Percutaneous antegrade nephroscopic holmium laser pyelotomy: Novel endourologic technique for removal of extruded ureteral stent

Abstract

Cite as: Can Urol Assoc J 2013;7(11-12):e830-2. http://dx.doi.org/10.5489/cuaj.1258 Published online December 5, 2013. AbstractUreteral stent malposition outside of the urinary tract is a very uncommon complication of retrograde or antegrade ureteral stent insertion. There are few reports of open, laparoscopic or endourologic approaches to remove malpositioned stents. We present a novel technique for the removal of an extruded retroperitoneal ureteral stent using percutaneous antegrade nephroscopic holmium laser pyelotomy. This previously undescribed procedure represents a new soft tissue application of the holmium laser. R etrograde or antegrade ureteral stent placement is a common practice to relieve upper urinary tract obstruction, pain, or infection.1 Minor complications of ureteral stents include pain, voiding symptoms, hematuria and infection, and major complications of stents include encrustation, fragmentation, migration, malposition, knot formation, forgotten stents, extrusion and death.1-3 Ureteral stent migration is rare and involves movement within the urinary system. Stent extrusion is extremely rare and involves movement outside of the urinary tract, sometimes into critical organs such as the inferior vena cava 4,5 or duodenum. 6Ureteral stent malposition is uncommon because of imaging techniques that are widely employed during stent placement. Ureteral stent malposition contained within the urinary tract lumen is often identified intraoperatively. However, malposition and extrusion of a ureteral stent outside of the urinary tract is extremely rare and may or may not be identified at time of stent insertion. We report a rare case of an antegrade malpositioned and extruded ureteral stent outside of the renal pelvis and its unique successful management via percutaneous antegrade nephroscopic holmium:yttrium aluminium garnet (YAG) laser pyelotomy -a procedure that has not been reported in the literature to date. Case reportA 78-year-old female presented with acute renal failure and bilateral hydronephrosis secondary to an obstructing, locally advanced and metastatic colorectal carcinoma. Serum creatinine was 922 μmol/L. Bilateral nephrostomy tubes and antegrade 8.5 Fr double J ureteral stents were placed by the interventional radiology service at our institution under ultrasonographic and fluoroscopic guidance. Within 3 days, the patient's creatinine returned to baseline (54 μmol/L) and both nephrostomy tubes were removed 5 days later. The patient was discharged in stable condition with indwelling bilateral ureteral stents. At initial follow-up 6 weeks after stent insertion, the patient reported mild intermittent gross hematuria, but no nausea or stent colic. Serum creatinine remained normal. Elective bilateral ureteral stent change was attempted under general anaesthesia 3 months later. Left-sided stent change was uneventful, despite a partially encrusted stent. The right-sided stent was not changed due to significant resistance that was met while attempting to remove it. The procedure was abandoned ...