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ORIGINAL ARTICLE
Year : 2002  |  Volume : 19  |  Issue : 1  |  Page : 54-57
 

Optimum duration of J.J. stenting in live related renal transplantation


Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Correspondence Address:
Balbir S Verma
Department of Surgery, Government Medical College and Hospital, Sector 32, Chandigarh - 160 047
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Purpose: Ureterovesical anastomosis related compli­cations might cause significant morbidity, allograft loss and even mortality. Routine prophylactic JJ stenting against these complications though controversial seems to be gaining literature support. - ' There is no consensus as to the optimum duration of stenting and various stud­ies report stenting for 1 week to 3 months. This study was conducted to know the optimum duration of JJ stenting in renal transplantation.
Material and Methods: 52 (group 1) live related renal transplant recipients, stented for 2 weeks were compared to 57 (group 2) historical controls (from our previous study 5), stented for 4 weeks. A 16 cm/6F polyurethane JJ stent was left across the ureteroneocvstostomy performed by Lich Gregoir technique. The stent was removed under local anesthesia within same admission in group 1 and in second admission in group 2. Both groups received simi­lar antibiotics and bnmunosuppression and were moni­tored for urological complications.
Results: There was no major urological complication requiring surgical intervention in either group. The inci­dence of minor complications resolving with conservative management was also similar in the 2 groups. There were 2 ,forgotten stents in group 2 (badly encrusted and removed at 3 years and 11 months respectively). The second ad­mission in group 2 for stent removal incurred extra cost as it was done in the routine operation theatre to avoid infection.
Conclusions: Reducing the duration of stenting from 4 weeks to 2 weeks avoids complications associated with pro­longed use of stent without compromising the beneficial ef-' feats of stent in preventing the urological complications. It obviates the risk of forgotten stent as well as curtails the cost of second admission for stent removal.


Keywords: Stenting, Renal Transplant, Ureteroneocystostomy, Urological Complications


How to cite this article:
Verma BS, Bhandari M, Srivastava A, Kapoor R, Kumar A. Optimum duration of J.J. stenting in live related renal transplantation. Indian J Urol 2002;19:54-7

How to cite this URL:
Verma BS, Bhandari M, Srivastava A, Kapoor R, Kumar A. Optimum duration of J.J. stenting in live related renal transplantation. Indian J Urol [serial online] 2002 [cited 2020 Dec 5];19:54-7. Available from: https://www.indianjurol.com/text.asp?2002/19/1/54/20292



   Introduction Top


Urological complications following renal transplanta­tion may cause significant patient morbidity, allograft loss and even patient mortality. [1] Majority of these complica­tions are related to ureterovesical anastomosis. The rou­tine use of JJ stent to prevent these complications has been a controversial issue. The review of literature appears to tilt the balance in favor of routine prophylactic stenting in renal transplant recipients. [1],[2],[3],[4] In a prospective randomized trial, we also found that routine stenting almost eliminated the urological complications. [5]

The routine use of JJ stents, though useful in prevent­ing urological complications, may be fraught with poten­tial complications like infection, stone formation/ encrustation/blockade or stent breakage, in case the stent is kept in for long.' There is no consensus on the optimum duration of stenting in literature. [6] Various studies report a wide range of duration of stenting : one week to three months. [1],[2],[3],[4],[5],[6] We therefore conducted a study to know the optimum duration of stenting in the recipients of renal transplantation so as to avoid potential stent related com­plications without compromising the beneficial effects of stent in preventing urological complications.


   Material and Methods Top


52 (group 1) live related renal transplantation performed between January 1996 and June 1996, having JJ stent for 2 weeks, made the study population for this trial. In our previous study, from January 1994 to April 1995, there were 57 patients who were stented for 4 weeks. [5] These 57 patients were taken as historical controls (group 2). Ure­teroneocystostomy was performed by Lich Gregoir tech­nique, [7] leaving a 16 cm/6F Polyurethane JJ stent across the anastomosis in both groups. All patients had indwell­ing urethral catheter for initial 5 days. Suction drains were used routinely in all patients and removed once the 24-hour drainage was less than 30 ml. The stent was removed cystoscopically under local anesthesia at 2 weeks in study group and 4 weeks in control group. Thus all patients in group 1 got their stent removed before discharge from the hospital. The controls were required to get admitted sec­ond time for stent removal which was undertaken in rou­tine operation theatre and not in the outpatient urology clinic to avoid infection.

