Case Report
Urologia Internationalis
Received: May 29, 2013 Accepted after revision: August 8, 2013 Published online: January 23, 2014
Urol Int 2014;92:373–376 DOI: 10.1159/000354936
Successful Endourological Management of the ‘Forgotten’ Stent in a Transplanted Kidney Fiona Mei Wen Wu a Mark Lim b Zhaolong Deng b Chin Tiong Heng a Ho Yee Tiong a a
Department of Urology, National University Health System, and b Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Key Words Forgotten stent · Renal transplantation · Endourological techniques
Abstract Background: Ureteric stents are used to prevent urological complications like ureteric fistulas and obstruction in kidney transplants. Despite its advantages, complications arising from delayed removal of a double J (DJ) stent include urinary tract infections, stone encrustation, and migration of the DJ stent [Sansalone et al.: Transplant Proc 2005;37:2511–2515]. Encrustation of the stent makes removal difficult and risks injury to the transplanted kidney. Case Presentation: We report a case of retained DJ stent for 19 years presenting with recurrent urinary tract infections. A radiograph revealed a retained ureteric stent extending from the right iliac fossa transplant kidney to the urinary bladder with multiple foci of large calcification along its length. Two sessions of extracorporeal shockwave lithotripsy along the stent were performed after a percutaneous nephrostomy tube had been placed in the transplanted kidney. Subsequently, the retained DJ stent was removed endoscopically after laser lithotripsy to remnant calcifications. Remnant stone fragments were removed with another session of ureteroscopy and la-
© 2014 S. Karger AG, Basel 0042–1138/14/0923–0373$39.50/0 E-Mail [email protected] www.karger.com/uin
ser lithotripsy. The patient achieved complete stent and stone clearance with a functioning graft. Conclusion: This case illustrates that significant stone encrustation of the retained stent in a transplanted kidney can be treated successfully with a combination of endourological techniques. © 2014 S. Karger AG, Basel
Introduction
When patients are faced with end-stage renal failure, the best therapy is kidney transplantation [1]. The majority of urological complications after transplantation arise from a compromised ureterovesical anastomosis, which include urine leakage or ureteric obstruction [2]. The common causes of urinary leakage are ureteric ischemia and suture failure [3]. Ureteric strictures may also be caused by intraluminal factors, such as calculi, blood clots, or extraluminal factors such as compression of blood and lymphatic fluid collections [4]. Double J (DJ) stents have been shown to reduce early postoperative major urological complications. Despite their advantages, complications arising from delayed removal of DJ stents include urinary tract infections, stone encrustation, and migration of the DJ stent [5]. Encrustation of the stent Ho Yee Tiong, MD, FAMS (Urology) National University Health System, Department of Urology 5 Lower Kent Ridge Road Singapore 119074 (Singapore) E-Mail cfsthy @ nus.edu.sg
makes removal difficult and risks injury to the transplanted kidney. We report a case of successful removal of a ‘forgotten stent’ 19 years after transplant using multimodal endourological techniques.
