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Combined Antegrade and Retrograde Endoscopic Approach for Management of a Forgotten Stent in the Pediatric Patient
John Barnard, MD, Ali Hajiran, MD, Chad Morley, MD, Osama Al-Omar, MD.
West Virginia University, Morgantown, WV, USA.

Background
Forgotten stents with significant incrustation remain a unique surgical challenge. Adult studies suggest a mean of 1.5 operative interventions to achieve stone free status and remove the incrusted stent. The degree of incrustation has been correlated with stent dwell time, need for multiple operations, operative times, and length of hospital stay. A combined antegrade and retrograde approach has been described in the literature to decrease operative times and avoid multiple operations. Our objective is to describe a technique where modified Barts flank free supine position is utilized in the pediatric patient to allow two teams of surgeons to work simultaneously in both antegrade and retrograde fashion to remove a forgotten stent in a pediatric patient with over 10 cm of total calcification.
Methods
The patient was an 11 year old male referred for forgotten, heavily incrusted stent status post pyeloplasty over 2 years prior for congenital UPJ obstruction. Preoperative CT imaging showed a distal coil calcification of 3 cm, numerous calcifications of the mid-portion of the stent (largest 1.2 x 4.2 cm), and 3.7 cm proximal coil calcification. The patient underwent simultaneous percutaneous cystolitholapaxy and percutaneous nephrolithotripsy followed by antegrade and retrograde ureteroscopy with laser lithotripsy. A Bart's flank free modified supine position was utilized.
Results
Total operative time was 333 minutes which is above average for the average forgotten stent case in the adult literature; however, it must be noted that this patient is an outlier due to the extremely large stone burden (over 10 cm of stone). The distal coil was successfully freed of stone using a 550-micron holmium laser fiber through an 18 Fr suprapubic access sheath. The proximal coil was similarly addressed using an ultrasonic lithotripter through a 30 Fr access sheath. A 200-micron holmium laser fiber was used from both the antegrade and retrograde approach to free the calcifications of the midportion of the stent and successfully remove it. Once all clinically significant stone burden was removed an 8.5 Fr nephroureteral stent and a Foley catheter were placed. The patient experienced no complications intraoperatively and was radiographically free of stone at the conclusion.
Conclusions
A combined antegrade and retrograde approach to the heavily incrusted, forgotten stent allows for shorter operative times and higher opportunity for stone free status in a single operation. The Bart's flank free supine position is technically feasible for the pediatric population and allows simultaneous antegrade and retrograde access to the kidney, ureter and bladder.


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