Objectives: Inserting a double J stent during kidney transplant has reduced the rate of urologic com­plications. Traditionally, a double J stent is removed via endoscopic intervention. Here, we assessed the safety and efficacy of a nonoperative method for double J stent removal.

Materials and Methods: Our study group included 200 consecutive patients who underwent kidney transplant from January 2013 to April 2014. Group A consisted of 100 recipients who had a double J stent that was tied to a Foley catheter with 2-0 silk suture. The stent was simply removed by taking out the Foley catheter after 3 weeks. Patients in group A were compared with a second group of 100 kidney transplant patients whose stents were removed endoscopically 3 weeks later (group B).

Results: Patients were matched between the 2 groups regarding age distribution, male-to-female patient ratio, deceased versus living donor graft, prevalence of type 2 diabetes mellitus, and body mass index. The incidence of urinary fistula (3% in group A and 4% in group B; P = .7), ureteral stenosis (1% in group A and 2% in group B; P = .56), wound infection (1% in group A and 2% in group B; P = .56), and positive urine culture (20% in group A and 29% in group B; P = .14) after stent removal were not significantly different between the 2 groups.

Conclusions: This study shows that nonoperative removal of a double J stent is a safe and effective method. This approach is simple, and there is no need for a surgical procedure or any outpatient surgical intervention.

Key words : Double J stents, Kidney transplantation, Urinary catheters

Introduction

Major urologic complications after renal transplant are well-known and accompanied by significant mortality and morbidity.¹ Some of these complications are related to the ureterovesical anastomosis. Urinary leakage, ureteral fistula, and ureterovesical junction stenosis are some of these complications that have been significantly reduced with use of a double J stent.²

However, the use of a double J stent may be associated with some difficulties and problems. Several studies have reported an increased rate of urinary tract infection in the recipients due to the indwelling ureteral stent.^3-6 In addition, the conventional method of stent removal requires endoscopic intervention and anesthesia or sedation, which may result in urinary tract infection, urethral trauma, and further financial costs. A forgotten double J stent, although uncommon, is another hazard, which may lead to stone formation, ureteral stricture, and decreased graft function.⁷

Several methods have been introduced to simplify double J stent removal after kidney transplant. Early removal of stent,⁸ simple removal of stent using a hanging knot,⁹ and attaching the double J stent to the Foley catheter are some of these innovations. In the latter method, both the Foley catheter and double J stent are removed simultaneously at a specific time. In this study, our objective was to evaluate the efficacy and safety of simultaneous removal of the Foley catheter and double J stent without use of cystoscopy, anesthesia, or sedation.

Materials and Methods

This study included recipients of kidney transplants conducted from January 2013 to April 2014. Our patient population consisted of 200 patients who underwent kidney transplant from either living or deceased donors. Patients in the age range of 18 to 60 years were included. Recipients with history of neurogenic bladder, cystoplasty, and second or third kidney transplants were excluded from the study.

All procedures were single renal transplants performed through an extraperitoneal approach in the iliac fossa. The renal vein was anastomosed to the side of the external iliac vein, and the renal artery was anastomosed end to end to the internal iliac artery or end to side to external or common iliac artery. The anastomosis of ureter to bladder was completed via a modified Lich external uretero­neocystostomy technique, and a double J stent was inserted in all patients. A cutaneous drain was inserted in the retroperitoneal area and removed after 3 days if its daily output was less than 50 mL. Double J stents were removed 3 weeks after surgical procedures in all cases.

Patients were alternatively assigned to treatment groups A and B. In group A, the double J stent was inserted during the operation, and its intravesical end was tied to the distal end of a sterile Foley catheter using 2-0 silk suture. Both the double J stent and Foley catheter remained for 3 weeks. The double J stent was simply removed by taking out the Foley catheter. This removal process was done in the outpatient clinic because no anesthesia or sedation was necessary.

Group B included 100 patients with the same kidney transplant approach. The only difference was the method for double J stent removal. In this group of patients, the Foley catheter was removed 7 days after the operation. The double J stent was removed 3 weeks after the operation, which was conducted in an outpatient operation room using cystoscopy under intravenous sedation or general or spinal anesthesia.

All patients were followed for 1 year after the procedure. Serum creatinine levels, urine analysis results, and culture tests were obtained from all patients 1 month after the surgery and compared between the 2 groups. All cases of wound infection, urinary fistula, and ureteral stenosis up to 1 year were identified and compared between the 2 groups. Written informed consent was obtained from all patients, and the ethical committee of Iranian Urology and Nephrology Research Center approved the study structure. Statistical analyses and data entry were performed with SPSS software (SPSS: An IBM Company, version 18.0, IBM Corporation, Armonk, NY, USA). Independent sample t test and chi-squared test were used for comparing quantitative and qualitative variables.