Case Presentation A 54-year-old female patient with end-stage renal disease underwent a living-related renal transplantation in 1992 (the patient has given her consent for this case report to be published). A DJ stent was inserted and good perfusion of donor kidney was noted intraoperatively. The patient recovered with no early postoperative complications and was discharged well. The standard protocol of stent removal 2 weeks after the surgery was, unfortunately, not performed. On subsequent regular follow-up the patient had stable kidney function. In 2010, she had several hospital admissions for recurrent urinary tract infections. Radiographs of the abdomen [kidney-ureter-bladder (KUB)] revealed a calcified and encrusted ureteric stent extending from the right iliac fossa transplanted kidney to the urinary bladder (fig. 1). Ultrasound of the kidneys revealed mild hydronephrosis with the DJ stent in situ. Her creatinine level was 122 mg/dl with an eGFR of 35 ml/min/1.73 m2 (MDRD equation). Treatment options were discussed with the patient and the decision was made to use multimodal endourological approaches to clear the stent and its associated calculi. A percutaneous nephrostomy (PCN) with an 8-Fr nephrostomy catheter was inserted to facilitate transplanted kidney drainage before subsequent treatments. The patient underwent two extracorporeal shockwave lithotripsy (ESWL) sessions in a supine position to clear the extensive calcifications along the stent. Shockwaves (Modularis Variostar Lithotripter; Siemens, Germany) were delivered over the table anteriorly over the patient’s right iliac fossa, but directed from the patient’s left side in view of the PCN tube on the right side of patient (fig. 2). As the kidney transplant is relatively superficial compared to native kidneys, treatment was limited to 3,200 shocks and a maximum power of 2 kJ for each session. The distal ureter segment of the stent was targeted initially and the shockwaves progressed proximally after achieving good fragmentation. The bladder portion of the stent was not targeted. Figure 3a shows the results after two sessions of ESWL. After achieving good fragmentation, the patient underwent cystoscopy and removal of the DJ stent under general anesthesia. Calcification of the stent within the bladder was fragmented with cystoscopic lithotrite and then withdrawn intact without breakage under direct vision and fluoroscopy guidance. Ureteroscopy of the transplanted ureter and holmium laser lithotripsy was then performed to clear all remnant calculi. The transplanted ureter was dilated, probably due to the retained stent, and was easy to cannulate with the semirigid ureteroscope (Karl Storz, Germany), despite a Lich-Gregor anastomosis of the ureter to the bladder dome. The PCN tube allowed free drainage intraoperatively and prevented high pressure generated within in the kidney during ureteroscopy. After two sessions of ureteroscopy and laser lithotripsy, all stone fragments were removed with a Nitinol tipless basket and a new DJ stent was placed (fig. 3b). This allowed the ureteric edema to resolve and the PCN tube to be removed.
374
Urol Int 2014;92:373–376 DOI: 10.1159/000354936
Fig. 1. X-ray KUB taken 19 years after DJ stent insertion. A right
DJ stent is visualized with foci calculi seen along its length.
The PCN tube and DJ stent were sequentially removed on day 2 and 2 weeks after surgery, respectively, after ensuring complete radiographic stone clearance. One year after surgery, there was no new stone formation and the patient had a stable creatinine level of 115 mg/dl and eGFR of 43 ml/min/1.73 m2. The entire treatment process was completed in 4 months.
Conclusion
There is now level 1 evidence from a meta-analysis of randomized controlled trials [6] to support the routine use of DJ stents in kidney transplantation, but it is important to be aware of the associated problems. These include urinary tract infections, lower urinary tract symptoms, and (most significantly) forgotten stents with resultant encrustations. To our knowledge, this case report of retained stent in a transplant kidney is of the longest duration in the literature. There is likely underreporting of this condition. Retained DJ stents have most commonly been reported in native kidneys after stone surgery, and various complications have been noted including encrustation [7], spontaneous fragmentation [8], and fistula formation [9]. Successful management in native kidneys has been reported using endourological techniques. All previously reported cases have involved treatment with a combination of percutaneous nephrolithotomy (PCNL) and retrograde endoscopic removal with or without the use of a laser [10–16]. We report the first use of the combination of ESWL and ureteroscopic laser treatment for the forgotten stent in the transplant kidney. AlWu /Lim /Deng /Heng /Tiong
Color version available online
b
a
ESWL probe over left anterior aspect of abdomen
PCN tube
PCN tube over right paraumbilical region
Fig. 2. a Position of the PCN tube over the right paraumbilical region to solitary transplanted kidney. b The ESWL
probe was placed over the left anterior aspect of the abdomen facing the transplanted kidney in view of the position of both the PCN tube and kidney.
