Fluoroscopy-guided transurethral resection with antegrade guidewire assistance for retrieval of a buried double-J stent: A case report.

BACKGROUND: Buried or submucosally embedded double-J (DJ) stents present a rare but technically demanding challenge in endourology, particularly in patients with malignant ureteral obstruction and prior instrumentation. We describe the case of a 72-year-old woman with metastatic bladder cancer who presented with urosepsis and right hydronephrosis. During attempted bilateral stent exchange, the left ureteral orifice and distal stent curl were completely obscured by fibrotic tissue. A combined antegrade-retrograde approach was employed: A guidewire was advanced from the nephrostomy under fluoroscopy, while controlled transurethral resection of the obstructed ureteral orifice permitted exposure and retrieval of the buried stent. A new stent was subsequently placed without complications. This hybrid technique offers an effective solution in cases where traditional retrograde stent retrieval is impossible.

CASE SUMMARY: A 72-year-old woman presented to the emergency department with a 2-day history of fever, nausea, and worsening malaise. She described progressive left flank discomfort and suprapubic pressure. Her medical history included muscle-invasive bladder carcinoma with metastatic spread to the vertebral column, pelvic bones, and sacrum. She was receiving immunotherapy and had undergone multiple prior chemotherapy cycles. Bilateral ureteral DJ stents had been placed several months earlier due to malignant ureteral obstruction, and a left nephrostomy tube had subsequently been inserted following a prior obstructive episode. On examination, she was febrile and clinically unwell, with left costovertebral angle tenderness. Laboratory tests revealed elevated inflammatory markers and leukocytosis. Computed tomography (CT) imaging demonstrated right-sided hydronephrosis despite the presence of a DJ stent, with the left kidney adequately decompressed through the nephrostomy tube. Urine and blood cultures were obtained, and intravenous antibiotics and hydration were initiated. Despite 48 hours of conservative treatment, the patient showed no clinical improvement. Given the persistent hydronephrosis and the need for source control, the decision was made to perform bilateral stent exchange.

CONCLUSION: On examination, she was febrile and clinically unwell, with left costovertebral angle tenderness. Laboratory tests revealed elevated inflammatory markers and leukocytosis. CT imaging demonstrated right-sided hydronephrosis despite the presence of a DJ stent, with the left kidney adequately decompressed through the nephrostomy tube. Urine and blood cultures were obtained, and intravenous antibiotics and hydration were initiated. Despite 48 hours of conservative treatment, the patient showed no clinical improvement. Given the persistent hydronephrosis and the need for source control, the decision was made to perform bilateral stent exchange.