Is stent placement necessary after uncomplicated ureteroscopy for removal of impacted ureteral stones?

Timing of Ureteral Stent Removal After Ureteroscopy on Stent-Related Symptoms: A Validated Questionnaire Comparison of 3 and 7 Days Stent Duration

Objectives: To determine whether urinary symptoms are significantly improved with a shorter duration of stent placement without an increase in complications. Methods: A total of 100 patients were prospectively randomized to two groups, either a 3-day (n = 59, Group 1) or 7-day (n = 41, Group 2) stent placement group depending on date of operation. Patients submitted Ureteral Stent Symptom Questionnaires both while stents were in situ and 2 to 3 days after removal. Results: Group 2 reported greater urinary symptoms (p < 0.001) and pain (p < 0.001) with stents in situ compared with Group 1. Urinary symptoms (p < 0.001), pain (p = 0.003), and general health (p = 0.02) were more severe in Group 2 after stent removal as well. The analysis also revealed that urinary symptoms, pain, and general health improved after stent removal compared with stent in situ (p < 0.001). There were no significant differences in work-related functioning between two groups. There was one complication in Group 1 requiring bilateral stent replacement. There were no significant differences in emergency department visits, unplanned clinic visits, or hospitalizations between Groups 1 and 2. Conclusions: Patients with stent removal at 3-day group had better reported urinary, pain, and general health score compared with 7-day group. Patients after stent removal had improved urinary symptoms, pain symptom, and general health compared with ureteral stent in situ. There was no statistically significant difference in complications between the groups.

Outcomes and Complications from a Randomized Controlled Study Comparing Conventional Stent Placement Versus No Stent Placement after Ureteroscopy for Distal Ureteric Calculus < 1 cm

Ureteric stent insertion following ureteroscopic lithotripsy (URSL) is a common and widely accepted procedure. However, there is no agreement on whether a ureteric stent should be placed following an uncomplicated URSL. Furthermore, the definition of uncomplicated URSL remains debatable. To compare the efficacy, safety, and morbidity of no stent placement with the conventional stent placement after uncomplicated retrograde semirigid URS for a distal ureteric calculus of size ≤1 cm, we compared the corresponding complication rates, emergency visits, secondary interventions, and pain at follow-up. Following an uncomplicated ureteroscopic lithotripsy, 104 patients were randomized into the conventional stented group (CSG) and nonstented group (NSG). Lower urinary tract symptoms and sexual function were evaluated using validated questionnaires (IPSS + IIEF-5 + MSHQ-EjD/FSFI) preoperatively and at 4 weeks during follow-up. Pain scores at follow-up were recorded using a visual analogue scale (VAS). Patients who visited the emergency room or needed secondary interventions before the recommended follow-up time were noted. The Generalized Estimating Equations method was used to explore the difference in change in the domains of IPSS, IIEF-5, MSHQ-EjD, and FSFI between the two groups over time. A significant difference was noted in the following IPSS domains: Frequency, Urgency, Nocturia, Storage Symptoms, Total IPSS Score (p ≤ 0.001), and QoL (p = 0.002); IIEF-5 domains: Overall Score (p = 0.004); MSHQ-EjD domains: Ejaculation Bother/Satisfaction (p ≤ 0.001); and FSFI domains: Lubrication (p ≤ 0.001), Satisfaction (p = 0.006), and Overall Score (p = 0.004). There was no significant difference between the various groups in terms of distribution of emergency visits, readmission and secondary interventions, pain at follow-up (VAS), and need for long-term analgesia. Nonplacement of stents after uncomplicated URS decreases stent-related symptoms and preserves QoL without placing the patient under increased postoperative risk.

Impact of eliminating urethral catheterization following ureterorenoscopic lithotripsy

OBJECTIVES

To show that elimination of a urethral catheter in ureterorenoscopic lithotripsy cases is not disadvantageous.

