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Radiol Case Rep
Radiol Case Rep
Radiology Case Reports
1930-0433
Elsevier

S1930-0433(24)00866-5
10.1016/j.radcr.2024.08.081
Case Report
Managing a challenging case of bilaterally fractured DJ stents following extracorporeal shock waves lithotripsy for chronic encrustations: A case report
Ali Rao Nouman MBBS, FCPS Urology, MRCPS Glasgow Consultant urologist & Andro-sexologist drnoumanali@gmail.com
a⁎
Ammar Muhammad MBBS, FCPS Urology Senior registrar urology b
Irfan Sohaib MBBS c
Irfan Wajiha MBBS, FCPS Diagnostic Radiology d
a Primary and Secondary Health Care Department, College of Physicians and Surgeons, Punjab, Pakistan
b Department of urology, Sir Ganga Ram Hospital, Lahore,Punjab, Pakistan
c Department of medical education, Aga Khan University Hospital, Karachi, Sindh, Pakistan
d Department of Radiology, Combined Military Hospital Multan, Punjab,Pakistan
⁎ Corresponding author. drnoumanali@gmail.com
13 9 2024
12 2024
13 9 2024
19 12 58395843
30 6 2024
14 8 2024
16 8 2024
© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Double-j stents are commonly used in many urological procedures to facilitate the drainage of renal systems postoperatively. Their usage has revolutionized the world of urological interventions but if left forgotten present serious complications. We report a case of an old man who was diagnosed with bilaterally fragmented DJ stents in situ in our urology department following his sessions of extracorporeal shock wave lithotripsy for chronic encrustations. These stents were placed after complete breakdown of bilateral ureteral stones through ureterorenoscopy and laser lithotripsy.

Keywords

ESWL
DJ stent
Percutaneous nephrolithotomy
Encrustation
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pmcIntroduction

The literature is loaded with cases of forgotten DJ stents that were removed with difficulty. DJ stents have been in use since their invention by Zimskind in 1960. These are tube-like structures placed from the kidney to the bladder to ensure safe drainage of renal systems [1]. Their indications are mostly postoperative like they are placed after breakage of ureteral stones, after reconstructive surgeries like pyeloplasties, and to relieve obstruction in emergencies before definitive management. Despite their promising benefits, DJ stents are associated with immediate complications like dysuria, hematuria, pyuria, flank pain and fever and delayed complications like systemic inflammatory response syndrome and sepsis. These stents are placed for about 6 weeks to 6 months but if retained for a longer period can lead to serious conditions like encrustations, stone formation, fragmentation, breakage of stent and migration [2].

These stent-induced complex scenarios create difficulty in management as it becomes difficult to remove them from renal systems and demand different management modalities like percutaneous nephrolithotomies, Ureterorenoscopy and ESWL [3].

We report a case of an old man who presented with forgotten, encrusted DJ stents bilaterally. He underwent 4 sessions of ESWL to release stents but both stents got fractured which were later removed with ureterorenoscopy and laser lithotripsy.

Case presentation

A 52-year-old man presented in the urology department with bilateral flank pain, fever and dysuria for 5 days following his sessions of extracorporeal shock wave lithotripsy for encrusted forgotten DJ stents bilaterally. These stents were placed 5 years back after the complete fragmentation of bilateral ureteral stones. The patient was diabetic and hypertensive and was on medication for the last 7 years and the rest of the history was unremarkable. The patient was undergoing sessions of ESWL to get his bilateral DJ stents released so that they may get removed with ease but after his 4th session of ESWL, he was admitted with the above-mentioned complaints. On physical examination he was febrile and his bilateral flanks and suprapubic region were tender. The laboratory results revealed a raised WBC count of 16.12 × 10 9/L (4.2-11.0 × 10 9 /L) with neurophilia 89% with decreased Hb of 10.4g/dl while platelets count normal. Some other notable abnormality was urea 138 mg/dL (7-30 mg/dL), and creatinine 3.9 mg/dL (0.7-30 mg/dL) while the rest of the labs were unremarkable.

