Early and Late complications of Ureteral stents: Our Clinical

Experience

Kilciler M, Erdemir F, Bedir S, Demir E, Guven O, Ozgok Y.

Gülhane Askeri Tıp Akademisi Üroloji Anabilim Dalı, Ankara

INTRODUCTION

Ureteral stents are placed to prevent or relieve ureteral obstruction due to an intrinsic or extrinsic etiology, including obstructing ureteral calculi, ureteral stricture, congenital
anomalies such as ureteropelvic junction obstruction, retroperitoneal tumor or fibrosis, or that developing after open or endoscopic ureteral surgery. Ureteral stents have been
widely used for more than two decades with different indications. Due to the widely spread usage of indwelling ureteral catheters, the number of possible complications such as
migration, infection, pyelonephritis, breakage, encrustation, stone formation and fragmentation have been noted. The aim of this study is to evaluate the clinical complications
of double-J ureteral stents. .

MATERIAL AND METHOHDS :

In this study, the medical records of 123 patients who had 138 ureteric double J catheters inserted over a 9-year period between 1995 and 2004 were reviewed. The study group
consisted of 68 male and 55 female patients. The left side was affected in 73 patients, the right in 47, and both ureters in 3 patients. Of 138 renal units, the ureteral stent was
inserted in 122 for management of nephroureterolithiasis and in 16 for extra-or-intra lluminal pathology. Retrograde stent insertion was performed through cystoscopy in all
patients. A 28 cm double pigtail ureteral stent was used in all patients. In all patients, a polyurethane double pigtail ureteral cathater was used.

RESULTS:The mean age of the patients was 41.4±5.3 (range 21-76) years. Total complication rate was detected as 41.30% (n=57). Of the 138 ureteral stents, 21.01% (n=19)
had to be removed because of early or late complications. Early complications during the first 4 weeks after stent insertion were irritative bladder symptoms (17.39%),
hematuria (7.9%), bacteriuria (10.14%), fever (5.07%) and flank pain (18.84%); late complications included hydronephrosis (1.4%), stent migration (5.07%), encrustation
(13.04%) and fragmentation (2.1%). Two patients underwent open surgical procedure for fragmanteted stents.

DISCUSSION :

The double J ureteral stents have become an integral part of the urological practice. Different complications may occur with short or long-term use of indwelling stents. Patients
with stent-related problems are common in urological practice. The ureteral stents present with a wide range of urological symptoms such as sepsis, UTI and loss of renal
function. Irritative voiding symptoms, including frequency, urgency and dysuria, as well as flank pain, suprapubic pain and hematuria are commonly described, occurring in up
to 85-90% of stented patients in contemporary studies. In addition lower abdominal pain and nocturia can be seen. In an 18-month study, Richter and colleagues prospectively
examined 110 stented renal units in 90 patients and outlined the morbidity and complications of indwelling ureteral stents. In this study 103 patients (94%) had stent-related
complications such as infection (38%) and flank pain on voiding. In the present study, the irritative voiding symptoms were the commonest presentation. The exact
pathophysiology of stent symptoms remains unknown. Lower urinary tract symptoms are theorized to be a result of mucosal irritation of nerves located in the submucosa
concentrated in the bladder trigone whereas the upper urinary tract symptoms are thought to be secondary to vesico-uretric reflux.

Ureteral stent fragmentation is rarely seen. El Faqih et al. reported stent fragmentation in 0.3% of their series. This ratio was found as 10% in study of Monga et al. Various
different mechanisms have been proposed to explain the ureteral stent fragmentation. Breakage of a stent has been attributed to the hostility of the urine solution. Interaction
with urine and extensive inflammatory reaction in situ may be important in the initiation and promotion of degradation. Some authors suggest that an accelerated aging process
is an important factor leading to early mechanical failure of ureteral stents.

Stent-related infection is a significant problem in patients with indwelling stents. This can lead to an increase in bothersome symptoms. Adherent bacteria in 90% of cases
colonize indwelling ureteric stents. However, this translates to clinical urinary infection in 27% of patients with longer stent placement time increasing the likelihood of
infection. Biofilm development can lead to urinary tract infection and subsequent sepsis. In literature studies show that stent colonization rate and bacteriuria correlated almost
linearly with the duration of stenting. The proximal and distal migration of a double pigtail ureteral stent is rare, occurring in only 0.6% to 8.2% of the cases. El Faqih et al.
reported stent migration in 3.7% of their series. Several theories have been proposed to account for this phenomenon. It is believed that the longer the indwelling time, the more
likely a stent will migrate. A double-pigtail catheter as opposed to one with a J-ending is less likely to migrate. It may also be that the migration occurs when the stent length is
shorter than the ureteral length.

Severe encrustation and stone formation in indwelling ureteral stents remains a distressing problem that can lead to severe morbidity and life-threatening urosepsis if
not followed up and managed carefully. The incidence of encrustation increases with the duration that the stent remains indwelling. El-Faqih et al evaluated 299
stents in patients with calculi and noted an encrustation rate of 9.2% before 6, 47.5% from 6 to 12 and 76.3% after 12 weeks. The etiology of encrustation is not
completely clear and it may be due to multifactorial causes. The probable risk factors include poor compliance, long indwelling times, sepsis, alkaline urine,
chemotheraphy, pregnancy, urinary tract infection, chronic renal failure, recurrent or residual stones, lithogenic history, metabolic abnormalities, congenital renal
anomalies, and malignant ureteral obstruction on chemotherapy with hyperuricosuria.

Generally, transurethrally intervention is enough for the removal of the bladder stents. However, several percutaneous and cystoscopic techniques have been used to retrive
uretreal stents that have migrated proximally beyond tye ureteral orifica, including the use of various types of baskets, hooks ande forceps. In addition rarely open procedure
necessitated to remove fragmented stent in renal pelvis. In present study two patients underwent open surgical procedure for fragmanteted stents.

CONCLUSIONS

Close follow-up of stented patients is valuable in early detection of morbidity or complications, and in such cases the stent should be removed or exchanged as soon as possible.