Prone split-leg position to manage encrusted ureteral stents in a single-stage procedure in women: Step-by-step surgical technique

Abstract

The management of encrusted ureteral stents is costly, time consuming and may be risky for the patient and challenging for the urologist. Treatment modalities for encrusted stents include extracorporeal shock wave lithotripsy, cystolithopaxy, rigid or flexible ureteroscopy with intracorporeal lithotripsy, percutaneous nephrolithotomy, open surgery, and a combination of those methods. In this study we describe the management of severe forgotten encrusted ureteral stents in 3 female patients using a prone splitleg position. This position allows us to effectively treat any site and degree of stent encrustation in a single-session approach with the patient in the same position during the whole procedure. All patients were rendered stent and stone free. No complications occurred. IntroductionIndwelling ureteral stents were introduced in 1967 and were instrumental in the advance of endourology.1 Ureteral stents are mainly used to manage ureteral obstruction due to intrinsic or extrinsic causes (e.g., urolithiasis, strictures, and malignancy) or after any ureteral surgery.1-4 Modern ureteral stents are usually designed in a double-pigtail configuration and are composed of polyurethane and/or polyethylene.5 New biomaterials and ureteral stent coatings, such as heparin and diamond-like carbon compounds, may reduce infection and encrustation rates.6-8 Nevertheless, underlying stone-forming conditions, pregnancy, and total indwelling-stent time affect the level of encrustation. Stent encrustation rates may increase from 9.2% at <6 weeks to 76.3% at >12 weeks. 9The management of encrusted ureteral stents is costly, time consuming and may be risky for the patient and challenging for the urologist. 10 The degree and site of encrustation are important considerations when dealing with forgotten stents. The term ''forgotten, encrusted, calcified (FECal)'' double-J ureteral stent was created to describe stents which cannot be removed cystoscopically without the aid of other auxiliary measures due to encrustation and/or stone formation. 11 The two most severe types of stent encrustation are Grade IV (circular encrustations completely encasing both of the pigtail portions of the stent) and Grade V (diffuse and bulky encrustations completely encasing both of the pigtail and ureteral portions of stent).11 The ideal method for stent encrustation image evaluation is the non-contrast computed tomography (NCCT), as the standard kidney-ureter-bladder x-ray may miss minor encrustations which can also intricate their removal.Treatment modalities for encrusted stents include extracorporeal shock wave lithotripsy (SWL), cystolithotopaxy, retrograde rigid or flexible ureteroscopy with intracorporeal lithotripsy (URS), percutaneous nephrolithotomy (PCNL), open surgery, and a combination of those methods. [12][13][14][15][16][17][18][19][20] Although there are no formal guidelines in the management of encrusted double-J stents, 15 several authors have reported their series and proposed algorithms: some with multiple sequential surgical t...

Combined Endoscopic and Percutaneous Retrieval of a Retained 4-Wire Ureteral Stone Basket

“…2 Retrieval of a retained foreign body, such as a cut portion of a 4-wire basket, can be approached in a similar manner to avoid potential damage to the ureter.…”

“…A combined endoscopic and percutaneous approach is feasible and appropriate for complex endoscopic cases 1 and has been used for the removal of severely encrusted stents and other endourologic challenges with success. 2 Retrieval of a retained foreign body, such as a cut portion of a 4-wire basket, can be approached in a similar manner to avoid potential damage to the ureter.…”