The double J ureteral stents have become an integral part of the urological armamentarium. They allow good urinary drainage from kidney to the bladder and usually are safe and well tolerated. However, complications may occur from minor irritative urinary symptoms, urinary tract infection, pain and hematuria to major complication such as encrustation, stone formation migration, stent fracture and malposition. Incident of stent encrustation needing intervention ranges from ranges from 1 to 3 % while misplacement of DJ stent is rarely reported in urologic literature. A case of encrusted misplaced Double J stent with stone formation is presented along with its management and techniques.

A 34-year-old male with recurrent UTI and a history of bilateral Double J stent insertion from another institution for obstructive uropathy was examined. Non-contrast CT scans showed a misplaced right Double J stent outside the ureter with a 1.5 cm proximal 3rd ureteral calculus and severe hydrophones. The left Double J stent had stone formation on the proximal coil with nephrolithiasis.

A right nephrostomy tube was placed initially under ultrasound guidance. Cystoscopy revealed stent encrustation with stone formation on the distal coil of the right Double J stent, holmium laser tripsy was performed until total fragmentation. We noted entanglement of the distal coil which was addressed by cutting the stent with a laser. We tried to pull out the right stent but resistance was noted. On a semi-rigid ureteroscopy, the stent was found to perforate the ureter with a calculus proximal to the area of perforation. A left supine percutaneous nephrostolithotomy was carried out with ultrasound-guided puncture and serial fluoroscopic dilatation up to 24 French. Using a 22 French nephroscope an ultrasonic energy device with suction was used for fragmentation, the Double J stent was removed in-Toto, and a French 10 nephrostomy tube was placed. An interval laparoscopic ureterolithotomy was done after 72 hours. After isolating the ureter, severe periureteral adhesion was noted with neovascularization. We inadvertently cut the stent proximal coil from the ureter due to the dense adhesion. Ureterolithotomy was then done, calculi were delivered, and the Double J stent was retrieved. Intraoperative DJ was inserted, and the ureter was repaired using continuous absorbable sutures. We then dissected the dense adhesion near the lower pole of the kidney to recover the proximal coil of the stent. The patient's post-operative course was unremarkable, and he was discharged after 3 days.

Double J stents are essential tools for urologists, but their placement must be assessed and addressed if complications arise. Multi modal and stage procedures may be necessary, combining endourological and laparoscopic intervention in cases of encrustation with stone formation and misplaced Double J stents. Urgent measures are necessary to minimize further complications.