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Retrieval of proximally migrated double J ureteric stents in children using goose neck snare

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  • Prashanth Women & Childrens Hospital

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Proximal migration of the ureteric double J stent is a rare but known complication. We describe three cases where a minimally invasive technique for retrieval of displaced double J stents using Amplatz(™) goose-neck snare was successful. A retrospective review of patients with displaced double J stent was carried out, in whom cystoscopy guided retrieval of double J stent was attempted with the help of Amplatz goose-neck snare under radiological control. All three patients were under the age of 3 years. Two patients had migrated double J stent following pyeloplasty and in one patient the double J stent was displaced during a retrograde insertion of double J stent. In all cases, retrieval of displaced double J stent was successfully achieved using Amplatz goose-neck snare. There were no postoperative complications. Our method of retrieval of stent from renal pelvis is simple, safe and minimally invasive. This technique is a useful and safe alternative option for retrieval of proximally migrated double J stents in children.
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6 Journal of Indian Association of Pediatric Surgeons / Jan-Mar 2012 / Vol 17 / Issue 1
INTRODUCTION
Insertion of double J (JJ) stent is common in pediatric
urology practice. Complications of ureteric stents
include stone formation, encrustation, fragmentation
of stent, fistula and migration of stent. Proximal
migration of the ureteric stent is a rare but a known
complication.[1,2] Various methods of retrieval of
stent have been described in adults,[2-5] but these are
technically more challenging in children and infants
due to the small anatomical caliber. We describe a
series of three patients under the age of 3 years, where
we demonstrate a minimally invasive technique for
retrieval of displaced double J stent using Amplatz™
goose-neck snare under radiological control.
MATERIALS AND METHODS
A retrospective review over a period of 5 years from 2000
to 2005 at our institution was carried out to identify
Original Article
ABSTRACT
Purpose: Proximal migration of the ureteric double J stent is a rare but known
complication. We describe three cases where a minimally invasive technique for
retrieval of displaced double J stents using Amplatz™ goose-neck snare was successful.
Materials and Methods: A retrospective review of patients with displaced double J stent
was carried out, in whom cystoscopy guided retrieval of double J stent was attempted
with the help of Amplatz goose-neck snare under radiological control. Results: All
three patients were under the age of 3 years. Two patients had migrated double J stent
following pyeloplasty and in one patient the double J stent was displaced during a
retrograde insertion of double J stent. In all cases, retrieval of displaced double J stent
was successfully achieved using Amplatz goose-neck snare. There were no postoperative
complications. Conclusion: Our method of retrieval of stent from renal pelvis is simple,
safe and minimally invasive. This technique is a useful and safe alternative option for
retrieval of proximally migrated double J stents in children.
KEY WORDS: Amplatz goose-neck snare, migrated double J stent, proximal migration of
ureteric stent
Retrieval of proximally migrated double J ureteric stents in
children using goose neck snare
Sivasankar Jayakumar, Mohamed Marjan, Key Wong, Amman Bolia1, George K. Ninan
Departments of Paediatric Urology and 1Interventional Radiology, Leicester Royal Infirmary, University Hospitals
Leicester, Leicester, LE1 5WW, United Kingdom
Address for correspondence: Dr. George K. Ninan, Department of Paediatric Urology, Leicester Royal Infirmary, Infirmary Road,
Leicester LE1 5WW, United Kingdom. E-mail: georgeninen@googlemail.com
proximal migration of double J stents in pediatric
patients. A total of three patients were identified and
Amplatz goose-neck snare under radiological control
was used to retrieve the proximally migrated double J
stents in all the three cases.
Equipment
An 8-F 30° cystoscope was used for the retrieval of
double J stents in all the three patients. Amplatz goose-
neck snare of appropriate size was used with the help
of a 0.035 guide wire. Standard fluoroscopy machine
that allowed screening, Digital Subtraction Angiography
(DSA) and road map facilities were used for all the three
procedures. The radiation dose, whilst not measured
exactly in each individual patient, was minimal,
involving screening for a minute or two in total, and a
single radiograph was taken for records.
