Feasibility and safety of double-J ureteral stent with a timed-release extraction string in children

Conventional removal of double-J ureteral stent (DJUS) in children typically requires cystoscopy under general anesthesia, which entails perioperative risks and increased healthcare costs. The DJUS with a timed-release extraction string (DJUS-TRES) potentially overcomes these limitations.

To evaluate the feasibility and safety of DJUS-TRES in children.

We prospectively collected data on children undergoing urological surgeries with DJUS-TRES between September 2022 and May 2025, with subsequent retrospective analysis. Postoperatively, the absorbable suture securing the extraction string undergoes hydrolysis, releasing the string. Once the string is spontaneously expelled through the urethra, the stent can be removed by traction in an outpatient settings or at home. Cystoscopic removal was reserved for cases where the string was not expelled after two months or if traction removal was unsuccessful.

DJUS-TRES was successfully placed in 69 out of 73 children (94.5 %), with a median age of 3.6 years (range: 1.2 months to 16 years). All four placement failures occurred during antegrade approach, due to inability to pass the ureterovesical junction (UVJ) (n = 2), misplacement into the preputial cavity (n = 1), and ureteral retention of the extraction string (n = 1). String removal was attempted within two months in 66 cases and was successful in 60 (90.9 %). Causes of failure included non-expulsion due to encrustation (n = 4) and string fracture during traction (n = 2). Complications included one case (1.5 %) of severe encrustation requiring pneumovesicoscopic removal, stent migration (n = 4, 5.8 %), stent-associated urinary tract infection (UTI; n = 13, 18.8 %), and significant urinary symptoms (n = 9, 13.0 %).

DJUS-TRES enabled stent removal without anesthesia or invasive procedures in most patients. However, several specific characteristics were observed. First, antegrade placement failed in approximately 14 % of attempts, primarily due to impaired passage of the distal stent end across the UVJ. Second, it carries a risk of urinary symptoms-such as foreign body sensation, urinary incontinence, and dysuria-likely resulting from the string in the urethra, interfering with sphincter function and causing obstructive voiding. Third, the most common complication was UTI, with stent migration and string encrustation occurring less frequently. Although the success rate of DJUS-TRES removal was moderately lower, it offered a favorable safety profile and minimized tissue damage compared to cystoscopy and other invasive alternatives.

The DJUS-TRES provides a safe and effective option for stent removal without the need for cystoscopy or anesthesia. Given the risks of failure and complications, further prospective controlled studies are warranted to evaluate its clinical efficacy.