Results

Our patient population included 200 consecutive kidney transplant recipients over a period of 15 months, who were divided into 2 groups. In group A, the double J stent was sutured to the Foley catheter, with both removed after 3 weeks. Group B were 100 matched patients, in whom double J stent removal was done via the conventional method. Patient characteristics for both groups are shown in Table 1. We found no statistically significant dif­ferences between groups A and B regarding age distribution, male-to-female patient ratio, deceased-donor versus living-donor graft, prevalence of type 2 diabetes mellitus, and body mass index.

Mean serum creatinine level (± standard deviation) was 1.58 ± 0.54 mg/dL for group A and 1.59 ± 0.53 mg/dL for group B (P = .8). Positive urine culture 1 week after double J stent removal was observed in 20 patients in group A and in 29 patients in group B (P = .14). The ratio of urinary fistula (P = .7), wound infection (P = .56), and ureteral stenosis (P = .56) were similar between the 2 groups. Urologic complication comparisons are summarized in Table 2. No stent-related complication and no missed stents, encrustation, migration, or stone formation were observed.

Discussion

Kidney transplant has been associated with several urologic complications, including urinary extra­vasation or fistula, ureterovesical junction stenosis, and wound infections. The use of a stent during extravesical ureteroneocystostomy has significantly reduced the rate of urologic complications after kidney transplant.^3,6,10 However, there are still some issues related to double J stent retrieval.

Recently, there have been some reports about neglected double J stents in kidney transplant recipients.^7,11 On the other hand, the classic method of double J stent removal is to take it out via an endoscopic approach.¹² This procedure requires patient sedation or anesthesia in the operation room setting. Because the double J stent is removed via cystoscopy, there is a possibility for urethral injury and urinary tract infections.¹³ These potential hazards have motivated some surgeons to search for a simple and safe method of double J stent removal in kidney recipients.

Morris-Stiff and associates introduced the technique of suturing the double J stent to the urinary catheter for its nonoperative removal after transplant. The double J stent was removed together with the Foley catheter after a mean of 8 days. The group studied 15 patients (8 male and 7 female patients) and observed no cases of urinary sepsis or complications related to stent removal. However, this study was only a primary report without a control group.¹⁴

The technique was followed by one from Sansalone and associates, who sewed the double J stent to the Foley catheter and left it for a mean of 10 days in the bladder. Although their main objective was to assess the effects of short-term stenting in reduction of urologic complications after surgery, their innovation in suturing the double J stent to the bladder catheter warranted its simple removal. In their study on 590 consecutive patients, the rates of urinary leakage and ureteral stenosis were 0.3% and 1.5%, which are results similar to those shown in our present study.¹⁵

Dong and associates introduced another technique in which a 2-0 silk suture was passed through the venting side hole of the double J stent into the bladder. After the Foley catheter is removed, the stream of urine would push the free end of the silk suture out from urethra and the double J is thus removed by simply withdrawing the silk suture from the urethra. Although this study did not include a control group, the results of this report on 76 patients is similar to our study, showing no significant complications.⁹

In a clinical trial that was carried out by Taghizadeh-Afshari and associates, 86 patients were randomly divided into 2 groups. In the study group, the double J stent was linked to the Foley catheter, and they were both removed 1 week after kidney transplant. In the control group, the double J stent was removed 1 month later using cystoscopy. The results of this study showed that the rate of complications was not different between the 2 groups. However, the time of double J stent removal was different in the 2 groups and the number of patients was less than in our study.¹⁶

Although inserting a double J stent may reduce the risk of urologic complications after kidney transplant, it may increase the likelihood of urinary tract infection.5 Several issues including impaired graft function and bacterial colonization of double J stent may contribute to urinary tract infection. There is always some concern regarding whether a urinary catheter may result in bacterial colonization of the sterile bladder environment and double J stent.¹⁷ A recent study has revealed that bacterial colonization of stent is common after kidney transplant, although it does not have a significant effect on graft function.18 The results of our study did not show a significant difference between the 2 groups regarding positive urine culture or febrile urinary tract infection.

Conclusions

This study shows that nonoperative removal of a double J stent in kidney recipients is a safe and effective method. This approach is simple and does not need an operating room setting. In addition, using this approach would eliminate the possibility of neglected double J stent, which is a potential hazard in kidney transplant recipients.

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