Technique
The patient is positioned as for cystoscopy under general
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DOI
DOI: 10.4103/0971-9261.91078
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7Journal of Indian Association of Pediatric Surgeons / Jan-Mar 2012 / Vol 17 / Issue 1
Jayakumar, et al.: Migrated double J ureteric stents in children
anesthesia and an 8-F 30° cystoscope is introduced into
the bladder. A 0.035 guide wire is introduced via the
cystoscope into the appropriate ureteric orifice and the
position checked with fluoroscopy. The cystoscope is
removed and replaced by a catheter that comes with
the Amplatz goose-neck snare. The catheter is placed
adjacent to the double J stent and an appropriate size
Amplatz goose-neck snare is introduced through the
catheter under fluoroscopy control. The snare is then
pushed against the stent and deployed and twisted
in order to engage the double J stent. Once the snare
is engaged with the stent, the catheter along with the
snare and the held double J stent are removed urethrally
whilst screening, confirming that the engagement is
maintained all the time [Figure 1].
RESULTS
There were three pediatric patients. It is our practice
to remove the ureteric stent 8 weeks following
pyeloplasty via a cystoscope. In two cases, migration
of double J stent was noted at the time of cystoscopy
for elective removal of the stent following pyeloplasty.
In one of these two cases, ureteroscopy and stent
retrieval was attempted at the time of detection of
stent migration, however, without success. In the third
case, the patient had a pyeloplasty 2 years back and
underwent a retrograde insertion of the double J stent
for persistent hydronephrosis. The stent was displaced
proximally during retrograde insertion of double J
stent. In all the three cases, an Amplatz goose-neck
snare under radiological control was used to retrieve
the proximally migrated double J stents. The patient
characteristics are displayed in Table 1. There were no
postoperative complications noted. The average total
time of procedure spent under general anesthesia in
the operating room was 20 minutes.
DISCUSSION
Dislodgement and migration of double J ureteric stents
are rare but known complications. Distally migrated
stents into the urinary bladder can be easily removed
using forceps with cystoscopy guidance. However, the
difficulty arises when the stent migrates proximally.
In a comparison study, the stent-to-ureter length ratio
was lower in the migrated than in the non-migrated
group of patients with ureteric stents, suggesting that
shorter ureteric stents predisposed stent migration
proximally. The incidence of ureteric stents migrating
proximally is quoted as 2%.[2] A shorter than ideal stent,
inadequate distal curl and a proximal curl in the upper
calyx appear to be significant factors in the process of
stent migration.[6]
It is important to reposition or remove a proximally
migrated stent as it may cause obstruction or poor
drainage to the urinary flow. This can be achieved either
by an invasive procedure opening the renal pelvis or via
less invasive methods. Numerous methods of retrieval
of ureteric stents have been described in the literature.
Among these methods, ureteroscopy with the use of
grasping forceps, helical basket and ureteral balloon
dilator tip have been described in adults.[3-5] In a study
on 37 adult patients, ureteroscopy has been used to
retrieve the stents with a 91.9% success rate and no
complications.[7] Although flexible ureteroscopy has
been shown to be a safe and effective modality in the
treatment of upper ureteral calculi, with a 90% success
rate in children,[8] use of flexible ureteroscopy for stent
retrieval in children is yet to be reported. Ureteroscopy
and retrieval of proximal stent might be feasible in
children, but it may be difficult in young children and
infants due to the small anatomical caliber of the ureter.
Fluoroscopy guided retrieval of proximally migrated
ureteric stents is an alternative option to ureteroscopy.
Under fluoroscopic guidance, an antegrade approach
for the removal of such stents via pre-existing non-
Table 1: Case features
Sex Primary procedure Method of JJ
stent insertion
Age at JJ stent
retrieval (months)
Cystoscope
size used (F)
Amplax goose-neck
snare size used (mm)
Case 1 M Retrograde insertion of JJ stent Retrograde 30 8 30
Case 2 M Pyeloplasty Antegrade 8 8 20
Case 3 F Pyeloplasty Antegrade 2 8 10
Figure 1: (a) Dislodged stent and Amplatz goose-neck snare in dilated
renal pelvis. (b) The Amplatz goose-neck snare is deployed to retrieve
the dislodged stent
ab
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8 Journal of Indian Association of Pediatric Surgeons / Jan-Mar 2012 / Vol 17 / Issue 1
dilated nephrostomy routes has been described.[9]
However, most studies in literature have described a
retrograde approach.[10,11] Use of goose-neck snare under
fluoroscopy guidance for migrated stent retrieval is a
straightforward, well-tolerated, minimally invasive
retrograde technique described in adults.[10] However,
our series represents the only study describing the
retrieval of stent from renal pelvis in children using
Amplatz goose-neck snare.
