Proximal Migration of Ureteric DJ Stent: A Case Series

  • Debansu Sarkar
  • Avisek Dutta
  • Dilip Kumar Pal 0000000189290961
Keywords: DJ stent, Proximal migration, Children

Abstract

Background: DJ stents are routinely used in urological procedures. Rarely these may dislodge or migrate.

Case Series: Here we report proximal migration of DJ stent in three children with pelvi-ureteric junction (PUJ) obstruction treated with dismembered pyeloplasty. Ureteroscopy and retrieval of migrated DJ stents were performed in each of these patients.

Conclusion: Proximal migration of DJ stent, though rare, can cause significant morbidity and complicates it’s removal. Proper size and positioning of stent is required for pediatric patients.

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References

Breau RH, Norman RW. Optimal prevention and management of proximal ureteral stent migration and remigration. J Urol. 2001; 166:890-3.

Garg RK, Menon P, Rao KLN, Arora S, Batra YK. Pyeloplasty for hydronephrosis: Issues of double J stent versus nephrostomy tube as drainage technique. J Ind Assoc Pediatr Surg. 2015; 20:32-6.

Mallikarjuna G, Ravichander G. Ureteric double-J stent related complications: a single tertiary care center experience from South India. Int J Res Med Sci. 2018; 6:3846-51.

Ahallal Y, Khallouk A. Risk factor analysis and management of ureteral double-J stent complications. Rev Urol. 2010; 12:e147-e151.

Slaton JW, Kftopp KA. Proximal ureteral stent migration: an avoidable complication? J Urol. 1996; 155:58-61.

Jayakumar S, Marjan M. Retrieval of proximally migrated double J ureteric stents in children using goose neck snare. J Indian Assoc Pediatr Surg. 2012; 17:6–8.

Meeks JJ, Helfand BT, Thaxton CS, Nadler RB. Retrieval of migrated ureteral stents by coaxial cannulation with a flexible ureteroscope and paired helical basket. J Endourol. 2008; 22:927–9.

Menezes P, Gujral S, Elves A, Timoney A. Ureteroscopic retrieval of proximally displaced ureteric stents using triradiate grasping forceps. Br J Urol. 1998; 81:758–9.

Yap RL, Batler RA, Kube D, Smith ND. Retrieval of migrated ureteral stent by intussusception of ureteral balloon dilator tip. Urol. 2004; 63:571–3.

Livadas KE, Varkarakis IM, Skolarikos A, Karagiotis E, Alivizatos G, Sofras F, et al. Ureteroscopic removal of mildly migrated stents using local anesthesia only. J Urol. 2007; 178:1998–2001.

Published
2020-01-12
How to Cite
1.
Sarkar D, Dutta A, Pal D. Proximal Migration of Ureteric DJ Stent: A Case Series. APSP J Case Rep [Internet]. 12Jan.2020 [cited 1Apr.2020];10:6. Available from: http://www.apspjcaserep.com/ojs1/index.php/ajcr/article/view/100
Section
Case Reports and Letters

INTRODUCTION

Ureteral stent placement is a common practice in urology practice. Stenting improves patient care by preventing or relieving the complications associated with ureteral obstruction and injury but they can invite further complications of their own.[1] Of note is proximal migration of stent into ureter or renal pelvis.[2,3] This has been found to occur in increased frequency in pediatric patients.[2] Here in, we present three cases referred with proximal migration of DJ stent.

CASE SERIES

Case 1: An 18-month-old male child underwent open dismembered pyeloplasty for right PUJ obstruction. A 3Fr and 14cm DJ stent was placed during the procedure. After 2 months, just before DJ removal, X-ray showed that whole of the stent had migrated to renal pelvis (Fig.1). The ureter was patulous enough to allow pediatric ureteroscope and it was removed with a grasper. The procedure was uneventful.

Figure 1: Figure 1: Xray shows DJ stent in Rt renal pelvis and a coil in right lower calyx.

Case 2: A 4-year-old boy underwent open dismembered pyeloplasty on right side for PUJ obstruction. During the procedure, a 4Fr 16cm DJ stent was placed. It was found to be in situ post-operatively (Fig.2A ). A month later, before removal of the stent, it was found to be proximally migrated into the renal pelvis (Fig.2B). The narrowest caliber ureteroscope 6/7.5Fr, that can admit a grasper, could not be inserted into the ureter. Through a 4/4.5Fr pediatric ureteroscope, we finally managed to have a hold of the DJ stent and removed it by a RIRS stone basket. There was no urethral or ureteric injury and he is doing well postoperatively.

Figure 2: Figure 2: 2A) Immediate postoperative X-ray showing properly placed DJ stent; 2B) Image from C-arm monitor showing DJ stent migrated into renal pelvis.

