The Forgotten Stent Problem in Low- and Middle-Income Countries: Encrustation, Endourological Management, and the STENT-SAFE Framework for Prevention

Double-J ureteral stents are essential in modern urology but require timely removal or exchange. When retained beyond their intended indwelling period, forgotten stents can progress to severe encrustation, infection, and irreversible renal damage, and this burden falls disproportionately on low- and middle-income countries (LMICs), where fragmented follow-up systems, financial barriers, and limited access to advanced endourological care compound risk. This narrative review critically examines the epidemiology, risk factors, complications, classification systems, imaging evaluation, and management of forgotten double-J stents, with particular emphasis on prevention strategies feasible in LMIC settings, and proposes a structured prevention framework. Reported incidence of forgotten stents ranges from under 1% to over 12%, with prolonged dwell time the strongest predictor of encrustation. Management requires individualized, distal-to-proximal endourological strategies, frequently involving multiple modalities or staged procedures in high-grade disease. Prevention is most effective when treated as an institutional responsibility rather than a matter of patient compliance: structured registries, multichannel reminder systems, and low-cost digital tools such as SMS-based tracking and smartphone registries have demonstrated substantial reductions in forgotten-stent rates, including in LMIC settings. Artificial intelligence shows early promise for follow-up risk prediction and encrustation grading but requires further external validation before clinical adoption. Forgotten double-J stents are a largely preventable patient-safety event rather than a failure of patient compliance alone. We propose the STENT-SAFE framework — Scrutinize the indication, Time-stamp removal, Educate using teach-back, Notify through multiple channels, Track every stent centrally, Safety-net high-risk patients, Act on overdue cases, Finalize only after verification, and Evaluate and audit — as a practical, resource-adaptable model for institutions across the LMIC resource spectrum.