Saha P K, Hossain M S, Ghosh K C, Alam M S, Nabi S, Saha B K, Pathan F H
Dr Prodyut Kumar Saha, Associate Professor, Department of Urology, Dhaka Medical College, Dhaka, Bangladesh.
Mymensingh Med J. 2018 Jan;27(1):149-158.
Ureteral stent placement is a common procedure in urologic practice. Forgotten, encrusted D/J stents represent a difficult problem for urologists. The major complications are infection, impaired renal function, migration, encrustation, stone formation and multiple fragmentation of stent. A consensus on the best therapeutic approach is still lacking. Here we present our experience with endoscopic management of this challenging problem and discuss the multimodal endourologic approaches for treating forgotten, encrusted ureteral stents. In this prospective observational study 29 patients (17 males and 12 females), age ranges from 19 to 57 years with 35 (23 unilateral and 6 bilateral) encrusted ureteral stents, indwelling for 5 to 78 months were treated in the Department of Urology, Dhaka Medical College Hospital (DMCH), Dhaka, Bangladesh from January 2011 to December 2015. All patients were evaluated by urine culture and sensitivity, renal function. Stent encrustation and the associated stone burden were estimated by plain radiograph. Treatment decisions were made based on the clinical presentation, degree of encrustation, stone burden and image findings. Patients were followed up to 06 months. The main indications for stenting were pyelolithotomy, ureterolithotomy, ureteroneocystostomy, URS and pyeloplasty. In kidney, mild encrustation was common (48.3%) moderate encrustation (27.6%) was less common; where as in ureter and urinary bladder, moderate encrustation was common (72.4% and 44.8%). Over three-quarters 22(75.9%) of the patients underwent extracorporeal shockwave lithotripsy (ESWL) and 10(34.5%) percuteneousnephrostomy preoperatively. Retrograde ureteroscopy with intracorporeal lithotripsy (URS & ICPL) was done in 29 cases and cystolitholapaxy (CLL) in 16(55%) cases. Cystolithotomy & PCNL was rarely done. The mean number of procedures was 2.8 (range: 1-7). Using these multimodal approaches, all stents and associated stones were eventually removed with minor complications. Nine patients developed haematuria, 5 urosepsis and 4 both haematuria & urosepsis. Multimodal endourologic approaches can safely remove forgotten, encrusted D/J stents, if treatment is tailored to the volume of encrustation and associated stone. Imaging evaluation and documentation of negative urine culture are imperative prior to any attempt to remove the stent.
输尿管支架置入是泌尿外科临床常见的操作。遗忘的、结壳的双J支架给泌尿外科医生带来了难题。主要并发症包括感染、肾功能受损、移位、结壳、结石形成及支架多处断裂。目前对于最佳治疗方法仍未达成共识。在此，我们介绍内镜处理这一棘手问题的经验，并讨论治疗遗忘的、结壳的输尿管支架的多模式腔内泌尿外科方法。在这项前瞻性观察性研究中，2011年1月至2015年12月期间，达卡医学院医院泌尿外科对29例患者（17例男性和12例女性）进行了治疗，年龄在19至57岁之间，有35个（23个单侧和6个双侧）结壳输尿管支架，留置时间为5至78个月。所有患者均接受了尿培养及药敏试验、肾功能评估。通过腹部平片评估支架结壳情况及相关结石负荷。根据临床表现、结壳程度、结石负荷及影像学检查结果做出治疗决策。对患者进行了6个月的随访。置入支架的主要适应证为肾盂切开取石术、输尿管切开取石术、输尿管膀胱再植术、输尿管镜检查及肾盂成形术。在肾脏，轻度结壳较为常见（48.3%），中度结壳（27.6%）较少见；而在输尿管和膀胱，中度结壳较为常见（分别为72.4%和44.8%）。超过四分之三（22例，75.9%）的患者术前接受了体外冲击波碎石术（ESWL），10例（34.5%）接受了经皮肾造瘘术。29例患者进行了逆行输尿管镜联合体内碎石术（URS & ICPL），16例（55%）进行了膀胱结石碎石术（CLL）。很少进行膀胱切开取石术及经皮肾镜取石术。平均手术次数为2.8次（范围：1 - 7次）。采用这些多模式方法，所有支架及相关结石最终均被取出，并发症较少。9例患者出现血尿，5例发生尿脓毒症，4例同时出现血尿和尿脓毒症。如果根据结壳量及相关结石情况进行个体化治疗，多模式腔内泌尿外科方法能够安全地取出遗忘的、结壳的双J支架。在尝试取出支架之前，必须进行影像学评估并记录尿培养阴性结果。
