Abstract
Background: Urolithiasis is a common surgical problem.75% patients of urinary stones present with pain. Sometimes it interferes with their daily activities. Diagnosis & assessment can be confirmed by imaging facilities. Surgical removal is the main stay of treatment. With the advancement of modern equipment all over the world, minimal invasive techniques are gaining popularity and despite being a developing nation we are not behind. However, in our perspective, open surgical technique still has a place in the armamentarium of general surgeon to remove larger stones with cost effectivity. To avoid operation related morbidity, peroperative placement of ureteric stent is safe on scientific grounds. We have completed the study on 100 patients with 5 years of time by the department of surgery of Central medical college of Cumilla, Bangladesh. Our results end up with a satisfaction of least urinary leakage but had some unexpected complications. So, although DJ stent facilitates proper urinary drainage, it still has some manageable morbidity.
Objectives: To establish that use of ureteric stent has major role to prevent postoperative urinary leakage.
Methods: Consecutive patients were admitted in surgery ward of Central medical college, Cumilla; with the diagnosis of renal or ureteric stone. After assessment of their operability, we used DJ stent in all patients & their outcome was observed.
Results: Present series showed male: female sex ratio to be 1.17:1. The mean age was 36 years (20-60 years). Open pyelolithotomy was done in 51% patients, extension of pelvic incision was done in 3% cases, 2% patients had undergone bilateral pyelolithotomy with small incisions & 49% were operated by ureterolithotomy. In all (100%) cases D-J stents were used. Among them 37% patients recovered completely who had no complaints at all,and among the rest-23% patients had stent colic, 10% suffered from increased frequency of micturition, 9% experienced haematuria, 8% stent encrustation, 8% dysuria, 7% infection, 3% stent fragmentation, 2% stent migration, 2% stent malposition where lower end were in ureter but did not enter into the bladder, 2% had urinary leakage, 1% passage fragments of stone & stent, and 1% patient required nephrectomy.
Conclusion: Intraoperative use of ureteric stent in pyelolithotomy & ureterolithotomy patients can prevent postoperative urinary leakage with some morbidity.
Key Words: Urolithiasis, Surgery, DJ stent, Morbidity.
Introduction
Renal and ureteric calculi are significant sources of morbidity. Approximately 50% of patients are of the age between 30 to 50 years. The male: female ratio is 4:3.1 Urinary tract stones are mostly managed with minimal invasive techniques preferably by urologists. Nevertheless, open pyelolithotomy & ureterolithotomy are under the domain of general surgeons for the removal of larger stones due to lack of instrumental facility everywhere and cost effectiveness.
Pyelolithotomy is primarily indicated for removal of large renal calculi in the renal pelvis and lower pole collecting system.2,3Ureterolithomy also offers removal of ureteric stone. Both the procedures can be performed by open, laparoscopic, or endoscopic maneuver.
There can be several complications arising from all techniques, but postoperative urine leakage may trouble both the patients and surgeons. Cutaneous urinary fistula after prolonged urinary leakage represents another complication associated with renal stone surgery.2
Peroperative routine placement of double-J (D-J) stent after removal of stone can overcome the problem and is also recommended.4,5 Gustav Simon described the first case of ureteral stenting during open cystostomy in the 1900s, and Yoaquin Albarann created the first ureteral stent in 1900. In 1974, the first commercial internal ureteral stent was made and described by Gibbons.6
There is a wide range of indications of D-J stent insertion. The most common purposes are to facilitate urinary drainage or to prevent its leakage, to prevent obstruction or delayed stricture.7,8
Use of ureteral stents is associated with many potentially uncomfortable urinary symptoms or morbidity such as flank or suprapubic pain, frequency, urgency, dysuria, hematuria, UTI, fever, and other voiding symptoms. There are also many complications related to ureteral stenting including migration, breakage, encrustation, stone formation, and trauma to the kidney. Furthermore, secondary cystoscopy is required to remove the stent in most patients, which may adversely affect quality of life.7
The aim of our study was to show that use of stent covered major benefits with minor complications.
The D-J stent is a double-edged weapon and though it is regularly used, it is not always justified. Certain precautions and guidelines should be abided by for its appropriate use. When it is necessary, the patient and the patient’s relatives should be thoroughly informed about the need, consequences, and complications, as well as its timely removal. The use of the D-J stent should be documented (name, address, and contact information). The practice of such protocols will avoid unnecessary morbidity and not to mention, legal problems.9,10
In our study it is documented that use of D-J stent can provide major benefit to our patients like prevention of disastrous urinary leakage and fistulas with acceptable morbidity although some additional cost to health budget.
Materials and Methods:
From January 2019 to December 2023, a total of 5 years period; 100 patients were selected according to inclusion & exclusion criteria in this observational series. All patients were admitted in the department of surgery of Central Medical College Hospital, Cumilla (CeMeCH) with the diagnosis of renal or ureteric stones. Selected patients were evaluated properly with history, clinical examination & investigations (complete blood count, routine examination of urine, serum creatinine, random blood sugar, blood grouping & Rh typing, IVU, USG of whole abdomen, CXR P/A view, ECG, Renogram). All patients with their accompanying responsible persons were given an explanation of the study and informed consents were obtained. Their knowledge and attitude about the procedure were assessed by taking interviews using a standardized questionnaire. Data collection sheet was maintained by Microsoft excel program. Patients of between 20-60 years, diagnosed with nephrolithiasis or ureterolithiasis, who willingly gave informed written consent about the procedure were Included. Patients who preferred minimal invasive technique, elderly patients more than 60 years with comorbid illness (bronchial asthma, COPD, IHD), and who were not willing to give consent, were excluded from the study.