METHODS

We reviewed 164 non-catheterized patients (experimental group) and 656 catheterized patients (control group) with renal or ureteral stones treated at our institution. Inclusion criteria were initial operation, patient age 18 to 75 years, no dysuria, and no preoperative febrile urinary tract infection due to calculi. The primary areas of evaluation were patient background, stone characteristics, perioperative factors, and postoperative evaluation results.

RESULTS

The proportion of women was significantly lower (24.4% vs 37.2%; P = 0.01) and the proportion of multiple stone cases was significantly higher (34.9% vs 19.2%; P < 0.001) in the experimental as compared to the control group, while there were no significant differences for patient background or stone characteristics. The percentages of short-term preoperative stent insertion (72.0% vs 33.0%; P = 0.009) and negative preoperative urine culture cases (58.0% vs 23.0%; P < 0.001) were significantly higher in the experimental than in the control group, with no differences regarding other perioperative factors. There was no significant difference for complete stone clearance rate between the groups (P = 0.339), while only one patient underwent re-catheterization and there were no cases of urinary retention. Interestingly, the rate of postoperative febrile urinary tract infection was significantly lower (P = 0.024) in the experimental (5.7%) than in the control (9.0%) group.

CONCLUSION

Postoperative urethral catheterization can be eliminated in low-risk ureterorenoscopic lithotripsy cases, although additional studies are needed.

Retrograde intrarenal surgery: Past, present, and future

With the recent technological advancements in endourology, retrograde intrarenal surgery has become a more popular procedure for treatment of urolithiasis. Furthermore, since the introduction of new laser systems and advanced flexible ureteroscopy with miniaturized ureteroscopes, the treatment indications for retrograde intrarenal surgery have expanded to include not only larger renal stones of >2 cm but also upper urinary tract urothelial carcinoma, ureteral stricture, and idiopathic renal hematuria. Clinicians must keep up with these trends and make good use of these technologies in the rapidly changing field of endourology. Simultaneously, we must consider the risk of various complications including thermal injury due to laser use, ureteral injury caused by the ureteral access sheath, and radiation exposure during retrograde intrarenal surgery with fluoroscopic guidance. This review focuses on the past, present, and future of retrograde intrarenal surgery and provides many topics and clinical options for urologists to consider.

Impacted ≥ 10-mm pelvic ureteric stone treatment: laser lithotripsy alone or in combination with pneumatic lithotripsy—a prospective, comparative study

Background

The aim of this study is to evaluate the outcome of ureteroscopic lithotripsy of combined pneumatic and laser versus laser lithotripsy alone for the treatment of impacted pelvic ureteral stones. Ninety patients with impacted stones 10 mm or more were selected and divided into two equal groups. The combined group included patients who treated by pneumatic lithotripsy (PL) and laser lithotripsy (LL), while those in the laser group were treated by LL alone via retrograde semirigid ureteroscopy. Exclusion criteria included urinary tract infection, radiolucent stones, ipsilateral concurrent stone, previous ureteral surgery, urinary tract anomalies, musculoskeletal deformities, renal failure and pregnancy. Any stone retropulsion or any residual stone detected 1 month postoperative was considered failure.

Results

The stone-free rate was 88.8% and 91.1% for laser and combined groups, respectively, which was statistically insignificant (p ≥ 0.05). Operative complications were 11.11% versus 4.4% for laser and combined groups, respectively, which is significant statistically (p ˂ 0.05). No ureteral perforation and no stricture were developed in the combined group, while one perforation and two strictures were developed in the laser group. The DJ stenting and second session lithotripsy requirements were 64.4% versus 51.1% and 15.5% versus 8.8% for laser versus combined group, respectively, and each was statistically significant.

Conclusion

When treating impacted stones, combining PL to LL can decrease the complication rate, DJ stenting and second session lithotripsy requirement, while preserving laser fragmentation capabilities.

