Patients with encrusted ureteral stents can be treated by a single session combined endourological approach

Lopes, Roberto Iglesias; Perrella, Rodrigo; Watanabe, Carlos Hirokatsu; Beltrame, Fabricio; Danilovic, Alexandre; Murta, Claudio Bovolenta; Claro, Joaquim Francisco de Almeida; Vicentini, Fabio Carvalho

doi:10.1590/S1677-5538.IBJU.2020.0511

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Original Article • IBJUInt. braz j urol 47 (3) • May-Jun 2021 • https://doi.org/10.1590/S1677-5538.IBJU.2020.0511 copy

Patients with encrusted ureteral stents can be treated by a single session combined endourological approach

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Purpose:

To describe our experience in the management of retained encrusted ureteral stents using a single session combined endourological approach.

Materials and Methods:

Patients with retained encrusted ureteral stents who had been submitted to a single session combined endourological approach from June 2010 to June 2018 were prospectively evaluated. Patients were divided according to the Forgotten-Encrusted-Calcified (FECal) classification. The stone burden, surgical intervention, number of interventions until stone free status, operation time, hospital stay, complications, stone analysis, and stone-free rate were compared between groups. ANOVA was used to compare numerical variables, and the Mann-Whitney or Chi-square test to compare categorical variables between groups.

Results:

We evaluated 50 patients with a mean follow-up of 2.9±1.4 years (mean±SD). The groups were comparable in terms of age, sex, laterality, BMI, comorbidities, ASA, reason for stent passage, and indwelling time. The stone burden was higher for grades IV and V (p=0.027). Percutaneous nephrolithotomy was the most common procedure (p=0.004) for grades IV and V. The number of procedures until the patients were stone-free was 1.92±1.40, and the hospital stay (4.2±2.5 days), complications (22%), and stone analysis (66% calcium oxalate) were similar between groups. The stone-free rate was lower in grades III to V (60%, 54.5%, and 50%).

Conclusions:

The endoscopic combined approach in the supine position is a safe and feasible technique that allows removal of retained and encrusted stents in a single procedure. The FECal classification seems to be useful for surgical planning.

Keywords
Stents; Ureter; Nephrolithotomy, Percutaneous

		Grade I	Grade II	Grade III	Grade IV	Grade V	Total	p - value
Number of patients		11	8	10	11	10	50
Age (Years, mean ± SD)		43.7 ± 12.5	47.7 ± 12.7	42.8 ± 9.9	47.1 ± 18.5	47.7 ± 15.8	45.7 ± 13.9	0.71
Gender (M:F)		27.3%: 72.7%	25%: 75%	40%: 60%	45.5%: 54.5%	50%: 50%	36%: 64%
Side
	Left	45.5%	25%	40%	54.5%	60%	46%
	Right	54.5%	75%	60%	45.5%	40%	54%
BMI (Kg/m², mean ± SD)		26.9 ± 4.5	28.8 ± 6.1	26.0 ± 3.9	24.1 ± 3.8	26.2 ± 6.53	26.3 ± 4.9	0.89
ASA classification
	I	54.5%	37.5%	60%	54.5%	20%	20%	0.35
	II	27.3%	62.5%	40%	18.2%	60%	60%
	III	9.1%	--	--	27.3%	20%	20%
	IV	9.1%	--	--	--	--	--
Reason for Stent Placement							–
	Urinary sepsis	4 (36.4%)	4 (50%)	4 (40%)	2 (18.2%)	3 (30%)	17 (34%)	0.47
	Acute kidney injury	2 (18.1%)	3 (37.5%)	1 (10%)	3 (27.3%)	2 (20%)	11 (22%)
	Pain and Hydronephrosis	2 (18.1%)	0	4 (40%)	3 (27.3%)	4 (40%)	13 (26%)
	Definitive treatment non-available	0	1 (12.5%)	0	1 (9.1%)	1 (10%)	3 (6%)
	Other	3 (27.3%)	0	1 (10%)	2 (18.2%)	0	6 (12%)
Indwelling Stent Time (Months, mean ± SD)		7.3 ± 3.0	26.1 ± 10.0	13.8 ±10.7	30.1 ± 20.1	32.8 ± 23.2	21.7 ± 13.4	0.11

		Grade I	Grade II	Grade III	Grade IV	Grade V	Total	P - value
Stone burden (cm³, mean ± SD)		288.4 ± 252.4	489.0 ± 385.7	1056.0 ± 842.4	8044.1 ± 4779.2	10699.3 ± 9497.8	4262.4 ± 3236.7	0.027
PCNL		0	62.5%	70%	81.9%	100%	64%	0.004
ULT		100%	100%	40%	54.5%	80%	60%	< 0.001
CLT		54.5%	0	0	100%	100%	62%	0.281
Surgical Time (Min, mean)		65 ± 32	100 ± 25	110 ± 64	138 ± 74	164 ± 67	115.5 ± 53.5	0.006
Number of Procedures to Stone Free Status		1.36 ± 0.9	2.25 ± 1.5	2.7 ± 2.0	1.28 ± 1.2	2.25 ± 1.5	1.92 ± 1.4	0.687
Hospital Stay (Days, mean ± SD)		4.4 ± 2.6	2.60 ± 1.8	2.9 ± 1.8	5.7 ± 2.4	7.0 ± 2.1	4.2 ± 2.5	0.141
Blood transfusion		0	0	0	9.1%	0	2%
Clavien classification
	Without Complication	81.8%	62.5%	80%	72.7%	90%	78%	0.541
	I	9.1%	37.5%	20%	9.1%	0	14%
	II	0	0	0	0	0	0
	III a	9.1%	0	0	0	0	2%
	III b	0	0	0	9.1%	10%	2%
	IV a	0	0	0	9.1%	0	2%
	IV b	0	0	0	0	0	2%
Success (Stone-free)		90.9%	87.5%	60%	54.5%	50%	66%	0.081
Stone Analysis
	Calcium Oxalate	81.8%	100%	50%	45.5%	60%	66%
	Struvite	0	0	50%	54.5%	20%	26%
	Calcium phosphate	9.1%	0	0	0	0	2%
	Mixed	9.1%	0	0	0	20%	6%

	Grade I	Grade II	Grade III	Grade IV	Grade V
URS + RIRS	5 (45.5%)	3 (37.5%)	3 (30%)	0	0
PCNL + RIRS	0	0	6 (60%)	0	0
PCNL + URS + RISRS	0	5 (62.5%)	1 (10%)	0	0
CLT + URS + RIRS	6 (54.5%)	0	0	2 (18.1%)	0
CLT + PCNL + RIRS	0	0	0	5 (45.5%)	2 (20%)
CLT + URS + PCNL + RIRS	0	0	0	4 (36.4%)	8 (80%)

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[1] Correspondence address: Rodrigo Perrella, MD Divisão de Urologia, Hospital Brigadeiro, Av. Brigadeiro Luis Antônio, 2651 São Paulo, SP, 01401-901, Brasil Fax: + 55 11 3289 3662 E-mail: perrella.uro@gmail.com