Fully proximal migrated double J-stent in a pediatric patient with congenital ureteropelvic junction obstruction: a pediatric case report

doi:10.21203/rs.3.rs-4869972/v1

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Case Report

Fully proximal migrated double J-stent in a pediatric patient with congenital ureteropelvic junction obstruction: a pediatric case report

https://doi.org/10.21203/rs.3.rs-4869972/v1

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Proximal double-J stents (DJ) migration is infrequent in the pediatric population. We present the case of a 5-year-old patient with a previous diagnosis of ureteropelvic junction obstruction who underwent a dismembered pyeloplasty in early infancy and suffered an anastomotic stricture. Endourological dilatation was performed. During placement of the DJ, it migrated proximally until it was wholly lodged in the renal pelvis. A second DJ was placed correctly, and the procedure was ended. Two months later, a successful retrograde removal was performed using an endourological hydrodistension system. We describe our technique, which may be a valuable resource for similar cases.

Urology & Nephrology

Surgery

Pediatrics

ureteral hydrodistension

proximally migrated double J-stent

UPJO

pediatric

retrograde extraction

The development of endourological techniques and their application to the pediatric population has led to a significant decrease in the morbidity and mortality of these patients and a significant improvement in clinical outcomes. These techniques are a technical challenge because of their procedural complexity and the instruments' limitations. Still, despite this, in recent years, they have been gaining popularity and are becoming established as the standard of reference in many centers for multiple pathologies [1–2]. Ureteropelvic junction obstruction (UPJO) is a congenital pathology that has classically been treated by surgery. However, endourological techniques have proven useful both in the primary treatment of the condition and in treating complications derived from surgery, such as the formation of anastomotic strictures [3–5]. However, endourological procedures are not without problems: multiple potential complications have been described both in the adult and the pediatric population, including perforation of the urinary tract, severe haematuria, or migration of the instruments used, especially Double-J stents (DJ) [6–7]. In the case of UPJO, the presence of a dilated renal pelvis with the capacity to accommodate a complete DJ favors this rare but potential complication.

Multiple approaches and techniques, both retrograde and antegrade, have been proposed to resolve the latter complication. Jayasimha et al. [6] presented a case series of 8 patients and proposed an algorithm based on the degree of DJ migration (partial or total). Of the 6 cases with complete DJ migration, only one case of successful retrograde ureteroscopic retrieval was reported. More recently, Sharifiaghdas et al. [7] reported ten patients with proximally migrated DJ in infants, demonstrating the anterograde approach's safety and efficacy using ultrasonographic guidance.

A 5-year-old female patient presented with a prenatal diagnosis of left hydronephrosis. An ultrasound scan and a MAG-3 scintigraphy established the diagnosis of left UPJO, and she underwent a dismembered Anderson-Hynes pyeloplasty in early childhood. During the post-surgical follow-up, initial ultrasonographic improvement and subsequent worsening were noted. The post-surgical MAG-3 scintigraphy showed the obstruction's persistence, so the diagnosis of anastomotic stricture was established. It was decided to calibrate and endourological dilatation of the ureteropelvic junction (UPJ). Under general anesthesia and in the lithotomy position, an 8 Fr cystoscopic access was performed. Both ureteral meatuses were orthotopically inserted, and there were no bladder alterations. After passing a 0.035’ hydrophilic guidewire through the left ureteral meatus, endourological dilatation of the UPJ was performed under videofluoroscopic control, which showed the presence of a notch (stricture) that resolved during the procedure. It was decided to insert a DJ. Controlled advancement of the DJ through the guidewire was performed, and during the procedure, an accidental migration of the DJ was noted. Intraoperative radiological examinations showed that the DJ was wholly lodged in the patient's left renal pelvis. Since the ureter had already been manipulated, it was decided to place a new DJ without attempting to remove the migrated DJ. This new DJ was placed without incident, and its position was checked before the end of the procedure. The patient evolved favorably, with occasional colic discomfort in the left flank during the first few days, which resolved spontaneously and did not require treatment. Figure 1 shows an abdominal radiograph of the patient after completion of the procedure. Two months later, a new endourological examination was performed. The bladder was accessed using an 8 Fr cystoscope, and a pressure system set at 80 mmHg was connected to the irrigation system. A ureteral hydrodistension was performed, allowing visualization of the catheter lodged in the pelvis. DJ removal forceps were used to quickly retrieve the catheter (Fig. 2, Supplementary file 1). The patient evolved favorably and is currently asymptomatic, undergoing follow-up, and has no new evidence of UPJ obstruction.

The field of endourology in the pediatric population is promising. It is feasible and safe, but the existing experience is scarcer than in adult populations, and the technical resources available are limited. This report details a simple, secure, and effective technical solution to a potential complication of pediatric DJ placement. We believe the procedure we propose has multiple advantages: the hydrodistension allowed ureteroscopic access with good visualization and allowed us to verify the absence of strictures in the previously dilated area. Likewise, resolving the complication with a retrograde approach significantly reduces the morbidity associated with the procedure. It should be noted, however, that sudden and excessive hydrodistension of the urological tract in pediatric patients may trigger severe haematuria, so the procedure should be performed prognostically. Finally, in our case, the cystoscope allowed for the complete performance of the procedure, and a ureterorenoscope was not required. This is another positive point, given that not all centers with pediatric surgery have a ureterorenoscope, being the cystoscope is much more widespread.

Before the procedure, we held a session to consider potential approaches to solve the problem. We decided that if the retrograde route was unsuccessful, the patient would be approached anterogradely. The interventional radiologist was consulted, given that one of the options we considered was an ultrasound-guided pyelostomy followed by a percutaneous extraction. In our case, it was not necessary.

In our case, we performed the procedure with an adult urologist with extensive experience in endourology. We believe this collaboration was very positive, and we consider adult urology teams a valuable resource for solving pediatric endourological problems in a multidisciplinary way. Their expertise and knowledge of the available resources in endourology are essential.

In conclusion, when faced with complete pelvic migration of a DJ in a patient with UPJO, retrograde extraction with ureteral hydrodistention should be considered a safe, quick, and simple technique. However, experience is minimal, and additional plans to resolve complications, such as antegrade access, are necessary. The support of adult endourology and adult interventional radiology teams is essential.

CRediT – Contributor Roles Taxonomy:

Javier Arredondo Montero: literature review, resources, data extraction, data curation, data interpretation, writing-original draft, writing-review and editing.

Alberto Rivero Cardenes, María Rodríguez Ruiz: resources, writing-review and editing.

Original work:

The manuscript authors declare that it is an original contribution, not previously published.

Conflict of interest:

There is no conflict of interest or external funding to declare. The authors don´t have anything to disclose.

Ethics statement:

Our center's IRB assessed and approved the present work under code 24072. Before the submission of this article, verbal and written informed consent was obtained from the patient's legal guardians, who were included in this publication. This work was carried out following the principles of the Helsinki Declaration (2013 statement).

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Sharifiaghdas F, Bonakdar Hashemi M, Dadpour M, Aslani A, Farshid S (2023) Antegrade Percutaneous Retrieval of Upward Migrated Double-J Stent in Very Small Size Pediatric Patients Under Ultrasonic Guide. J Laparoendosc Adv Surg Tech A 33(3):303–307 Epub 2023 Feb 14. PMID: 36787464

The authors declare no competing interests.

Supplementaryfile1.mp4
Supplementary material 1. Cystoscopy video.

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Fully proximal migrated double J-stent in a pediatric patient with congenital ureteropelvic junction obstruction: a pediatric case report

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