Comparison of the Effects of Four Treatment Techniques Commonly Used in Ureteral Stone Treatment on Patients' Daily Physical Functioning: An Observational Randomized-Controlled Study

Objective: To investigate the effect of four different techniques used in the treatment of ureteral stones on patients' daily physical functioning (PF) and quality of life (QoL). Materials and Methods: Patients who underwent ureterorenoscopy (URS)-with or without Double-J stenting (DJS)-and extracorporeal shock wave lithotripsy (SWL) were divided into four groups: Group I: SWL (n = 29), Group II: URS (n = 43), Group III: URS +4.8F DJS (n = 39), Group IV: URS +6F DJS (n = 42), and Group V: Control (n = 30). Short Form-36 (SF-36) was administered to each participant both preoperatively and 14 days after operation. Based on the SF-36 results, the changes in patients' PF and QoL were evaluated. Results: Ureteral stone treatment was performed in 202 patients. Of these, 153 patients who underwent an effective SWL or URS procedure in the first attempt were included in the study. Success rates in the first session were 53.7% (29/54) and 83.8% (124/148) for SWL and URS, respectively (p < 0.001). All the four groups were similar with regard to age, gender, body mass index, stone size, preoperative PF, and QoL. However, although postoperative PF, role limitations due to physical health, and energy/fatigue scores were similar in Group I, III, and IV, they were significantly higher in Group II. No major complication associated with SWL or URS occurred in any patient. However, in Group 2, DJS was inserted in three (7.7%) patients in the early postoperative period (within the first 48 hours) due to renal colic attacks secondary to ureterovesical junction mucosal edema. Conclusion: URS without DJS seems to be the most advantageous technique in the treatment of ureteral stones in terms of daily PF and QoL. However, it should be noted that patients undergoing URS may require postoperative emergency stenting, although rarely.

Ureteric stenting vs not stenting following uncomplicated ureteroscopic lithotripsy: A prospective randomised trial

Objective

To compare three groups of patients who underwent uncomplicated ureteroscopic lithotripsy (URSL) and to evaluate whether stenting could be eliminated after the procedure, as there is no consensus about whether a ureteric stent should be placed after uncomplicated ureteroscopy for stone retrieval.

Patients and methods

In this randomised clinical trial (NCT04145063) 105 patients underwent uncomplicated URSL for ureteric stones. They were prospectively randomised into three groups: Group 1 (34 patients) with a double pigtail ureteric stent, Group 2 (35 patients) with a double pigtail ureteric stent with extraction string, and Group 3 (36 patients) with no ureteric stent placed after the procedure. The outcomes measured were: postoperative visual analogue scale (VAS) score for flank pain and dysuria score, urgency, frequency, suprapubic pain, haematuria, analgesia requirement, operative time, re-hospitalisation, and return to normal physical activity.

Results

The mean (SD) operative time was significantly longer in groups 1 and 2 compared to Group 3, at 22.2 (9.1), 20.2 (6) and 15.1 (7.1) min, respectively (P < 0.001). The results of the VAS for flank pain and dysuria scores, urgency, frequency, haematuria, and suprapubic pain showed a significant difference at all time-points of follow-up, being significantly higher in groups 1 and 2 compared to Group 3 (all P < 0.001). Further analysis showed that measured outcomes, and analgesia need for groups 1 and 2 were similar, at all time-points except at week 1 and 1 month where Group 2 patients’ had less symptoms (P < 0.001).

Conclusion

Double pigtail ureteric stent placement appears to be unnecessary in procedures considered ‘uncomplicated’ by operating urologists during surgery. The advantages of the double pigtail ureteric stent with extraction string over the double pigtail ureteric stent only include earlier and easier removal with earlier relief of symptoms, and less analgesia requirements.

Abbreviations

KUB: plain abdominal radiograph of the kidneys, ureters and bladder; URSL: ureteroscopic lithotripsy; VAS: visual analogue scale

Reprint - Ureteral stent vs. no ureteral stent for ureteroscopy in the management of renal and ureteral calculi: A Cochrane review

INTRODUCTION

We aimed to assess the effects of postoperative ureteral stent placement after uncomplicated ureteroscopy.

METHODS

We performed a comprehensive search with no restrictions on publication language or status up to February 1, 2019. We only included randomized trials. Two review authors independently examined full-text reports, identified relevant studies, assessed the eligibility of studies for inclusion, extracted data, and assessed risk of bias. We performed statistical analyses using a random-effects model and assessed the certainty of the evidence according to GRADE.

