Study to Enhance Understanding of Stent-Associated Symptoms: Rationale and Study Design

Daily Ecological Momentary Assessments of Pain and Ability to Work After Ureteroscopy and Stenting

Introduction: Ureteral stents can cause significant patient discomfort, yet the temporal dynamics and impact on activities remain poorly characterized. We employed an automated tool to collect daily ecological momentary assessments (EMAs) regarding pain and the ability to work following ureteroscopy with stenting. Our aims were to assess feasibility and better characterize the postoperative patient experience. Materials and Methods: As an exploratory endpoint within an ongoing clinical trial, patients undergoing ureteroscopy with stenting were asked to complete daily EMAs for 10 days postoperatively or until the stent was removed. Questionnaires were distributed through text messages and included a pain scale (0-10) and a single item from the validated Patient-Reported Outcomes Measurement Information System Ability to Participate in Social Roles and Activities instrument, as well as days missed from work or school. Results: Among the first 65 trial participants, 59 completed at least 1 EMA (overall response rate 91%). Response rates were >85% for each time point through postoperative day (POD)10. Median respondent age was 58 years (interquartile range [IQR] 50-67), and 56% were female. Stones were 54% renal and 46% ureteral, with a median diameter of 9 mm (IQR 7-10). Median stent dwell time was 7 days (IQR 6-8). Pain scores were highest on POD1 (median score 4) and declined on each subsequent day, reaching a median score of 2 on POD5. Sixty-three percent of patients on POD1 reported that they had trouble performing their usual work at least sometimes, but by POD5, this was <50% of patients. Patients who work or attend school reported a median of 1 day missed (IQR 0-2). Conclusions: An automated daily EMA system for capturing patient-reported outcomes was demonstrated to be feasible with sustained excellent engagement. Patients with stents reported the worst pain and interference with work on POD1, with steady improvements thereafter, and by POD5, the majority of patients had minimal pain or trouble performing their usual work. This work is associated with a registered clinical trial [NCT05026710].

Contribution of Hypersensitivity to Postureteroscopy Ureteral Stent Pain: Findings From Study to Enhance Understanding of Stent-associated Symptoms

OBJECTIVE

To examine the relationships between preoperative hypersensitivity to pain and central sensitization, and postoperative ureteral stent pain after ureteroscopy (URS) for urinary stones.

METHODS

Adults enrolled in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS) underwent quantitative sensory testing (QST) prior to URS and stent placement. Hypersensitivity to mechanical pain was assessed using a pressure algometer. Participants rated their pain intensity to pressure applied to the ipsilateral flank area and lower abdominal quadrant on the side of planned stent placement, and the contralateral forearm (control). Pressure pain thresholds were also assessed. Central sensitization was assessed by applying a pointed stimulator (pinprick) and calculating the temporal summation. Postoperative stent pain intensity and interference were assessed using PROMIS questionnaires. Data were analyzed using repeated-measures mixed-effects linear models.

RESULTS

Among the 412 participants, the median age was 54.0years, and 46% were female. Higher preoperative pain ratings to 2 kg and 4 kg mechanical pressure to the ipsilateral flank and abdominal areas were associated with higher postoperative stent pain intensity with the stent in situ. Greater degree of central sensitization preoperatively, manifesting as higher temporal summation, was associated with higher postoperative pain intensity. Factors associated with preoperative hypersensitivity on QST included female sex, presence of chronic pain conditions, widespread pain, and depression.

CONCLUSION

Hypersensitivity to pain and central sensitization preoperatively was associated with postoperative ureteral stent pain, suggesting a physiologic basis for stent symptom variation. QST may identify patients more likely to develop stent pain after URS and could inform selection for preventive and interventional strategies.

Patients' Experiences With the Removal of a Ureteral Stent: Insights From In-depth Interviews With Participants in the USDRN STENTS Qualitative Cohort Study

OBJECTIVE

To describe the experiences of patients undergoing stent removal in the USDRN Study to Enhance Understanding of Stent-Associated Symptoms (STENTS), a prospective, observational cohort study of patients with short-term ureteral stent placement post-ureteroscopy.

METHODS

We conducted a qualitative descriptive study using in-depth interviews. Participants reflected on (1) painful or bothersome aspects of stent removal, (2) symptoms immediately after removal, and (3) symptoms in the days following removal. Interviews were audio-recorded, transcribed, and analyzed using applied thematic analysis.

