Forgotten, Encrusted Ureteral Stents: Removal - Multimodal Endourologic Approach.

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.