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REMOVAL OF RETAINED

iOUBLE-J STENTS

KEVIN F KILLEEN, M .

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GV, ILLIA J BFIdRLE, 11L, From the Department of 1Jrolog, Medical Center, Burlington, Massae isetts

ABSTRACT_At the Lahey Clinic Medical Center; Double-J .stents are placed prim management of patients with calculi . They are used before extracorporeal shock-way (ESFVL) of large renal calculi or bilateral ESWL treatments and after ureteroscopie ins Lion or removal of calculi, They are also used for palliative urinary diversion for pati ureteral obstruction secondary to pelvic cancer. Fluoroscopy with C-arm guidance is the rnr is logcrc technique employed for manipulation of all calculi and insertion of steam . Reseal been good with the use of these stents, but in 3 patients the rigid ureteroscope was req remove a retained Double-J steret .

The use of endoscopic teehniques rr ingperc (a nexus nephrostomy with fluoroscopic or direct visualization of the retained stem or the combined use of cystoscopy and fluoroscopy to remove proximally migrated stents has been well reported in the literature,' -" however, the use of ureteroscopy was unique in the patients reported on here because the stents, which were retained in the middle to distal portion of the ureter, were not accessible by previously described techniques . In. general, stents that are inserted for shortterm use are well tolerated lap patients ; but when stents are inserted for Long-term use, difficulties and mechanical problems arise that have been well described . 9- ' 2 We report our experience with 3 patients who had the unusual complication of a retained Double-j stent and their successful management using three different ureteroscopic techniques to remove the stint under direct vision, thereby avoiding open surgical removal . Ureteroscopv can be helpful in the management of patients with retained i reteral stents and can be used in combination with endoscopie and radiologic, techniques to avoid open surgical removal .

Case Reports Case 1 A fort ' .five 'ear hypertensi calculus disease presen a Excretory urography and retrograd phy demonstrated a calculus I A)) crn m dt above the ureterovesical junction wit narrowing of the ureter. The patient and ureteroscopy, and the calculus wish enga~ fragmented using the ultrasonic pro ureter was stented using a `-F stiff D ureteral stentt (Fig . IA) The patient returned five weeks late tine removal of the ureteral scent . Do,," procedure, the proximal portion of thhe e carne kinked in the distal ureter (Fi 'ire was used to regain access t ter, and direct ureteroseopv using ateroseope was carried out (Fig . 1C) . teroscope was used as a fulcrum , stent . Retrograde pyclography reveale ter to he intact, and a straight i lexi' Ndi

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ure t a f attempted rerigid biopsy became lodged as 'stal ureter {arr(yw) . ,de Wire was placed d into stunt, 10-F c was used as move kinked use, z (D) tietrograd( 0 nun)

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SIY.ice 1951 right renal cal ion re veal.ec the right urec left kidney, nE} hrostomv tube and riglit ureteral Dolll stmt were in place (Fig . 2A) when she was referred for extracorporea.l sh.o - =k-wave lithotrir (ES ,vy'L) therapy. Examination one month later resealed bilateral calculi and a mass in the left breast . The



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Plain Ann ;bows v. al eider lns 1st, ?TI cube, ,_ Uarrow), and a burnt underu cut right uretcrasc t, I extraction of calculi in a 'ia placement, and left ciarned three months after i'i,, to;ny had been removed and she ha gone left mastec€oamr . Plain film shows go c/feet but residual calculus and suggests sate stvasse along Double-J stunt (curved arrow) : to. . sent could rot be rermred usin, Direct vieleroseapy using 10-F ed incru°tatiou of calculi along s trasonic probe used to fragment ca noval was then easy using ups . (C) Irnnrcclmte follow-up plain good ESWL effect . Fvrthersttutiesshou tale tins disease .

csstoseups; removal of 3 oustc-J steins, the pat .iei i 'ii surgeon and . u-nderw and areteroscopy with oitc trasouie disruption and removal of the calculus mastectomy in Jury .,.IMO The r °nt 1w as removed by the referri in the right ureter . Bilateral placement of Dow ble-J stunts and left ESWI therapy were per3. formed -in June . 1986 . the nephrostornv tube Ithree months after the first ESN was damped and removed, and the patient was •, vent the patient returned for EStM left with residual left renal calculi and bilateral of the remaining lr d e,ateuli P