Case 3: A 10-year-old boy underwent left open dismembered pyeloplasty for PUJ obstruction and during the procedure a 5Fr 24cm DJ stent was placed. However when he was readmitted for removal a month later, the lower end of the stent was up-migrated into the ureter (Fig.3). The lower end of DJ stent was not visible on cystoscopy. The DJ stent was removed by 6.5Fr ureteroscope and grasper.

Figure 3: Figure 3: X-ray showing lower end of the DJ stent drawn up into the left ureter.

DISCUSSION

Proximal migration of DJ stent is rarely encountered, occurring in 0.6 to 3.5% of the cases.[4] It has been found in few studies that the migrated group had significantly less distal curl, implying that the low stent- to-ureter length ratio may be important because the curl in the bladder was inadequate to maintain stent position.[1] It is important to measure accurately the distance from the ureterovesical to the ureteropelvic junction or mid kidney on imaging.[1]

Placement of the curl in the renal pelvis instead of the upper calyx has less risk of migration.[5] The length of the curl for an 18cm DJ stent is approximately 4cm. While placing the stent from the renal pelvis during a pyeloplasty, urethral catheter should be clamped to fill the bladder. As the stent reaches the filled bladder reflux of urine is seen; the stent is then pushed a further 4cm (the length of J loop) for a proper distal curl. This method which is followed in our department allows placement of stent without the use of C-arm. Increased indwelling time is also considered one of the factors of stent migration.[1] Moreover, our all the three cases have a dilated pelvis, which might be a factor in allowing proximal migration.

Various methods of retrieval of migrated DJ stents have been described. Ureteroscopy with use of grasping forceps, helical basket, and ureteral balloon dilator tip have been described in adults.[6-9] In a study on 37 adult patients, ureteroscopy has been used to retrieve the stents with a 91.9% success rate without complications.[10] Ureteroscopy and removal of migrated DJ stent may be feasible in children, but it is difficult in young children and infants due to the small anatomical caliber of the ureter. Similarly, we encountered difficulty in stent retrieval in our second case owing to small ureteric caliber not allowing adequate size ureteroscope.

In conclusion, proximal migration of DJ stent though rare can cause significant morbidity of its removal. Proper size and positioning of stent is required for pediatric patients. The position of stent should be confirmed by imaging after placement.

Conflicts of interest. None declared

Source of Support: Nil

Author contributions: All authors contributed equally in concept, drafting, literature review, and approval of final manuscript.

Consent Statement: Authors declared that they have informed written consent for publication of this case report including clinical material (photographs/video), and every effort will be made to conceal the identity of the patient although not fully guaranteed.

  1. (). . Breau RH, Norman RW. Optimal prevention and management of proximal ureteral stent migration and remigration. J Urol. 2001; 166:890-3.
  2. (). . Garg RK, Menon P, Rao KLN, Arora S, Batra YK. Pyeloplasty for hydronephrosis: Issues of double J stent versus nephrostomy tube as drainage technique. J Ind Assoc Pediatr Surg. 2015; 20:32-6.
  3. (). . Mallikarjuna G, Ravichander G. Ureteric double-J stent related complications: a single tertiary care center experience from South India. Int J Res Med Sci. 2018; 6:3846-51.
  4. (). . Ahallal Y, Khallouk A. Risk factor analysis and management of ureteral double-J stent complications. Rev Urol. 2010; 12:e147-e151.
  5. (). . Slaton JW, Kftopp KA. Proximal ureteral stent migration: an avoidable complication? J Urol. 1996; 155:58-61.
  6. (). . Jayakumar S, Marjan M. Retrieval of proximally migrated double J ureteric stents in children using goose neck snare. J Indian Assoc Pediatr Surg. 2012; 17:6–8.
  7. (). . Meeks JJ, Helfand BT, Thaxton CS, Nadler RB. Retrieval of migrated ureteral stents by coaxial cannulation with a flexible ureteroscope and paired helical basket. J Endourol. 2008; 22:927–9.
  8. (). . Menezes P, Gujral S, Elves A, Timoney A. Ureteroscopic retrieval of proximally displaced ureteric stents using triradiate grasping forceps. Br J Urol. 1998; 81:758–9.
  9. (). . Yap RL, Batler RA, Kube D, Smith ND. Retrieval of migrated ureteral stent by intussusception of ureteral balloon dilator tip. Urol. 2004; 63:571–3.
  10. (). . Livadas KE, Varkarakis IM, Skolarikos A, Karagiotis E, Alivizatos G, Sofras F, et al. Ureteroscopic removal of mildly migrated stents using local anesthesia only. J Urol. 2007; 178:1998–2001.