b
a
Fig. 3. a X-ray KUB done after the second session of ESWL. The PCN tube and DJ stent are visualized with small fragments of calculi still seen around the DJ stent; urine was clear. b X-ray KUB after insertion of the new DJ stent. The PCN tube had been removed, the new DJ stent was visualized, and no ureteric calculi were noted. The DJ stent was subsequently removed 2 weeks later.
though our technique required more than one stepwise treatment sessions, it was a much less invasive approach to the treatment of the retained stent. PCNL often requires the surgical dilatation of the percutaneous puncture track from the skin to the kidney and carries with it the risk of perforation, infection, and bleeding even in native kidneys [17]. Our case demonstrated that despite significant stone burden, the superficial location of the transplant kidney facilitates effective ESWL with minimal complications. It should therefore be presented as a suitable alternative treatment option.
For a transplanted kidney, special considerations have to be taken in the management of an encrusted DJ stent. Firstly, the PCN tube placed prior to any intervention facilitated drainage as a steinstrasse was likely to develop after ESWL due to the high stone burden. This precaution is similar to that taken for the treatment of calculi in a solitary kidney. Secondly, ESWL to the transplanted kidney and ureter was performed over the anterior aspect of the abdomen from the left side. As the kidney is superficial, treatment was limited to 3,200 shocks and titrated to a power of 2 kJ. A higher power more than necessary may
Managing Forgotten Stents in Transplant Kidneys
Urol Int 2014;92:373–376 DOI: 10.1159/000354936
375
increase risk of hematoma to the kidney or fragmentation of the DJ stent. These experiences were adapted from reported experiences of ESWL to transplanted kidney stones [18]. Lastly, although ureteroscopy is expected to be difficult in the transplanted ureter due to its position over the dome of the bladder, we did not find it to be the case as the stent resulted in significant dilation of the ureterovesical junction. Although this case showed that successful removal of the forgotten DJ stent without significant deleterious effect to the transplanted kidney was possible, the best treatment is still prevention. The current protocol we use is a computerized registry maintained by our transplant coordinators. All patients are informed of their stent placements. A Cochrane analysis [19] of seven RCTs has shown that the incidence of major urological complications after renal transplantation was significantly reduced (RR = 0.24, 95% CI 0.07–0.77, p = 0.02, NNT = 13) by universal prophylactic stenting. Although the incidence of urinary tract infections was more common in stented patients, with the administration of antibiotics, the inci-
dence became equivalent between the two groups. With this recommendation, it can be seen that the benefit of stenting outweighs the risks of complications. To overcome the problem of ‘forgotten’ stents, we suggest that the transplant recipients be closely followed up in the renal transplant clinic. Other than reducing complications, ureteral stenting has also been shown to be a protective factor for surgical revision after renal transplantation [20]. To decrease stent-related symptoms, the choice of stent length must also be optimal [21]. The study by Kawahara et al. [21] showed that it is appropriate to choose a loop type stent that is the same or 1 cm less than the length of ureter. All of the above should prompt a transplant surgeon to insert a stent during renal transplantation despite the risks as described.
Disclosure Statement The authors report no conflicts of interest.
References 1 Andrés A: Indications and contraindications of living donor kidney transplantation (in Spanish). Nefrologia 2010;30(suppl 2):30–38. 2 Rajaian S, Kumar S: There is no need to stent the ureterovesical anastomosis in live renal transplants. Indian J Urol 2010;26:454–456. 3 Minnee RC, Surachno S, Kox C, ten Berge IJ, Aronson DC, Idu MM: Is a selective splinted ureterocystostomy protocol feasible in renal transplantation. An analysis of 475 renal transplantations? Transpl Int 2006; 19: 558– 562. 4 Blanchet P, Hammoudi Y, Eschwege P, Droupy S, Bensadoun H, Hiesse C, et al: Urinary complications after kidney transplantation can be reduced. Transplant Proc 2000;32: 2769. 5 Sansalone CV, Malone G, Aseni P, Mangoni I, Soldano S, Minetti E, et al: Advantages of short time ureteric stenting for the prevention of urological complications in kidney transplantation: an 18-year experience. Transplant Proc 2005;37:2511–2515. 6 Mangus RS, Haag BW: Stented versus nonstented extravesical utereroneocystostomy in renal transplantation: a metaanalysis. Am J Transplant 2004;4:1889–1896. 7 Gallego D, Persiva JB, Mestre MP, Martin IJP, Aguado JM, Perello CM, Argente VG, Sanz MB, De Francia Valero JA: Double J catheter migrated to the bladder and encrusted. Case report and bibliographic review. Arch Esp Urol 2012;65:251–255.