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;aSe I (/A) ionfunctionleft renal hlea in film suggestee 'gration . Serum )el elevated to I )usly re it normal artipte+d seent both cystoescope . q at urelera juef I cattle] not b (B) With patient Anesthetic, lef y tube was ~, atient undertherapy. ced down oscopJ. 5hrough and guide renal

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revealed renal. calculi and a lreteral calculi alongside the Dount (Fig, 28) . The pa cystoseopy and attempted removal o al slant using the cold-cup biopsy forver, the scent was impacted and 'emoved . A guide wire was placed reter and ureteroscopy performed scope . Because the ,stent was ulus debris, an ultrasonic tp the ,tent and permit 'he patient then underwent 'th satisfactory results

three-year-old man presente at trl with left renal colic . Excretory Baled a nonfunctioning right kidrenal calculus . The patient had c.

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VOLUME XXXV

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c} stoscopy and left Double-i scent and was referred to therapy with essentially a solitary left rc . At the time of referral, a plain i proximal migration of the Donl3 grade into the ureter (Fig . 3A) creatinine level wyas 5 .4 mgidT . The derwent cystoscopy and ureteroscopy with attempted 1reteroscapic removal of the ureteral scent . A left nephrostomy tube was placed the same day, and the patient under .wvent left i'.SI\-t'I . therapy Wig . 3B) . A week after ASS-s"h therapy, a 5-F angiographic catheter was placed into the bladder through the nephrostomy tube in antegrade fashion st_i), Then, in the cystoscopy suite, the an aphfe



catheter was exchang o 0.38-inch guide wire . Direct u reteroscopy usin a 10-i' u reteroscope was carried out, and the i inert Doublej ureteral stent was grasped using a four-wire basket and removed . Nephrostograrn the next day showed good flow with only a small amount of calcule remaining in the upper pole kig . .'3D) Serum creatinine levels, however. remained elevated around 5 .3 mg/dl at discharge . Comment The Double-j ureteral stent has been employed increasingly in our patients and in patients ref' erred to us for ESWL therapy . NA76 have used ureteroseopy for the management of ureteral calculi in approximately 225 patients, al ways inserting a guide wire in the ureter before ureteroscopy. A Double-J ureteral stunt is placed routinely in patients after they have undergone procedures in the distal ureter lasting over one-half hour, for patients with suspected or documented ureteral perforation, or for patients in whom we are unable to engage or remove the calculus . For patients undergoing lengthy ureteroscopprocedures, a stent is placed to prevent the occurrence of renal colic from swelling of the ureter at the ureterovesieal junction and stricture formation, although no data are available to support the latter statement . In patients with suspected or documented ureteral perforation, a Douhlc j stunt is placed using the Seldinger teehniuuc to Meat any ureteral perforation and to permit healing of the distal ureter . For palients with a large perforation, a Foley catheter is also placed to decompress the system completely and to permit healing of the ureter_ Fortunately, we have not had a high incidence of complications from perforation except in our early use of the ureteroscope . Only 2 patients have been explored for this complication . V e will not persist in our attempt at ureterosny when it is difficult to engage the calculus t will stent the ureter using the Seldinger technique and ask the patient to return for repeat ureteroscopy. Balloon or bougie dilation of the ureter during repeat ureteroscopv may not be necessary. W'c prefer to give the patient another anesthetic and repeat ureteroscopy than to risk injstry to die distal ureter resulting in urgent exploration and repair, Our experience with ESWL therapy has also increased the number of patients we have seen with a Double-j nreteral stunt in place . Treat-

