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INTRODUCTION

Since their inception in 1967, Double J (DJ) stents have been widely used for the purpose of alleviation from extrinsic and intrinsic obstruction. Double J stents are used as a modality of maintaining patency as well as drainage of the urinary tract as well as facilitating the passage of small fragments post-urologic intervention. However, delayed removal or failure of follow-up may lead to this results in complications in the form of stent encrustation, migration, fracture, stone formation, adjacent organ penetration, urinary tract infections (UTI), ureteral  erosion, or fistula formation. Many of these patients remain asymptomatic for months, and such forgotten stents are detected incidentally, resulting in late presentation[ 2. A retained DJ stent however indicates either a system failure or poor patient compliance and understanding. In the covid era, however, an extrinsic factor has increased the incidence of retained DJ stents. Our study examines the occurrence of retained DJ stents considering their placement in the pre-covid as well as covid era. With improvement in bio-materials, stent- related symptoms have reduced greatly and at times may be missed by the patient. In this study, we take into account the impact of COVID as an independent parameter which lead to stent retention as well as other factors such as socio-economic and education status.

MATERIALS AND METHODS
This was a Retrospective observational study conducted at the Department of Urology, Bharati Hospital, Pune, over a period of 24 months (January 2021 to December 2022).
 
Data collection was carried out in accordance to SCARE 2020 criteria [ Hospital records of all patients who underwent removal of forgotten/retained DJ ureteral stent at our hospital were reviewed for ape, tender, indication for insertion of DJ stent, duration of stent insertion, radiological imapes and surgical procedures performed as well as educational qualifications and area of residence (urban/rural) were reviewed. The patients were also analyzed as to whether their procedure occurred durinp the covid era or prior to the same or whether covid was a factor for their hesitancy to pet their retained stents removed. The patients were evaluated for the most common symptom on presentation. A total of 24 patients data was collected prospectively, who met the eligibility criteria of forgotten DJ stent (> 6 months), and factors such as duration of DJ stent indwelling, presenting complaints, and type of previous procedure were noted. Additionally, current procedures performed for the removal of DJ stent and any associated complication were noted. The patients included in this study were those referred from peripheral hospitals as well as previously operated in our institute. All the patients were evaluated with the medical history, socioeconomic status and literacy. Each patient underwent ultrasonography kidney— ureter—bladder (KUB), X-ray KUB, urine analysis and serum creatinine. Computed tomography (CT) was performed when indicated (mainly for radiolucent calculi and in complex cases like fractured or broken stent). Sterile urine was ensured before intervention. The plan of treatment was decided on the basis of investigations. Institutional ethics committee approval was taken[4

Figure 1. Retrieved retained DJ stent with visible encrustation.

Figure 2. Fractured stent

Figure 3. Fractured stent with the calci(ied lower end (arrow).

RESULTS

patients were from rural India and from a poor A total of 24 patients were selected for the socioeconomic background. study. Out of the total, 12.5% (n=3) Out of the total patients who were taken in the underwent previous surgery at our hospital. In study, 6 patients were unaware of their stent all cases a polyurethane stent was used. Mean placement due to inadequate counselling ape of the patients was 49.45 years. 10 provided to them post procedure. 14 patients patients were females (41.66%) and 14 were (58.3%) cited covid as a reason for their delay males (48.34%). Mean duration of the  in  seeking  treatment.  The  commonest indwelling stents was 3.68 years (ranpe  6  indication  was  DJ  stent  insertion  for months to 14 years). 6 patients had formal obstructive calculi noted in 8 patients (33%). 7 secondary education, 13 had primary patients had undergone PCNL (29%). Rest education and 5 were found to be illiterate. 12 summarized as per Table 1.

Table 1 — Indications for DJ Stent Insertion.

Table 2 — Procedures performed (or DJ stent removal.