376
Urol Int 2014;92:373–376 DOI: 10.1159/000354936
8 Sengottayan VK, Vasudeva P, Goel A, Dalela D: Incontinence due to fragmentation of forgotten ureteral stent: an unusual complication. Urology 2009;74:1230–1231. 9 Lee SW, Kim JH: Renocolic fistula secondary to a perinephric abscess: a late complication of a forgotten double J stent. J Korean Med Sci 2009;24:960–962. 10 Giustacchini M, Tazza L, Raguso M, Albino G: Ureteral stent forgotten in renal transplanted patient. Its removal. Arch Ital Urol Androl 1999;71:223–224. 11 Bhuva S, Kennish SJ, Wah TM: Forgotten indwelling stent in a transplanted kidney: a case report. Cases J 2009;2:27. 12 Veltman Y, Shields JM, Ciancio G, Bird VG: Percutaneous nephrolithotomy and cystolithalapaxy for a ‘forgotten’ stent in a transplant kidney: case report and literature review. Clin Transplant 2010;24:112–117. 13 Henderson A, Gujral S, Mitchelmore AE, Keeley FX Jr: Endo-urological techniques in the management of stent complications in the renal transplant patient. Transpl Int 2002;15: 664–666. 14 Yenicesu M, Aydur E, Yildirim I, Yenicesu F, Seckin B: A long-forgotten indwelling ureteral stent in a renal transplant patient. Transplant Proc 2004;36:1395–1397. 15 Gedroyc WM, MacIver D, Joyce MR, Saxton HM: Percutaneous stone and stent removal from renal transplants. Clin Radiol 1989; 40: 174–177.
16 Romanowsky I, Lupu L, Lismer L, Babaev L, Neulander EZ, Kaneti J: Percutaneous nephrolithotomy in transplanted kidney – forgotten stent with complete staghorn and large bladder stone. Case report. Transpl Int 2005; 17:877–879. 17 de la Rosette JJ, Zuazu JR, Tsakiris P, Elsakka AM, Zudaire JJ, Laguna MP, et al: Prognostic factors and percutaneous nephrolithotomy morbidity: a multivariate analysis of a contemporary series using the Clavien classification. J Urol 2008;180:2489–2493. 18 Rhoderick TM, Yang HC, Escobar FS, Belis JA, Gifford RR: Extracorporeal shock wave lithotripsy in the renal transplant patient: a case report and review of literature. Clin Transplant 1992;6:375–378. 19 Wilson CH, Bhatti AA, Rix DA, Manas DM: Routine intraoperative ureteric stenting for kidney transplant recipients. Cochrane Database Syst Rev 2005;4:CD004925. 20 Alberts VP, Minnee RC, Bemelman FJ, van Donselaar-van der Pant KA, Laguna Pes P, Idu MM: Ureteral reconstruction after renal transplantation: clinical outcome and risk factors. Urol Int 2012;88:333–337. 21 Kawahara T, Ito H, Terao H, Yoshida M, Ogawa T, Uemura H, Kubota Y, Matsuzaki J: Choosing an appropriate length of loop type ureteral stent using direct ureteral length measurement. Urol Int 2012;88:48–53.
