Stesura Seveso Archivio Italiano di Urologia e Andrologia 2025; 97(1):13301 1 REVIEW practice. The DJ stent is the most frequently applied indwelling stent in the treatment of symptoms of upper urinary tract obstruction (1). The DJ stent is essential and frequently employed in var- ious procedures. It helps keep the ureters open, ensuring the reduction of swelling and the healing of any potential injuries. Therefore, it is considered a useful tool in the postoperative therapy of patients with retroperitoneal tumours or fibrosis, ureteropelvic junction stenosis, ureteral strictures, ureteral stones, or iatrogenic ureteral injury, A DJ stent is typically the preferred treatment option for patients suffering from obstructive uropathy caused by urinary tract stones. Nevertheless, the use of DJ stents can causes some com- plication (2). Forgotten DJ stent is one of the problems associated with the use of DJ stents which have become a challenging problem for urologists. As a consequence of h widespread use of stents, in association to lack of infor- mation and compliance with routine follow up visits, patients may forget for years that they have had the place- ment of a DJ stent in the pelvic-ureteral system. Hematuria, stent occlusion, migration, fragmentation, encrustation, stone formation, recurrent urinary tract infec- tions (UTI), obstruction of the urinary tract, kidney failure, fistula formation in the iliac arteries, and even fatal com- plications can result from a forgotten DJ stent (3). Management of the forgotten DJ stent varies depending on the complications experienced and differs from patient to patient (1). This management requires an indi- vidual approach in view of possible long-term and short- term complications secondary to the use of DJ stents. Comparison of complications and assessment of out- comes of management in different cases can provide new insights into managing forgotten DJ stents. Managing a forgotten DJ may be time-consuming, complex, compli- cated, risky, and expensive, so the treatment choice must be precise and accurate (4). METHODS Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) were adhered to in the present study (5). Background: Double J Stent is one of the procedures frequently performed in the field of urology. Forgotten DJ Stent is a problem that can cause serious complications. This systematic review aims to explore complications and management of patients with forgotten double J stents. Methods: Scientific literature was obtained from PubMed, ScienceDirect, and Google Scholar with a publication year limit- ed to 2013-2023. The search string included ‘forgotten DJ stent, case report, complication’. Inclusion criteria were as follows: (1) case report or series, (2) available individual patient data, and (3) English language. Data are presented descriptively. Results: Of the 210 records, 14 articles published were analyzed after the full-text assessment. Forgotten DJ stent sufferers vary from age 7 years to 88 years. Male gender was predominant. The initial symptoms were flank pain and micturition disorders. The complications experienced were encrustation, multiple stones formation, emphysematous pyelonephritis, emphysema- tous perinephric abscess, fragmentation, and vesical calculus. In management, it was found that procedures were selected according to patient's situation at that time and the condition of the stent. There are case reports that report management that differed from those initially planned. All the patients were alive after treatment. Conclusions: A forgotten DJ stent can have serious conse- quences. The management approach requires a combination of various endourological procedures. In consideration of potential complications, urologists need to be careful in making decisions about the choice of technique used. KEY WORDS: Complication; Management, Forgotten Double J stents; Endourology. Submitted 26 October 2024; Accepted 9 December 2024 INTRODUCTION The DJ Stent is one of the tools that urologists need to drain and divert upper urinary tract. Over the past few decades, there have been continued advances in place- ment techniques and materials used for ureteral stent. This technique has gained recognition from urologists worldwide as a necessary procedure in urology surgical Management of forgotten