In our small series of three pediatric patients, the
proximally migrated double J ureteric stents were
successfully retrieved using the Amplatz goose-neck
snare under fluoroscopy guidance. The technique is
simple, minimally invasive with minimal radiation
exposure. The patients in our series were very young
at 2, 8 and 30 months of age, and in our experience,
ureteroscopic retrieval of migrated double J stent in
one child was unsuccessful and we attribute this to the
small anatomical caliber of ureter in young children.
We believe that this technique with Amplatz goose-
neck snare is a safe and alternative option for retrieval
of proximally migrated double J stents in infants and
young children.
REFERENCES
1. Collier MD, Jerkins GR, Noe HN, Soloway MS. Proximal stent
displacement as complication of pigtail ureteral stent. Urology
Jayakumar, et al.: Migrated double J ureteric stents in children
1979;13:372-5.
2. Breau RH, Norman RW. Optimal prevention and management
of proximal ureteral stent migration and remigration. J Urol
2001;166:890-3.
3. 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.
4. 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.
5. Yap RL, Batler RA, Kube D, Smith ND. Retrieval of migrated
ureteral stent by intussusception of ureteral balloon dilator tip.
Urology 2004;63:571-3.
6. Slaton JW, Kropp KA. Proximal ureteral stent migration: An
avoidable complication? J Urol 1996;155:58-61.
7. 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.
8. Nerli RB, Patil SM, Guntaka AK, Hiremath MB. Flexible
ureteroscopy for upper ureteral calculi in children. J Endourol
2011;25:579-82.
9. Shin JH, Yoon HK, Ko GY, Sung KB, Song HY, Choi E, et al.
Percutaneous antegrade removal of double J ureteral stents via
a 9-F nephrostomy route. J Vasc Interv Radiol 2007;18:1156-61.
10. Wetton CW, Gedroyc WM. Retrograde radiological retrieval and
replacement of double-J ureteric stents. Clin Radiol 1995;50:
562-5.
11. Boardman P, Cowan NC. Technical report: Fluoroscopically
guided retrograde ureteric stent retrieval and replacement using
a guide catheter directed snare. Clin Radiol 1997;52:308-9.
Cite this article as: Jayakumar S, Marjan M, Wong K, Bolia A, Ninan
GK. Retrieval of proximally migrated double J ureteric stents in children
using goose neck snare. J Indian Assoc Pediatr Surg 2012;17:6-8.
Source of Support: Nil, Con ict of Interest: None declared.
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... Conventionally retrograde cystoscopic route is the preferred route for removal of these stents [2,3]. However, the conventional method of retrograde cystoscopic stent removal may not be feasible in presence of proximal stent migration, distorted anatomy secondary to PEDIATRIC UROLOGY CASE REPORTS ISSN 2148-2969 urinary diversion or previous bladder surgeries [2][3][4]. Antegrade percutaneous nephrostomic removal of the ureter stent can be used as a bailout technique in these cases and is well described in the literature [2][3][4]. However, our case was unique as it was performed in an infant which required certain modifications in standard technique. ...
... However, the conventional method of retrograde cystoscopic stent removal may not be feasible in presence of proximal stent migration, distorted anatomy secondary to PEDIATRIC UROLOGY CASE REPORTS ISSN 2148-2969 urinary diversion or previous bladder surgeries [2][3][4]. Antegrade percutaneous nephrostomic removal of the ureter stent can be used as a bailout technique in these cases and is well described in the literature [2][3][4]. However, our case was unique as it was performed in an infant which required certain modifications in standard technique. ...
... Percutaneous antegrade nephrostomic removal of ureteral stent is well described in literature and generally considered a safe procedure despite few reported complications like nephrostomy wound infection, pelvicalyceal system injury, and clot in renal pelvis [2][3][4][5][6][7]. Major studies in this regard have described the use of 8F or 9F vascular access sheath placed through a percutaneous nephrostomic route and removal of the DJ stent using micro-snares or foreign body removal forceps [2,3,6]. ...
