Images for surgeons

Perforation may occur from one of three mechanisms: direct impaling trauma, over‐inflation of the balloon or exaggerated hydrostatic pressure during water instillation.2 The patient in the case we report had multiple previous pelvic operations for pelvic floor dysfunction as well as underlying functional pathology. Despite this the perforation did not occur at an area of pathological weakness, and given its location impaling by the catheter tip is the most likely reason for the perforation. The perforation occurred after the first irrigation event despite the patient being well educated prior to use by a nurse specialist, suggesting poor technique was not a contributing factor. The risk of perforation from transanal irrigation may be higher than reported, and patients and clinicians need to be aware of this potentially serious complication and its associations.

References 1. Shandling B, Gilmour RF. The enema continence catheter in spina bifida: successful bowel management. J. Pediatr. Surg. 1987; 22: 271–273. 2. Emmanuel AV, Krogh K, Bazzocchi G et al. Consensus review of best practice of transanal irrigation in adults. Spinal Cord 2013; 51: 732–738. 3. Christensen P, Krogh K, Buntzen S, Payandeh F, Laurberg S. Long‐term outcome and safety of transanal irrigation for constipation and fecal incontinence. Dis. Colon Rectum 2009; 52: 286–292.

413

4. Paran H, Butnaru G, Neufeld D, Magen A, Freund U. Enema‐induced perforation of the rectum in chronically constipated patients. Dis. Colon Rectum 1999; 42: 1609–1612. 5. Nakamura H, Iyoda M, Sato K, Kitazawa K. Retrograde hydrostatic irrigation enema‐induced perforation of the sigmoid colon in a chronic renal failure patient before colonoscopy. J. Int. Med. Res. 2005; 33: 707–710. 6. Biering‐Sørensen F, Bing J, Berggreen P, Olesen GM. Rectum perforation during transanal irrigation: a case story. Spinal Cord 2009; 47: 266–267. 7. PatientsVille.com. Adverse events and reactions involving rectal catheters. [Cited 22 Mar 2014.] Available from URL: http://patientsville.com/ devices/rectal‐catheter.htm 8. Christensen P, Krogh K. Transanal irrigation for disordered defecation: a systematic review. Scand. J. Gastroenterol. 2010; 45: 517–527.

Sameer Memon, FRACS Ian P. Bissett, MD, FRACS Department of Surgery, Auckland City Hospital, Auckland, New Zealand doi: 10.1111/ans.12680 Correction added on 21 May 2015, after initial online publication. A duplicate of this article was published under the DOI 10.1111/ ans.12761. This duplicate has now been deleted and its DOI redirected to this version of the article.

Knotted multi‐length ureteric stents: a case series Ureteric stents are commonly used in urology to relieve ureteric obstruction or to protect a ureteric anastomosis or injury. Haematuria, urinary tract infection, stent migration, encrustation, fracture and ureteric erosion/fistula are among the reported complications. Ureteric stents can be either fixed length or multi‐length with no reported difference in stent‐related symptoms between these types.1 Fixed length stents can be customized to each patient, adhering to the optimum length ratio, demonstrated to be 104% of the length of the ureter.2 Multi‐length stents place a larger coil in the renal pelvis and bladder and are favoured in many units as they can be reliably used by all grade of staff and are easier to order and stock, possibly reducing costs. The increased length of coil is usually of little consequence, although it can produce some rare and difficult complications. Knotted stents have been increasingly reported, particularly with very long fixed length (28 cm in men and 26 cm in women) and multi‐length stents, exposing these patients to unnecessary and potentially morbid surgical procedures.3–7 We present four cases where the proximal ends of multi‐length stents were knotted, without calcification, resulting in difficult removal. (1) A 65‐year‐old man presented with right loin pain secondary to a 6‐mm right ureteric calculus. A 24–32 cm multi‐length 4.8Fr stent was inserted as an emergency prior to definitive removal of the stone with ureteroscopy at four weeks. At the second procedure, the stent knotted and fractured. The proximal third was retained. This could not be removed via © 2014 Royal Australasian College of Surgeons