double J stents: Insight from a systematic review of case reports Antonius Galih Pranesdha Putra 1*, Yufi Aulia Azmi 2*, Soetojo Wirjopranoto 1, Nadya Rahmatika 3, Agustin Junior Nanda De Niro 1, Alviano Satria Wibawa 1, Kevin Muliawan Soetanto 4 1 Department of Urology, Faculty of Medicine, Universitas Airlangga; Dr. Soetomo General Academic Hospital, Surabaya, Indonesia; 2 Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; 3 Faculty of Medicine, Universitas Wijaya Kusuma, Surabaya, Indonesia; 4 Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol, University, Bangkok, Thailand. * These authors shared first author. DOI: 10.4081/aiua.2025.13301 Summary Archivio Italiano di Urologia e Andrologia 2025; 97(1):13301 A. Galih Pranesdha Putra, Y. Aulia Azmi, S. Wirjopranoto, et al. 2 Ethics statement Ethical approval was not crucial for this study, as it did not involve direct patients, and all included data were previously published. The Protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) by PRISMA-P guidelines (PROSPERO CRD42024577367). Eligibiliy A systematic search focused on case reports and a series about forgotten dou- ble J stents, which featured information on individual patients. Case reports published in 2013-2023 having com- plete individual data, written in English, discussing appropriate topics, namely management and complications of for- gotten DJ stents, were included in the analysis. Exclusion criteria were being not case report manuscript, lack of indi- vidual data, not written in English and not open access. Article duplication were eliminated prior to the screening of titles and abstracts. Search strategy and selection of studies On August 23, 2023, we performed a systematic database search in PubMed, ScienceDirect, and Google Scholar. An exhaustive exploration was also accomplished through a manual or bibliography search of relevant papers. The keywords "forgotten/neglected double J stent, complica- tion, case report" were used in the search. The titles and abstracts of the articles were assessed independently for prospective eligibility as studies for the full-text review. Article extraction We independently extracted essential information from the included studies using a structured and standardized form. The extracted information includes author, year, country, number of patients, age, sex, symptoms, history, forgotten DJ stent time duration, complication, manage- ment and outcome. Quality assessment We independently assessed the risk of bias in included studies by implementing Joanna Briggs Institute (JBI) checklist, that is used for critical appraisal of case studies. We categorized the results as 'yes, cannot tell, and no' (6). Statistical analysis A meta-analysis was not feasible because this systematic review evaluated a rare condition which relies on pub- lished case reports. Similar findings of variables, such as symptoms, are grouped to evaluate their frequency. RESULTS Study selection Ten of the 210 records returned by the search were duplicates. After sifting through titles and abstracts, we eliminated 149 articles. Following the full-text assess- ment, we included 14 published articles in this system- atic review. The PRISMA flow diagram (Figure 1) pres- ents the procedure for selecting studies and the exclu- sion justifications. Quality assessment We evaluated each included case report using the JBI crit- ical appraisal checklist (Table 1). The summarized critical appraisal checklist shows that the studies were generally of moderate to good quality. Study and demographic characteristics This systematic review of published cases included 14 case reports (Table 2). Most research was conducted in devel- oping countries, including India (4 studies). Forgotten DJ stent sufferers range in age from 7 to 88. Male gender pre- dominated in most of the studies (10 studies). Figure 1. Flowchart study selection. Archivio Italiano di Urologia e Andrologia 2025; 97(1):13301 3 Forgotten double J stent Symptoms Most people complain of flank pain and micturition dis- orders as their initial symptoms. Diarrhea and nocturia are sporadic. The duration of symptoms varies depending on their appearance. History and forgotten DJ stent time duration The patient's medical history varies, including procedures related to ureteric/pelvic/kidney