Stent Removal Research Articles

Treatment of a staple-line leak after laparoscopic sleeve gastrectomy using an esophagoduodenal Niti-S Mega-stent.

A 56-year-old female with class 3 obesity, was previously submitted to laparoscopic sleeve gastrectomy (LSG) two weeks before current admission. The patient was admitted due to fever, abdominal pain and vomiting. CT revealed a 13.5cm collection between the gastric wall and left hepatic lobe. Piperacillin-Tazobactam was initiated, and percutaneous drainage of the purulent collection was performed. The upper endoscopy showed pus in the gastric lumen and a 10-mm leak at the esophago-gastric junction with contrast extravasation. Argon plasma coagulation (40W, 2L/min) was applied at the orifice margins to promote healing. After 0,038'' guidewire placement through the proximal jejunum, a Niti-S™-MEGA™ (Mega-Stent) 28x230mm (Taewoong Medical™) was deployed under fluoroscopic control. CT at 72h showed absence of leakage. Oral nutrition was started uneventfully. Ambulatory endoscopy was scheduled for eight weeks later to remove the stent, which was easily accomplished with a foreign body forceps. Granulation tissue was observed in the previous leak location and no extraluminal contrast was observed at fluoroscopic evaluation, confirming complete healing and successful endoscopic treatment. Three weeks after stent removal, the patient presented with dysphagia. Upper endoscopy revealed a short and narrowed lumen stenosis at 28cm from the incisives, which was easily manage through TTS balloon dilation. No additional complications were observed.

Management of Incidentally Detected Urinary Tract Calculus in Patients Awaiting Living Donor Liver Transplantation: A Protocol-Based Approach

BackgroundUrinary tract calculi (UTC) in patients awaiting living donor liver transplant (LDLT) requires proper management due to increased risk of infections in the post-liver transplant (LT) period. Materials and MethodsA retrospective analysis of records of LDLT recipients with UTC was conducted between July 2019 and July 2023. No prisoners or paid participants were included. ResultsThirty patients (25 women and 5 men) with a mean age of 44.45 ± 9.67 years, model of end stage liver disease with sodium (MELD-Na) of 20.5 ± 12.2 were diagnosed to have a UTC during pre-LT evaluation. Twenty-five patients had renal stones, whereas five patients had ureteric calculus (22 were unilateral and 8 were bilateral calculi). Fifteen patients underwent double J (DJ)-stenting prior to LT. The mean stone size in patients who underwent DJ stenting was 13.6 (±9.83) mm vs 4.78 (±5.3) mm in whom stenting was not done. Patients with preoperative DJ stenting had a significantly reduced hospital stay (18.5 ± 2.1 days), lower mortality rates (0%), and lower rates of hematuria (6.66%) vs (23.4 ± 12.8 days, 13.33% and 13.3%, respectively). Patients with preoperative DJ stenting underwent post-transplant definitive procedure for UTC without any complications.Our Protocol for Incidentally Detected Ureteric Stones in LT Recipients:a. Proximal-ureteric calculi: Preoperative DJ stenting (2-3 days prior/ on day of LT) → LT → ESWL/URS 2-3 weeks later → DJ stent removal after 2-3 weeks.b. Distal-ureteric calculi: Preoperative DJ stenting ± URS (2-3 days prior/ day of LT) → LT → DJ stent removal after 2-3 weeks.Our protocol for incidentally detected renal stones in LT recipients:a. Stone size (< 5 mm) and nonobstructive calculi with no active UTI:No surgical intervention → Liver transplant under antibiotics cover → medical management of stone.b. Multiple calculi sized < 5 mm or single stone 5-10 mm:DJ stent placement → LT → ESWL/RIRS after 4-6 weeks → DJ stent removal after 3 weeks.c. Single stone size > 10 mm or multiple calculi > 5 mm:DJ stent placement → LT → RIRS/PCNL after 4-6 weeks→DJ stent removal after 3-4 weeks. ConclusionA systemic minimally invasive approach is needed for pre-LT management of UTC for better patient outcomes.