All patients received prophylactic antibiotics for initial 2 days followed by 960 mg of Co-trimoxazole on alter­nate days for 3 months, as prophylaxis against urinary tract infection and Pneumocystis carinii infection. Immunosup­pression was based on Azathioprine, Cyclosporine and Prednisolone in both groups. All patients were monitored routinely with serum creatinine, blood urea nitrogen (BUN), leukocyte counts, chemical analysis of drainage fluid and culture of urine and drainage fluid. Ultrasono­graphy and radionuclide renal scans were performed on day 1, 3 and 7 and repeated at 3, 6 and 12 months rou­tinely. All episodes of urinary tract infection, rejection. urinary leak, obstruction and stent-related problems were recorded. Evaluation of urological complications was done to see the impact of early removal of stent at 2 weeks.


   Results Top


Both groups were comparable in terms of age, sex, as­sociated medical illness and age of donor [Table - 1]. There was no major urological complication requiring surgical intervention, in either group. The frequency of minor complications, which resolved with conservative management, was similar in the 2 groups. The incidence of sonographi­cally detected fluid collection of more than 5 ml, not re­quiring surgical intervention, was 5.8% in group 1 and 10% in group 2. The duration of drainage was 3.2 days and 4.1 days in groups I and 2 respectively. Hospital stay was similar in two groups (17.1 ± 1.4 days in group I and 16.8 ± 1.6 days in group 2). The incidence of stent-related problems is depicted in [Table - 2]. Asymptomatic urinary in­fection (>l0 5 bacteria/ml) rate was 25.2% and 35.1% re­spectively in groups I and 2. In group 2, stent was forgotten in 2 patients and removed after 3 years in one and 11 months in another. These stents were badly encrusted and difficult to remove. These patients presented with recurrent urinary tract infections and persistently positive urine cul­tures. Problem of forgotten stents was never faced in group 1, as the stent was always removed before discharge of pa­tients from the hospital. In group 2, stent had to be removed in 2 patients, at 14 and 18 days respectively due to persist­ent symptomatic urinary tract infection. These patients com­plained of dysuria before stent removal, both of them having positive culture. 1 patient in group 1 and 3 patients in group 2 complained of dysuria before stent removal. There was no case of stent migration, breakage, stone formation, stent­related obstruction or hematuria in either group.


   Discussion Top


The majority of urological complications occur within first 3 months after renal transplantation and have been successfully treated using ureteric stents. [8],[9] In 1990s there has been a surge in literature supporting routine prophylactic use of JJ stent in renal transplant recipients. [1],[2],[3],[4],[5],[6] However there is a genuine concern regarding potential stent-related prob­lems like hematuria, encrustation/stone formation, forgot­ten stents and stent breakage.

Basssiri et al 1995, in a prospective, randomized, stent versus non-stent study, kept stent for 6-8 weeks (average 54 days). They came across 2 cases with frank hematuria after 2 weeks in the stent group, which was terminated by removing the stent. Another 2 patients with stents devel­oped extensive calcification of the stent, making stent re­moval difficult. Moreover, they found the frequency of urinary tract infection to be 33% in those with the stent and 5% in those without (P<0.01). [10]

In another study by Nicholson et al (1991), the frequency of infection has been reported to be 27% with the stent and 14% without stent with one stented patient develop­ing fungal septicemia. [9] But Pleass et al (1995) reported similar incidence of UTI in stented and non-stented pa­tients. [1]

Gedroyc et al (1988) reported 7 cases of transplant ureteric obstruction despite the stent being in situ. Out of these 7 patients, 2 had forgotten stents removed at 4.5 and 16 months respectively. They postulated that stents which were left in situ for long, were likely to become blocked, resulting in urine reaching the bladder by passing down the ureter between the stent and the ureteric wall, so that when such a ureter was compressed frank obstruction would supervene. These findings made them suggest that stents should be removed at an earlier stage in order to decrease the complications related to stents.b Occurrence of stent-related complications on their prolonged use, has made many other authors suggest early removal of stent on logical basis but none has addressed this issue on ana­lytical basis. [7],[11]

