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Table of Content - Volume 19 Issue 2- August 2021
Vidyadhar P Kelkar1*, Aashish Ramesh Chavan2, Boda Raju3, Sachin Kanakapur4
1Associate Professor, 2Assistant Professor, 3,4Junior Resident, Department of General Surgery, Dr Shankarrao Chavan Government Medical College Vishnupuri, Nanded, Maharashtra. INDIA. Email: drvidu24@gmail.com, aashish.chavan85@gmail.com, bodaraju2063@gmail.com, sachinkanakapur16@gmail.com
Abstract Background: Urolithiasis is one of the major causes of morbidity in our society as our country is located near to equatorial distribution of stone disease Indwelling ureteral stents provide free drainage from the kidney to the bladder, reduce or eliminate urinary leakage and provide ureteral stenting. The present study was designed to observe indications, difficulties and complications of indwelling double J ureteral stenting. Material and Methods: Present study was single-center, prospective, observational study, conducted in patients undergoing DJ stenting URS/ESWL (stone size > 2cm), willing to participate in study. The data collected was entered into Microsoft excel and analyzed. Statistical analysis was done using descriptive statistics. Results: In the present study, we assessed prospectively the effectiveness of DJ stent insertion for treatment of ureteral stones in 100.patients. Gender distribution in the current study was 65% male and 35 % female. 65 % patients were between the age 10 to 40 years; 20 patients have lower ureteric calculi, 37 patient having mid ureteric calculi and 8 patients having upper ureteric calculi. In current study out of 100 patients 32 patients have stone between the range of 6-10 mm, 42 patients have stone size range between 11-16 mm and only 26 patient have stone size more than 16 mm. 32 patients having mid ureteric calculi in which 30 patients DJ stent procedure successfully completed, remaining 2 patients had ureteric stricture treated with URSL. 27 patients having lower ureteric calculi in which 25 patients DJ stent procedure successfully completed, remaining 2 patient had ureteric stricture treated with ESWL followed by cystoscopy removal. 8 patients having bilateral ureteric calculi in which 6 patients DJ stent procedure successfully completed, remaining 2 patient have impacted stone treated with URSL with PCNL. 100% success rate in DJ stent insertion in patients with stone size 11-16mm followed by in 93% with stone size 6-10mm and in 76% with stone size >16mm. Conclusion: Most of the ureteral DJ stent related complications can be managed by surgical procedures hence they should be removed as soon as their purpose solves. The proper follow up from patients can help to early identification of post insertion complications of DJ stent and timely management of them. Keywords: DJ stent, cystoscopy, Urolithiasis, ureteric calculi
INTRODUCTION Urolithiasis is one of the major causes of morbidity in our society as our country is located near to equatorial distribution of stone disease. 1 Such stones can be a source of pain and lead to hydronephrosis or urinary tract infections, which can outcome in loss of renal function.2 Management of urolithiasis has changed dramatically since the advent of different endoscopes in urology. Among all of the above, stone fragmentation with ESWL and retrograde Ureteroscopy (URS) with lithoclast are considered the most acceptable minimal invasive procedures.3 Ureterolithotripsy is an endoscopic procedure to fragment and remove ureteral stone which cannot be eliminated on their own from the urinary system. The procedure proceeds 30-60 minutes dependent on the size of the stones, site of stone that is whether unilateral or bilateral, location of stone, numbers and surgeon expertise. Intraoperative problems were particularly related with proximal- ureteral calculi.4 Indwelling ureteral stents provide free drainage from the kidney to the bladder, reduce or eliminate urinary leakage and provide ureteral stenting.5 The use of the indwelling stents for internal drainage of the upper urinary tract has now become an essential part of the urologist's armamentarium.6 JJ or double J stents have proved their efficacy in relieving and preventing upper urinary obstruction in the various urological conditions. The present study was designed to observe indications, difficulties and complications of indwelling double J ureteral stenting.