A forgotten double J stent with encrustation leading to pelvi-ureteric obstruction: A case report

Double J (DJ) ureteric stents are widely applied in urological operations, they maintain patient’s urinary system postoperatively, thereby accelerating recovery. Prolonged stent insertion is associated with complications. A 38-year-old woman presented with hematuria, right flank pain, and urinary tract infection. She underwent renal calculi removal 8 years ago. KUB radiograph revealed and indwelling DJ stent with vesical calculus and pyelonephritis. Ultrasound revealed a large bladder stone with mild right hydronephrosis. Computed tomographic (CT) urography revealed a DJ stent encrustation and further formation into core of the bladder stone. Cystolithotomy was performed, vesicle calculi retrieved. At 4 weeks, the patient presented with a right-side flank pain for which patient was evaluated with a contrast-enhanced CT urography which revealed a pelvi-ureteric junction obstruction with hydronephrosis. A pyeloplasty was performed and DJ stent was placed in situ, to be retrieved at 6 weeks. With improved biomaterials, design and technological improvements of DJ stents, patient’s discomfort is greatly reduced. As a result, DJ stents got left in place for a longer duration of time, and therefore high incidences of forgetfulness, retained DJ stents. Encrustation, however, is frequently encountered. Patient factors such as low education and socioeconomic status and patients living in far off rural places also contribute to forgotten indwelling stents. Authors recommend placement of DJ stents after pyeloplasty for treating pelvi-ureteric junction obstructions following long-term retained stents. Patient counseling, education, and strict follow-up should ensure a timely stent removal and improved patient safety. Effective patient counseling and awareness reduces incidences of forgotten indwelling stents and patient-related complications.

Co-existing obstructed and refluxing lower moiety megaureter in a female without incontinence: a perplexing myriad in a duplex system with ectopic lower moiety ureter

Ectopic ureter is a rare congenital anomaly that predominantly affects females and typically manifests as urinary incontinence due to atypical ureteral openings in structures such as the vagina or cervix. This condition is estimated to occur in approximately 1 in 4000-10,000 female births. An exceptional variant, the intrasphincteric ectopic ureter, poses significant diagnostic challenges due to its atypical presentation, as it may cause dynamic obstruction and reflux phenomena without resulting in incontinence. A 28-year-old female presented with severe left flank pain, fever, and chills persisting for 10 days. Her medical history included intermittent dull, aching left flank pain over 7 years, exacerbated during voiding, but no urinary incontinence. Physical examination revealed marked tenderness in the left flank, and laboratory investigations showed elevated leukocyte count and normal serum creatinine levels. Computed tomography urography revealed a left duplex moiety with upper moiety infected hydronephrosis, necessitating percutaneous nephrostomy placement. Subsequent nephrostogram and micturating cystourethrogram identified a grossly dilated and tortuous upper moiety ureter with intrasphincteric ectopic ureteral opening, confirming the diagnosis of obstructed and refluxing megaureter. Following infection resolution, the patient underwent laparoscopic extravesical non-refluxing reimplantation of the upper moiety ectopic ureter with DJ stenting. The postoperative course was uneventful, and the patient reported no flank pain or fever upon stent removal. Periodic evaluations showed no increase in hydronephrosis, indicating a successful intervention. This case underscores the diagnostic complexity of intrasphincteric ectopic ureter, a rare anomaly presenting with obstructed and refluxing megaureter without incontinence. Heightened clinical vigilance and comprehensive radiological evaluation are imperative for timely diagnosis and intervention. Preservation of continence further complicates the clinical picture, necessitating early intervention to prevent renal function deterioration and improve long-term outcomes.

The PAUL Glaucoma Implant in the management of uveitic glaucoma-3-year follow-up.

