Use of Stents after Ureteroscopic Stone Removal

Flexible ureteroscopy: technique, tips and tricks

During the last decades, the surgical management of kidney stones benefited of many technological advances and one of them is the development of flexible ureteroscopy (fURS). This tool, ancillary equipment such as graspers and baskets, and lithotripsy technique with Holmium:YAG laser underwent many improvements leading to a widening of its indications with diagnostic and therapeutic management of upper urinary tract pathologies such as urolithiasis and urothelial tumors. The objective of this review is to describe the surgical technique for fURS as well as tips and tricks for the treatment of renal stones.

Use of fibrin glue as a sealant at the anastomotic line in laparoscopic pyeloplasty: A randomised controlled trial

Objective

To assess the effectiveness of fibrin glue as a sealant at the anastomotic line of a stentless laparoscopic pyeloplasty (LPP) repair instead of JJ stent insertion.

Patients and methods

In all, 46 patients with pelvi-ureteric junction obstruction scheduled for LPP were randomised into two groups each containing 23 patients. Group A underwent stented repair, while group B had a stentless repair together with sealing of the anastomotic line with fibrin glue.

Results

There was no statistically significant difference between the groups for the postoperative improvement in the renal scan and intravenous urography. However, there was a statistically significant decrease in early postoperative adverse events in group B. In group A, all the patients had irritative lower urinary tract symptoms (LUTS) and 16 (72.7%) had postoperative urinary tract infections (UTIs). In group B, no patient had a UTI or irritative LUTS. In all, 21 patients (95.4%) in group A had minimal terminal painful haematuria; while in group B, only one patient (4.3%) had minimal total painless haematuria. Also, patients in group B were spared the need for a second anaesthesia exposure for stent removal.

Conclusion

The use of fibrin glue is a valid alternative to stenting in LPP with the same excellent outcome but with markedly lower short-term postoperative adverse events.

Does Omission of Ureteral Stents Increase Risk of Unplanned Return Visit? A Systematic Review and Meta-Analysis

PURPOSE

Post-ureteroscopy ureteral stent omission remains controversial. Although omission is associated with reduced postoperative discomfort, concern remains for early obstruction. We performed a systematic review and meta-analysis of trials to compare the risk of unplanned visits with vs without a stent following ureteroscopy for nephrolithiasis.

MATERIALS AND METHODS

Randomized, controlled trials and observational studies comparing post-ureteroscopic stent omission vs placement and reporting unplanned visits within 30 days were identified via a search of MEDLINE® (1946 to 2015), CENTRAL (Cochrane Central Register of Controlled Trials, 1898 to 2015), Embase® (1947 to 2015), ClinicalTrials.gov (1997 to 2015), AUA (American Urological Association) Annual Meeting abstracts (2011 to 2015) and reference lists of included articles as last updated in October 2015. Two reviewers independently extracted data and assessed methodological quality. ORs, RRs and weighted mean differences were calculated as appropriate for each outcome.

RESULTS

Of the initial 1,992 studies 17 in a total of 1,943 participants met inclusion criteria. Unstented patients were significantly more likely to have an unplanned medical visit compared to those who received a post-ureteroscopy stent (OR 1.63, 95% CI 1.15-2.30). Unstented patients had shorter operative time (weighted mean difference -3.19 minutes, 95% CI -5.64--0.74) and were less likely to experience dysuria (RR 0.39, 95% CI 0.25-0.62). They were also less likely to experience postoperative infection (OR 0.89, 95% CI 0.59-1.33) and pain (OR 0.64, 95% CI 0.39-1.05), although these results were not significant.

CONCLUSIONS

Stent omission is associated with an increased risk of unplanned medical visits despite reduced symptoms compared to those in stented patients. Patients and physicians should weigh these trade-offs when considering post-ureteroscopy stent placement.

Stentless laparoscopic pyeloplasty: A single center experience

AIM

To assess the effectiveness of laparoscopic stentless pyeloplasty for congenital ureteropelvic junction obstruction.