Wu /Lim /Deng /Heng /Tiong
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
Urologia Internationalis
Received: May 29, 2013 Accepted after revision: August 8, 2013 Published online: January 23, 2014
Urol Int 2014;92:373–376 DOI: 10.1159/000354936
Successful Endourological Management of the ‘Forgotten’ Stent in a Transplanted Kidney Fiona Mei Wen Wu a Mark Lim b Zhaolong Deng b Chin Tiong Heng a Ho Yee Tiong a a
Department of Urology, National University Health System, and b Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Key Words Forgotten stent · Renal transplantation · Endourological techniques
Abstract Background: Ureteric stents are used to prevent urological complications like ureteric fistulas and obstruction in kidney transplants. Despite its advantages, complications arising from delayed removal of a double J (DJ) stent include urinary tract infections, stone encrustation, and migration of the DJ stent [Sansalone et al.: Transplant Proc 2005;37:2511–2515]. Encrustation of the stent makes removal difficult and risks injury to the transplanted kidney. Case Presentation: We report a case of retained DJ stent for 19 years presenting with recurrent urinary tract infections. A radiograph revealed a retained ureteric stent extending from the right iliac fossa transplant kidney to the urinary bladder with multiple foci of large calcification along its length. Two sessions of extracorporeal shockwave lithotripsy along the stent were performed after a percutaneous nephrostomy tube had been placed in the transplanted kidney. Subsequently, the retained DJ stent was removed endoscopically after laser lithotripsy to remnant calcifications. Remnant stone fragments were removed with another session of ureteroscopy and la-
© 2014 S. Karger AG, Basel 0042–1138/14/0923–0373$39.50/0 E-Mail [email protected] www.karger.com/uin
ser lithotripsy. The patient achieved complete stent and stone clearance with a functioning graft. Conclusion: This case illustrates that significant stone encrustation of the retained stent in a transplanted kidney can be treated successfully with a combination of endourological techniques. © 2014 S. Karger AG, Basel
Introduction
When patients are faced with end-stage renal failure, the best therapy is kidney transplantation [1]. The majority of urological complications after transplantation arise from a compromised ureterovesical anastomosis, which include urine leakage or ureteric obstruction [2]. The common causes of urinary leakage are ureteric ischemia and suture failure [3]. Ureteric strictures may also be caused by intraluminal factors, such as calculi, blood clots, or extraluminal factors such as compression of blood and lymphatic fluid collections [4]. Double J (DJ) stents have been shown to reduce early postoperative major urological complications. Despite their advantages, complications arising from delayed removal of DJ stents include urinary tract infections, stone encrustation, and migration of the DJ stent [5]. Encrustation of the stent Ho Yee Tiong, MD, FAMS (Urology) National University Health System, Department of Urology 5 Lower Kent Ridge Road Singapore 119074 (Singapore) E-Mail cfsthy @ nus.edu.sg
makes removal difficult and risks injury to the transplanted kidney. We report a case of successful removal of a ‘forgotten stent’ 19 years after transplant using multimodal endourological techniques.