In current study there was no major urological compli­cation in either group. This means that stenting for 2 weeks is as effective as 4 weeks in preventing urological compli­cations. Incidence of positive culture was numerically higher in 4-week group, though it could not reach statisti­cal significance. The biggest mind-boggling were the 2 incidences of forgotten stents in group 2 which were de­tected at 3 years and 11 months respectively and were dif­ficult to remove because of heavy encrustation. These patients were being followed by local urologists and came to us because of persistent symptomatic urinary tract in­fections. The advantage of 2 weeks time is that the stent is removed in the same admission before the patient is discharged from the hospital, obviating the risk of forgot­ten stent. Secondly, the cost of second admission is cur­tailed if stent is removed in the same admission as we remove all the stents of transplant patients in the routine operation theatre to avoid infection as opposed to the re­moval of all other stents in outpatient clinic in general urological practice.

We conclude that earlier removal of JJ stent at 2 weeks, does not increase morbidity (rate of urological complica­tions) in transplant recipients and prevents stent related complications associated with prolonged use of stent. It obviates the risk of forgotten stents as well as curtails the cost of second admission for stent removal.


   Acknowledgement Top


Dr. Deepali for her valuable help in data collection and drafting the manuscript and Mr. Umesh D. Sharma for the secretarial support.

 
   References Top

1.Pleass HCC, Clark KR, Regg KM, Forsyth JLR, Proud G, Taylor RMR. Urologic complications after renal transplantation. A pro­spective randomized trial comparing different techniques of ureteric anastomosis and the use of prophylactic ureteric stents. Transplant Proc 1995; 27(1): 1091-1092.  Back to cited text no. 1    
2.Khanli RB. Modified extravesical ureterovesical ureteroneocysto­stomy and routine ureteral stenting in cadaveric renal transplanta­tion. Transplant Proc 1991; 23(5): 2627-2628.  Back to cited text no. 2    
3.Shah MH. Ureteral complications of renal transplant surgery. Trans­plant Proc 1995: 27(5): 2708-2711.  Back to cited text no. 3    
4.Eschwege P, Blanchet P, Bellamy J, Charpentier B, Jardin A, Benoit G. Does the use of double J stent reduce stenosis and fistula in renal transplantation? Transplant Proc 1995; 27(4): 2436.  Back to cited text no. 4    
5.Kumar A, Kumar R, Bhandari M. Significance of routine JJ stenting in living related transplantation: A prospective randomized study. Transplant Proc 1998; 30: 2995-2997.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Gedroyc WM, Koffman G, Saunders AGS. Ureteric obstruction in stented renal transplants. Br J Urol 1988; 62(2): 123-126.  Back to cited text no. 6    
7.Lich R Jr, Howerton LW, Davis LA. Recurrent urosepsis in chil­dren. J Urol 1961; 86: 554.  Back to cited text no. 7    
8.Keller H, Noldge G, Wilms H et al. Transplant Int 1994; 7: 253.  Back to cited text no. 8    
9.Nicholson MI, Reiter P, Donnely PK et al. Ann R Coll Surg Engl 1991; 73: 316.  Back to cited text no. 9    
10.Bassiri A, Amiransari B, Yazdani M, Sesawr Y. Gol S. Renal trans­plantation using ureteral stents. Transplant Proc 1995; 27(5): 2593-­2594.  Back to cited text no. 10    
11.Konnak JW, Herwing KR, Finkbeiner A, Jurcotte JG, Frier DT. Extravesical ureteroneocystostomy in 170 renal transplant patients. J Urol 1975; 113: 199.  Back to cited text no. 11    



 
 
    Tables

  [Table - 1], [Table - 2]

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    Abstract
    Introduction
    Material and Methods
    Results
    Discussion
    Acknowledgement
    References
    Article Tables

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