Fragmented ureteral stent extraction by antegrade and retrograde access:using ureteroscope and nephroscope.

there are different complications of using ureteral stents in urology field, one of the challenging complications is stent fragmentation which is frequent in patients with missed and forgotten stents accompanying encrustation, presented case was 70- year-old female, left single kidney with stent fragmentation After TUL and stent insertion one year ago, because of retained fragments in kidney, ureter, and bladder, combined antegrade and retrograde approach was used for stent fragments extraction, for preventing stent related complications we should signify the importance of timely extraction of ureteral stents during inpatient and outpatient visits and using remembrance methods.

Introduction

Ureteral stents are Commonly used in urologic surgeries for reducing obstructions, and ureteral healing after surgeries done on ureter, the most common indication for ureteral stent placement was kidney and ureteral stone surgeries, irrtitative bladder symptoms and hematuria and other complication are urinary tract infections, stent encrustation, migration, stent fracture, in this case study, stent fragmentation and it's management will be discussed.

Case

A 70-year-old female presented with complaints of lower urinary tract symptoms, frequency, urgency and dysuria and hematuria, patient was undergone Left TUL and ureteral stent insertion one year ago, and right kidney function was reduced because of previous surgeries and stone formation, after imaging studies; in the kub we observed the ureteral stent fragmens in the kidney, ureter and kidney [Fig. 1], at first we start to extract bladder and ureteral parts of stent by ureteroscope, two ureteral fragments was extracted but another ureteral fragment cant be extracted because of ureteral stricture encountered in ureter, and it couldn't be passed even with 6fr ureteroscope, so 5 fr ureteral catheter was passed and antergrade access under fluoroscopy was done to extract stents fragments inside the kidney, after changing patient position from lithotomy to prone, the lower calyce acces was done and after amplatz sheath placement all fragments inside the kidney was extracted successfully without any uneventful event [Fig. 2] and finally ureteral stent placed in an antegrade manner because of ureteral stricture and small segment remained in the ureter [Fig. 3].

Fig. 1

Intrarenal fragments (red circle)ureteral fragments (blue circle) intravesical fragments (green circle), Right side (non functional) kidney with multiple stone.

Fig. 2

Ureteral catheter and fragments of stents is seen inside th kidney(a)kidney pyelogram after contrast injection retrogradely(b)kidney final fluoroscopic view after extractin of all fragments(C).

Fig. 3

KUB after ureteral stent insertion by nephroscope(a), small fragment remained in the ureter is showed by Arrow All of the fragments extracted from the kidney,ureter, bladder(b).

Discussion

There are different complications of ureteral stents, ureteral stents made of biomaterials have low complications and lower discomfort for patients, but stents despite these biomaterial benefits,infection, biofilm formation, encrustation was reported after long term insitue of these stents.

There are different biomaterials used as ureteral stent compositions, polyethylene, mixture of polyethylene and polyurethane, Silicone, metal, titanium, nickel/titanium mixed alloys.

Stents made of Polyethylene are susceptible to fracture even after short time remaining insitu but recently stent fracture was reported in silicon stents the most common problem lead to stent fracture is 1.stent encrustation Inflammatory response and long indwelling time ureter

Stent fracture usually occur along stent side holes, so stents with multiple side holes are susceptible for fracture management of fractured stents depends on where the fragments retained, can be managed by retrograde approach using ureteroscope or antegrade approach using nephroscope or combined retrograde and antegrade approach the same management which is used in our case

Conclusion

Forgotten or missed stents are the most important risk factor for stent fracture by using the methods such as 1. reducing stent usage in our surgeries 2. computerized registry 3. multiple visits after surgery we can prevent stent complications such as stent fracture.