15 patients presented with flank pain as a commonest beinp dysuria. Hematuria was a presenting symptom. 3 patients presented presenting symptom in 2 patients. 4 patients with lower urinary tract symptoms, the were asymptomatic (Table 3). Of the total, 5 patients required a combination of 2 transfusion. Fever was noted in one patient endourological procedures. 12 patients post-operatively. All patients  were  followed required a PCNL (50%). Cystolithotrypsy was up one week after discharge and repeated X- required in 6 patients. Of the 24 patients, 1 ray KUB was carried out to  rule  out  any  patient had been stented prior to pregnancy remnant fragment or stent displacement. in view of pyelonephritis. However, she failed Stent removal was then done on the second to return within the stipulated time post follow up i.e., 2 weeks after discharge.  22  procedure and required a PCNL, wherein an patients were rendered stone free with only 2 encrusted upper portion of the  stent  was  presenting  with  radiologically  insignificant noted in addition to an existing renal calculus.  remnant  stones.  The  patients  who  had  No patient of the given set was converted to fractured stents were found to have  brittle open surgery and endourological management spots at the site of encrustation. No patients was sufficient. 2 patients required blood required re-look or staged procedures.

Table 3 — Presenting indications.

DISCUSSION

Over the last few years, we have ensured months as a safe period. Patients requiring prompt stent removal as we maintain a stents beyond this period should be kept on directory of patient’s details. However, it was prophylactic antibiotics and have their stents noted that patients were shy of visiting the frequently changed.  Stent  material  may  hospital during the covid era. We also take the contribute to encrustation: silicone containing patients or relatives signature on discharge stents tend to be more resistant to card making sure  that  they  are  actively  encrustation,  followed  by  polyurethane, involved in necessary follow-ups. Every effort silitek, percuflex and hydrogel coated  is made to help patients to follow up on time. polyurethane. Our study included the Double J stent has been a useful tool socioeconomic status of a patient along with since its invention by Zimskind et al in 1967[ 3!       their education and awareness. Most patients However, the stents themselves are not included in the study were of a poorer section without complications if not removed within 6 of society. Most were aware of the presence of indwelling stents, however covid added to the list of factors which already delayed stent removal. The mass horrors of the covid waves struck fear into most patients who shied away from hospitals.

The exact mechanism of encrustation, however several factors are believed to be causative for the same. UTI is a factor for encrustation. Urease produced by bacteria hydrolyses urea in the urine to produce ammonia causing elevated urinary pH and favoring the precipitation of magnesium and calcium as struvite and hydroxyapatite onto the stent surface[. Most studies showed a predominance of encrustation at the upper coil of the stent. This may be because more effective peristalsis at the lower part of the stent sweeps any deposits off the stent, thus minimizing encrustation at the lower end[8, however, in our experience 7 patients required cystolithotrypsy either alone or in combination with other procedures (29% of participants). In a study by Divakaruni[ 5!, nearly 1 2% of all DJ stents are forgotten by the  patient.  Mulay  et  al[. 7  provided  insights into electronic monitoring of the patient via the use of a mobile phone application to prevent such stent retention. In a study by Nawaz et al.[^!, the common complications reported were stent encrustation (10.5%), stent migration (3.5%) and stent breakage (4.5%); similarly, in another study, stent encrustation (24.5%), stent migration (9.5%) and stent breakage (1.3%) were reported as common complications. Stent breakage is sometimes associated with encrustation in forgotten stents. Stents may fracture spontaneously after being in situ for a long time, due to hardening and loss of tensile strength.

Newer efforts should involve a more comprehensive counselling of the patient as well as a responsible relative along with maintaining a database with stent removal dates included in it to ensure minimizing the occurrences of forgotten stents. Each patient is aware of the consequences of a retained stent along with pictorial depiction of the complications so as to make the patient as well as the relative aware of the burden both emotionally as well as financially which could occur if timely stent removal is not done.

CONCLUSION:

Forgotten DJ stents are a common occurrence seen up to 12% [^! of cases undergoing urological surgeries in the developing world. Poor counselling, patients educational as well as socioeconomic status are contributing factors to delay in stent removal as poorer sections of society are still hesitant to visit hospitals. The above was worsened by the onset of the pandemic which led to patients deferring their follow up either due to being in remote locations for isolation or due to the fear of contracting infection during their hospital visit. It is the responsibility of the patient as well as the operating surgeon to ensure timely removal of DJ stents.

Corresponding Author:
Dr. Hrishikesh Deshmukh Department of Urology, Bharati Vidyapeeth Medical College and Research Centre, Dhankawadi, Pune satara road, 411043, Pune, Maharashtra, India

Email: [email protected]

Telephone: +91 9860427793
 
Conflicts of Interest Statement None

Funding Statement: None

Acknowledgement None

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