RESULTS

The 38 participants interviewed were aged 13-77 years, 55% female, and 95% White. Interviews were conducted 7-30 days after stent removal. Almost all participants (n = 31) described that they experienced either pain or discomfort during stent removal, but for most (n = 25) pain was of short duration. Many participants (n = 21) described anticipatory anxiety related to the procedure, and several (n = 11) discussed discomfort arising from lack of privacy or feeling exposed. Interactions with medical providers often helped put participants at ease, but also increased discomfort for some. Following stent removal, several participants described lingering pain and/or urinary symptoms, but these largely resolved within 24 hours. A few participants described symptoms persisting for more than a day post stent removal.

CONCLUSION

These findings on patients' experiences during and shortly after ureteral stent removal, particularly the psychological distress they experienced, identify opportunities for improvement in patient care. Clear communication from providers about what to expect with the removal procedure, and the possibility of delayed pain, may help patients adapt to discomfort.

The Patient Voice: Stent Experiences After Ureteroscopy-Insights from In-Depth Interviews with Participants in the USDRN STENTS Nested Qualitative Cohort Study

Purpose: Ureteral stents are commonly used after ureteroscopy and cause significant discomfort, yet qualitative perspectives on patients' stent experiences remain unknown. We describe psychological, functional, and interpersonal effects of post-ureteroscopy stents and whether additional patient-reported assessments may be needed. Materials and Methods: Using a qualitative descriptive study design, we conducted in-depth interviews with a nested cohort of participants in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS). Participants shared their symptoms with a post-ureteroscopy stent and described symptom bother and impact on daily activities. All interviews were audio-recorded, transcribed, and analyzed using applied thematic analysis. During analysis, participants' experiences with interference in daily activities were categorized into three groups based on their impact: minimal, moderate, and substantial. Results: All 39 participants experienced pain, although descriptions varied and differentiated between feelings of pain vs discomfort. Almost all experienced urinary symptoms. Only a few reported other physical symptoms, although several psychological aspects were identified. In the areas of sleep, mood, life enjoyment, work, exercise, activities of daily living, driving, childcare, and leisure/social activities, the stent had little impact on daily living among participants placed in the minimal group (n = 12) and far greater impact for participants in the substantial group (n = 8). For patients in the moderate group (n = 19), some daily activities were moderately or substantially affected, whereas other activities were minimally affected. Conclusions: Counseling to better prepare patients for the impact of stent-associated symptoms may help mitigate symptom burden. While existing instruments adequately cover most symptoms, additional assessments for other domains, particularly psychological factors, may be needed.

Risk Factors for Increased Stent-associated Symptoms Following Ureteroscopy for Urinary Stones: Results From STENTS

PURPOSE

The STudy to Enhance uNderstanding of sTent-associated Symptoms sought to identify risk factors for pain and urinary symptoms, as well as how these symptoms interfere with daily activities after ureteroscopy for stone treatment.

MATERIALS AND METHODS

This prospective observational cohort study enrolled patients aged ≥12 years undergoing ureteroscopy with ureteral stent for stone treatment at 4 clinical centers. Participants reported symptoms at baseline; on postoperative days 1, 3, 5; at stent removal; and day 30 post-stent removal. Outcomes of pain intensity, pain interference, urinary symptoms, and bother were captured with multiple instruments. Multivariable analyses using mixed-effects linear regression models were identified characteristics associated with increased stent-associated symptoms.

RESULTS

A total of 424 participants were enrolled. Mean age was 49 years (SD 17); 47% were female. Participants experienced a marked increase in stent-associated symptoms on postoperative day 1. While pain intensity decreased ∼50% from postoperative day 1 to postoperative day 5, interference due to pain remained persistently elevated. In multivariable analysis, older age was associated with lower pain intensity (P = .004). Having chronic pain conditions (P < .001), prior severe stent pain (P = .021), and depressive symptoms at baseline (P < .001) were each associated with higher pain intensity. Neither sex, stone location, ureteral access sheath use, nor stent characteristics were drivers of stent-associated symptoms.

CONCLUSIONS

In this multicenter cohort, interference persisted even as pain intensity decreased. Patient factors (eg, age, depression) rather than surgical factors were associated with symptom intensity. These findings provide a foundation for patient-centered care and highlight potential targets for efforts to mitigate the burden of stent-associated symptoms.