RESULTS

We included 23 studies with 2656 randomized patients. Primary outcomes: It is uncertain whether stenting reduces the number of unplanned return visits (very low certainty of evidence [CoE]). Pain on the day of surgery is probably similar (mean difference [MD] 0.32; 95% confidence interval (CI) -0.13-0.78; moderate CoE). Pain on postoperative days 1-3 may show little to no difference (standardized mean difference [SMD] 0.25; 95% CI -0.32-0.82; low CoE). It is uncertain whether stented patients experience more pain on postoperative days 4-30 (very low CoE). Stenting may result in little to no difference in the need for secondary interventions (risk ratio [RR] 1.15; 95% CI 0.39-3.33; low CoE).

SECONDARY OUTCOMES

We are uncertain whether stenting reduces the need for narcotics and reduces ureteral stricture rates up to 90 days (very low CoE). Rates of hospital admission may be slightly reduced (RR 0.70; 95% CI 0.32-1.55; low CoE). This review was limited to patients in whom ureteroscopy was deemed 'uncomplicated.' In addition, time intervals for the grouping for the reported degree of pain were established post-hoc. The CoE for most outcomes was rated as low or very low for methodological reasons.

CONCLUSIONS

Findings of this review illustrate the tradeoffs of risks and benefits faced by urologists and their patients when it comes to decision-making about stent placement after uncomplicated ureteroscopy for stone disease.

The effect of using ureteral access sheath for treatment of impacted ureteral stones at mid-upper part with flexible ureterorenoscopy: a randomized prospective study

BACKGROUND

The number of the studies made on the efficacy of flexible ureteroscopy (FURS) with ureteral access sheath (UAS) for impacted ureteral stones is limited. The aim of our study was to compare the efficacy and reliability of FURS in treatment of mid-upper impacted ureteral stones in cases where access is used or not.

METHODS

Between January 2017 and June 2018, 131 adult patients who applied to our clinic with complaints of mid-upper impacted ureteral stones. Patients were randomized as group 1 (without UAS) and group 2 (with UAS) by means of a draw and assessed in terms of demographic features, stone size, stone localization, hydronephrosis grade, operation time, scope time, the need for additional surgery, hospitalization time and complications.

RESULTS

The mean age of the patients in group 1 was 45.01 years (19-76) and was 37.01 years (16-80) in group 2. Mean stone size was 9.04 mm2 and 9.77 mm2 in group 1 and 2, respectively. Additional treatment was required for 26 (42.6%) patients in group 1 and 8 (11.4%) in group 2. No major intraoperative and postoperative complications developed in both groups. Although bleeding as a postoperative complication rate was similar, fever (>38° C) and urinary tract infection were higher in group 1 than in group 2.

CONCLUSIONS

In the treatment of mid-upper impacted ureteral stones, using UAS during the application of FURS is an advantageous procedure due to shorter operation time, fever intraoperative stone migrations and the need for additional surgery, less postoperative infection.

Ureteral stent versus no ureteral stent for ureteroscopy in the management of renal and ureteral calculi

BACKGROUND

Ureteroscopy combined with laser stone fragmentation and basketing is a common approach for managing renal and ureteral stones. This procedure is associated with some degree of ureteral trauma. Ureteral trauma may lead to swelling, ureteral obstruction, and flank pain and may require subsequent interventions such as hospital admission or secondary ureteral stent placement. To prevent such issues, urologists often place temporary ureteral stents prophylactically, but the value of doing so remains unclear.

OBJECTIVES

To assess the effects of postoperative ureteral stent placement after uncomplicated ureteroscopy.

SEARCH METHODS

We performed a comprehensive search using multiple databases (the Cochrane Library, MEDLINE, Embase, Scopus, Google Scholar, and Web of Science), trials registries, other sources of grey literature, and conference proceedings, up to 01 February 2019. We applied no restrictions on publication language or status.