Evaluate the mid-term outcomes of the PAUL Glaucoma Implant (PGI) in the management of uveitic glaucoma. This was a single-centre, multi-surgeon, retrospective analysis of 50 consecutive cases of PGI for uveitic glaucoma performed between April 2019 and August 2021. Primary outcomes include: complete and qualified success (IOP ≥5 mmHg to ≤21 mmHg with ≥20% IOP reduction) or failure (IOP exceeding the success criteria, additional glaucoma procedures, no perception of light vision). Secondary outcomes included: visual acuity, IOP, medications, complications and intraluminal stent removal. We included 50 eyes of 41 patients. Mean age was 45.8 ± 19.8 years (range 6-81 years) in this heterogenous and complex cohort. Mean pre-op IOP was 30.6 ± 9.8 mmHg on 3.9 ± 0.9 medications. In total, 62% of patients were on acetazolamide, and 64% required systemic immunosuppression. At final follow-up (mean: 35.8 ± 9.8 months, range 5-58 months), IOP and medications were significantly reduced (12.2 ± 4.4 mmHg, requiring 1.1 ± 1.3 medications, p < 0.0001). Resulting in 48% complete and 92% qualified success rates. Failure occurred in 8% of cases, 6% due to hypertension but only one case of prolonged hypotony (2%). To date, this study represents the first publication looking specifically at the efficacy and safety of the PGI in the management of complex uveitic glaucoma. With an average follow-up of 3 years, it shows high levels of complete and qualified success with few complications.

A case of pancreatic fistula with disruption of the inferior branch of the pancreatic duct caused by a pancreatic stent after endoscopic papillectomy.

A 73-year-old man underwent upper gastrointestinal endoscopy for abdominal pain, which revealed an ampullary adenoma with no obvious extension into the bile or pancreatic ducts. Endoscopic papillectomy (EP) was performed and a 5-Fr 5-cm stent was placed in the pancreatic duct. The patient developed acute pancreatitis on postoperative day (POD) 1 and contrast-enhanced computed tomography performed on POD 2 revealed that the proximal end of the stent had migrated into the retroperitoneum, forming a pancreatic fistula. Stent removal and endoscopic nasopancreatic drainage were performed and the pancreatitis rapidly improved. The tumor was completely resected and after approximately three years of follow-up, no tumor recurrence or acute pancreatitis was observed.Retrospectively, the inferior branch of the pancreatic duct was prominent on pancreatography at the time of EP and the proximal end of the stent had dislocated into the inferior branch. The stent subsequently moved proximally, which could have caused pancreatitis and pancreatic fistula. The morphology of the pancreatic duct should be carefully monitored during stenting. Selecting a stent that matches each patient's specific pancreatic duct morphology may help physicians minimize the risk of adverse outcomes.

Transanastomotic Forward-Viewing EUS-Guided Pancreatic Duct Drainage via Afferent Loop for Pancreaticojejunostomy Anastomotic Stricture After Pancreaticoduodenectomy.

Although balloon enteroscopy-assisted ERCP and transgastric EUS-guided pancreatic duct drainage (EUS-PD) are treatment option for pancreaticojejunostomy anastomotic stricture (PJAS), they are often challenging with several limitations. This study aimed to examine the feasibility of transanastomotic forward-viewing EUS-PD (FVEUS-PD) via the afferent loop for PJAS after pancreaticoduodenectomy. Ten consecutive patients with symptomatic PJAS who underwent FVEUS-PD between 2015 and 2021 were retrospectively evaluated. Study outcomes included technical and clinical success, adverse events, and recurrence rates associated with FVEUS-PD. A short dumbbell-shaped, fully covered metal stent was deployed in all cases, and the stent was removed 3month after placement, after which it became stent-free. The technical success rate was 80% (8/10), and the scope could not reach the PJAS in two patients. Clinical success was achieved in all technically successful patients. No procedure-related adverse events observed. All patients were followed up for over three years after metal stent removal and becoming stent-free; the median follow-up period was 63month. One patient developed symptomatic stricture recurrence 36month after removal, with a stricture recurrence rate of 13% (1/8). The remaining patients did not experience any recurrence or late adverse events during the study period. This study is the first to investigate FVEUS-PD, demonstrating promising technical feasibility with low adverse event and recurrence rates, potentially becoming a useful treatment option for PJAS.

Antegrade stenting for chronic malignant ureteral obstruction with the Resonance® metallic stent: a case series.