Results:
In this study 100 patients were included. The mean age was 36 years (20-60 years). Maximum patients (55%) were from the age group 31-40 years. Male female sex ratio was 1.17:1. Professionally about 31% patients were housewives, 20% were workers & 15% were service holders. 43% of the patients were from average socioeconomic group, 41% were poor and only 16% were from affluent background.
The study showed the common presentations that most patients came with were flank pain in 38%, loin pain in 23%, hematuria in 21%, silent stone in 16%, pyuria in 9%, and among them renal angle tenderness were present in 40% patients. In radiological findings (KUB X-ray) 31% patients had unilateral single kidney stone, 19% had unilateral multiple kidney stones, 2% had bilateral renal stones, 18% had upper ureteric stone, 19% had mid ureteric stone & 11% had lower ureteric stone. 48% of patients were admitted with ureteric stones and 52% patients were diagnosed with renal stone. For the assessment of renal function in obstructed kidney, 6% needed DTPA isotope renogram.
All patients were admitted under the department of surgery of CeMeCH from January 2013 to December 2017. Before the operative procedures, all patients were assessed clinically and through investigation for their operability. 38% of patients were operated under general anaesthesia (G/A) and 62% under Subarachnoid Block (SAB). Open pyelolithotomy was done in 51% patients; extension of pelvic incision was done in 3% cases; 2% patients had undergone bilateral pyelolithotomy with small incisions & 49% were operated by ureterolithotomy. In all (100%) cases D-J stents were used. Postoperative analgesia was maintained by I/M pethidine for the 1st 48 hours, then pain management was maintained with NSAID. Intravenous cefuroxime was given in all cases for 48 hours then was switched to oral form. All patients were advised to come after one month for the removal of stents.
Among them 37% patients recovered completely who had no complaint at all, 23% patient had stent colic, 10% suffered from increased frequency of micturition, 9% experienced hematuria, 8% had stent encrustation, 8% dysuria, 7% infection, 3% stent fragmentation, 2% stent migration, 2% stent malposition where lower end were in ureter but did not enter into the bladder, 2% had urinary leakage, 1% passed fragments of stone & stent, and 1% patient required nephrectomy. Stent colic was treated with analgesic & antispasmodic, hematuria was managed conservatively, infection was controlled by antibiotic according to C/S report, dysuria & increase frequency was treated conservatively, and two fragmented stents were removed combinedly with cystoscopic and PCNL procedure. In one patient, a fragmented stent caused pyonephrosis in an obstructed kidney, where nephrectomy was required. Two malpositioned stent cases produced urine leakage from the pelvic site, one of which was managed through ureteroscopy & remaining one was stopped after 7 days, but its removal demanded ureteroscopy.
All the stents were kept in situ for 1 to 11/2 months with the advice to come for cystoscopic removal under Local Anaesthesia. 88% followed their scheduled removal time but 12% came late with some serious problem. They were late by 6 months, 1 year, and even 3 years. Patients who required ureteroscopic & nephroscopic intervention were also attended by urologists for additional care. Most of the complications of D-J stent like encrustation, stone formation, fragmentation, infection was due to the delay to come for follow up & poor compliance, although all the patients & their attendance were counseled about the matter both pre & post operatively. During our follow up we found 16% of patients had recurrence of renal stone.
Graphical representation of the study(n=50)
Age distribution of the study group
Sex variant of the study group
Mood of Presentation
Presentation on the sites & number of stones (kidney & ureter)
Treatment of the Study Group (n=50)
Complications of the study
DISCUSSION:
Urolithiasis is a common surgical entity. With the advances of modern technology in urological practice most of the stones are removed by minimal invasive effort. However, instrumental intervention is still not affordable to all patients. So, besides the laparoscopic & endoscopic procedures, open surgical technique still has a place in patient management. From this point of view, we selected 100 patients with renal & ureteric stone disease who went for open pyelolithotomy & ureterolithotomy procedure where D-J stents were used in all cases. Stent-related problems were observed, recorded & compared to other studies.
This observational study was carried out from January 2019 to December 2023(5 years) by the department of surgery of Central Medical College Hospital, Cumilla. The mean age of the study was 36 years (20-60 years) where 54% were male & 46% female. Most of the candidates (43%) were from average socioeconomic status & a large portion were housewives (31%).