SELECTION CRITERIA

We included trials in which researchers randomised participants undergoing uncomplicated ureteroscopy to placement of a ureteral stent versus no ureteral stent.

DATA COLLECTION AND ANALYSIS

Two review authors independently classified studies and abstracted data from the included studies. We performed statistical analyses using a random-effects model. We rated the certainty of evidence (CoE) according to the GRADE approach.

MAIN RESULTS

Primary outcomesStenting may slightly reduce the number of unplanned return visits (16 trials with 1970 participants; very low CoE), but we are very uncertain of this finding.Pain on the day of surgery as measured on a visual analogue scale (scale 0 to 10; higher values reflect more pain) is probably similar (mean difference (MD) 0.32 higher, 95% confidence interval (CI) 0.13 lower to 0.78 higher; 4 trials with 346 participants; moderate CoE). Pain on postoperative days 1 to 3 may show little to no difference (standardised mean difference (SMD) 0.25 higher, 95% CI 0.32 lower to 0.82 higher; 8 trials with 683 participants; low CoE). On postoperative days 4 to 30, stented participants may experience more pain (8 trials with 903 participants; very low CoE), but we are very uncertain of this finding.Stenting may result in little to no difference in the need for secondary interventions (risk ratio (RR) 1.15, 95% CI 0.39 to 3.33; 10 studies with 1435 participants; low CoE); this corresponds to three more interventions per 1000 participants (95% CI 13 fewer to 48 more).Secondary outcomesStenting may reduce the need for narcotics (7 trials with 830 participants; very low CoE), but we are very uncertain of this finding.Rates of urinary tract infection (UTI) up to 90 days are probably not substantially different (RR 0.94, 95% CI 0.59 to 1.51; 10 trials with 1207 participants; moderate CoE); this corresponds to three fewer infections per 1000 participants (95% CI 23 fewer to 29 more).Ureteral stricture rates up to 90 days may be slightly reduced (14 trials with 1625 participants; very low CoE), but we are very uncertain of this finding.Rates of hospital admission may be slightly reduced (RR 0.70, 95% CI 0.32 to 1.55; 13 studies with 1647 participants; low CoE). This corresponds to 15 fewer admissions per 1000 participants (95% CI 33 fewer to 27 more).

AUTHORS' CONCLUSIONS

Findings of this review illustrate the trade-offs of risks and benefits faced by urologists and their patients when it comes to decision-making about stent placement after uncomplicated ureteroscopy for stone disease. We noted that both desirable and undesirable effects were small in absolute terms, with findings based mostly on low and very low CoE. The main issues reducing our confidence in research findings were study limitations (mostly risk of performance and detection bias) and imprecision. We were unable to conduct any of the preplanned subgroup analyses, in particular those based on stone size, stone location, and use of ureteral dilation, which may be important effect modifiers. Given the importance of this question, higher-quality and sufficiently large trials are needed to better inform decision-making.

A cost analysis of stenting in uncomplicated semirigid ureteroscopic stone removal

OBJECTIVE

To evaluate the outcome and the costs of stenting in uncomplicated semirigid ureteroscopic stone removal.

MATERIALS AND METHODS

A decision tree model was created to evaluate the economic impact of routine stenting versus non-stenting strategies in uncomplicated ureteroscopy (URS). Probabilities of complications were extracted from twelve randomized controlled trials. Stone removal costs, costs for complication management, and total costs were calculated using Treeage Pro (TreeAge Pro Healthcare version 2015, Software, Inc, Williamstown Massachusetts, USA).

RESULTS

Stone removal costs were higher in stented URS (€1512.25 vs. €1681.21, respectively). Complication management costs were higher in non-stented procedures. Both for complications treated conservatively (€189.43 vs. €109.67) and surgically (€49.26 vs. €24.83). When stone removal costs, costs for stent removal, and costs for complication management were considered, uncomplicated URS with stent placement yielded an overall cost per patient of €1889.15 compared to €1750.94 without stent placement. The incremental costs of stented URS were €138.25 per procedure.

