P1736FIRST PROSPECTIVE CLINICAL STUDY OF A SINGLE-USE STERILE CYSTOSCOPE DESIGNED FOR DOUBLE J (DJ) STENT REMOVAL IN AN ITALIAN TRANSPLANT CENTER
Authors: AMATO Antonio 
Published: June 2020

Abstract

Background and Aims
A DJ is routinely placed during kidney transplantation then post-operatively removed, usually within the first month after transplantation.
The removal is mainly performed in urology unit, through reusable rigid scope in an operating theatre with anesthesiologist assistance. Such removal procedure requires a complex environment with reprocessing, periodic maintenance and repairs of scopes, leading to delays and postponed stent removals.
Hematuria, pain or dysuria due to the local trauma, and urinary infection are the most common complications of the DJ removal procedure.
To overcome these issues, we introduced in April 2018 in our unit the single use sterile cystoscope ready to use with integrated grasper designed for DJ removals.

Method
We hereby report our experience with single-use flexible cystoscope (Isiris® – Coloplast).
We prospectively collected data of any DJ stent removal operation from April 2018 to December 2019 (92 procedures). Urine culture at the removal day and usually 1 week after, at the first outpatient control was performed. All complications (related or not to the procedure) were recorded.
All removals were performed in our unit by the nephrologist.
87 patients were treated, from which 82 as outpatients, and 5 as in-patients.

Results
86 out of 87 patients stent removals were effectively done with Isiris®.
In a single case, we could not remove the stent with the single-use instrument and resorted to traditional rigid cystoscopy under general anaesthesia. This happened with the sixth patient of our series and we think that this failure happened in the learning curve phase.
In 4 cases stent removal wasn’t possible at first attempt due to likely interference of the internal stitches of the anastomosis: our policy is NOT to force stent removal if any resistance is felt to light pulling. Indeed, in all 4 cases a second procedure performed one month later was completely successful with smooth withdrawal of the device.
In one case, a removal procedure was not possible because of urethral stricture and stent removal was postponed after its treatment.
Taking into account these five patients the success rate of using Isiris® is 98.9% during this period.
No patient was admitted for complications related to the removal procedure, namely for symptomatic urinary tract infection requiring antibiotics.
Two patients were admitted for obstructive nephropathy (namely ureteral stenosis) which became evident after stent removal.
16 patients had an asymptomatic positive urine culture for a multi-resistant microbe before the stent removal and maintained positivity after the procedure.
11 patients were negative on the day of the stent removal and resulted positive in the control done at the first control. Again, none developed symptoms, and none required treatment.
9 patients were positive before stent removal and were negative on the first control.
The rest of the patients were negative both at baseline and thereafter.

Conclusion
Due to the simplicity of the procedure by the single use solution (with 98.9% removal success, no operating theatre, no anaesthesiologist) and the fact that it is entirely managed by the transplantation clinic staff, the timing of the stent removal always respected physician’s indication, with no procedure delayed for organizational reasons. Knowing the infection risk associated with longest ureteral stent dwell durations, and the vulnerability of these immunosuppressed patients, it is important to remove the DJ as safely as possible and in defined time. In our study, no patient had to be admitted for urinary tract infection after the procedure nor developed symptomatic urinary tract infection to be treated with antibiotics.