Authors' Response to Ozveren and Sahin

To the Editor:

T he use of an ureteral Double-J stent is prevalent for prevention or management of ureter-related problems in urologic diseases. ^{1 –4} In high-risk patients, including cases with probable inflammation, edema, ischemia, fibrosis, or malformation of the ureter, the safe and effective insertion of an ureteral stent is important to avoid complications such as mucosal tearing or erosion, fistulization, malposition, and migration. ^{5 –7} Because of friable mucosa or luminal stricture in these cases, using a proper and high-quality guidewire and fluoroscopic imaging are necessary for realization of the above matters. ^1,3,8

After the placement of an ureteral Double-J stent in centers without fluoroscopic equipment, immediate and serial kidneys-ureters-bladder (KUB) radiography is recommended in all patients for assessing its position. ^4,8 In addition, unusual patient complaints and hematuria have important roles in suspicion for ureteral stent complications including malposition, migration, and fistulization. ^1,3,5,6 Although intravascular malposition and migration of an ureteral double-J stent are the rare complications, early diagnosis and management may prevent life-threatening conditions such as severe bleeding or complete displacement of a malpositioned or migrated stent into the vascular system because of intravascular blood flow and subsequent complications. ^1,4,6,9,10 These complications may lead to a hypercoagulable state because of an intravascular foreign body, and prophylaxis or management of probable deep vein thrombosis or thromboembolism should be accomplished. ^6,9

Removal of an intravascular (including intravenous) malpositioned or migrated ureteral Double-J stent can be performed by minimally invasive techniques. ^6,9,10 According to the position of the Double-J stent, the approach of removal may be different. If the total or the main portion of the stent is located in the vascular system, the preferable procedure is the performance of angiography and fluoroscopic-guided percutaneous removal of the stent via the femoral vein. ^6,9,10 In cases with normal positioning of the distal portion of the intravenous malpositioned or migrated stent in the urinary tract, especially in the ureter, however, the stent can be extracted via intravascular and transurethral approaches. ¹⁰

Although the percutaneous intravascular approach may be accompanied with the risks of radiation and angiographic-related problems, this procedure provides access to an intravascular malpositioned or migrated stent and its extraction in almost all positions. ^6,9,10 Also, it is possible to evaluate vascular anatomy and serious problems including probable oozing or bleeding and concomitant fistula formation necessitating immediate intervention in the angiographic-guided percutaneous intravascular procedure especially in high-risk patients. ⁴ Nevertheless, transurethral endoscopic removal of a malpositioned or migrated ureteral Double-J stent should not be forgotten in cases with a partially located stent in the urinary tract especially in the ureter, if this technique is achieved by safety and success in serial cases. It seems that the use of fluoroscopy should be popularized and performed for ureteral Double-J stent placement in cases with high susceptibility to stent-related adverse events.