CONCLUSION

Semirigid URS with stent placement leads to higher direct procedural costs. Costs for managing URS-related complications are higher in non-stented procedures. Overall, a standard strategy of deferring routine stenting uncomplicated ureteroscopic stone removal is more cost efficient.

Meta-Analysis of Stenting versus Non-Stenting for the Treatment of Ureteral Stones

Background and aim

Ureteroscopic lithotripsy (URL) and extracorporeal shock wave lithotripsy (ESWL) are two widely used methods for the treatment of ureteral stones. The need for ureteral stenting during these procedures is controversial. In this meta-analysis, we evaluated the benefits and disadvantages of ureteral stents for the treatment of ureteral stones.

Methods

Databases including PubMed, Embase and Cochrane library were selected for systematic review of randomized controlled trials (RCTs) comparing outcomes with or without stenting during URL and ESWL. Meta-analysis was performed using RevMan 5.3 and STATA 13.0 software.

Results

We identified 22 RCTs comparing stenting and non-stenting. The stented group was associated with longer operation time (WMD: 4.93; 95% CI: 2.07 to 7.84; p < 0.001), lower stone-free rate (OR: 0.55; 95% CI: 0.34 to 0.89; p = 0.01). In terms of complications, the incidence of hematuria (OR: 3.68; 95% CI: 1.86 to 7.29; p < 0.001), irritative urinary symptoms (OR: 4.40; 95% CI: 2.19 to 9.10; p < 0.001), urinary infection (OR: 2.23; 95% CI: 1.57 to 3.19; p < 0.001), and dysuria (OR: 3.90; 95% CI: 2.51 to 6.07; p < 0.001) were significantly higher in the stented group. No significant differences in visual analogue score (VAS), stricture formation, fever, or hospital stay were found between stenting and non-stenting groups. The risk of unplanned readmissions (OR: 0.63; 95% CI: 0.41 to 0.97; p = 0.04) was higher in the non-stented group.

Conclusions

Our analysis showed that stenting failed to improve the stone-free rate, and instead, it resulted in additional complications. However, ureteral stents are valuable in preventing unplanned re-hospitalization. Additional randomized controlled trials are still required to corroborate our findings.

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.

CUA Guideline: Management of ureteral calculi

The focus of this guideline is the management of ureteral stones. Specifically, the topics covered include: conservative management, medical expulsive therapy, active intervention with either shockwave lithotripsy (SWL) or ureteroscopy (URS), factors affecting SWL treatment success, optimizing success, and special considerations (e.g., pregnancy, urinary diversion). By performing extensive literature reviews for each topic evaluated, we have generated an evidence-based consensus on the management of ureteral stones. The objective of this guideline is to help standardize the treatment of ureteral stones to optimize treatment outcomes.

Holmium laser lithotripsy with semi-rigid ureteroscopy: a first-choice treatment for impacted ureteral stones in children?

Background

We aimed to assess the effectiveness of semi-rigid ureteroscopy and holmium laser lithotripsy in the treatment of impacted ureteral stones in children.

Material/Methods

We evaluated a total of 32 children under the age of 18 years treated with ureteroscopic holmium laser lithotripsy for impacted ureteral stones between January 2005 and July 2013. Their stone-free state was defined as the absence of any residual stone on radiologic evaluation performed 4 weeks postoperatively. Complications were evaluated according to the modified Clavien classification.

Result

The mean patient age was 9.5±5.1 years (range 1–18 years). Seven (21.8%) of the stones were located in the proximal ureter, 9 (28.2%) were in the mid-ureter, and 16 (50%) were in the distal ureter. The mean stone size was calculated as being 10.46±3.8 mm² (range 5–20). The stone-free rate was 93.75% (30/32 patients) following primary URS. Additional treatment was required for only 2 (6.25%) of the patients. After the procedure, a D-J stent was placed in all the patients. The total complication rate was 15.6% (5 patients). The 10 total complications in these 5 patients were 5 (15.6%) Grade I, 1 (3.1%) Grade II, 2 (6.25%) Grade IIIa, and 2 (6.25%) Grade IIIb. The mean follow-up period was 16.5 months (range 3–55).