Case Presentation A 54-year-old female patient with end-stage renal disease underwent a living-related renal transplantation in 1992 (the patient has given her consent for this case report to be published). A DJ stent was inserted and good perfusion of donor kidney was noted intraoperatively. The patient recovered with no early postoperative complications and was discharged well. The standard protocol of stent removal 2 weeks after the surgery was, unfortunately, not performed. On subsequent regular follow-up the patient had stable kidney function. In 2010, she had several hospital admissions for recurrent urinary tract infections. Radiographs of the abdomen [kidney-ureter-bladder (KUB)] revealed a calcified and encrusted ureteric stent extending from the right iliac fossa transplanted kidney to the urinary bladder (fig. 1). Ultrasound of the kidneys revealed mild hydronephrosis with the DJ stent in situ. Her creatinine level was 122 mg/dl with an eGFR of 35 ml/min/1.73 m2 (MDRD equation). Treatment options were discussed with the patient and the decision was made to use multimodal endourological approaches to clear the stent and its associated calculi. A percutaneous nephrostomy (PCN) with an 8-Fr nephrostomy catheter was inserted to facilitate transplanted kidney drainage before subsequent treatments. The patient underwent two extracorporeal shockwave lithotripsy (ESWL) sessions in a supine position to clear the extensive calcifications along the stent. Shockwaves (Modularis Variostar Lithotripter; Siemens, Germany) were delivered over the table anteriorly over the patient’s right iliac fossa, but directed from the patient’s left side in view of the PCN tube on the right side of patient (fig. 2). As the kidney transplant is relatively superficial compared to native kidneys, treatment was limited to 3,200 shocks and a maximum power of 2 kJ for each session. The distal ureter segment of the stent was targeted initially and the shockwaves progressed proximally after achieving good fragmentation. The bladder portion of the stent was not targeted. Figure 3a shows the results after two sessions of ESWL. After achieving good fragmentation, the patient underwent cystoscopy and removal of the DJ stent under general anesthesia. Calcification of the stent within the bladder was fragmented with cystoscopic lithotrite and then withdrawn intact without breakage under direct vision and fluoroscopy guidance. Ureteroscopy of the transplanted ureter and holmium laser lithotripsy was then performed to clear all remnant calculi. The transplanted ureter was dilated, probably due to the retained stent, and was easy to cannulate with the semirigid ureteroscope (Karl Storz, Germany), despite a Lich-Gregor anastomosis of the ureter to the bladder dome. The PCN tube allowed free drainage intraoperatively and prevented high pressure generated within in the kidney during ureteroscopy. After two sessions of ureteroscopy and laser lithotripsy, all stone fragments were removed with a Nitinol tipless basket and a new DJ stent was placed (fig. 3b). This allowed the ureteric edema to resolve and the PCN tube to be removed.
374
Urol Int 2014;92:373–376 DOI: 10.1159/000354936
Fig. 1. X-ray KUB taken 19 years after DJ stent insertion. A right
DJ stent is visualized with foci calculi seen along its length.
The PCN tube and DJ stent were sequentially removed on day 2 and 2 weeks after surgery, respectively, after ensuring complete radiographic stone clearance. One year after surgery, there was no new stone formation and the patient had a stable creatinine level of 115 mg/dl and eGFR of 43 ml/min/1.73 m2. The entire treatment process was completed in 4 months.
Conclusion
There is now level 1 evidence from a meta-analysis of randomized controlled trials [6] to support the routine use of DJ stents in kidney transplantation, but it is important to be aware of the associated problems. These include urinary tract infections, lower urinary tract symptoms, and (most significantly) forgotten stents with resultant encrustations. To our knowledge, this case report of retained stent in a transplant kidney is of the longest duration in the literature. There is likely underreporting of this condition. Retained DJ stents have most commonly been reported in native kidneys after stone surgery, and various complications have been noted including encrustation [7], spontaneous fragmentation [8], and fistula formation [9]. Successful management in native kidneys has been reported using endourological techniques. All previously reported cases have involved treatment with a combination of percutaneous nephrolithotomy (PCNL) and retrograde endoscopic removal with or without the use of a laser [10–16]. We report the first use of the combination of ESWL and ureteroscopic laser treatment for the forgotten stent in the transplant kidney. AlWu /Lim /Deng /Heng /Tiong
Color version available online
b
a
ESWL probe over left anterior aspect of abdomen
PCN tube
PCN tube over right paraumbilical region
Fig. 2. a Position of the PCN tube over the right paraumbilical region to solitary transplanted kidney. b The ESWL
probe was placed over the left anterior aspect of the abdomen facing the transplanted kidney in view of the position of both the PCN tube and kidney.