Dr. Faysal in his dissertation mentioned that 50 case series, >50% of the patients were distributed among the age group of 31- 40 years and male were 70% & female 30%.11
Common sign symptoms were flank pain in 38%, loin pain in 23%, hematuria in 21%, silent stone in 16%, pyuria in 9%, and among them renal angle tenderness were present in 40% patients which were also described by Christopher GF in the kidneys and ureters chapter of surgical textbook.1 In this series, X-ray findings showed 31% patients had unilateral single kidney stone, 19% had unilateral multiple kidney stones, 2% had bilateral renal stones, 18% upper ureteric stone, 19% mid ureteric stone & 11% had lower ureteric stone. This was comparable to Dr. Faysal’s findings where he found 36% patients had single stone, 64% multiple kidney stones, 20% upper ureteric stone, 8% mid ureteric stone & 12% lower ureteric stone.11
Our study showed open pyelolithotomy was done in 47% patients, extended pyelolithotomy was done in 3% cases, 2% patients underwent bilateral pyelolithotomy with small incisions & 48% were operated by ureterolithotomy. Dr. Faysal showed in his results, open pyelolithotomy was done on 50%, URS+ICPL=36% & open ureterolithotomy was done on 14%.9 We did not include any patient who preferred minimal access surgery.11
All patients were advised to come after one month for the removal of stents. While most of the patients (88%) attended on time, some patients (12%) forgot their schedule or failed to realize the importance of the matter. The delayed removers had serious complications.
The indications for insertion of stents into the urinary tract have expanded significantly during the last decade. However, their use is not free of complications, the problems were discussed by Pansota MS et al.7 In our study, the purpose of use of D-J stents were to prevent urinary leakage, proper drainage of urine into the bladder. In this series of D-J stent related observation, 37% patients recovered completely who had no complaint at all, 23% patient had stent colic, 10% suffered from increased frequency of micturition, 9% experienced hematuria, 8% had stent encrustation, 8% had dysuria, 7% had infection, 3% had stent fragmentation, 2% had stent migration, 2% had stent malposition where lower end were in ureter without entering into the bladder, 2% had urinary leakage, 1% passed fragments of stone & stent, and 1% patient required nephrectomy.
Dr. Faysal found in his series, a complete recovery of 30%, irritative symptoms in 24%, dysuria in 20%, haematuria in 10%, infection in 4%, stent migration in 6%, stent encrustation in 2%, stent fracture in 2%, and stent colic in 2% cases.11
Al-Mahroon SA et al, showed in his series of 220 cases, the complications rate was 59.5% & 29.1% of patients required treatment. Among them, loin pain (10.9%), UTI (10.9%), dysuria (7.7%) was marked. 80% of patients had variable degree of stent related discomfort & morbidity.12
Pansota MS et al, mentioned in their 100 cases series the complications of D-J stenting were fever & septicaemia in 8%, painful trigone irritation in 13%, haematuria in 11%, ureteral perforation in 1%, stent migration in 2%, and stent encrustation or stone formation in 5% cases.7
The main complications of D-J stent are dislocation, encrustation, and infection. Other complications like haematuria, urgency, increased frequency, urine leakage & pain in loin or flank are also established.11 Double J shape of stent is manufactured to prevent migration.13
Dakkak Y mentioned in his article, the main problem of longstanding ureteral stents was encrustation (90.1%), UTI (45.5%) and site of encrustation was in the bladder (68.2%), ureter (59%) & kidney (36.4%).14 We removed forgotten stents by combined cystoscopic/ureteroscopic & PCNL technique, similar approach was also recommended by Kelkar V et al.10 Chander J et al described in his comparative study that wherever retroperitoneoscopic pyelolithotomy was performed, with or without stents, the respective complications were 25.5% and 29.2%.15 Malposition of stent in ureter can be prevented by image guided placement of catheter, which is also recommended.16,17
During the follow up period we removed most of the stent by cystoscopy, but use of magnetic stent can be safely removed by magnetic catheter.18,19
Ben HC at recommends, to overcome stent colic analgesic eluting stent,to combat infection antibiotic eluting stent & to overcome forgotten stent biodegradable stent also recommended by Altarac Set al.16,20
So, use of ureteric stent has some benefit, but delay of its removal may damage the kidney.
Conclusion:
In pyelolithotomy and ureterolithotomy procedures, peroperative use of D-J stent has obvious benefit in term of reducing postoperative urine leakage. But there is no significant difference in operative time, intraoperative blood loss and postoperative other complications. But forgotten & neglected stent may carry serious hazards.
Authors of this article
1. Dr. Nasir Uddin Mahmud, Associate Professor, Department of Surgery, Central Medical College & Hospital, Cumilla.
2. Professor Dr. Mohammad Serajul Hoque, Professor of Urology, Department of Urology, Cumilla Medical College& Hospital.
3. Dr. Mohammad Siddiqur Rahman, Associate Professor, Department of Urology, Sylhet Women’s Medical College & Hospital, Sylhet.
4. Dr.Mohammad Zahidur Rahman Mazumder, Associate Professor,Department of Anesthesia,Analgesia and ICU, Cumilla Medical College & Hospital,Cumilla.
5. Dr.Mohammad Abu Bakar Siddiq Faysal, Junior Consultant (Surgery), Upazilla Health Complex, Brammanpara, Cumilla.
6. Dr.Md.Abul Khair, Registrar, Department of Surgery, Central Medical College & Hospital, Cumilla.
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