Extra-anatomical complications of antegrade double-J insertion

Abstract

Introduction: Insertion of a double-J (JJ) stent is a common procedure often carried out in the retrograde route by the urologists and the antegrade route by the radiologists. Reported complications include stent migration, encrustation, and fracture. Extra-anatomic placement of an antegrade JJ stent is a rare but infrequently recognized complication.

Materials and methods: We performed a retrospective audit of 165 antegrade JJ stent insertions performed over three consecutive years by a single interventional radiologist. All renal units were hydronephrotic at the time of nephrostomy. All procedures were performed under local anaesthetic with antibiotic prophylaxis.

Results: Antegrade stent insertion was carried out simultaneously at the time of nephrostomy in 55 of the 165 cases (33%). The remainder were inserted at a mean of 2 weeks following decompression. In five (3%) patients, who had delayed antegrade stenting following nephrostomy, the procedure was complicated by silent ureteric perforation and an extra-anatomic placement of the stent. These complications had delayed manifestations, which included two retroperitoneal abscesses, a pelvic urinoma, a case each of ureterorectal fistula, and ureterovaginal fistula. Risk factors for ureteric perforation include previous pelvic malignancy, pelvic surgery, pelvic radiation, and a history of ureteric manipulation.

Conclusion: Antegrade ureteric JJ stenting is a procedure not without complications. Extra-anatomic placement of the antegrade stent is a hitherto the infrequently reported complication but needs a high index of suspicion to be diagnosed. Risk factors for ureteric perforation at the time of stent insertion have to be considered to prevent this potential complication.

Keywords: Antegrade; complications; stent; ureter.

Figure 1

Nephrostogram demonstrating a tight stricture at the lower end of left ureter

Figure 2

Nephrostogram suggesting that the lower end to be in the bladder

Figure 3

Resection of the bladder wall with demonstration of blue staining by methylene blue. The lower end of the stent in perivesical fat

Figure 4

Plain X-ray of abdomen showing an abnormal position of the lower end of the left JJ stent

Figure 5

Nephrostogram showing stricture at the lower end of the left ureter

Figure 6

Plain X-ray KUB showing the lower end of the stent in the bladder region

Figure 7

Fluoroscopic examination at the time of cystoscopy demonstrating extra-anatomic location of JJ stent

Figure 8

Left nephrostogram showing the dye to be stopping at the site of stricture

Figure 9

Unusual anterior location of the lower end of the JJ stent and demonstration of dye in the vagina

Figure 10

Right nephrostogram showing narrowing of the uretero-ileal junction

Figure 11

Ultrasound showing the presence of the lower end of the right JJ stent in the abscess cavity