stone treatment, ureteral stricture with UTI, a surgical procedure to remove a giant uterine myoma, renal transplant, muscle-invasive bladder tumour, sigmoid colon cancer, partial resection of the bladder and nonspecific flank surgery. In addition, there were patients with a history of previously forgotten DJ stent treatment. DJ stents were forgotten per periods ranging from 1 to 17 years. Complications The complications experienced were encrustation, multi- ple stones formation, emphysematous pyelonephritis, emphysematous perinephric abscess, fragmentation, and vesical calculus. Table 1. Article quality assessment. No Author Were patient’s Was the patient’s Was the current Were diagnostic Was the Was the Were adverse Does the demographic history clearly clinical condition tests or assessment intervention(s) post-intervention events (harms) case report characteristics described of the patient on methods and the or treatment clinical condition or unanticipated provide clearly described? and presented presentation results clearly procedure(s) clearly described? events identifie akeaway as a timeline? clearly described? described? clearly described? and described? lessons? 1 Aboutaleb, et al, 2021, UAE (12) Yes Yes Yes Yes Yes Yes Yes Yes 2 Ahmed, et al, 2021, Yemen (13) Yes Yes Yes Yes Yes Yes Yes Yes 3 Sigdel et al, 2021, Nepal (14) Yes Yes Yes Yes Yes Yes Yes Yes 4 Hee lee et al, 2022, Republic of Korea (15) Yes Yes Yes Yes Yes Yes Yes Yes 5 Prihadi et al, 2018, Indonesia (16) Yes Yes Yes No Yes Yes No Yes 6 Alwesali et al, 2022, Saudi Arabia (17) Yes Yes Yes Yes Yes Yes Yes Yes 7 Sharma, 2018, India (18) Yes Yes Yes Yes Yes Yes Yes Yes 8 Ghorai et al, 2022, India (19) Yes Yes Yes Yes Yes Yes Yes Yes 9 Kandemir et al, 2019, Turkey (20) Yes Yes Yes Yes Yes Yes Yes Yes 10 Nihal Er et al, 2023, Turkey (21) Yes Yes Yes Yes Yes Yes Yes Yes 11 Aamiir, et al, 2022, India (22) Yes Yes Yes Yes Yes Yes Yes Yes 12 Gupta et al, 2017, India (23) No Yes Yes Yes Yes Yes Yes Yes 13 Yan Gu et al, 2016, China (24) Yes Yes Yes Yes Yes Yes Yes Yes 14 Kumsa, et al, 2022, Ethiopia (25) Yes Yes Yes Yes Yes Yes Yes Yes Table 2. Research characteristics. NAuthor, year, country Number Age Sex Symptoms of patient Flank ache Micturition Abdominal Lower Fever Hematuria Diarrhea Nocturia Duration of disorders pain limb swelling symptoms Aboutaleb, et al, 2021, UAE (12) 1 49 yo male Yes Yes No No No No No No 1 month Ahmed, et al, 2021, Yemen (13) 1 32yo male yes Yes No No No No No No 3 days Sigdel et al, 2021, Nepal (14) 1 35 yo female No Yes Yes Yes No No No No 3 days Hee lee et al, 2022, Republic of Korea (15) 1 56 yo female No No Yes No Yes No No No 4 days Prihadi et al, 2018, Indonesia (16) 1 40 yo female Yes Yes No No No Yes No No NA Alwesali et al, 2022, Saudi Arabia (17) 1 13 yo male No No Yes No No No Yes No 3 days Sharma, 2018, India (18) 1 38 yo male Yes Yes No No Yes, low grade No No No 1 year Ghorai et al, 2022, India (19) 1 65 yo male No Yes No No No No No Yes 2 years Kandemir et al, 2019, Turkey (20) 1 30 yo male Yes Yes No No No No No No NA Nihal Er et al, 2023, Turkey (21) 1 7 yo female No Yes No No No No No No 10 days Aamiir, et al, 2022, India (22) 1 28 yo male Yes No No No No No No No 5 months Gupta et al, 2017, India (23) 1 32yo male Yes No No No No No No No NA Yan Gu et al, 2016, China (24) 1 88 yo male No Yes No No Yes No No No 1 week Kumsa, et al, 2022, Ethiopia (25) 1 22 yo male Yes Yes No No No No No No 3 years Archivio Italiano di Urologia e Andrologia 2025; 97(1):13301 A. Galih Pranesdha Putra, Y. Aulia Azmi, S. Wirjopranoto, et al. 4 Management and outcome Procedures used for treatment were based on the patient's situation. Sometimes procedures differed from those ini- tially planned. For example, a percutaneous nephrolithotomy (PCNL) was performed in a patient who was originally scheduled for ureterorenoscopy lithotripsy, that was not effective in removing the DJ stent. In another case, the planned cysto- scopic laser lithotripsy was not feasible because the preop- erative endoscopic examination showed a bladder stone with a radius of about 2 cm at the tip of the double-J catheter from the right kidney. All the patients remained alive after treatment for DJ stent removal. Table 3. Management and outcome. History Post ureteric stone treatment Right open