MATERIAL AND METHODS Present study was single-center, prospective, observational study, conducted in Department of General Surgery, Dr Shankarrao Chavan Government Medical College Vishnupuri, Nanded, Maharashtra, India. Study duration was of 2 years (July 2018 to June 2019). Study was approved by institutional ethical committee. Inclusion criteria: All patients undergoing DJ stenting URS/ESWL (stone size > 2cm), willing to participate in study. Exclusion criteria
Patients were evaluated by taking a detailed history followed by a complete clinical examination. Patients were evaluated on Hematological investigations (Complete blood count, Liver function test, Kidney function test, Serum electrolytes, Serum proteins, Serum calcium, Blood group, HIV HbsAg) and Radiological investigations (Ultrasonography of abdomen and pelvis, Conventional IVU, X-ray KUB, CT IVP). After pre-anaesthetic checkup patients were posted for ureteroscopy and DJ stent insertion. An informed consent and consent for stenting was obtained from the patient after clearly explaining about the procedure and the implications. Indication for stent placement in each case was noted. Patients are given a questionnaire to assess the baseline symptoms using the IPSS questionnaire along with the quality of life component of the chart as prescribed by AUA guidelines. A post-operative imaging is done to confirm the position of the stent. Then the patients are discharged on the 2nd /3rd post-operative day if there is no significant event. Various parameters such as clearance of the stone, patient compliance, hospital stay, time required to do the procedure, any intra operative complications, post-operative complications such as hemorrhage trauma to the ureter retention of urine hematuria stricture were noted. Stone clearance and position of DJ stent were confirmed by postoperative X KUB or USG. The data collected was entered into Microsoft excel and analyzed. Statistical analysis was done using descriptive statistics.
RESULTS In the present study, we assessed prospectively the effectiveness of DJ stent insertion for treatment of ureteral stones in 100.patients. Gender distribution in the current study was 65% male and 35 % female. Male to female ratio in this study was 1.8:1. Pain (100%), associated vomiting (50%), fever (30%) and hematuria (32 %) were major complaints noted. 6fr ureteroscope used in 40 cases and 7.5 fr used in 60 cases. 80 % patients have normal KFT profile while 90 % patients have normal calcium levels.
Table 1: General characteristics
The optimal choice of treatment depends on various factors, including stone size, composition and location, clinical factors, equipment availability, and surgeon capability. All patients were operated under spinal anaeshetia. Second time anesthetic exposure is required in 2% cases as in that case stone fragmentation was incomplete. In present study 60 minute time was utilized for the surgery of 16 female and 20 males. In current study, 52 patients including 37 male and 15 females was stayed for less than 3 days while 48 patients of 29 male and 19 female gender stayed for more than 3 days.
Table 2: Operative characteristics
In current study out of 100 patients 32 patients have stone between the range of 6-10 mm, 42 patients have stone size range between 11-16 mm and only 26 patient have stone size more than 16 mm.
Table 3: Distribution of patients according to Size of Stone
Size between 6-10 mm stones takes 50 minutes for surgery, while 11- 16 mm stones takes 45-90 min and more than 16mm stones takes 60-90 minutes for surgery.
Table 4: Distribution according to Size of Stone and operative time
In current study intraoperative complications occurred are stone migration in patient (0%), incomplete fragmentation occurred in 10% patient, 21% patient have mucosal injury and in 20% patient bleeding and 1% of perforation occurs which was overcome by normal saline irrigation during operation and DJ stent insertion. Postoperatively out of 100 patients 40 patients experienced Pain [40%]. About 10 patients have fever in postoperative period [10%] and hematuria is seen in 48 patients [48%]. 2 patients have reported ureteric stricture formation. Table 5: Operative complications
100% success rate in DJ stent insertion in patients with stone size 11-16mm followed by in 93% with stone size 6-10mm and in 76% with stone size >16mm.
Table 6: Success rate in relation to Stone Size
Out of 100 patients 3 patients having stent migrations, 7 patients having stent blockage for this cystoscopic removal of stent. Ureteroscopic removal of DJ stent done for stent fracture in 1 patient and 5 encrustation. PCNL done for 4 patient having encrustation. URSL + PCNL and URSL + Open cystolithotomy done in 1 patient each having Encrustation. ESWL followed by cystoscopic removal in 2 patients having fragmentation. Early removal of DJ stent within 2-3 weeks had less complications.