b
a
Fig. 3. a X-ray KUB done after the second session of ESWL. The PCN tube and DJ stent are visualized with small fragments of calculi still seen around the DJ stent; urine was clear. b X-ray KUB after insertion of the new DJ stent. The PCN tube had been removed, the new DJ stent was visualized, and no ureteric calculi were noted. The DJ stent was subsequently removed 2 weeks later.
though our technique required more than one stepwise treatment sessions, it was a much less invasive approach to the treatment of the retained stent. PCNL often requires the surgical dilatation of the percutaneous puncture track from the skin to the kidney and carries with it the risk of perforation, infection, and bleeding even in native kidneys [17]. Our case demonstrated that despite significant stone burden, the superficial location of the transplant kidney facilitates effective ESWL with minimal complications. It should therefore be presented as a suitable alternative treatment option.
For a transplanted kidney, special considerations have to be taken in the management of an encrusted DJ stent. Firstly, the PCN tube placed prior to any intervention facilitated drainage as a steinstrasse was likely to develop after ESWL due to the high stone burden. This precaution is similar to that taken for the treatment of calculi in a solitary kidney. Secondly, ESWL to the transplanted kidney and ureter was performed over the anterior aspect of the abdomen from the left side. As the kidney is superficial, treatment was limited to 3,200 shocks and titrated to a power of 2 kJ. A higher power more than necessary may
Managing Forgotten Stents in Transplant Kidneys
Urol Int 2014;92:373–376 DOI: 10.1159/000354936
375
increase risk of hematoma to the kidney or fragmentation of the DJ stent. These experiences were adapted from reported experiences of ESWL to transplanted kidney stones [18]. Lastly, although ureteroscopy is expected to be difficult in the transplanted ureter due to its position over the dome of the bladder, we did not find it to be the case as the stent resulted in significant dilation of the ureterovesical junction. Although this case showed that successful removal of the forgotten DJ stent without significant deleterious effect to the transplanted kidney was possible, the best treatment is still prevention. The current protocol we use is a computerized registry maintained by our transplant coordinators. All patients are informed of their stent placements. A Cochrane analysis [19] of seven RCTs has shown that the incidence of major urological complications after renal transplantation was significantly reduced (RR = 0.24, 95% CI 0.07–0.77, p = 0.02, NNT = 13) by universal prophylactic stenting. Although the incidence of urinary tract infections was more common in stented patients, with the administration of antibiotics, the inci-
dence became equivalent between the two groups. With this recommendation, it can be seen that the benefit of stenting outweighs the risks of complications. To overcome the problem of ‘forgotten’ stents, we suggest that the transplant recipients be closely followed up in the renal transplant clinic. Other than reducing complications, ureteral stenting has also been shown to be a protective factor for surgical revision after renal transplantation [20]. To decrease stent-related symptoms, the choice of stent length must also be optimal [21]. The study by Kawahara et al. [21] showed that it is appropriate to choose a loop type stent that is the same or 1 cm less than the length of ureter. All of the above should prompt a transplant surgeon to insert a stent during renal transplantation despite the risks as described.
Disclosure Statement The authors report no conflicts of interest.
References 1 Andrés A: Indications and contraindications of living donor kidney transplantation (in Spanish). Nefrologia 2010;30(suppl 2):30–38. 2 Rajaian S, Kumar S: There is no need to stent the ureterovesical anastomosis in live renal transplants. Indian J Urol 2010;26:454–456. 3 Minnee RC, Surachno S, Kox C, ten Berge IJ, Aronson DC, Idu MM: Is a selective splinted ureterocystostomy protocol feasible in renal transplantation. An analysis of 475 renal transplantations? Transpl Int 2006; 19: 558– 562. 4 Blanchet P, Hammoudi Y, Eschwege P, Droupy S, Bensadoun H, Hiesse C, et al: Urinary complications after kidney transplantation can be reduced. Transplant Proc 2000;32: 2769. 5 Sansalone CV, Malone G, Aseni P, Mangoni I, Soldano S, Minetti E, et al: Advantages of short time ureteric stenting for the prevention of urological complications in kidney transplantation: an 18-year experience. Transplant Proc 2005;37:2511–2515. 6 Mangus RS, Haag BW: Stented versus nonstented extravesical utereroneocystostomy in renal transplantation: a metaanalysis. Am J Transplant 2004;4:1889–1896. 7 Gallego D, Persiva JB, Mestre MP, Martin IJP, Aguado JM, Perello CM, Argente VG, Sanz MB, De Francia Valero JA: Double J catheter migrated to the bladder and encrusted. Case report and bibliographic review. Arch Esp Urol 2012;65:251–255.