His x-ray Kub showed bilaterally fractured DJ stents with multiple fragments (Fig. 1) and an ultrasound abdomen depicted broken fragments in the renal pelvis and parts of DJ stents traced along the line of ureter and separated lower curls in bladder. These findings were confirmed with plain computed tomography (Fig. 2) and 3D volume rendering images which revealed bilateral broken encrusted dj stents with upper curls in the renal pelvis bilaterally and separated shaft in ureter bilaterally while lower curls were found separately in the urinary bladder (Fig. 3) . The patient was given broad-spectrum antibiotics and proceeded with bilateral ureterorenoscopy with the help of a flexible ureterorenoscope under general anesthesia and laser lithotripsy was done to release the stent fragments from stones and all fragments removed with the help of grasper in toto (Fig. 4). The bilateral new DJ stents were placed after the procedure (Fig. 5). The Foleys catheter 16fr placed was removed after 3 days and the patient was discharged after complete recovery.Fig. 1 X-ray KUB depicting bilaterally fragmented DJ stents.

Fig 1

Fig. 2 Plain CT KUB showing bilateral broken DJ stents with dismembered upper and lower curls of DJ stents from shaft.

Fig 2

Fig. 3 Three-Dimensional volume rendering imaging showing bilateral fractured DJ stents along with encrustations.

Fig 3

Fig. 4 Removed DJ stents along with encrustation after using multimodal therapy.

Fig 4

Fig. 5 X-ray KUB showing newly placed bilateral DJ stents after the procedure.

Fig 5

Discussion

DJ stents are deployed in renal systems for various urological ailments like stones, strictures, trauma, and reconstructive procedures. If these stents are left inside for a longer duration got stuck inside due to encrustation or stone formation around the stents which makes them difficult to remove [4].

Most of these patients with forgotten DJ stents inside are diagnosed when they develop irresistible symptoms like severe flank pain, Hematuria and fever. Most of these retained stents require advanced urological modalities like extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy and retrograde intrarenal surgery, flexible URS and cystolitholapaxy to make them release from encrustations or stone entrapment. There are many reasons documented in literature why these stents are forgotten in renal systems like poor counselling from the urological surgeon, lack of communication between the surgeon and the patient, low socioeconomic status, language barriers for complete understanding of the disease and deliberate delay from the patients because of nonbothersome symptoms [5].

In our case patient when came to know his stents were now encrusted in the side due to a lack of knowledge of its dreadful consequences and retrieval failed with cystoscopy he was advised extracorporeal shock wave lithotripsy sessions and following these sessions, he presented with severe bilateral flank pain and dysuria. On subsequent investigations, it was diagnosed bilateral fractured DJ stents inside which were removed with the help of ureterorenoscopy and laser lithotripsy respectively.

In literature, Ghimire et al. [6] documented a similar case of chronically retained and uni lateral broken DJ stent following percutaneous nepholithotomy which was managed with difficulty similarly Kumsa et al. [7] reported an encrusted and forgotten DJ stent with multiple kidney and bladder stones for about 15 years which was managed with multimodal therapy including all ureterorenoscopy and holmium lithotripsy, cystolithotripsy and percutaneous nephrolithotomy. In another study Gupta et al. [8] reported the management of thirty patients with broken DJ stents which were managed by utilizing a multimodal approach ureterorenoscopy, percutaneous nephrolithotomy and cystolithotripsy whereas the Sharma et al. [9] reported 2 similar cases of encrusted and broken DJ stents which were removed with percutaneous nephrolithotomy and ureterolithotomy.

Similar to our patient stents with fragmentations and encrustations are managed with multimodal approaches like percutaneous nephrolithotomy, flexible URS with holmium laser and cystolitholapaxy. We recommend regular monitoring during sessions of ESWL because sometimes stents are broken or fractured during sessions worsening the situation more and the material used in DJ stents should be manufactured in such a way as to prove less fatal in case it is forgotten, encrusted or fractured.

Conclusion

The neglected DJ stents are difficult to remove due to their complex presentations and demand multimodal therapy for management. They may get fractured while undergoing ESWL sessions as well hence monitoring is necessary during the sessions. Hospital stent registry should be managed to maintain the record of patients who underwent procedures with DJ stents so that they can be given timely reminders. The manufacturing companies should be contacted to find out the ways to design stents in such a way as to delay encrustations, and fragmentation if forgotten.

Patient consent

We confirm that we have obtained written, informed consent from the patient for the publication of this case report. The patient has been thoroughly informed about the details that will be published and understands the implications of the publication. The written consent is stored securely and is available for review by the editorial team upon request.

Authorship contributions

R.N.A crafted the concept, M.A provided design of the study and proofread the content and finalized the manuscript. S.I. collected data for other comparing studies. W.I. collected the images with interpretation.

Ethical approval

Not applicable.

Acknowledgments: We are in debt to the services of our Professor Muhammad Khalid butt who supervised us in the creation of this novel literary work for the readers of the urology world. The author received no financial support for the research, authorship and publication of this article.

Competing Interests: All the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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