Polymeric and metallic stents are commonly used to manage patients with chronic malignant ureteric obstruction (CMUO). This paper compares the outcomes of ureteral stenting via the Resonance® metallic stent against its polymeric counterpart in published literature, as well as between antegrade and retrograde approaches. A retrospective case series was conducted whereby patients who had undergone Resonance® stent insertions via an antegrade route from June 2022 to May 2023 were reviewed through our electronic medical record system. Descriptive statistics were used to summarise patient demographics and clinical outcomes. 11 patients who presented with CMUO underwent 12 separate procedures of either unilateral or bilateral ureteral stenting. Total number of stents inserted was 16. Median age of patients was 65 (Range = 32) and 72.73% were males. 66.67% of the procedures yielded an improvement in the estimated glomerular filtration rate (eGFR) in patients as compared to before stenting. Stent failure, defined by stent removal before recommended removal date, occurred in 4 out of 16 (25%) stents. The median duration of Resonance® stent in situ at the time of data collection (4th December 2023) was 245days. We conclude that the Resonance® stent is more effective at providing long term urinary drainage for CMUO, compared to its polymeric counterpart. However, antegrade insertion of the Resonance® stent does not significantly decrease indwelling stent duration compared to retrograde insertion.

EGS SO27 - Removable covered stent as an alternative to traditional methods in management of Oesophageal Perforation in unfit surgical patients: A Tertiary Care Hospital Experience

Abstract Background Oesophageal perforation in elderly and frail patients carries a significantly higher mortality rate. Traditionally, management involves surgery for patients who are fit for surgery, or a conservative approach for those with minimal contamination. Endoscopy, with procedures such as endoscopic washout of mediastinal collections and placement of covered removable stents, sometimes in conjunction with chest drain insertion, is emerging as a minimally invasive option for a selected group of patients who are not suitable for traditional methods. This technique aims to seal perforations, promote healing, and facilitate early restoration of oral intake. Method This retrospective study was conducted at a tertiary care hospital. Data were collected over a 10-year period starting from 2012. The study enrolled all patients aged 18 and older, admitted with oesophageal perforation and underwent oesophageal stent insertion. SX-ELLA Danis-seal stents (30-25-30 × 135mm) were used for benign perforations, while permanent covered metal stents were used for patients with underlying malignancy. Variables analyzed included age, gender, Charlson Comorbidity Index (CCI), WHO performance status, location and size of esophageal perforation, type and dimensions of stent used, length of hospital stay, and mortality rates. Data analysis was conducted using SPSS version 25. Results During study period, 11 out of 78 patients with esophageal perforation underwent stent insertion (M:F=7:4, median age-71 (range 48-85) years, median CCI -5). Causes included spontaneous perforation (n=3,27.3%), iatrogenic (n=4,36.4%), and malignancy (n=4,36.4%). Distal esophageal perforation was observed in 7 patients (63.6%). Oral intake was commenced within 72 hours post-insertion. A single procedure sufficed for 10(90%) patients. Stents used for non-malignant perforations were removed endoscopically after an average of 12 weeks. No major complications; minor complications included stent migration (n=1, 9.1%), failed placement (n=1, 9.1%), and loss to follow-up (n=1, 9.1%). The 90-day mortality rate was 45.5% (n=5/11). Conclusion Endoscopy with mediastinal cavity washout and insertion of a covered metal stent in unfit surgical patients provides an alternative and improves outcomes. It could also be considered in patients with non-healing perforations to facilitate early resumption of oral intake.

Prostatic stents: a systematic review and analysis of functional outcomes and complication rate.

This review aims to identify and summarize the current literature on the use of prostatic stents or nitinol devices as minimally invasive techniques for the management of lower urinary tract symptoms (LUTS) resulting from benign prostatic hyperplasia (BPH). A comprehensive search of the literature was conducted until October 2023. Only original articles written in English were considered for inclusion. This review has been registered in PROSPERO (registration number CRD42023474884). Thirty-eight articles were included (2618 patients). Generally, the risk of bias was deemed as high or very high. The most frequently investigated stents were the UroLume, followed by the Memokath/Memotherm. The mean age was 72.01 ± 5.6 years, with a mean prostate volume of 48.27 ± 12.8 cc and a mean urethral length of 40.53 ± 9.16 mm. Surgeries were usually performed under local anesthesia. The rates of catheter-free status and complications were 85.2% and 30.83%, respectively. The primary complications included urinary tract infections (17.2%), followed by calcifications (12.6%), irritative symptoms (12.2%), and acute urinary retention (10.4%). During a follow-up period of 12 months, the failure rate intended as stent removal or repositioning was 14.8%. The International Prostate Symptom Score (IPSS) showed an overall improvement of 9.85 points. The mean improvement in maximum flow rate and post-void residual volume were 6.62 ml/sec and 147 ml, respectively. Prostatic stents remain an efficient choice for addressing obstructive symptoms from BPH, offering the advantage of being performed under local anaesthesia, relieving symptoms with good functional outcomes and a low incidence of major complications. Prospective studies are needed to corroborate these results.

