Ureteric stent left in situ for 27 years

In 1986, a 27-year-old man underwent left renal surgery for congenital hydronephrosis. He had an indwelling ureteric stent placed during the procedure which he was under the impression was to be left permanently. In 2014, he presented to a urology clinic with a long-standing history of voiding symptoms including frequency, nocturia, hesitancy and post-void dribbling, as well as one recent symptomatic urinary tract infection. A kidney–ureter–bladder (KUB) ultrasound showed a crescenteric-shaped shadowing echogenic lesion in the bladder. A subsequent KUB plain radiograph showed curvilinear opacities consistent with ureteric stent fragments in the lower pole of the left kidney, middle of the left ureter and in the bladder (Fig. 1). The patient, now 54 years old, proceeded to undergo cystoscopy and ureterorenoscopy and the presence of the three heavily encrusted stent fragments seen in the radiograph was confirmed (Fig. 2). Approximately three-quarters of a heavily encrusted stent coil was found in the bladder, which was amenable to stone crushing forceps and removed. Another 1.5-cm stent fragment was found in the left ureter that was removed with a Segure Hemisphere 2.4 fg stone retrieval basket (Boston Scientific, Marlborough, MA, USA). A final 1-cm stent fragment was visualized in the left lower pole of the kidney and removed with an NGage 1.7 fg Stone Extractor (Cook Medical, Bloomington, IN, USA) via flexible ureterorenoscopy and a ureteric access sheath. Intra-operative radiographs confirmed there were no stent fragments remaining, and pathology reports confirmed the presence of mainly calcium and oxalate calculi. It is uncertain what happened to the rest of the stent – we suspect it may have disintegrated over time and passed spontaneously. This could have contributed to his voiding symptoms, as well as the larger calcified pieces remaining in situ. Ureteric stents are routinely inserted during reconstructive urological surgery to prevent urinary tract obstruction secondary to an oedematous healinganastomosis.All indwellingureteric stents shouldbe removedor replaced in due time to avoid the well-documented sequelae of retained stents including encrustation, migration and urosepsis. There is evidence that the rate of encrustation of stents rises with increased indwelling time, with one series quoting a 76.3% rate of encrustation if left longer than 12 weeks. A number of other risk factors for encrustation have been identified, including history of urolithiasis, certain biomaterials, bacterial colonization and pregnancy. This case is consistent with a reported trend of the greatest degree of encrustation occurring in the upper coil of the stent. It is highly unlikely there will ever be a consensus guideline for the management of encrusted or retained stents, as each case has individual peculiarities and each urologist has different preferences and skill sets. A wide variety of successful management techniques have been described, ranging from intracorporeal lithotripsy and basketing, to extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy. There are some common features of management that are important regardless of the chosen management strategy. Thorough preoperative imaging should be undertaken to provide a clear picture of the problem, with a view to minimizing the number of anaesthetic sessions required. Any forceful attempt to remove stents should be avoided due to the risk of ureteral injury or