nephrolithotomy with double j stent placement due to obstructed right renal pelvis stone History of extracorporeal shock wave lithotripsy (ESWL) Ureteral stricture with UTI Surgical procedure to remove a giant uterine myoma Renal transplant 13 years ago in India for end stage renal disease of unknown etiology History of right-sided laparoscopic Anderson-Hynes dismembered pyeloplasty with double J (DJ) stenting performed for right pelviureteric junction obstruction 5 years back ureterolithotomy with left sided DJ stenting elsewhere 17 years ago for a ureteral stone Endoscopic stone surgery due to right ureteral stone and kidney stone 11 years ago A history of kidney stones, and a double-j catheter was placed in her right kidney as a treatment for kidney stones The stent placed 11 years back as a part of Percutaneous Nephrolithotomy (PCNL) for right renal stone, had forgotten Forgotten DJ stent timeduration 10 years 1 year 5 years 10 years 4 years 13 years 5 years 17 years 11 years 1 year Complication The whole stent was covered with a thick layer of encrustation with multiple stones formation Double-J stent was separated into four parts. and the stones were observed in the total parts of the right urinary tract system from the renal pelvis to the bladder with a 20 £ 15 mm stone impacting the left renal pelvis. huge radiolucent bladder stone around the double j stent Emphysematous pyelonephritis Encrustation, Emphysematous perinephric abscess No No encrustation Right DJ stent without encrustation and radiopaque shadow in left renal region An abdominal X ray revealed an encrusted left sided DJ stent with its lower end showing a large radio opacity suggestive of a vesical calculus fragmented and severely encrusted ureteral A bladder stone about 2 cm in size was formed around the double-J catheter Large urinary baldder stone with encrusted Double J stent and calculus deposits along the entire length of the stent Management Endorse cystolithotripsy with Holmium YAG laser for the bladder calculus and semirigid/flexible ureteroscopy with Holmium YAG laser lithotripsy for ureteral stones and encrusted stent The left ureteroscopic ureterolithomy and double j stent placement were done under spinal anesthesia during the first operation. Then, right open nephro- ureterolithotomy with open cystolithotomy were performed after 1 month of previous surgery to remove the stone and forgotten double j stent Surgical drainage to control the sepsis. Few days later after control of sepsis and optimization, left nephrecto- my and removal of retained DJ stent was done Retained DJS removal and vesicolitholapaxy. A piece of fractured stent was removed via open ureterolithotomy Ureterorenoscopic lithotripsy, but it failed to remove the remaining encrusted double-J stent. As a result, percutaneous nephrolithotomy was performed successfully Nephrostomy was performed and antegrade pyelogram. Two weeks later, the patient became hemodynamically stable and underwent a DJ stent removal without any stenting due to stricture Ureteric stent removal followed by placement of right-sided percutaneous nephrostomy (PCN). He underwent right nephrectomy followed by left percutaneous nephrolithotomy underwent percutaneous cystolithotomy using pneumatic lithotripsy along with removal of the forgot- ten DJ stent under intravenous antibiotic cover Cystoscopy was made under general anesthesia. The foreign object was removed with forceps. Then with ureterorenoscope, the stones integrated with the stent at the end of the piece of DJ stent in the ureter were fragmented with pneumolithotriptor. Stone pieces and the second removed part of the stent were extracted with foreign object forceps. Then using nephroscope through percutaneous intervention, the stones at the end of the third torn piece of DJ stent were fragmented with pneumolithotriptor. They were extracted with forceps The patient was planned cystoscopic laser lithotripsy. After the pre-operative examinations and follow-up results came out normal, the patient was taken to operation. Because a bladder stone with a radius of approximately. 