Complete intraureteral stent placement reduces stent-related pain in normotensive subjects and in diabetes: Subgroup analysis of a prospective randomized clinical trial

Purpose: Pain is a common symptom that is associated with ureteral stent placement, but its degree of perception might vary among individuals. Compared with conventional stent placement (C-SP), complete intraureteral stent placement (CIU-SP) has shown promise in reducing stent-associated pain. This study aimed to investigate the effect of patient characteristics and comorbidities on pain reduction after CIU-SP. Materials and methods: Patients who underwent ureteroscopic lithotripsy and stent placement were randomized into the CIU-SP and C-SP groups. Stent-associated symptoms were evaluated using the Ureteral Stent Symptom Questionnaire on day 7, immediately before stent removal. Stent-associated pain was determined by the answer to question P1 (yes or no). Subgroup analysis was conducted based on various patient characteristics and comorbidities. Results: Of the 103 randomized patients, 91 (45 in CIU-SP and 46 in C-SP) were included in the final analysis. Body pain was reported by 31 (68.9%) after CIU-SP and 41 (89.1%) after C-SP (P = 0.021). Compared with C-SP, CIU-SP significantly reduced pain in the normotensive population (66.7% versus 93.7%, P = 0.006) but not in hypertensive individuals (77.8% versus 76.9%, P = 1.000). Conversely, compared with C-SP, CIU-SP was associated with less pain in patients with diabetes (37.5% versus 88.9%, P = 0.05) but not in patients without diabetes (75.7% versus 89.2%, P = 0.221). Age, sex, stone laterality, body mass index, and smoking status did not influence the reduction of pain after CIU-SP. Conclusion: Compared with C-SP, CIU-SP was effective in reducing stent-associated pain, especially in normotensive and diabetic populations. These findings align with existing literature, which emphasized the potential impact of hypertension on decreased pain perception and highlighted the known association between diabetes and bladder hypersensitivity.

Metal Stents for the Management of Massive Hemobilia in Patients with Hilum-Involving Cholangiocarcinoma Receiving Multi-Regimen Chemotherapy.

Recent clinical outcomes of multi-regimen chemotherapy in patients with cholangiocarcinoma (CCC) have shown benefits in terms of overall survival. However, repeated endoscopic biliary drainage (EBD) and serious adverse events negatively affect prolongation of the survival period. The aim of this study was to investigate the prevalence of massive hemobilia and the outcomes of its management with fully covered self-expandable metal stents (FC-SEMSs) in patients with hilum-involving CCC receiving multi-regimen chemotherapy. The methods and effects of FC-SEMS placement were retrospectively investigated following the occurrence of massive hemobilia during EBD. A total of 356 patients with CCC received multi-regimen chemotherapy. Among them, 181 patients had hilar invasion, and seven patients (3.9%) developed massive hemobilia during repeated EBD using removable stents. In all cases, the tumor encased the right hepatic artery. In six patients (85.7%), hemostasis was immediately and completely achieved by inserting one or two FC-SEMSs proximal to the hilar invasion area. Therefore, if the tumor encases the right hepatic artery, massive hemobilia is likely to occur during multi-regimen chemotherapy. Thus, prompt placement of a FC-SEMS would be an effective treatment option for massive hemobilia in patients with hilum-involving CCC.