376
Urol Int 2014;92:373–376 DOI: 10.1159/000354936
8 Sengottayan VK, Vasudeva P, Goel A, Dalela D: Incontinence due to fragmentation of forgotten ureteral stent: an unusual complication. Urology 2009;74:1230–1231. 9 Lee SW, Kim JH: Renocolic fistula secondary to a perinephric abscess: a late complication of a forgotten double J stent. J Korean Med Sci 2009;24:960–962. 10 Giustacchini M, Tazza L, Raguso M, Albino G: Ureteral stent forgotten in renal transplanted patient. Its removal. Arch Ital Urol Androl 1999;71:223–224. 11 Bhuva S, Kennish SJ, Wah TM: Forgotten indwelling stent in a transplanted kidney: a case report. Cases J 2009;2:27. 12 Veltman Y, Shields JM, Ciancio G, Bird VG: Percutaneous nephrolithotomy and cystolithalapaxy for a ‘forgotten’ stent in a transplant kidney: case report and literature review. Clin Transplant 2010;24:112–117. 13 Henderson A, Gujral S, Mitchelmore AE, Keeley FX Jr: Endo-urological techniques in the management of stent complications in the renal transplant patient. Transpl Int 2002;15: 664–666. 14 Yenicesu M, Aydur E, Yildirim I, Yenicesu F, Seckin B: A long-forgotten indwelling ureteral stent in a renal transplant patient. Transplant Proc 2004;36:1395–1397. 15 Gedroyc WM, MacIver D, Joyce MR, Saxton HM: Percutaneous stone and stent removal from renal transplants. Clin Radiol 1989; 40: 174–177.
16 Romanowsky I, Lupu L, Lismer L, Babaev L, Neulander EZ, Kaneti J: Percutaneous nephrolithotomy in transplanted kidney – forgotten stent with complete staghorn and large bladder stone. Case report. Transpl Int 2005; 17:877–879. 17 de la Rosette JJ, Zuazu JR, Tsakiris P, Elsakka AM, Zudaire JJ, Laguna MP, et al: Prognostic factors and percutaneous nephrolithotomy morbidity: a multivariate analysis of a contemporary series using the Clavien classification. J Urol 2008;180:2489–2493. 18 Rhoderick TM, Yang HC, Escobar FS, Belis JA, Gifford RR: Extracorporeal shock wave lithotripsy in the renal transplant patient: a case report and review of literature. Clin Transplant 1992;6:375–378. 19 Wilson CH, Bhatti AA, Rix DA, Manas DM: Routine intraoperative ureteric stenting for kidney transplant recipients. Cochrane Database Syst Rev 2005;4:CD004925. 20 Alberts VP, Minnee RC, Bemelman FJ, van Donselaar-van der Pant KA, Laguna Pes P, Idu MM: Ureteral reconstruction after renal transplantation: clinical outcome and risk factors. Urol Int 2012;88:333–337. 21 Kawahara T, Ito H, Terao H, Yoshida M, Ogawa T, Uemura H, Kubota Y, Matsuzaki J: Choosing an appropriate length of loop type ureteral stent using direct ureteral length measurement. Urol Int 2012;88:48–53.
Wu /Lim /Deng /Heng /Tiong
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