2 cm on the end of a double-J catheter from the right kidney was spotted, It was decided that it was no suitable for lithotripsy because of the size of the stone. Therefore, transition to open surgery was decided The patient was then managed in two sittings, as an open cystolithotomy, followed a few months later by a combination of uretroscopic lithotripsy and percuta- neous lithotomy Outcome Alive Alive Alive Alive Alive Alive Alive Alive Alive Alive Alive Author, year, country Aboutaleb, et al, 2021, UAE Ahmed, et al, 2021, Yemen Sigdel et al, 2021, Nepal Hee lee et al, 2022, Republic of Korea Prihadi et al, 2018, Indonesia Alwesali et al, 2022, Saudi Arabia Sharma, 2018, India Ghorai et al, 2022, India Kandemir et al, 2019, Turkey Nihal Er et al, 2023, Turkey Aamiir, et al, 2022, India Archivio Italiano di Urologia e Andrologia 2025; 97(1):13301 5 Forgotten double J stent DISCUSSION Demographic characteristics Most cases were observed in developing countries, includ- ing India (4 cases). A forgotten DJ stent is frequent in developing nations, with patients from lower socioeco- nomic classes being more susceptible (7). in fact, patients from lower socioeconomic backgrounds may have less access to quality healthcare. They need to receive adequate counselling, to avoid misunderstandings about their treat- ment. Individuals from lower socioeconomic classes often face financial constraints that can affect their ability to seek medical care or to attend follow-up appointments. Delays in stent removal can increase the risk of complications (26). The age of patients with forgotten DJ stent ranged from 7 to 88. Male gender predominated in most studies (10 studies). A review of hospital data from 2000 to 2013, including 28 cases of forgotten DJ stents, revealed that the average age of patients was 37.7 ± 14 years (3). A retro- spective study on forgotten DJ stent patients between January 2009 and December 2019 reported an average age of 32.1 years (1). Patil et al. reported an average age of 56.66 years 2 and Adanur et al. of 38.2 ± 25.06 years (range from 2 to 86 years) (4). Ali observed an average age of 59.12 ± 9.8 years, ranging from 34 to 70.8. The majority of these cases involved men. In Adanur’s study, 39 out of 54 patients were men, while 15 were women (4). This contrasts with the findings on another study, where the majority were women, with 9 out of 16 patients (56.25%) (8). Lin et al. observed that patients over 60 were 3.6 times more likely to forget their DJ stent than younger patients (27). Symptoms Most patients complained of flank pain and micturition dis- orders as their initial symptoms. Diarrhea and nocturia are sporadic. The duration of symptoms was variable. A study identified urinary irritation and hematuria as the most fre- quent complaints (3). In another study, pain and dysuria were the most common issues (1). Patil et al. reported that patients typically presented with low back pain, dysuria, hematuria, and fever (2). Additionally, another study indi- cated that pelvic pain with lower urinary tract symptoms were reported by most patients, with 9 out of 16 (56.25%) experiencing these symptoms. Recurrent urinary tract infections were found in 2 patients (12.5%), while 4 cases (25%) showed no symptoms (8). History and forgotten DJ stent time duration The medical history of patients varies, including proce- dures related to ureteric/pelvic/kidney stone treatment, ureteral stricture with UTI, surgical removal of a giant uterine myoma, renal transplant, muscle-invasive bladder tumour, sigmoid colon cancer, partial resection of the bladder and nonspecific flank surgery. In addition, there are patients with a history of previously forgotten DJ stent treatment. DJ stents remained forgotten for a period rang- ing from 1 to 17 years. Other studies reported an average stent indwelling time of 38.96 months1, 22.6 ± 30.3 (6- 144) months 4 and 1.73 ± 0.9 (0.11-3.4) years (8). DJ stents generally must be replaced or removed within six weeks to 6 months to avoid complications (2). Complications The complications observed were encrustation, multiple stones formation, emphysematous pyelonephritis, emphy- sematous perinephric abscess, fragmentation, and vesical calculus (1). The study of Hajjaj reported several compli- cations occurring during or after stent removal, including stent fragmentation (20%), fever (16%), sepsis (8%), and hematuria requiring a transfusion (4%) (9). In a series of 16 cases, severe stent encrustation was seen in ten cases; two cases involved