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iln ent come a i'e treat patients wi clod from the dine oa r ca may haww colic before treatment,, they mr quire softie type of decompression, usual Double-j ureteral stent . Additionally, 1 with a 2,0 to 2 .5 em calculus usually stent placed to decrease the incidence o toniatic steinstrisse . Almost all patients going bilateral ESWL therapy have placed on one side to prevent the risk o oral steinstrasse and to reduce the chant acute renal failure from obstruction . Usually, the Double-] sttent is well l by the patient with the exception of 1„-, eo cation of mild renal colic associated wit] ing and complaints of urinary frequency complaints subside, however, when the are removed . The potential for mocha complications, including retention of a st malposition of a ureteral stent, ' present anytime a ureteral stent is place' Stenting of the ureter was deseri Zimskind, Fetter, and 4 .1'iikersonn in 193? .' aerials and techniques have improved ti time . Indications for ureteral stentiuu creased after reports, such ass ti Green, and Yatsuhashi,° on patients wit eral ureteral obstruction . Hepperlen . Mardis, and Karma described the use of a pigtail stunt for pa with ureteral obstruction secondary , recurrent cancer . Andriole, et al . 1 ° report placement of a scent for ureteral obstru and fistula formation, These authors h that urinary diversion was well :olerale improved quality of life, Abbot and Kahn" described pyelonep resulting from ureteral scents . It has clear that the major complications .assn with an indwelling ureteral stent w'(, much cal. The most common complications are , struction and .migration of the scent ." calculi form near the proximal and dis' ments of the scent . Since 1981, numerous reports' described niethods of percutaneours at scopic retrieval of retained ureteral ste eluding retrieval with hooks,'',' all' ceps" balloon catheters,r and stone baskets°- 7 through a pervert nephrostomy tube tract, C vstoscopic ext ;if a retained stent using C ;-arm guidar Flexible alligator forceps has a,

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f'eferenees r r 'R, Dot e r C l McKinnei M -ad Bu h j 7 ercuta nexus re neVal of urete at scents, huha,otry- 132 2,30 (1984), 2, LeRov AJ, et a2 . Indwelling eteral senh percutanemta r taoag< rnene of compltcations. Radiology 158 : 219 (18861 . 3 . Hearnall HP, Pleeh net SM . and Sandier CM C e oiled er.el catheters using Fluoroscopic doscopic retrieval of r e c pi - reteral guidance, Urology 25 : 613 (19.85; . 4 . Zegel HC, Taplhek SK ., and Khnnna OP : Removal of a dislodged ureteral stmt through a percutaneous nephrastomy . A)R 1 .37 :4329 (1981), 5 . Moranze SC, Po)iack HM, and Banner 'MP : Thc- u, grasping forceps in the u7 per urinary t, a : t : technique and ran) logic implications . Radiology 144: 171 ,1082) . 6 . G'r ossnrm : 1, Pollack 1451, Banner MY, and cte!n Aj : F ndoscop:e removal of it v . arenal foreign body na -g D2nda arnroe basket .1rologry 20: 458 (1982) . r . Smith AD : Retrieval of mete al . aunts . UrsA I lia North Am 9 : 109 (19821 . 8 . Berman D . Donovarr J, Ats{u:ns D, and O'Cunnor Y'J Jr : 'Pran rretheral removal. of ntgrated i dw ;lling v re aril stark : a new technique, j Urol, 130 : 76> (1883) . 9, Meyer JE, Green TIT Ji, .r,6 Ya•.suhashi Sri ; Palliative e_rinary (-:vers ion in ca inoma of the cervix, Caa t_c Uynecoi 55 : 05 (1 )50}) 10, Andrmle CL, Betontmn and Bichie JF' : I clungDoublr j rt ralstents : 'O nap : cxrersence •

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second patient had inerustaon the stent along the midureter c s of ureteral stenting . This paee nix s unusual because formation of calculus Usually at the proximal or distal aspect that increasing use of )le-J stents could lead to an in-

of formation of calculi along J stent . The third patient the stmt managed by ante grade but a number of methods were rating that several methods, inof the ureteroseope, can be emxtract retained stents .

s loyal of relot eon described previously . cope can be used as a fulcrum, to e i t ureteral stmt incrustation, or to grasp ained stent with a wire basket or grasp°, ail being performed under direct o a observation is how easily accept a 10-F ureteroe ureteral stent. stent that is retained in the mid-

C . and Kahn Ii7 : Jet eio sic ureteral :;tent; : m Mhttlaufer JN, and Oldani G : Encrustation and ste ion : cou :pticatioc. of indwelling ureterai stints, ologv 25 : - (19SSi_ 13. Y mskisad PD, e na: 1R, are , Willcerson IL Clinical use o : long-term indwelling g silicone rubber enthral . 'plc-t", inserted evstoscopically. J llroi 97 : 54(7 31967) . 14 . Tlepper en TW Mandis HKand Kanieua avde1 11 : '1he pig_etc al stern, is : the e anew p mien(, J U30, 121 ; 17 (1979}_

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Ureteroscopic removal of retained ureteral Double-J stents.

At the Lahey Clinic Medical Center, Double-J stents are placed primarily for management of patients with calculi. They are used before extracorporeal ...
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