Clinical challenge

Prof. Oliver Hakenberg Section editor Rostock (DE)

Oliver.Hakenberg@ med.uni-rostock.de The Clinical challenge section presents interesting or difficult clinical problems which in a subsequent issue of EUT will be discussed by experts from different European countries as to how they would manage the problem.

Readers are encouraged to provide interesting and challenging cases for discussion at h.lurvink@uroweb.org

Case study No. 70

This 61-year-old woman was referred with an incrustated ureteral stent on the left side for further management (fig.1). The stent had been in situ for almost four years and had been inserted because of symptomatic lower calyx stones.

The patient suffers from severe cardiac insufficiency (NYHA 3-4) due to coronary artery disease, rheumatoid arthritis with prednisolone medication and COPD (Gold 4) requiring permanent oxygen treatment. For those reasons the symptoms of left stone disease were at the time treated just by stent insertion.

Figure 1 Somehow, the stent was “forgotten”. A urologist now tried to take the stent out but was unsuccessful. Therefore the patient was referred to us.

Discussion point • Which management and treatment is advisable?

Case provided by Oliver Hakenberg, Rostock, Germany. email: oliver.hakenberg@ med.uni-rostock.de

As minimally invasive as possible

Comments by Dr. Mariela Corrales Paris (FR)

Dr. Alba Sierra Del Rio Paris (FR)

Prof. Olivier Traxer Paris (FR)

Encrusted stents are, without a doubt, every urologist’s nightmare. One of the causes of this undesired scenario is when stent removal has been missed for months or even years, as it was in this patient’s case. So, how to deal with this problem? There is a wide range of treatment options. For instance, some may say that perhaps the percutaneous access is the way to go, others may say that it could be treated by flexible and/or semi-rigid ureteroscopy and finally, there is the group that will select a combined approach, using percutaneous access and ureteroscopy to treat simultaneously the encrustations of the renal and ureteral segments of the stent.

In this case, all these approaches are feasible and could work. However, we need to remember two crucial points. The first one is that we are dealing with a fragile patient with several comorbidities. It is of utmost importance to take into account the patient’s condition before choosing the treatment that is best suited. The second one, with the improvements in the ureteroscopy field and the experience gained in flexible ureteroscopy, cases like this could be treated by ureteroscopy alone.

That being said, for this patient, we recommend a session of flexible ureteroscopy by using the laser to cut the stent itself and to fragment the encrustations on the stent. Nowadays, we have two different laser technologies on the market, the thulium fiber laser (TFL) and the holmium yttrium aluminum garnet (Ho:YAG) laser; both are safe and effective. The TFL brings a more precise cut, when compared to the Ho:YAG laser and would be the laser of choice, if available. After ablating the stent, a control ureteropyelography must be performed to reveal any contrast media extravasation and a control ureteroscopy also needs to be done to show the integrity of the ureteral mucosa.

Additionally, it seems that only the retrograde approach does not increase the risk of severe complications when compared to combined procedures. Nonetheless, as encrusted stents are usually covered by biofilms and have resistant bacterial colonisation, all precautions should be taken against urinary sepsis.

References

1. Thomas A, Cloutier J, Villa L, Letendre J, Ploumidis A,

Traxer O. Prospective Analysis of a Complete

Retrograde Ureteroscopic Technique with Holmium

Laser Stent Cutting for Management of Encrusted

Ureteral Stents. J Endourol. 2017 May;31(5):476-481. doi: 10.1089/end.2016.0816. 2. Barghouthy Y, Wiseman O, Ventimiglia E, Letendre J,

Cloutier J, Daudon M, Kleinclauss F, Doizi S, Corrales

M, Traxer O. Silicone-hydrocoated ureteral stents encrustation and biofilm formation after 3-week dwell time: results of a prospective randomized multicenter clinical study. World J Urol. 2021 Sep;39(9):3623-3629. doi: 10.1007/s00345-021-03646-0.

The ‘Forgotten’ ureteric stent management

Comments by Dr. Abdelfttah Omran Doha (QT)

Dr. Abdulkader Alobaidy, Doha (QT)

Prof. Omar Aboumarzouk, Doha (QT)

The missed stent or ‘forgotten’ stent is a urological disaster and a treatment nightmare for any urologist. Missed stents occur for many reasons: poor patient compliance in that the patient does not return for change or removal or poor counselling by the practitioner if the patient does not understand follow-up. No matter the cause, this highlights the importance of a stent registry which needs to be regularly updated and monitored. Encrustations in stents that have been left in situ for years occur in various forms. However, generally it concerns either segmental incrustation of the coiled parts of the stent, or along the whole length of the stent.

Management in these scenarios can be challenging. A step-by-step, multi-disciplinary and multimodality and even multi-sessional approach might be required. Generally, endourologists might require the use of all the modalities at their disposal, including SWL, ureteroscopy (rigid and flexible), PCN, PCNL, cystolitholapaxy, even open or laparoscopic/ robotic surgical techniques, including nephrectomy if the kidney is non-functioning. Therefore, a CT scan and a functional nuclear renogram are required.

Given the fact that the patient was deemed unfit for endoscopic intervention at the time due to extensive co-morbidity, options for treatment are limited. Therefore, we would seek an anaesthetic opinion. Spinal anaesthesia could be the most appropriate method. We also do not tend to insert a second stent in these patients, as we found no additional benefit and there is a risk of the second stent becoming encrusted as well, even in short intervals. fragmentation of the heavily encrusted segments and potentially allows for the stent to straighten as well as giving more mobility.

Then, we would deal with the lower coil encrustation with a cystolitholapaxy with all endourological safety measures such as the use of contrast media and a safety wire. Following that, we would use rigid ureteroscopy and a pneumatic lithoclast or laser fragmentation to deal with the encrustations along the stent. We would fragment the encrustations along the whole stent length, especially the large encrusted segments. Throughout the procedure, we would assess stent mobility as we progress upwards inside the ureter. Once all impacted areas have been desintegrated and the stent has more mobility without any impacted areas remaining, and with upper coil flexibility, the stent will come out without further problems.

In our experience dealing with complete total stent encrustations, we found that using this multi-modality technique is successful.

Important points: 1. It is vital to have and maintain a stent registry 2. Patient and family counselling of stent management and potential complications is essential A 28-year-old man has undergone several hypospadias repairs since childhood. Nevertheless, he is still complaining of dysuria and physical examination shows a meatal stenosis which only admits a guidewire (Fig. 1). His voiding urethrogram is also shown (Fig. 2).

Fig. 1

Fig. 2

Discussion point • What surgical procedure is advisable?

Case provided by Dr. Amin Bouker, Clinique Taoufik, Tunis, Tunisia. E-mail: aminbouker@gmail.com

3. A multi-disciplinary approach, by a radiological, anaesthetic and urological team is needed 4. A multi-modality approach utilising all technical options is needed 5. A step-wise approach is the key to solving the problem, first debulking the upper coil encrustations and then working from below upwards.

Case study No. 70 continued

In this severely ill patient we chose to perform ureteroscopy only under peridural anesthesia with sedation. Using a combination of rigid and flexible ureteroscopy, the stent was completely freed from all encrustations and finally, after a long procedure, the stent could be removed completely. All debris was cleared and a new stent was inserted for the lower pole stones still present. A second procedure to remove the remaining stones was planned but the patient refused and went home.