Qualitative research in pediatric urology

INTRODUCTION

Qualitative studies have become increasingly common in the pediatric urology literature due to their ability to enhance our understanding of physicians' and patients' preferences, attitudes, and beliefs. The pediatric urology literature currently lacks clear guidelines for reporting qualitative research. In their absence, it is challenging to judge the quality of these studies.

OBJECTIVES

The objectives of this educational article are to define what is involved in rigorous qualitative research studies, help readers recognize high-quality qualitative research, and provide practical skills in designing and implementing qualitative research.

RESULTS

Acknowledging researcher biases, taking steps to reduce bias and increase reflexivity, and clear descriptions of research and data collection methods all contribute increased rigor and trustworthiness of qualitative studies. Proper selection of qualitative methodology, derived from the research question to be answered, establishes a foundation for reliable and meaningful data.

CONCLUSION

As the field continues to grow, the standardization of reporting of these essential parameters becomes paramount so readers can gauge how findings can be appropriately applied to clinical practice.

Randomized controlled trial of NSAID prior to cystoscopic ureteral stent removal in a pediatric population

INTRODUCTION

Ureteral spasm, common with ureteral stents, is partially mediated by prostaglandins and may be suppressed by cyclooxygenase inhibitors like non-steroidal anti-inflammatory (NSAIDs). Practices currently vary widely for pain management in patients with ureteral stents, sometimes including opioids.

OBJECTIVE

We aimed to determine if NSAID given prior to stent removal would reduce postoperative pain. We hypothesized there would be at least a 75% reduction in postoperative severe pain (pain score ≥7) in patients receiving ibuprofen compared to placebo.

STUDY DESIGN

We performed a double-blind, placebo-controlled randomized controlled trial on pediatric urology patients with an indwelling ureteral stent undergoing removal in the operating room from 2014 to 2019. 20 patients in each arm were needed to achieve 80% power to detect a 75% reduction in the estimated 55% incidence of severe postoperative pain (α = 0.05). Patients ≥4 years old who had a unilateral stent placed after treatment of urolithiasis or ureteropelvic junction obstruction were randomized to NSAID or placebo in a 1:1 ratio at least 15 min prior to scheduled stent removal. Patients estimated pain using Faces Pain Scale-Revised (FPS-R) or visual analogue scale (VAS) prior to and 24 h after stent removal.

RESULTS

254 patients undergoing stent removal were assessed for eligibility, and 44 randomized patients were analyzed using intention to treat analysis. The cohorts were demographically similar and received similar anesthesia treatment. There was no significant difference in maximum post anesthesia care unit pain score (p = 0.269) or use of in-hospital opioids (p = 0.626) between the two groups. No difference was seen in the incidence of severe postoperative pain (p = 1.0), thus rejecting the hypothesis. Significant worsened postoperative pain (pain score increases of ≥2 between time points) decreased from 22.7% to 13.6% between placebo and NSAID, but this did not reach significance (p = 0.410).

DISCUSSION

There was no difference in postoperative pain for patients undergoing ureteral stent removal given preoperative NSAID versus placebo. The incidence of severe pain before and after stent removal was low, ranging from 4.5 to 9.1%.

CONCLUSION

Research to understand the etiology of pain after stent removal and techniques to minimize or prevent discomfort should continue in order to optimize patient outcomes.

Quality of life impact and recovery after ureteroscopy and stent insertion: insights from daily surveys in STENTS

BACKGROUND

Our objective was to describe day-to-day evolution and variations in patient-reported stent-associated symptoms (SAS) in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS), a prospective multicenter observational cohort study, using multiple instruments with conceptual overlap in various domains.

METHODS

In a nested cohort of the STENTS study, the initial 40 participants having unilateral ureteroscopy (URS) and stent placement underwent daily assessment of self-reported measures using the Brief Pain Inventory short form, Patient-Reported Outcome Measurement Information System measures for pain severity and pain interference, the Urinary Score of the Ureteral Stent Symptom Questionnaire, and Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index. Pain intensity, pain interference, urinary symptoms, and bother were obtained preoperatively, daily until stent removal, and at postoperative day (POD) 30.