retrograde ureteral access and required staged percutaneous antegrade removal (Fig. 1) and a 4‐day admission. (2) A 68‐year‐old woman sustained a right ureteric injury at the pelvic brim during laparoscopic excision of a gastrointestinal stromal tumour and bilateral salpingo‐oophorectomy. A 24– 32 cm multi‐length 4.8Fr ureteric stent was sited to manage this partial injury at the time. After 6 weeks, the stent could not be removed due to a knot in the proximal end. A rigid ureteroscopy was successful in accessing the knot, which was fragmented by holmium laser. All fragments were removed endoscopically. (3) A 55‐year‐old woman underwent elective flexible ureteroscopy and incomplete removal of right renal calculi. A 22– 30 cm 6Fr multi‐length JJ stent was sited at the end of the procedure. Six weeks later, she was brought back for completion surgery. The stent was unable to be removed due to a knot proximally (Fig. 2). This was accessed with a rigid ureteroscope and divided with holmium laser. All fragments, and subsequent residual stones, were successfully removed. (4) A 59‐year‐old male underwent an elective flexible ureteroscopy and holmium laser fragmentation of a 9‐mm left lower pole renal calculus. Although the stone was successfully fragmented, there was difficulty on routine insertion of a 22– 30 cm multi‐length 4.8Fr stent over a Sensor (Boston Scientific, MA, USA) wire at the end of the procedure. On

Images for surgeons

414

Fig. 3. Multi‐length stent knotted around guide‐wire.

Fig. 1. Fluoroscopic image and post‐extraction photograph demonstrating knotted ureteric stent.

Although multi‐length stents are generally more available in theatres and allow less experienced clinicians to proceed without considering the length of the ureter, a little thought, and the siting of a fixed length stent, can prevent this rare but morbid complication.

References 1. Calvert RC, Wong KY, Chitale SV et al. Multi‐length or 24 cm ureteric stent? A multicentre randomised comparison of stent‐related symptoms using a validated questionnaire. BJU Int. 2013; 111: 1099–1104. 2. Breau RH, Norman RW. Optimal prevention and management of proximal ureteral stent migration and remigration. J. Urol. 2001; 166: 890–893. 3. Corbett HJ, Dickson AP. Knotting of a ureteric stent in a child. Int. Urol. Nephrol. 2005; 37: 493–494. 4. Eisner B, Kim H, Sacco D. Repeat knot formation in a patient with an indwelling ureteral stent. Int. Braz. J. Urol. 2006; 32: 308–309. 5. Sighinolfi MC, De Stefani S, Micali S et al. A knotted multi‐length ureteral stent: a rare complication. Urol. Res. 2005; 33: 70–71. 6. Nettle J, Huang JG, Rao R, Costello AJ. Ureteroscopic holmium laser ablation of a knotted ureteral stent. J. Endourol. 2012; 26: 968–970. 7. Picozzi S, Carmignani L. A knotted ureteral stent: a case report and review of the literature. Urol. Ann. 2010; 2: 80–82.

Fig. 2. Fluoroscopic and intra‐operative image of knotted stent impacted in proximal ureter.

retraction of both the wire and the stent, it was noted that the stent had knotted around the wire (Fig. 3) in the renal pelvis. A retrograde pyelogram did not reveal any traumatic injury, and a 22–30 cm multi‐length 4.8F stent was re‐inserted. Techniques for removal of a knotted stent include railroading a wire to straighten the stent; laser fragmentation of the stent; or percutaneous antegrade removal.

Paul Manohar, MBBS, PGDipAnat Wen Ter Kan, MBBS Weranja K. B. Ranasinghe, MBChB, MRCSED Richard J. Cetti, BSc, MBBS, FRCS (Urol) Philip McCahy, MBBS, FRCS (Urol), FRACS Department of Urology, Casey Hospital, Monash Health, Melbourne, Victoria, Australia doi: 10.1111/ans.12689

© 2014 Royal Australasian College of Surgeons

Knotted multi-length ureteric stents: a case series.

Knotted multi-length ureteric stents: a case series. - PDF Download Free
362KB Sizes 2 Downloads 3 Views