second postoperative day, fever, diarrhea, creatinine elevation were seen.Dialyse was initiated to patients and ertapenem was given. Left percutaneous nephrostomy was performed on the third day. On the seventh day,2 seance of ESWL were performed for calculi of proximal ureter and pelvis. On the 12th day,DUSG showed that DJS migrated 5 cm into bladder(Figure1D).There was reproduction with Non-albicans Candida in urine culture obtained from nephrostomy.Cefpodoxime+itraconazole were initiated.On the 16th day,ureterorenoscope was performed to fragmante remaining residual calculi by laser lithotripter and DJS was taken out in one piece by forceps(Figure1E).
CONCLUSION: ESWL,URS,cystolithotripsy,percutaneous nephrolithotomy,chemolysis through percutaneous nephrostomy and open surgery(pyelolithotomy-ureterolithotomy-cystolithotomy) can be used in alone or in combination for removel of forgotten DJS.After insertion of DJS,each patient should be given necessary information about removal of DJS.
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Figure 1A: CT image of the renal pelvic part of the forgotten DJ stent
Figure 1B: CT image of the bladder part of the forgotten DJ stent
Figure 1C: Cystoscopic view of the bladder part of the incrustated DJ stent
Figure 1D: DUSG image of DJ stent after ESWL
Figure 1E: Appearance of DJ stent,which was removed in one piece
Figure 1B: CT image of the bladder part of the forgotten DJ stent
Figure 1C: Cystoscopic view of the bladder part of the incrustated DJ stent
Figure 1D: DUSG image of DJ stent after ESWL
Figure 1E: Appearance of DJ stent,which was removed in one piece