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Breakage of a Silicone Double Pigtail Ureteral Stent as a Long-Term Complication
0022-534 7/93/1506-1898$03.00/0 Vol. 150, 1898-1899, December 1993
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1993 by AMERICAN UROLOGICAL ASSOCIATION, INC.
BREAKAGE OF A SILICONE DOUBLE PIGTAIL URETERAL STENT AS A LONG-TERM COMPLICATION J. A. WITJES From the Department of Urology, University Hospital, Nijmegen, The Netherlands
ABSTRACT
A variety of indications have made the use of double pigtail ureteral catheters routine in urological practice. Although side effects are frequent they are usually mild. Complications with long-term indwelling stents are mainly due to stent incrustation or stone formation. We report a case of stent breakage without incrustation after an indwelling period of 29 months. To our knowledge such a severe complication of a silicone double pigtail stent has not been described previously. This complication also signifies that the period a stent is left indwelling is critical and should be monitored carefully. KEY
WORDS:
catheterization, stents, complications
Ureteral stents have been used for several decades. In 1967 Zimskind et al reported the first successful long-term use of a ureteral stent for ureteral obstruction. 1 Finney developed the double pigtail stent in 1978. 2 Improvements in materials and design, together with the development of endoureteral surgery and extracorporeal shock wave lithotripsy, have made the use of these stents routine in urological practice. The maximal time a ureteral stent can safely remain in place is not well defined, and varies between less than 6 weeks and 6 months. 3- 5 Stent incrustation seems to be the most significant problem of longterm placement. We describe a patient in whom a silicone double pigtail stent remained in place for 31 months without incrustation. However, after 29 months the stent had broken into several pieces, causing obstruction of the kidney. Nephroureterectomy was performed. To our knowledge, this complication has not been described previously. CASE REPORT
A 68-year-old white man was operated on for carcinoma of the sigmoid in April 1989. Preoperatively dilatation and loss of parenchyma of the right kidney were documented, which appeared to be caused by biopsy proved fibrosis. Ureterolysis was performed on the right side together with sigmoid resection. Postoperatively both kidneys showed progressive dilatation and creatinine increased from 111 before to 608 µmol./1. 6 months after the operation (normal 60 to 110). After referral to our hospital in November bilateral percutaneous nephrostomies were placed. Kidney function improved (creatinine decreased from 868 to 244 µmol./1.) but it did not normalize. Antegrade pyelography showed obstruction on the right side at the level of the ureterolysis and on the left side at the level of the sigmoid resection. Antegrade dilation of the stenosis was performed on the right side and an SF 30 cm. silicone double pigtail catheter* was left in place. A similar procedure for the left ureter failed because the stricture could not be passed. A week later the left kidney started to bleed and nephrectomy was done. Renal function was borderline, with a creatinine of greater than 400 µmol./1. During the following months kidney function decreased and hemodialysis was started. The double pigtail catheter that had been inserted in November 1989 caused no complications and there was no dilatation of the kidney, with a diuresis of 1,000 ml. a day. Regular plain x-rays of the abdomen showed good position of the catheter without calcification and, therefore, it was decided not to replace the stent at regular intervals. However, in April 1992 the double pigtail catheter appeared to have Accepted for publication May 7, 1993. * Angiomed, Karlsruhe, Germany.
FIG. 1. Abdominal plain x-ray shows broken double pigtail catheter
broken into several pieces, although the patient did not complain (fig. 1). Because of the dilatation of the kidney and the risk of infectious problems, nephroureterectomy was performed in June and all parts of the stent were removed. The stent showed no calcifications (fig. 2). Convalescence was uneventful and the patient remained on hemodialysis. DISCUSSION
Indications for the placement of ureteral stents include ureteral trauma, fistula or strictures; treatment of ureteral or kidney stones; hydronephrosis during pregnancy; obstruction due to malignancy or retroperitoneal fibrosis, and as an adjunct in reconstructive urinary tract surgery. 5 • 6 Side effects and complications of double pigtail stents include patient discomfort and irritative bladder symptoms, stent migration, stent occlu-
1898
BREAKAGE OF SILICONE DOUBLE PIGTAIL URETERAL STENT
1899
abdominal plain x-rays are warranted. Patients with infections might benefit from antibiotic prophylaxis. Breakage of polyethylene catheters was common when they were left in place for more than 6 months 10 and, therefore, this material is no longer used. To our knowledge, breakage of a silicone double pigtail catheter has not been reported to date. Mardis and Kroeger studied stent material and found that silicone stents did not lose tensile strength after an indwelling period of 20 months but elasticity diminished somewhat. 11 Although in our patient the kidney was already nonfunctioning, breakage of the stent in the absence of calcification resulting in the subsequent nephroureterectomy remains a severe complication of long-term double pigtail placement. This complication stresses the importance of meticulous attention to the time a stent is left indwelling, for example by use of a stent log. REFERENCES
FIG. 2. All parts of broken double pigtail catheter after nephroureterectomy.
