Double-J^® stents (DJSs) are widely used in urology. However, they are not without complications like lower urinary tract symptoms, migration, fragmentation, encrustation, and “forgotten stent.”^1,2 We encountered a rare situation where the DJS was improperly placed during open ureterolithotomy and extended into the mediastinum. We discuss the precautions to avoid misplacement.

An 85-year-old woman underwent right open ureterolithotomy for right upper ureteric calculus in another hospital. The calculus was removed uneventfully and a DJS was placed without fluoroscopy control. Patient had uneventful recovery. One month later when the DJS was planned for removal an X-ray of the kidney, ureters and bladder was performed. It showed mis-positioned DJS that extended into the chest. A computerized tomography (CT) scan of the chest and abdomen was performed to confirm the location of the DJS which showed right hydronephrosis with the lower part of the DJS in the ureter and the upper part in the mediastinum (fig. 1). On retrograde pyelogram (RGP), the DJS was found completely outside the ureter (fig. 2). The DJS was removed by open surgical approach using subcostal flank incision (fig. 2).

Figure 1. CT scan showing upper part of DJS in mediastinum (1a), DJS passing behind liver (1b), right hydronephrosis (1c), lower part of DJS in ureter (1d) and CT coronal view showing complete DJS (1e).

Figure 2. RGP showing DJS completely outside right ureter (2a–d) and intraoperative image (2e) showing DJS in ureteral sheath outside ureteral lumen (ureter looped by artery forcep).

A laparoscopic approach was not chosen due to surgeon preference and also because of potential risk of gas leakage into the mediastinum.³ Intraoperatively, the DJS was found in ureteral sheath outside the ureteral lumen. The mal-positioned stent was removed and replaced by a new DJS by performing a ureterotomy and ensuring correct placement. Her postoperative recovery was uneventful. The DJS was removed endoscopically after 2 weeks.

In endoscopic surgery, the stents are placed under endoscopic vision and fluoroscopic guidance and, therefore, the chances of dissection of the stent into ureteral sheath is rare.⁴ Ureteric stent placement during open or laparoscopic ureterolithotomy is challenging.⁵ Here, the stent has to be maneuvered both proximally and distally. Wrong placement can thus happen on both sides; mostly distally, as the proximal ureter is typically dilated.⁶ In this patient, the stent was wrongly placed while inserting, both proximally and distally.

If the ureter at the site of ureterotomy is thick and edematous, the ureteral lumen may be difficult to identify, especially during open surgery that is often done without magnification (that is available with laparoscopy).⁷ The guidewire can, then, dissect into wrong tissue planes. This is what probably happened in this patient. Also, in open/laparoscopic procedures, DJSs are usually inserted without fluoroscopy assistance due to problems of maneuverability of the C-arm machine in the lateral position.

Various maneuvers have described for correct DJS placement after ureterolithotomy.^8,9 The stent can be pre-placed under fluroscopy.¹⁰ A method to confirm correct placement of the lower end of the DJS is to instill about 50 ml sterile methylene blue into the bladder through the Foley catheter and watch for efflux of blue urine through the side holes of the stent.¹¹ Alternatively, the stent can be placed after stone removal by ureteroscopy⁷ or its position checked by flexible cystoscopy.⁵

DJS misplacement after open/laparoscopic ureterolithotomy is rare. Also, as DJS placement is considered a simple procedure it is often left to junior colleagues. However, it should be remembered that serious complications may happen due to incorrect placement. This patient had to undergo laparotomy for DJS removal. Proper precautions during stent placement can avoid such complications.