Long-term indwelling double-J stents : bulky kidney and urinary bladder calculosis , spontaneous intraperitoneal perforation of the kidney and peritonitis as a result of “ forgotten ” double-J stent

Background. The first double-J (DJ) stents were manufactured in 1978. Their J-shaped tips efficiently prevent their migration from kidneys and from the urinary bladder. Nowadays, DJ stents are in common use because they provide efficient and relatively safe urinary derivation between the kidney and the urinary bladder. We report this case with the aim to point out possible serious complications with long-term indwelling stents. Case report. The patient was admitted to hospital five years after the placement of DJ in a bad general condition, with symptoms of peritonitis. Radiological examination (plain abdominal film, computerized tomography, excretory urogram and cystography) showed bulky calculosis at each tip of the stent, affunctional right kidney, vesicoureteral reflux through the DJ stent and ureter all the way to the right kidney, as well as a large amount of turbid liquid in the abdomen. In the course of the operation, the bulky stone with the DJ stent was removed form the urinary bladder, followed by a large amount of turbid liquid extracted from the abdomen. During adhesiolysis, a small intraperitoneal perforation through which a tip of the stent prolapsed, was found on the upper pole of the kidney. After that, nefrectomy was performed. The patient was discharged 18 days after the surgery. Conclusion. There are usually no complications with shortterm DJ stent urinary drainage. However, indwelling DJ stents can cause serious complications, such as migration, incrustration and fragmentation. DJ indwelling should be as short as possible. If indwelling stenting is necessary, the DJ stent should be replaced with a new one in due time, or another kind of derivation should be performed. Careful monitoring of patients could exclude any possibility of a stent being forgotten at all.


Gustav Simon described the first case of ureteral sondage during open cistostomy in the 1900s, and Yoaquin
Albarann created the first ureteral stent in 1900.In the course of time, ureteral stents were improved to provide good urine drainage from the kidney with as few complications as possible 1 .In 1974 the first commercial internal ureteral stent was made and described by Gibbons 2 .The important problem of stent migration was solved in 1978 when double-J (DJ) stents were made.The tips of these stents are J-shaped and urologists place them endoscopically over the guidewire.
Nowadays, double-J stents are frequently used in the management of different urinary diseases, especially urinary stones.Although it is usually an uncomplicated procedure, long term morbidity and complications depend mainly on the duration of ureteral stenting.In this report we described an unusual complication -bulky calculosis of the kidney and urinary bladder on the double-J stent and peritonitis caused by "spontaneous" intraperitoneal perforaton of the kidney due to a "forgotten" double-J stent five years after the placement.

Case report
A 46-year-old female patient underwent right ureteral double-J stent placement in 2000.After the stenting, four extracorporeal shock wave lithotripsy (ESWL) treatments of the 18 mm large right kidney stone were performed.The patient missed control and stent extraction for five years.She was admitted to hospital in 2005 in a generally bad health condition, with 15-day long history of abdominal pain, fever and vomiting.Clinical and laboratory findings revealed sepsis with severe abdominal distention and defence in the suprapubic area extending to the level of umbilicus.A plain abdominal film revealed a big stone in the urinary bladder fixed to the distal tip of the double-J stent.The upper tip of the double-J stent was laterally positioned with a big incrusration in the level of renal pelvis (Figure 1, left).A computer assisted tomography (CT) demonstrated the presence of a significant amount of turbid liquid in the abdominal cavity (Figure 2).An excretory urogram (IVP) showed an affunctional right kidney.Cystography confirmed that there was no visible leakage of contrast medium outside the urinary bladder, but there was vesicoureteral reflux through the double J stent and ureter all the way to the right kidney (Figure 1, right).
Midline lower abdominal incision was made and the urinary bladder stone was removed with the whole double J stent transvesically (Figure 3).Afterwards, the incision was elongated upwards and 1.3 L of supurative urine was evacuated from the abdomen.Communication between the right kidney and abdomen through the mesocolon (above the right colonnic flexure) was found during adhesiolysis of the bowels.Right sided nephrectomy was than performed.The patient was discharged from the hospital 18 days after the surgery.placement, resistance to migration, easy removing, radioopacity, biological inertion, chemical stability, resistance to encrustations, non-refluxing, excellent flow characteristics and reasonable price 4 .Unfortunately, a stent with these characteristics does not exist in spite of many improvements in stent composition and design 3,5,6 .Up to 80% of patients with ureteral stents have a wide range of urinary tract symptoms immediately after placement, measured by validated questionnaires [7][8][9] .However, indwelling ureteral stents can cause more serious complications in time, such as fragmentation, migration and incrustation 10,11 .El Faquih et al. 12 reviewed 299 stents in 290 stone patients and reported encrustation in 9.2% of stents retrieved in six-week time.Stents that had been in the ureter for 6 to 12 weeks or more were encrusted in 47.5% and 76.3%, respectively.It was found that associated morbidity was minimal if indwelling time did not exceed six weeks.Most of these complications could be solved by non-invasive urological procedures such as ESWL or/and endourological.
Indwelling time increases prevalence and consequences of all complications.Serious complications, even death, may happen as a result of cases of forgotten stents that stay longer than initially planned or more than six months 13 .The most uncommon complication of ureteral stenting is erosion of the ureteral wall and fistulisation into adjacent structures -arterial vessels or bowels 14,15 .The perforation of DJ stent into the peritoneum is an extremely rare, but possible complication.Vesicoureteral reflux occurs in 63% and 80% of patients with a double-J stent, during the filling and voiding phase of cystography, respectively 16 .In these patients, vesicoureteral reflux was intensified by the bladder neck being obstructed by a big stone formed on the lower end of double-J stent.In our patient, peritonitis had developed slowly due to small amounts of urine refluxing into the peritoneum, and a period of time long enough to develop a full clinical appearance (Figure 1).

Conclusion
Complications can be avoided if ureteral stents are removed as soon as possible or changed periodically.Appropriate suppression of infection, prompt ESWL treatment and careful monitoring of patient's complaints are very important, as well.In certain groups of patients, changing of double-J stent or another method of urinary diversion (percutaneous nephrostomy) could be recommended.Finally, the patient must be informed about any consequences and complications of stent placement.Database regarding inserted stents seems to be mandatory in urological departments with high frequency of stenting.