MATERIALS AND METHODS

This was a prospective comparative study conducted over a period of 5 years. The study included 35 cases of primary ureteropelvic junction obstruction (UPJO) with mean age of 29.5 years, divided in two groups- Group A (stent-less, 18 patients) and Group B (stented, 17 patients). Follow up ranged from one to 4years (mean 2 years). Transperitoneal laparoscopic Anderson- Hyene's pyeloplasty was standard for both the groups. Perioperative and postoperative complications were prospectively collected and analyzed by Statistical Package for Social Sciences (SPSS) 17 version using Pearson chi square test.

RESULTS

Both the groups were comparable with respect to preoperative differential renal function (DRF) and time required for maximum activity in minutes (tmax.min). Average post operative DRF was significantly higher than preoperative DRF in both the groups. Average tmax was significantly lower after pyeloplasty than pre operative tmax. Mean operative time, mean duration of urethral catheter, and mean duration of drain removal were comparable in both the groups. However bothersome irritative lower urinary tract symptoms (LUTS) and hematuria were significantly more in group B patients (P < 0.0001 and <0.013 respectively).

CONCLUSION

In experienced hands, laparoscopic stentless pyeloplasty is as effective method for treating UPJO as its stented counterpart. It is cost effective, avoids stent-related morbidity, and could be performed without compromising the success rate. However, more randomized studies are needed to evaluate the safety of stentless pyeloplasty.

Impact of ureteral stenting prior to ureterorenoscopy on stone-free rates and complications

Objective

To date, only few studies have evaluated the impact of ureteral stenting prior to ureterorenoscopy. This study is to clarify the role of preoperative ureteral stenting in the treatment for ureteral stones.

Methods

We retrospectively reviewed 550 ureterorenoscopies from 1998 to 2008. Patients were classified into two groups depending on whether they had a stent placed before URS. Baseline characteristics of patients and stone properties, stone-free rates, complications, and operation times were compared between both groups. Subanalysis was performed regarding stone localization. We retrospectively reviewed data from patient documentation, X-ray imagery, intravenous urography, and operation reports.

Results

Baseline characteristics of patients were similar in both groups. The majority of patients underwent stent placement before the ureteroscopic stone treatment (88.4%). The mean operation time in the prestented group was longer (43.3 vs. 38.4 min). Stone-free rate of patients with stent was 72.2%, compared to 59.4% without preoperative stenting. The rate of minor complications was 4.7% with stent versus 9.4% without stent, major complications 0.6% versus 1.6%, respectively. Patients with distal ureter stones had similar stone-free rates regardless of a stent placement (90.1% with stent vs. 87.6% without), and no difference in complication rates was observed (3.5% with stent vs. 3.1% without), respectively.

Conclusions

Stent placement prior to ureteroscopic stone treatment in distal ureter is not reasonable and does not considerably improve stone-free rates.

Ureteral stent discomfort: Etiology and management

Objectives:

To review the evidence-based literature on the causes, characteristics, and options to manage double J stent-related symptoms.

Methods:

We performed a Medline database assessment on papers that investigated the prevalence, mechanisms, risk factors, bothersome and management of double-J stent-related symptoms. Articles in English were reviewed and summarized.

Results:

Stent-related symptoms have a high prevalence and may affect over 80% of patients. They include irritative voiding symptoms including frequency, urgency, dysuria, incomplete emptying; flank and suprapubic pain; incontinence, and hematuria. Assessment tools are important to determine their intensity and allow for comparisons between different points in the timeline. The Urinary Stent Symptom Questionnaire (USSQ) is the most proper tool used for this purpose. Management should be focused on the prevention and management of symptoms. In this sense, research has focused on new materials and stent designs that would be more compatible to the physiologic properties of the urinary tract and medications that can ameliorate the sensitivity and motor response of the bladder.

Conclusions:

Stent-related symptoms are very common in the Urological clinical setting. It is of major importance for the urologist to understand their physiopathology and to be familiar with ways to avoid or manage them.