sion, stent incrustation, stone formation, reflux with loin pain on voiding, erosion and fistula formation, bacteriuria and macroscopic hematuria. 7• 8 Although patient discomfort was thought to be minimal, 2 recent studies showed that more than 90% experience symptoms, irrespective of stent composition. 7• 8 Loin pain on voiding appears to be the most frequent and troublesome short-term complication. 8 · 9 Upward migration of the stent can be a severe complication, sometimes necessitating ureterorenoscopy or open surgery. 5 Stent calcifications and subsequent stone formation are associated with the long-term use of indwelling ureteral stents. Calcification might cause obstruction or difficult removal of the stent. In a report of 5 cases of stone formation due to ureteral stents the stent had been in place for 6 to 24 months in 4. 3 Patients with urinary tract infections, metabolic disturbances and stone history seem to be at high risk for stone formation. 3 • 4 In these patients stents should be used with care and changed frequently, usually within 6 to 12 weeks. Regular
L Zimskind, P. D., Fetter, T. R. and Wilkerson, J. L.: Clinical use of long-term indwelling silicone rubber ureteral splints inserted cystoscopically. J. Urol., 97: 840, 1967. 2. Finney, R. P.: Experience with new Double J ureteral catheter stent. J. Urol., 120: 678, 1978. 3. Spirnak, J.P. and Resnick, M. I.: Stone formation as a complication of indwelling ureteral stents: a report of 5 cases. J. Urol., 134: 349, 1985. 4. Schulze, K. A., Wettlaufer, J. N. and Oldani, G.: Encrustation and stone formation: complication of indwelling ureteral stents. Urology, 25: 616, 1985. 5. Pocock, R. D., Stower, M. J., Ferro, M. A., Smith, P. J. B. and Gingell, J. C.: Double J stents: a review of 100 patients. Brit. J, Urol., 58: 629, 1986. 6. Saltzman, B.: Ureteral stents. Indications, variations, and complications. Urol. Clin. N. Amer., 15: 481, 1988. 7. Pryor, J. L., Langley, M. J. and Jenkins, A. D.: Comparison of symptom characteristics of indwelling ureteral catheters. J. UroL, 145: 719, 1991. 8. Pollard, S. G. and Macfarlane, R.: Symptoms arising from DoubleJ ureteral stents. J. Urol., 139: 37, 1988. 9. Greenstein, A., Chen, J., Matzkin, H., Baron, J. and Braf, Z.: Potential pitfalls in the obstructive renal scan in patients with double-pigtail ureteral catheters. J. UroL, 141: 283, 1989. 10. Smith, A. D.: Percutaneous ureteral surgery and stenting. Urology, suppl. 5, 23: 37, 1984. 11. Mardis, H.K. and Kroeger, R. M.: Ureteral stents. Materials. Urol. Clin. N. Amer., 15: 471, 1988.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1993 by AMERICAN UROLOGICAL ASSOCIATION, INC.
BREAKAGE OF A SILICONE DOUBLE PIGTAIL URETERAL STENT AS A LONG-TERM COMPLICATION J. A. WITJES From the Department of Urology, University Hospital, Nijmegen, The Netherlands
ABSTRACT
A variety of indications have made the use of double pigtail ureteral catheters routine in urological practice. Although side effects are frequent they are usually mild. Complications with long-term indwelling stents are mainly due to stent incrustation or stone formation. We report a case of stent breakage without incrustation after an indwelling period of 29 months. To our knowledge such a severe complication of a silicone double pigtail stent has not been described previously. This complication also signifies that the period a stent is left indwelling is critical and should be monitored carefully. KEY
WORDS:
catheterization, stents, complications
Ureteral stents have been used for several decades. In 1967 Zimskind et al reported the first successful long-term use of a ureteral stent for ureteral obstruction. 1 Finney developed the double pigtail stent in 1978. 2 Improvements in materials and design, together with the development of endoureteral surgery and extracorporeal shock wave lithotripsy, have made the use of these stents routine in urological practice. The maximal time a ureteral stent can safely remain in place is not well defined, and varies between less than 6 weeks and 6 months. 3- 5 Stent incrustation seems to be the most significant problem of longterm placement. We describe a patient in whom a silicone double pigtail stent remained in place for 31 months without incrustation. However, after 29 months the stent had broken into several pieces, causing obstruction of the kidney. Nephroureterectomy was performed. To our knowledge, this complication has not been described previously. CASE REPORT
A 68-year-old white man was operated on for carcinoma of the sigmoid in April 1989. Preoperatively dilatation and loss of parenchyma of the right kidney were documented, which appeared to be caused by biopsy proved fibrosis. Ureterolysis was performed on the right side together with sigmoid resection. Postoperatively both kidneys showed progressive dilatation and creatinine increased from 111 before to 608 µmol./1. 6 months after the operation (normal 60 to 110). After referral to our hospital in November bilateral percutaneous nephrostomies were placed. Kidney function improved (creatinine decreased from 868 to 244 µmol./1.) but it did not normalize. Antegrade pyelography showed obstruction on the right side at the level of the ureterolysis and on the left side at the level of the sigmoid resection. Antegrade dilation of the stenosis was performed on the right side and an SF 30 cm. silicone double pigtail catheter* was left in place. A similar procedure for the left ureter failed because the stricture could not be passed. A week later the left kidney started to bleed and nephrectomy was done. Renal function was borderline, with a creatinine of greater than 400 µmol./1. During the following months kidney function decreased and hemodialysis was started. The double pigtail catheter that had been inserted in November 1989 caused no complications and there was no dilatation of the kidney, with a diuresis of 1,000 ml. a day. Regular plain x-rays of the abdomen showed good position of the catheter without calcification and, therefore, it was decided not to replace the stent at regular intervals. However, in April 1992 the double pigtail catheter appeared to have Accepted for publication May 7, 1993. * Angiomed, Karlsruhe, Germany.