urinary tract obstruction, one involved stent migration, and two involved stent fragmentation8. Another study reviewed 50.000 procedures performed on 36.688 patients between 1996 and 2021. Complications were related to malposition of the DJ stent, migration and obstruction of the ureteral stent, and symptoms of bladder irritation; hematuria was detected in 5.213 cases, it for 6 years, underwent open cystolithotomy for the encrusted DJ stent and concomitant urinary bladder stone, was again lost to follow up Passage of tube like structure (lower end of right DJ stent) through ileal conduit 15 days back. He had undergone radical cystectomy with ileal conduit for muscle invasive bladder tumor six years back in another hospital Approximately 6 years prior, the patient had undergone simulta- neous radical resection of sigmoid colon cancer and par- tial resection of the bladder Nonspecific flank surgery 15 years ago 5 years 6 years 6 years 15 years Bilateral Staghorn Calculus with Forgotten Double J Stent in Ileal Conduit Patient Presence of an entire coiled double-J stent with calculi from the kidney to the bladder Severe stent encrustation at the presentation. He also had a solitary bladder stone and many pelvic stones discovered Patient was successfully treated with minimally invasive therapy in the form of combined bilateral PCNL (Percutaneous Nephrolithotomy) and ESWL (Extracorporeal Shock Wave Lithotripsy) therapy A computed tomography scan revealed mild hydronephrosis of the left kidney and one J end of the stent in the bladder. The stent was removed successful- ly by cystourethroscopy and holmium laser lithotripsy Cytolithotrity and semirigid ureteroscopy with laser lithotripsy were performed, and the encrusted stent was removed. Subsequently, an open cytolitotomy was done. Followed by an ultrasound-guided PCNL at which time the remaining stones were removed Alive Alive Alive Gupta et al, 2017, India Yan Gu et al, 2016, China Kumsa, et al, 2022, Ethiopia Archivio Italiano di Urologia e Andrologia 2025; 97(1):13301 A. Galih Pranesdha Putra, Y. Aulia Azmi, S. Wirjopranoto, et al. 6 demanding blood transfusion in 7 instances 10. The sever- ity of symptoms depends on the duration of stent indwelling time and the degree of encrustation and stone formation. Longer forgotten stents are more likely to cause significant morbidity (28). The treatment of case reported in our review yielded the encouraging result that every patient survived, whereas three of the twenty-eight patients involved in another investigation passed out due to complications following the intervention for stent removal (3). Management and outcomes The treatment should be multimodal and individualized and often the initial planned treatment has to be changed due to unexpected situations. Sometimes the DJ stent can- not be removed with the planned procedure, so a different procedure has to be performed. In addition, during the examination, other unexpected problems, such as stones, can be found requiring making adjustments. The proce- dure performed also depends on the patient's condition. Many procedures can be performed for the removal of forgotten stents, such as cystoscopic extraction of the stent, percutaneous cystolithotomy (PCLT), percutaneous nephrolithotomy (PCNL), ureterorenoscopy lithotripsy (URSL), extracorporeal shock wave lithotripsy (ESWL) with cystoscopic stent removal (1). The choice of procedure depends on variables such as location and extent of calci- fication and associated stent injury. All patients with stents should receive counseling regarding potential long- term complications. Especially if stents are forgotten for more than a year, they may have a very thick layer of deposits on their surface and may require additional pro- cedures such as shock wave lithotripsy, ureteroscopy (URS), and PCNL, alone or in combination, with great caution to prevent related morbidities (2). The procedure to be carried out requires accurate preop- erative evaluation. Preoperative evaluation is critical, involving a thorough history and physical examination, evaluation through urine culture and sensitivity tests, appropriate radiological imaging, such as Kidney Ureter Bladder (KUB) X-ray, ultrasound, or non-contrast CT (NCCT), and serum creatinine assessment (26-28). Sohrab et al. described