Adherence to follow-up ten years after hypospadias repair

IntroductionPeriodic follow-up prior to and after puberty to evaluate for long-term sequalae following hypospadias repair is commonly recommended. Few studies have evaluated this follow-up, especially into adulthood. This study aimed to evaluate adherence to routine postoperative follow-up appointments over 10 years following elective hypospadias repair. Material and MethodsRetrospective review of all patients undergoing hypospadias repair at our institution under the age of 10 from January-December 2012 was performed. Data were extracted including demographics, meatal location, type of hypospadias and chordee repair, use of postoperative stent, adherence to follow-up, re-operations, and postoperative concerns. Primary outcome was adherence to long-term follow-up. Secondary outcomes included re-operative rates and complications. ResultsA total of 213 patients underwent hypospadias repair in 2012 with 52 (24%) having a distal repair without urethral stent, 112 (53%) distal repair with urethral stent, 29 (14%) midshaft repair with urethral stent, and 20 (9%) proximal repair with urethral stent. Almost all patients followed up for stent removal at our clinic (88%), and the remaining with a local provider. Overall, 64% of patients presented for their postoperative check within 3 months which was consistent between groups (p=0.300). Only 12% (25/213) of patients followed up after toilet training with the proximal group having the highest rate at 40% (8/20, p=0.003). In those following up after toilet training, 36% (9/25) of patients followed up due to clinical symptoms attributed to their hypospadias repair or another unrelated urologic issue; the vast majority (87.5%) of those with proximal hypospadias did so without any urologic issues. 15% (31/213) of patients never followed up. Five (2.7%) patients underwent secondary procedures related to their initial hypospadias surgery. DiscussionWe noted poor rates of follow-up at our institution for boys undergoing hypospadias repair. Short-term follow-up was uniformly poor. After toilet training, boys with proximal hypospadias were more likely to follow-up. This study is limited in being a retrospective, single center study and that some urologic follow-up may not have been captured outside of our tertiary referral center. ConclusionsDespite our recommendations, patient adherence to follow-up after hypospadias repair is poor. More research and attention are needed to optimize and better understand poor adherence to long-term follow-up. Follow-up is essential to assess true rates of long-term complications, and to help develop specific education regarding consequences of unrecognized surgical complications, especially in more complex cases. Sharing such information may ensure parents understand the need for routine and regular evaluation. [Display omitted]

Investigation of stent retriever removal forces in an experimental model of acute ischemic stroke.

Mechanical thrombectomy becomes more complex when the occlusion occurs in a tortuous cerebral anatomy, increasing the puncture to reperfusion time and the number of attempts for clot removal. Therefore, an understanding of stent retriever performance in these locations is necessary to increase the efficiency and safety of the procedure. An in vitro investigation into the effects of occlusion site tortuosity, blood clot hematocrit, and device geometry was conducted to identify their individual influence on stent retriever removal forces. Embolus analogs were used to create occlusions in a mock circulatory flow loop, and in vitro mechanical thrombectomies were performed in arterial models of increasing tortuosity. The stent retriever removal forces of Solitaire Platinum and EmboTrap II devices were recorded through each geometry with and without embolus analogs present. Similar experiments were also conducted with Solitaire stent retrievers of varying lengths and diameters and 0, 25, and 50% hematocrit embolus analogs. The removal force increased as model tortuosity increased for both the Solitaire Platinum and EmboTrap II stent retriever devices. The average removal forces in the simplest geometry with the Solitaire Platinum and EmboTrap II were 0.24 ± 0.01 N and 0.37 ± 0.02 N, respectively, and increased to 1.2 ± 0.08 N and 1.6 ± 0.17 N, respectively, in the most complex geometry. Slight increases in removal force were found with 0% hematocrit embolus analogs, however, no statistical significance between removal force and EA hematocrit was observed. A comparison between stent retriever removal forces between devices of different diameters also proved to be significant (p < 0.01), while forces between devices of varying lengths were not (p > 0.05). Benchtop mechanical thrombectomies performed with commercial stent retrievers of varying geometry showed that device removal forces increase with increasing model tortuosity, clot hematocrit does not play a significant role in device removal force, and that a stent retriever's diameter has a greater impact on removal forces compared to its length. These results provide an improved understanding of the overall forces involved in mechanical thrombectomy and can be used to develop safer and more effective stent retrievers for the most difficult cases.