Table 7: Complications of DJ Stent and their management
DISCUSSION Ureteral stents plays an essential role in various endourologic and open surgical procedures like relief of upper urinary tract obstruction, ureteral injury and various urinary reconstructive procedures. Extensive uses and multiple indications in urology, DJ stents are prone for complications like fragmentation, stone encrustation, recurrent urinary tract infection and loss of renal functions.7,8 In the current study there were 65% male and 35 % female. Male to female ratio in this study was 1.8:1. In study by Sandeep Gupta et al.9 65.2% patients were males and 34.7% were females, mean age of patients was 40.3±13.4 years. Similar findings were noted in present study. Stent discomfort affects over 80% of patients and can vary from one individual to another in an idiosyncratic manner.10,11 The symptoms related to ureteral stents are irritative voiding symptoms including frequency (50-60%), urgency (57-60%), dysuria (30-40%), incomplete emptying (76%), flank (20-30%) and suprapubic pain (30%), incontinence, and hematuria (20-25%) are included.10,11 Frequency is caused by the bladder coil which acts as a mechanical stimulus. Together with urgency, it bothers significant proportion of patients (60%). Daytime frequency differentiated by the lack of concomitant nocturia suggests that mechanical stimulation is related to physical activity and/or awareness of this stimulation during the day, which may not be felt during the night. Recently, investigators confirmed that when a stent gets displaced with physical activity that may cause stent discomfort.12,13 Urgency is found to be associated directly to the presence of the stent, which may also unveil or exacerbate underlying pre-existing subclinical detrusor overactivity.14 Flank pain seems to be caused as a result of reflux of urine towards the kidney raises the intra-pelvic pressure that thereby produces the pain. The pain is not stimulated by the position of the proximal coil that is in the upper calyx or in the renal pelvis.15 Suprapubic pain may be due to a local bladder irritation caused by the distal coil or it can also be associated complications such as encrustation or infection. Hematuria may occur due to the surgical procedure done for the existing disease or due to the stent placement itself .Incontinence occurs concomitant with episodes of urgency, or may be due to stent migration crossing the bladder neck into the proximal urethra hence bypassing the urethral sphincteric mechanism of continence.16 Moreover all these symptoms can be as a consequence of associated stent morbidities like urinary tract infection and encrustation, so their presence should always be ruled out by urinalysis and definitive imaging.17 In the study conducted by Gupta S. et. al.9, the common early complications encountered with these DJ stents are flank pain, hematuria, lower urinary tract symptoms predominantly in the form of urgency frequency. The late complications are encrustation and blockage, spontaneous fragmentation, stent migration, ureteroarterial and ureterointestinal fistulae (especially with rigid stents) and late complications are somewhat similar to this present study. Similar findings were noted in present study. In our study Encrustation (12.75%) was most common complications occurred due to DJ stent insertion which is similar to study conducted by Gupta S.9 but percentage of occurrence is high in Gupta’s study (47.8%). This difference might be due to Gupta S. conducted study in patients with long standing stent insertion. Mohan-Pillai K et. Al18 stated in his study that either retrograde ureteroscopy alone or a combination of ureteroscopy and PCNL procedures were used for Encrustation. Kumar M et al. 19 mentioned in his 2 case report studies that stone fragmentation was treated in case-1 by pyelolithotomy and removal of the stent fragment and in case-2 by percutaneous nephrostomy. Stent Blockage (8.75%) was another common complication occurred due to DJ stent insertion. This followed by Stent Migration (3.75%). The stent migration is another well-known complication observed in study conducted by Gupta S.9 and Damiano R20 but proportion of occurrence is higher than our study. (13% and 9.5% to 6.84%). In our study fragmentation was also seen in 2.5%. Stent Fracture (1.25%) is also observed in our study which is in similar range of study conducted by Damiano R et al.20 (1.3% to 4.79%). In current study Cystoscopic removal procedure was used for Stent Blockage (8.75%) and Stent Migration (3.75%) whereas a study conducted by Gupta S et al.9 All this procedure was used in 34.7% patients. An appropriate stent length is critical for the prevention of irritative voiding symptoms and malpositioning of the stent during insertion.11 Stent length may be based on operator experience, the measured length of the ureter as determined from imaging studies, the patient’s body habitus, or use of the bent guide wire technique. 3,4
CONCLUSION Ureteric stents are most important intervention for many urological surgeries however inappropriate follow up from patient or urologist may lead to severe complications and medicolegal issues. Most of the ureteral DJ stent related complications can be managed by surgical procedures hence they should be removed as soon as their purpose solves. The proper follow up from patients can help to early identification of post insertion complications of DJ stent and timely management of them.
REFERENCES
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