FIG. 1. Abdominal plain x-ray shows broken double pigtail catheter
broken into several pieces, although the patient did not complain (fig. 1). Because of the dilatation of the kidney and the risk of infectious problems, nephroureterectomy was performed in June and all parts of the stent were removed. The stent showed no calcifications (fig. 2). Convalescence was uneventful and the patient remained on hemodialysis. DISCUSSION
Indications for the placement of ureteral stents include ureteral trauma, fistula or strictures; treatment of ureteral or kidney stones; hydronephrosis during pregnancy; obstruction due to malignancy or retroperitoneal fibrosis, and as an adjunct in reconstructive urinary tract surgery. 5 • 6 Side effects and complications of double pigtail stents include patient discomfort and irritative bladder symptoms, stent migration, stent occlu-
1898
BREAKAGE OF SILICONE DOUBLE PIGTAIL URETERAL STENT
1899
abdominal plain x-rays are warranted. Patients with infections might benefit from antibiotic prophylaxis. Breakage of polyethylene catheters was common when they were left in place for more than 6 months 10 and, therefore, this material is no longer used. To our knowledge, breakage of a silicone double pigtail catheter has not been reported to date. Mardis and Kroeger studied stent material and found that silicone stents did not lose tensile strength after an indwelling period of 20 months but elasticity diminished somewhat. 11 Although in our patient the kidney was already nonfunctioning, breakage of the stent in the absence of calcification resulting in the subsequent nephroureterectomy remains a severe complication of long-term double pigtail placement. This complication stresses the importance of meticulous attention to the time a stent is left indwelling, for example by use of a stent log. REFERENCES
FIG. 2. All parts of broken double pigtail catheter after nephroureterectomy.
sion, stent incrustation, stone formation, reflux with loin pain on voiding, erosion and fistula formation, bacteriuria and macroscopic hematuria. 7• 8 Although patient discomfort was thought to be minimal, 2 recent studies showed that more than 90% experience symptoms, irrespective of stent composition. 7• 8 Loin pain on voiding appears to be the most frequent and troublesome short-term complication. 8 · 9 Upward migration of the stent can be a severe complication, sometimes necessitating ureterorenoscopy or open surgery. 5 Stent calcifications and subsequent stone formation are associated with the long-term use of indwelling ureteral stents. Calcification might cause obstruction or difficult removal of the stent. In a report of 5 cases of stone formation due to ureteral stents the stent had been in place for 6 to 24 months in 4. 3 Patients with urinary tract infections, metabolic disturbances and stone history seem to be at high risk for stone formation. 3 • 4 In these patients stents should be used with care and changed frequently, usually within 6 to 12 weeks. Regular
L Zimskind, P. D., Fetter, T. R. and Wilkerson, J. L.: Clinical use of long-term indwelling silicone rubber ureteral splints inserted cystoscopically. J. Urol., 97: 840, 1967. 2. Finney, R. P.: Experience with new Double J ureteral catheter stent. J. Urol., 120: 678, 1978. 3. Spirnak, J.P. and Resnick, M. I.: Stone formation as a complication of indwelling ureteral stents: a report of 5 cases. J. Urol., 134: 349, 1985. 4. Schulze, K. A., Wettlaufer, J. N. and Oldani, G.: Encrustation and stone formation: complication of indwelling ureteral stents. Urology, 25: 616, 1985. 5. Pocock, R. D., Stower, M. J., Ferro, M. A., Smith, P. J. B. and Gingell, J. C.: Double J stents: a review of 100 patients. Brit. J, Urol., 58: 629, 1986. 6. Saltzman, B.: Ureteral stents. Indications, variations, and complications. Urol. Clin. N. Amer., 15: 481, 1988. 7. Pryor, J. L., Langley, M. J. and Jenkins, A. D.: Comparison of symptom characteristics of indwelling ureteral catheters. J. UroL, 145: 719, 1991. 8. Pollard, S. G. and Macfarlane, R.: Symptoms arising from DoubleJ ureteral stents. J. Urol., 139: 37, 1988. 9. Greenstein, A., Chen, J., Matzkin, H., Baron, J. and Braf, Z.: Potential pitfalls in the obstructive renal scan in patients with double-pigtail ureteral catheters. J. UroL, 141: 283, 1989. 10. Smith, A. D.: Percutaneous ureteral surgery and stenting. Urology, suppl. 5, 23: 37, 1984. 11. Mardis, H.K. and Kroeger, R. M.: Ureteral stents. Materials. Urol. Clin. N. Amer., 15: 471, 1988.