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Double J stent is an essential tool in urology, being a basic part of many urological procedures. However, some issues related to their use still occur. Our study aimed to evaluate an important number of procedures, the complications of ureteral stents, and their prevention and treatment retrospectively. We evaluate 50,000 procedures performed between 1996 and 2021 on 36,688 patients. According to the stenting duration, the cases were divided into short-term (less than 6 weeks - 34,213 procedures), respectively long-term stenting (more than 6 weeks - 15,757 procedures). The indications of stenting for both groups were noted. The total number of complications was 41,369. We encountered 153 cases (0.3%) of JJ stent malposition, of which 3 cases were into the retroperitoneum, one case with parenchymal perforation and hematoma. Considering the double J migrations, we found proximal migration in 427 cases (0.9%) and distal double J migrations in 352 (0.7%) cases. The obstruction of the ureteral stent, causing inefficient drainage, was encountered in 925 cases, while irritative bladder symptoms occurred in 16,326 cases (32.7%). Hematuria was observed in 5,213 cases, in 7 cases blood transfusion being necessary. Urinary tract infection was diagnosed in 7,436 cases (14.8%). Stent encrustation and calcification occurred in 832 cases, while stent fragmentation was noted in 52 cases. Double J stent complications should be promptly evaluated and treated. Encrustation and stone formation in forgotten stents often lead to serious complications and should be managed with stent removal and combined endourological techniques.
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To evaluate the safety and clinical efficacy of an antegrade approach in the removal of double J ureteral stents via preexisting nondilated nephrostomy routes under fluoroscopic guidance. Under fluoroscopic guidance and local anesthesia, antegrade removal of 39 ureteral stents in 27 patients was attempted by using a snare or basket. Indications for percutaneous stent removal included the presence of a preexisting nephrostomy route (n = 8), a surgical history resulting in an inaccessible retrograde route (n = 8), urethral stricture (n = 5), upward stent migration (n = 2), inability to obtain a lithotomy position (n = 1), fragmentation of the proximal stent (n = 1), and inability to find the ureteral orifice with a cystoscope (n = 2). Thirty-seven of the 39 stents (95%) were successfully removed by using a snare or basket. Two stents (5.1%) could not be removed with a snare or basket because they were embedded against the renal calyx or pelvis. There were no major complications. Blood clot formation or laceration or tract leakage of the pelvicalyceal system occurred in six and two patients, respectively, all of which resolved spontaneously. Percutaneous antegrade removal of double J ureteral stents with a snare or basket via a nondilated nephrostomy route is effective without major complications in patients with an available nephrostomy route or an inaccessible retrograde option.
Article
In the outpatient office setting we evaluated the feasibility and efficacy of ureteroscopic removal of upward migrated ureteral stents using local or no anesthesia. Prospectively 37 patients with mild upward stent migration underwent ureteroscopic stent removal under local or no anesthesia. Stent migration was always below the pelvic brim. It was diagnosed by plain x-ray of the kidneys, ureters and bladder, and flexible cystoscopy. Semirigid ureteroscopy was performed in the office outpatient setting. After each procedure patients graded the discomfort and/or pain level experienced by completing 2 separate 5-scale visual analog pain scores, including 1 for flexible cystoscopy and 1 for the ureteroscopic procedure. Pain scores were compared between the 2 procedures. Stent removal was successful in 34 of 37 patients (91.9%). Successful procedures were never interrupted due to pain intolerance. No complications occurred. The mean visual analog pain score for ureteroscopic stent removal was 1.73 and it was similar in men and women (p = 0.199). The mean visual analog pain score for flexible cystoscopy was 1.27. This procedure was significantly more painful in men than in women (p = 0.018). Ureteroscopic stent removal was more painful than flexible cystoscopy overall and in women (each p <0.01) but not in men (p = 0.3). All patients were discharged home within 1 hour after the procedure and no patient required hospital admission or a new hospital visit. Ureteroscopic removal of a migrated stent using local anesthesia is effective, safe and tolerable in select patients. Preventing the complications and costs associated with general or spinal anesthesia makes this option appealing to patients and it should be offered when possible.