RESULTS

The median age was 44 years (IQR 29,58), and 53% were female. The size of the dominant stone was 7.5 mm (IQR 5,11), and 50% were located in the kidney. There was consistency among instruments assessing similar concepts. Pain intensity and urinary symptoms increased from baseline to POD 1 with apparent peaks in the first 2 days, remained elevated with stent in situ, and varied widely among individuals. Interference due to pain, and bother due to urinary symptoms, likewise demonstrated high individual variability.

CONCLUSIONS

This first study investigating daily SAS allows for a more in-depth look at the lived experience after URS and the impact on quality of life. Different instruments measuring pain intensity, pain interference, and urinary symptoms produced consistent assessments of patients' experiences. The overall daily stability of pain and urinary symptoms after URS was also marked by high patient-level variation, suggesting an opportunity to identify characteristics associated with severe SAS after URS.

Comparative effectiveness of paediatric kidney stone surgery (the PKIDS trial): study protocol for a patient-centred pragmatic clinical trial

INTRODUCTION

The strength of the evidence base for the comparative effectiveness of three common surgical modalities for paediatric nephrolithiasis (ureteroscopy, shockwave lithotripsy and percutaneous nephrolithotomy) and its relevance to patients and caregivers are insufficient. We describe the methods and rationale for the Pediatric KIDney Stone (PKIDS) Care Improvement Network Trial with the aim to compare effectiveness of surgical modalities in paediatric nephrolithiasis based on stone clearance and lived patient experiences. This protocol serves as a patient-centred alternative to randomised controlled trials for interventions where clinical equipoise is lacking.

METHODS AND ANALYSIS

The PKIDS is a collaborative learning organisation composed of 26 hospitals that is conducting a prospective pragmatic clinical trial comparing the effectiveness of ureteroscopy, shockwave lithotripsy and percutaneous nephrolithotomy for youth aged 8-21 years with kidney and/or ureteral stones. Embedded within clinical care, the PKIDS trial will collect granular patient-level, surgeon-level and institution-level data, with a goal enrolment of 1290 participants over a 21-month period. The primary study outcome is stone clearance, defined as absence of a residual calculus of >4 mm on postoperative ultrasound. Secondary outcomes include patient-reported physical, emotional and social health outcomes (primarily using the Patient-Reported Outcome Measurement Information System), analgesic use and healthcare resource use. Timing and content of secondary outcomes assessments were set based on feedback from patient partners. Heterogeneity of treatment effect for stone clearance and patient-reported outcomes by participant and stone characteristics will be assessed.

ETHICS AND DISSEMINATION

This study is approved by the central institutional review board with reliance across participating sites. Participating stakeholders will review results and contribute to development dissemination at regional, national and international meetings.

TRIAL REGISTRATION NUMBER

NCT04285658; Pre-results.

Evidence and clinical trials in Endourology: where are we going

PURPOSE OF REVIEW

There is an ongoing explosion in the amount and quality, of research in the field of Endourology. From a solid basis of systematic reviews and small, single centre trials it has been possible to design large randomised controlled trials in the UK and in the USA. This review will describe some of the more recent trials (small and large) that are helping to provide a solid evidence base for our practice in Endourology.

ONGOING STUDIES

Randomised controlled trial (RCTs) include: The Therapeutic Interventions for Stones in the Ureter (TISU), the Percutaneous nephrolithotomy, flexible Ureterorenoscopy and extracorporeal Shockwave lithotripsy for lower pole kidney stones (PURE RCTs) and the Prevention of Urinary Stones with Hydration (PUSH). Quality of life (QoL) measures and studies include: the Wisconsin Stone QoL Questionnaire, the Cambridge Renal Stone PROM, the Cambridge Ureteral Stone PROM, the Urinary stone and Intervention QoL questionnaire and the Study to Enhance Understanding of sTent-associated Symptoms (STENTS). The Core Outcome Set in Trials on treatments for Renal and UreteriC sTones (COSTRUCT) study aims to define a core outcome set to be used in future trials.

SUMMARY

On-going studies will provide higher quality evidence on the treatment of ureteric and renal stones to inform treatment decision making and guideline recommendations. They will also guide decisions relating to prevention and recurrence and give insight into the true impact of urinary stones and endourological interventions on patients' quality of life. Future studies will incorporate big data and artificial intelligence.