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Gupta R et al, 2017: Bilateral Staghorn Calculus with Forgotten Double J Stent in Ileal Conduit Patient - A Rare Urological Challenge.

Gupta R, Dey RK, Sharma R, Gupta S.
Department of Urology, RG Kar Medical College and Hospital, Kolkata, West Bengal, India.
Department of Urology, SMS Medical College, Jaipur, Rajasthan, India.
Department of Obstetrics And Gynaecology, RG Kar Medical College and Hospital, Kolkata, West Bengal, India.

Abstract

Forgotten DJ stent associated stone formation is not an uncommon entity. Here we are reporting the uncommon case of bilateral staghorn calculus due to forgotten DJ stent who had undergone radical cystectomy with ileal conduit diversion six years back. Management of these cases is a challenging urological situation due to inaccessible ureteric orifices. Patient was successfully treated with minimally invasive therapy in the form of combined bilateral PCNL (Percutaneous Nephrolithotomy) and ESWL (Extracorporeal Shock Wave Lithotripsy) therapy. The purpose of reporting this case is to highlight the grave consequences of a forgotten DJ stent and to discuss the difficulties encountered during the surgical steps of stone removal.

J Clin Diagn Res. 2017 Jun;11(6):PD09-PD10. doi: 10.7860/JCDR/2017/24704.10074. Epub 2017 Jun 1.

 

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Comments 1

Hans-Göran Tiselius on Wednesday, 27 December 2017 08:47

Forgotten internal stents are a serious clinical shortcoming. This is particularly the case when – as in the presented patient - the result was development of bilateral staghorn stones.
Inasmuch as urine examination and subsequent stone analysis showed that the stones were composed of struvite, it is likely that the patient was or had been infected with some other micro-organism than E. coli; a strain that only occasionally produces urease.
The authors chose PCNL for stone-removal and they were fortunate that none of the stents were stuck in the ureter due to encrustations.
An alternative solution to the problem might have been to combine SWL with chemolytic dissolution. Such an approach, although more time consuming, is probably less traumatic even though two thin nephrostomy catheters had been required and a relatively long period had been necessary for complete stone dissolution. One major advantage would be that in case of impacted stents such calcifications might also be dissolved without invasiveness.
The authors describe the outcome as: “almost complete clearance achieved on the right side” and “near complete clearance” on the left side. Also when PCNL is selected as primary procedure for stone removal, it can be recommended to add chemolytic irrigation afterwards with the aim of eliminating every little fragment of struvite, carbonate apatite or calcium phosphate.
Another lesson learnt from this report is that the responsibility for stent removal never should be handed over to the patient. Today a computerized registry ideally should be used to keep track of all patients in whom internal stents have been inserted. The number of inserted stents minus the number of removed stents must be zero! Every forgotten stent means a threat to the patient and a heavy load on the health care system.

Forgotten internal stents are a serious clinical shortcoming. This is particularly the case when – as in the presented patient - the result was development of bilateral staghorn stones. Inasmuch as urine examination and subsequent stone analysis showed that the stones were composed of struvite, it is likely that the patient was or had been infected with some other micro-organism than E. coli; a strain that only occasionally produces urease. The authors chose PCNL for stone-removal and they were fortunate that none of the stents were stuck in the ureter due to encrustations. An alternative solution to the problem might have been to combine SWL with chemolytic dissolution. Such an approach, although more time consuming, is probably less traumatic even though two thin nephrostomy catheters had been required and a relatively long period had been necessary for complete stone dissolution. One major advantage would be that in case of impacted stents such calcifications might also be dissolved without invasiveness. The authors describe the outcome as: “almost complete clearance achieved on the right side” and “near complete clearance” on the left side. Also when PCNL is selected as primary procedure for stone removal, it can be recommended to add chemolytic irrigation afterwards with the aim of eliminating every little fragment of struvite, carbonate apatite or calcium phosphate. Another lesson learnt from this report is that the responsibility for stent removal never should be handed over to the patient. Today a computerized registry ideally should be used to keep track of all patients in whom internal stents have been inserted. The number of inserted stents minus the number of removed stents must be zero! Every forgotten stent means a threat to the patient and a heavy load on the health care system.
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