Management of Ureteral Stricture Disease After Radiation Therapy for Pelvic Malignancies: A Retrospective, Multi-Institutional Analysis.

A radiation-induced ureteral stricture (RIUS) is a challenging condition in urologic surgery, and the optimal surgical strategy is still a matter of debate. The aim of this study was to report post-operative outcomes of minimally invasive management of this condition from a multi-institutional cohort. Data of patients with diagnoses of RIUS at five referral robotic centers between January 2017 and December 2022 were retrospectively analyzed. Pre-, intra- and post-operative variables were collected. Recurrence was defined as the presence of flank pain combined with imaging findings for obstruction, and requiring further management. Univariate and multivariate logistic regression models were built to identify predictors of ureteral stricture recurrence. Fifty-three patients with a diagnosis of an RIUS were included. Primary pelvic malignancy was mostly cervical (42%). In 72% of cases (mostly mid-proximal and short strictures) endourological management was attempted, which was deemed successful in 74% of patients at stent removal. The endourology success rate at a median follow-up of 12 months was 59%. Twenty-five patients (47%) were scheduled for robotic surgery. The reconstructive techniques most often performed were end-to-end anastomosis (44%) and ureteral reimplantation (52%). Three low-grade Clavien-Dindo post-operative complications (12%) occurred. Robotic surgery was successful in all cases except one. Considering the entire cohort, eight patients (15%) developed recurrence at a median follow-up of 5 months. All patients with recurrence were managed by permanent drainage. A statistically significant improvement in eGFR with respect to baseline was found at a median follow-up of 12 months (p = 0.007). The univariate logistic regression model identified ureteral stricture length >2 cm (OR 6.4, 95% C.I. 1.1-36.9, p = 0.04) and concomitant chemotherapy (OR 8.9, 95% C.I. 1.6-49.9, p = 0.01) as predictors of recurrence. At multivariate analysis concomitant chemotherapy was confirmed as an independent predictor of recurrence (OR 7.8, 95% C.I. 1.3-49.0, p = 0.03). Endourological management of an RIUS is reasonable for short and mid-proximal ureteral strictures, while robotics is required in almost all the remaining cases. Up to 15% of recurrence develops within 6 months. Re-do reconstructive surgery is rarely performed, even in referral centers.

Health perceptions of patients with forgotten double-J stent.

In this article, we aimed to determine the health perceptions of the patients who did not apply for double-J stent (DJS) removal on time and evaluate whether health perceptions impact this behavior. Health perceptions of 22 patients who were treated for forgotten double-J stent (FDJS) between January 2017-October 2020 and 25 patients who applied for DJS removal during the given appointment time in the urology department of Elazig Training and Research Hospital and Elazig Fethi Sekin City Hospital were compared using the "Health Perception Scale". Health perception scale scores in the FDJS group and control group were 62-68 (mean = 64.27±1.75) and 63-68 (mean = 65.36±1.55), respectively. With regard to the sub-factors of the scale, control center scores were 21.86±0.77 and 22.08±1.15; precision scores were 16.54±0.80 and 16.56±0.82; importance of health scores were 12.77±0, 92 and 13.32±0.74; and self-awareness points were 13.04 ±0.72 and 13.48±0.58, respectively. There was a statistically significant difference between the health perception scale in total, importance of health, and self-awareness scores between the two groups. At the same time, there was no difference in terms of the control center and precision scores (p∗=0.029, p∗=0.030, p∗=0.028, p=0.460, p=0.951). Patients' and their families' educational status, income levels and lack of follow-up by healthcare professionals play an important role in forgotten DJS cases and patients' perception of health may also have an impact on this behavior.

Double J Ureteral stent removal in children non cystoscopically: A preferred innovation.