Conclusions

For the treatment of impacted ureteral stones in children, holmium laser lithotripsy with semi-rigid ureteroscopy, with its low retreatment requirement and acceptable complication rates, is an effective and reliable method in experienced and skilled hands as a first-choice treatment approach.

Is stone diameter a variable in the decision process of employing a ureteral stent in patients undergoing uncomplicated ureterorenoscopy and associated intracorporeal lithotripsy?

INTRODUCTION

A number of randomized trials and meta-analysis in patients who underwent ureteroscopic stone removal investigated the effects of placing a ureteral stent at the end of the procedure on complication rates. However, none of these investigates the stone diameter and its possible influence on complication rates and, as such, if it should be considered a possible variable in the decision process of placing or not a ureteral stent.

MATERIALS AND METHODS

A bibliographic search covering the period from January 1990 to March 2012 was conducted in PubMed, MEDLINE and EMBASE. This analysis is based on the fifteen remaining studies which fulfilled the predefined inclusion criteria. All statistical evaluations were performed using SAS version 9.2. and by RevMan 5.0.

RESULTS

A total of 1,416 patients were included. All the studies were published after 2000. Mean stone diameter ranged between 5.3 and 13.3 mm in the non-stented group and between 6.26 and 13.28 mm in the stented group. Meta-analysis showed that stone diameter was not statistically different for stented or non-stented subgroups, whereas surgical operative time was shorter for the non-stented subgroup. The effect of stone diameter, irrespectively if patients were operated with or without stents were grouped or considered separately, did not influence complications of fever, haematuria, unplanned medical visits after surgery and urinary tract infections.

CONCLUSIONS

Stone diameter is not a variable in the pre- or intraoperative decision process of placing or not placing a ureteral stent in patients undergoing uncomplicated ureterorenoscopy with intracorporeal lithotripsy.

Endoscopic holmium laser treatment for ureterolithiasis

INTRODUCTION

The rapid development and invention of ever more technologically advanced ureterorenoscopes as well as other instruments used in fragmenting ureteral stones have made the traditional surgical treatment of ureterolithiasis very rare.

MATERIAL AND METHODS

We investigated 727 patients treated for ureterolithiasis. 769 ureteroscopic lithotripsies (URSL) with the holmium laser were performed. We evaluated the relation of the stone size, the section of the ureter involved, length of time of the stone within the ureter and the condition of the urinary tract to the results of the ureterolithiasis treatment.

RESULTS

A good result of breaking up the stone and passing its fragments out of the ureter within 3 months following the first URSL was observed in 642 (90.9%) out of 706 patients. The remaining 64 (9.1%) patients required additional procedures: ESWL was performed on 44 patients; URSL was repeated for 20 patients. The most serious early post-URSL complications involved: urinary tract infection with symptoms of urosepsis in 10 patients, leading to death in 1 case, ureteral perforation in 3 patients, including 1 case presenting a periureteral leak that necessitated a surgical intervention.

CONCLUSIONS

URSL with the holmium laser is an effective and safe method for treating ureterolithiasis.

The results of ureteral stenting after ureteroscopic lithotripsy for ureteral calculi: a systematic review and meta-analysis

PURPOSE

We evaluated the necessity and adverse effects of routine ureteral stent placement after ureteroscopic lithotripsy for ureteral stones.

MATERIALS AND METHODS

A systematic search of PubMed®, Embase® and the Cochrane Library was performed to identify all randomized controlled trials. All relevant studies were on the outcomes and complications of ureteroscopic lithotripsy in the management of ureteral stones with or without a Double-J stent. The outcomes and complications included stone-free rate, operative time, lower urinary tract symptoms, hematuria, fever, urinary tract infection, pain and analgesia, unplanned medical visits and late postoperative complications. The Cochrane Collaboration Review Manager software (RevMan 5.0.2) was used for statistical analysis.

