Flank pain, haematuria and poor patient compliance: beware the 'forgotten' JJ stent!
|Article Type:||Case study|
Hematuria (Risk factors)
Hematuria (Care and treatment)
Hematuria (Case studies)
Kidney stones (Care and treatment)
Kidney stones (Prognosis)
Kidney stones (Case studies)
Stent (Surgery) (Usage)
Stent (Surgery) (Health aspects)
|Publication:||Name: South African Medical Journal Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 South African Medical Association ISSN: 0256-9574|
|Issue:||Date: Dec, 2009 Source Volume: 99 Source Issue: 12|
|Geographic:||Geographic Scope: South Africa Geographic Code: 6SOUT South Africa|
A 40-year-old man presented with right-sided flank pain of sudden
onset and intermittent macroscopic haematuria that had been present for
the past 3 months. He had had a hospital admission for a right ureteric
stone 3 years previously, where some 'intervention' had been
performed. He had been told to return for a follow-up visit, but had
defaulted as he felt well after being discharged.
The patient was clearly distressed, with right-sided renal angle tenderness and severe suprapubic pain. A plain supine abdominal film (Fig. 1) and non-contrast computed tomography (CT) scan (Fig. 2) revealed an encrusted 'forgotten' JJ stent with a significant associated secondary stone burden.
A renogram confirmed that the right kidney had been severely affected by the subsequent stone burden, now contributing only 10.32% of the overall renal function.
Ureteral JJ stents are invaluable in endo-urological practice, as they provide free drainage from the kidney to the bladder and are effective in relieving and preventing upper urinary tract obstruction. (1) However, complications occur in up to one-third of patients, (2,3) which most commonly include stent encrusation, stent migration, stent fracture and secondary stone formation. (1) Other complications include dysuria, frequency, vesico-ureteric reflux and ureteral fistula. (3) For stents that have lost their radio-opaque coating or when radiography is contraindicated, ultrasonography is the diagnostic modality of choice. (1)
Treatment usually involves endoscopic removal of the retained stent. For stents with a high stone burden, the use of a combination of percutaneous nephrolithotripsy, extracorporeal shockwave lithotripsy, ureteroscopy, electrohydraulic lithotripsy, laser lithotripsy and percutaneous chemolysis may be necessary, with clearance rates of up to 100% being achieved. (4)
[FIGURE 1 OMITTED]
Careful selection of patients who stand to benefit most from JJ stent insertion is essential to prevent unnecessary complications. (1) Some patients may disregard counselling concerning the stent's impermanent nature, the need for a return visit for its timeous removal and subsequent intervention.
This is particularly relevant in settings with poor patient compliance, inadequate record keeping, language barriers, ineffective follow-up strategies and limited access to specialised health care. The presence of a 'forgotten' JJ stent in patients presenting with flank pain and haematuria should be considered, as it may have devastating consequences if left undetected.
[FIGURE 2 OMITTED]
We would like to thank Drs J van Heerden and R Roux of the Department of Radiology, Kalafong Hospital, for assisting with the images.
(1.) Memon NA, Talpur AA, Memon JM. Indications and complications of indwelling ureteral stenting at NMCH, Nawabshah. Pakistan Journal of Surgery 2007; 23(3): 187-191.
(2.) Ringel A, Richter S, Shalev M, Nissenkorn I. Late complications of ureteral stents. Eur Urol 2000; 38: 41-44.
(3.) Singh I, Singh S. Missed fractured 'trapped JJ stent' in a solitary functioning renal unit--Implications of management. Int Urol Nephrol 2003; 35: 247-249.
(4.) Park K, Jeon S, Park H, Kim HH. Clinical features determining the fate of a long-term, indwelling, forgotten double J stents. Urol Res 2004; 32: 416-412.
Yusuf Seedat, MB BCh (Wits), is currently a medical officer in the Department of Radiology, Leratong Hospital, and is intending to pursue a long-term career in that field. He hopes to be part of a system that will eventually make advanced diagnostic imaging an affordable and accessible reality for those South Africans most in need.
Ahmed Adam, MB BCh (Wits), Dip PEC (SA), is currently a registrar in the Department of Urology, University of Pretoria.
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