Objective: To determine the feasibility of non cystoscopic removal of double J ureteral (DJ) stent using a foley catheter with suture in children in terms of success rate, number of attempts required and complications. Study Design: Cross Sectional study. Setting: Department of Pediatric Surgery, Services Hospital, Lahore. Period: August 2022 to August 2023. Methods: All the children who underwent DJ stent placement for any urological procedure were included if DJ stent was seen in the bladder postoperatively. After informed consent, under sedation and aseptic measures, the foley catheter with suture already passed through its eye, was introduced per urethral after adequate lubrication. The foley was given five to six rotations in clockwise direction for right sided and anti-clockwise for left sided stents respectively and pulled out keeping traction on the suture. In case of three failed attempts, a cystoscope was introduced under general anesthesia and the stent was removed. Successful removal, number of attempts needed, time taken, and post removal complications were noted to determine feasibility of the procedure. Results: Out of twenty patients, 17 patients (85%) underwent successful removal of DJ stent. The failure rate was 15% as three patients required cystoscope assisted removal. In 13 patients (76.5%) DJ stent was removed in first attempt, whereas in 4(23.5%) patients it required two attempts. Mean time taken was 8.83±7.33 minutes. Complications were noted in 2 patients (10%). Conclusion: Removal of DJ stent in children without cystoscope, using a foley catheter with suture is a safe and feasible procedure with a high success rate and should be attempted in selected cases.

Needle knife assisted removal of the displaced metal stent.

The removal of a metal stent with proximal displacement was challenging. We present a case where a needle knife was used to incise the duodenal papilla to remove the displaced metal stent.

Endoscopic Removal of Uncovered Metallic Airway Stents.

Self-expandable uncovered metallic stents (SEUMS) have been used in benign tracheobronchial stenosis. Stent complications may require risky removal due to SEUMS integration in the tracheobronchial wall. Our study aims to report techniques, including a novel one, and outcomes of SEUMS removal by rigid bronchoscopy. We studied a case series of 7 patients from a tertiary medical center, who underwent SEUMS removal from 2017 to 2022. SEUMS removals were performed through rigid bronchoscopy. We used a new technique with bronchoscopic hook scissors to gradually dissect the stent from the airway wall. Nine SEUMS were removed from 7 patients. The mean duration of stenting was 7 years (5 to 12y). Indications for stent removal included mostly recurrent pulmonary infections, obstructive granulation tissue, and stents' fractures. We used the usually described technique in the literature known as the "piecemeal fashion" without dissection in 4 SEUMS removals and a new dissection technique in 5 procedures. We reported one major intraoperative complication using the former technique in the form of tracheal tear with mediastinal breach, while we did not experience any major complications with the later one. One patient died 8 days after surgery from respiratory failure. Dissection and "piecemeal fashion techniques" can be used to remove SEUMS by rigid bronchoscopy even after long-term stenting. SEUMS removal is a very risky procedure and must be performed by a trained operator. Patients should be aware of possible severe complications.

Timing of lumen-apposing metal stents removal in pancreatic fluid collections: Could we go beyond?

Background and aimsLumen-apposing metal stents (LAMS) are the mainstay treatment for pancreatic fluid collections (PFC). A 4-weeks interval for LAMS removal has been suggested to avoid adverse events (AEs). Primary aim is to evaluate the AEs rate in patients with LAMS removal <4 and >4 weeks from placement and possible associated factors. MethodsRetrospective study on patients underwent EUS-guided drainage of PFC with LAMS at two Italian centers between January 2017 and November 2023. PFC and LAMS features were collected. AEs were defined as bleeding, obstruction and buried LAMS. Results108 patients were enrolled (62.9 % males; mean age 61 ± 14 years old). In 38 % PFC was in pancreatic head.In 64.8 % of patients LAMS ≥15 mm was used. Mean time of LAMS indwelling was 71 ± 87 days and in 73.1 % of patients the LAMS was removed after 4 weeks. AE occurred in 8.3 % of patients and the most common (77.8 %) was bleeding.There was no association between LAMS indwelling >4 weeks (8/9 vs 65/93 p = 0.44) and the rate of AE. A comparable mean time of LAMS persistence (108 ± 96 vs 67 ± 86 p = 0.18) between patients with and without AE was observed. PFC in the head (7/9 vs 33/93 p = 0.02) and LAMS ≥15 mm (9/9 vs 58/93 p = 0.03) were associated with a higher rate of AE. ConclusionWhen needed, LAMS removal >4 weeks appears to be as safe as LAMS removal within 4 weeks. LAMS ≥15 mm and Head location were associated with higher rate of AE and thus should arouse more caution.