removal of stent using endourolo- gy techniques and extracorporeal shock wave lithotripsy (ESWL) (3). Mahmood et al. reported ureteroscopy as the most common primary surgery (1). Another paper reported that 14 children experienced retention of DJ stent retention that were removed using ESWL, cys- tolithotripsy (CLT), and PCNL (11). In Nawaz Ali's study, four patients underwent cystoscopic stent removal, four CLT, three had CLT followed by PCNL, two had their fragmented stents removed by ureteroscopy and one by open pyelolithotomy (8). Prevention Prevention remains a critical aspect of managing forgot- ten stents, emphasizing the importance of proper patient counseling regarding the stent's indwelling time and the necessity of follow-up. Establishing a stent registry with patient details and scheduled removal dates coupled with automated reminders via social media to patients and healthcare providers can significantly reduce the inci- dence of forgotten stents. Additionally, engaging patients and relatives in the follow-up process is essential to pre- vent complications and mitigate the associated morbidity and healthcare costs. The effective management of forgot- ten DJ stents hinges on a comprehensive approach that integrates timely intervention, meticulous follow-up, and proactive prevention strategies (26-28). Limitation of the study This review considered case report data, so further research needs to be carried out prospectively. This research also has not been able to explore long-term complications from stent removal management due to forgotten DJ Stent. Future research is recommended to investigate complica- tions from stent removal management. CONCLUSIONS A forgotten DJ stent can lead to significant consequences, necessitating a management approach that combines var- ious endourological procedures while carefully consider- ing potential complications. Urologists must exercise cau- tion when deciding on the appropriate technique. Healthcare providers must inform all patients with an implanted stent about the long-term risks of prolonged stenting and stress the need for timely removal or replace- ment. REFERENCES 1. Mahmood K, Singh KH, Upadhyay R, et al. Management of for- gotten double-J stent in a tertiary care center with ten years of expe- rience: a retrospective study. Int Surg. J 2020; 7:2615. 2. Patil S, Raghuvanshi K, Jain DK, Raval A. Forgotten ureteral dou- ble-J stents and related complications: a real-world experience. African J Urol. 2020; 26:8. DECLARATIONS Ethical approval: Ethical approval was not crucial for this study, as it did not involve direct patients, and all included data were previously published. Availability of data and material: Availability of Data and Materials Data and materials used in our study are open to access by request. Competing interests: No conflict of interest was declared by the authors. Funding: -. Authors' contributions: Y.A.A, S.W, N.R, A.G.P.P, A.J.N.D.N and K.M.S; Methodology: Y.A.A, S.W, N.R, A.G.P.P, A.J.N.D.N and K.M.S; Investigation: Y.A.A, S.W, N.R, A.G.P.P, A.J.N.D.N, A.S.W, and K.M.S; Writing Original Draft: Y.A.A, S.W, N.R, A.G.P.P, A.J.N.D.N, A.S.W, and K.M.S; Writing review & editing: Y.A.A, S.W and K.M.S; Resources: Y.A.A, S.W, N.R, A.G.P.P, A.J.N.D.N and K.M.S; Visualization: N.R, and A.G.P.P; Supervision: Y.A.A and S.W. Acknowledgments: None. 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Correspondence Soetojo Wirjopranoto (Corresponding Author) stjowirjopranoto@gmail.com Department of Urology, Faculty of Medicine, Universitas Airlangga- Dr. Soetomo General Academic Hospital, Jl. Mayjen Prof. Dr. Moestopo No.6-8, Surabaya, East Java, Indonesia, 60286 Antonius Galih Pranesdha Putra galihpranesdha@gmail.com Agustin Junior Nanda De Niro deniro_nanda@yahoo.co.id Alviano Satria Wibawa alvianosw65@gmail.com Department of Urology, Faculty of Medicine, Universitas Airlangga- Dr. Soetomo General Academic Hospital, Surabaya, Indonesia Yufi Aulia Azmi yufiazmi@gmail.com; y.aulia.azmi@umcg.nl Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands Nadya Rahmatika nadyasaham@gmail.com Faculty of Medicine, Universitas Wijaya Kusuma, Surabaya, Indonesia Kevin Muliawan Soetanto kmskevinmuliawan@gmail.com Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol, University, Bangkok, Thailand