RESULTS

A total of 16 randomized controlled trials were enrolled for analysis and involved 1,573 patients. Of these patients 797 were in the nonstented group and 776 in the stented group. There was a statistically significant difference in mean operative time between the 2 groups. The incidence of lower urinary tract symptoms and pain was significantly higher in the stented group than in the nonstented group. Significant differences between the groups were not found in fever, urinary tract infection, need for analgesia, unplanned readmission and late postoperative complications.

CONCLUSIONS

This systematic review reveals the obvious disadvantages of ureteral stents after ureteroscopic lithotripsy in lower urinary tract symptoms and pain. Stents do not improve stone-free rate, fever, incidence of urinary tract infection, unplanned medical visits, requirement for analgesia and late postoperative complications. Ureteral stenting after uncomplicated ureteroscopic lithotripsy could be unnecessary.

Is ureteral stenting really necessary after ureteroscopic lithotripsy with balloon dilatation of ureteral orifice? A multi-institutional randomized controlled study

PURPOSE

Our aim was to evaluate the role of balloon dilatation of the ureteral orifice on the decision to stent after ureteroscopy.

MATERIALS AND METHODS

We prospectively enrolled 505 patients from two clinics, undergoing ureteroscopy (URS) for urolithiasis. Patients having balloon dilatation of the ureteral orifice and uncomplicated ureteroscopy were randomized to be either stented (n = 144) or nonstented (n = 142). Ureteroscopy was done with a 9.8 rigid ureteroscope. For dilatation of ureteral orifice, 18Fr-4 cm balloons were used (Uromax™, Boston Scientific, USA). Holmium laser or pneumatic devices were used for lithotripsy. In the second postoperative week, patients were asked to assess: pain, dysuria, and urgency using a 10-cm visual analog score (VAS) and unplanned visits. In each visit, urinalysis, urine culture, plain X-ray, and ultrasound examinations were performed. Six months after URS, follow-up IVU was performed to evaluate ureteral narrowing. Results for the separate clinics were not revealed until the end of study.

RESULTS

There were no significant differences between the two groups regarding gender, age, preoperative serum creatinine levels, stone size, stone side and location, lithotripsy type, pain, infectious complications, unplanned visits, and ureteral narrowing. However, irritative symptoms were more common in the stented group. Success rates of 97.8 and 97.2% were similar in the unstented and stented groups.

CONCLUSION

In uncomplicated URS, balloon dilatation of the ureteral orifice should not significantly affect the decision for or against stent placement. Avoiding stents lowers costs and gives fewer irritative symptoms.

Meta-analysis of postoperatively stenting or not in patients underwent ureteroscopic lithotripsy

The aim of this study was to evaluate the necessity for stenting after ureteroscopic lithotripsy. We performed a systematic research of Medline, Embase, Cochrane central registration for RCTs concerning the comparison between stented and non-stented post-ureteroscopic procedures for stone removal and reference lists of the included study were also screened. 15 trials were included and data related was extracted and analyzed in meta way. No difference was detected in stone free rate and stricture formation between the two groups (P = 0.69; P = 0.67). Participants with stents had higher risk of being infected than those without, RR = 1.72, but with no difference. Stent related lower urinary symptoms were more frequently experienced by stented patients, dysuria (RR = 5.24, P = 0.003); hematuria (RR = 7.28, P = 0.001); loin voiding pain (RR = 5.24, P = 0.003). Postoperative pain score were also higher in patients with stent in the early period after surgery with mean difference 0.95 (P = 0.002). With additional time needed for the placement of stent, the operative time in stented patients were 3.36 min longer than those without stenting (P = 0.02). The additional cost for longer operative room stay, together with the sent and cystoscopic stent removed conditionally, and made the cost for stented patients much higher. No difference were detected in length of hospital stay between both groups (P = 0.22), the stented patients were even of lower rate pay unplanned hospital visit (RR = 0.81, P = 0.55). Stenting did not improve the outcome of patients who underwent ureteroscopic lithotripsy, but associated with increased complication rate. Routinely stenting after ureteroscopic procedure for stone removal was not necessary; however, it still should be reserved conditionally.