Do patients benefit from miniaturized tubeless percutaneous nephrolithotomy? A comparative prospective study

BACKGROUND AND PURPOSE

A benefit of miniaturized percutaneous nephrolithotomy (MPCNL) compared with conventional percutaneous nephrolithotomy (PCNL) has not been demonstrated as yet. Thus, the aim of this study was to evaluate the outcome of conventional vs MPCNL and to determine if MPCNL offers an advantage for the patient.

PATIENTS AND METHODS

A prospective, nonrandomized series of 50 consecutive patients with solitary calculi (lower pole or the renal pelvis) were treated either by conventional PCNL (26F) or MPCNL (18F). Ultrasound or holmium laser were used for lithotripsy. Patients were treated tubeless after uncomplicated MPCNL, with thrombin-matrix tract closure and antegrade Double-J catheter placement. After PCNL, all patients received 22F nephrostomies. Demographic data, stone characteristics, perioperative course, and complication rates were assessed.

RESULTS

Patients characteristics were comparable in both groups, except for stone size, which was 18 +/- 8 mm (MPCNL) and 23 +/- 9 (PCNL; P = 0.042). Operative time was comparable in both groups (48 +/- 17 vs 57 +/- 22 min, not significant [NS]). After MPCNL, 96% were stone free at day 1 vs 92% after PCNL (NS). Significant complications did not occur in both groups. Minor complications were: Fever, 12% (MPCNL) vs 20% (PCNL; NS); bleeding, 4% vs 8%; perforations, 0% vs 4% (all NS). Overall outcome was not influenced by body mass index. Calcium oxalate stones were predominant with 75%. Patients after tubeless MPCNL had less pain (visual analogue score, 3 +/- 3 vs 4 +/- 3; P = 0.048.) and needed slightly less additional pain medication (25 +/- 12 mg/d vs 37 +/- 10 mg/d piritramid; NS). Hospital stay was significantly shorter after MPCNL (3.8 +/- 28 vs 6.9 +/- 3.5 d; P = 0.021.).

CONCLUSIONS

Both techniques were safe and effective for the management of renal calculi. While stone-free rates were comparable in our series, MPCNL showed advantages in terms of shorter hospital stay and postoperative pain. The lower stone burden and the tubeless fashion of MPCNL, however, might have influenced these results.

A randomized trial evaluating type of nephrostomy drainage after percutaneous nephrolithotomy: small bore v tubeless

PURPOSE

To compare the outcome of tubeless percutaneous nephrolithotomy (PCNL) with small-bore nephrostomy drainage after PCNL.

PATIENTS AND METHODS

We tested the hypothesis that tubeless PCNL is superior to small-bore nephrostomy drainage after PCNL in terms of postoperative pain, analgesic requirement, and hospital stay. To show a 10% difference in these parameters, a sample size of 30 persons per group would be needed. All patients undergoing PCNL from September 2005 to May 2006 were included in the study. Patients meeting the inclusion and exclusion criteria were then randomized to either a tubeless approach with insertion of a ureteral stent or placement of an 8F nephrostomy tube without insertion of a ureteral stent. The perioperative outcomes of patients in the two groups were compared.

RESULTS

Tubeless PCNL was performed in 33 patients, and an 8F nephrostomy tube was placed in 32 patients. The two groups had comparable demographic data. The hemoglobin drop and complication rate between the two groups were comparable. Patients undergoing tubeless PCNL experienced less postoperative pain (P = 0.001), needed less analgesia (P = 0.006), and were discharged 9 hours earlier than patients in the other group. Complete stone clearance was achieved in 87.87% patients in the tubeless group and 87.5% patients in the nephrostomy group. In the tubeless group, 39.4% of patients had bothersome stent-related symptoms, of whom 61.5% needed analgesics and/or antispasmodic agents.

CONCLUSIONS

Tubeless PCNL offers the potential advantages of decreased postoperative pain, analgesic requirement, and hospital stay without increasing the complications. It was associated with stent-related discomfort in 39% of patients.