Identifying patients who are suitable for stentless ureteroscopy following treatment of urolithiasis

Evaluating predictive factor of Systemic Inflammatory Response Syndrome and Postoperative Pain in Patients Without Ureteral Stent Placement After Ureteral Access Sheath Use in Flexible Ureteroscopy for Stone Management

BACKGROUND AND OBJECTIVE

This retrospective cohort study aimed to evaluate the safety of stentless flexible ureteroscopy (fURS) using a ureteral access sheath (UAS) for stone management.

PATIENTS AND METHODS

A total of 270 ureteral stentless postoperative patients were analyzed. Stentless indication was characterized by having no ureteral wall or mucosa injury with only slight erosion, < 1-hour operative time, and no endoscopic stone fragments with or without stone dust. Postoperative complications and pain were analyzed for safety measurements. In addition, preoperative and intraoperative risk factors associated with the incidence of systemic inflammatory response syndrome (SIRS) and postoperative pain were evaluated.

RESULTS

The most common UAS sizes were 10/12 Fr (69.6%) and 9.5/11.5 Fr (28.1%). The rate of patients who were stone-free was 95.9%. The median operation time was 34 min. Only three grade 1 ureteral injuries occurred intraoperatively. Postoperative SIRS occurred in 8.8% of patients, and postoperative use of analgesics was 35.9%. Only four patients were required to undergo eventual ureteral stenting. Less than 10/12-Fr UAS was the only factor positively associated with preventing postoperative SIRS (odds ratio [OR], 4.733; 95% confidence interval [CI], 1.085-20.644). Older age and preoperative ureteral stenting were positively associated with preventing postoperative pain (OR, 0.970; 95% CI, 0.951-0.990 and OR, 0.427; 95% CI, 0.232-0.786; respectively).

CONCLUSION

Stentless fURS with UAS in stone management was feasible for selected patients. UAS size of < 10/12 Fr, older age, and preoperative stenting are possible keystones to achieving stentless fURS with UAS postoperatively.

Effect of alpha1-blockers on stentless ureteroscopic lithotripsy

Objective

To evaluate the clinical efficiency of alpha1-adrenergic antagonists on stentless ureteroscopic lithotripsy treating uncomplicated lower ureteral stones.

Materials and Methods

From January 2007 to January 2013, 84 patients who have uncomplicated lower ureteral stones treated by ureteroscopic intracorporeal lithotripsy with the holmium laser were analyzed. The patients were divided into two groups, group A (44 patients received indwelled double-J stents) and group B (40 patients were treated by alpha1-adrenergic antagonists without stents). All cases of group B were treated with alpha1 blocker for 1 week.

Results

The mean operative time of group A was significantly longer than group B. The incidences of hematuria, flank/abdominal pain, frequency/urgency after surgery were statistically different between both groups. The stone-free rate of each group was 100%.

Conclusions

The effect of alpha1-adrenergic antagonists is more significant than indwelling stent after ureteroscopic lithotripsy in treating uncomplicated lower ureteral stones.

Efficacy of surgical techniques and factors affecting residual stone rate in the treatment of kidney stones

OBJECTIVE

In this study, we aimed to evaluate, the efficacy of surgical methods and the factors affecting the residual stone rate by scrutinizing retrospectively the patients who had undergone renal stone surgery.

MATERIAL AND METHODS

Records of 109 cases of kidney stones who had been surgically treated between January 2010, and July 2013 were reviewed. Patients were divided into three groups in terms of surgical treatment; open stone surgery, percutaneous nephrolithotomy (PNL) and retrograde intrarenal surgery (RIRS). Patients' history, physical examination, biochemical and radiological images and operative and postoperative data were recorded.

RESULTS

The patients had undergone PNL (n=74; 67.9%), RIRS (n=22;20.2%), and open renal surgery (n=13; 11.9%). The mean and median ages of the patients were 46±9, 41 (21-75) and, 42 (23-67) years, respectively. The mean stone burden was 2.6±0.7 cm(2) in the PNL, 1.4±0.1 cm(2) in the RIRS, and 3.1±0.9 cm(2) in the open surgery groups. The mean operative times were 126±24 min in the PNL group, 72±12 min in the RIRS group and 82±22 min in the open surgery group. The duration of hospitalisation was 3.1±0.2 days, 1.2±0.3 days and 3.4±1.1 days respectively. While the RIRS group did not need blood transfusion, in the PNL group blood transfusions were given in the PNL (n=18), and open surgery (n=2) groups. Residual stones were detected in the PNL (n=22), open surgery (n=2), and RIRS (n=5) groups.

CONCLUSION

PNL and RIRS have been seen as safe and effective methods in our self application too. However, it should not be forgotten that as a basical method, open surgery may be needed in cases of necessity.

Ureteral stenting after uncomplicated ureteroscopy for distal ureteral stones: a randomized, controlled trial

Objectives. We compared outcome and complications after uncomplicated ureteroscopic treatment of distal ureteral calculi with or without the use of ureteral stents. Materials and Methods. 117 patients, prospectively divided into three groups to receive a double j stent (group 1, 42 patients), ureteral stent (group 2, 37 patients), or no stent (group 3, 38 patients), underwent ureteroscopic treatment of distal ureteral calculi. Stone characteristics, operative time, postoperative pain, lower urinary tract symptoms (LUTS), analgesia need, rehospitalization, stone-free rate, and late postoperative complications were all studied. Results. There were no significant differences in preoperative data. There was no significant difference between the three groups regarding hematuria, fever, flank pain, urinary tract infection, and rehospitalisation. At 48 hours and 1 week, frequency/urgency and dysuria were significantly less in the nonstented group. When comparing group 1 and group 3, patients with double j stents had statistically significantly more bladder pain (P = 0.003), frequency/urgency (P = 0.002), dysuria (P = 0.001), and need of analgesics (P = 0.001). All patients who underwent imaging postoperatively were without evidence of obstruction or ureteral stricture. Conclusions. Uncomplicated ureteroscopy for distal ureteral calculi without intraoperative ureteral dilation can safely be performed without placement of a ureteral stent.

New developments in ureteral stent design, materials and coatings

Ureteral stents are used in a variety of urological diseases and procedures. The majority of patients with indwelling ureteral stents experience bothersome symptoms and are at increased risk for urinary tract infection. Stent encrustation and the associated complications can also result in significant patient morbidity. The development of new stent designs using novel biomaterials, stent coatings and drug-eluting technologies are being applied to reduce the disadvantageous features of ureteral stents.

Emergency double-J stent insertion following uncomplicated Ureteroscopy: risk-factor analysis and recommendations

PURPOSE

Emergency double-J (DJ) stenting following ″uncomplicated″ ureteroscopic (UURS) stone treatment is both morbid and costly. Our study aims at identifying those patients who are more likely to require such an extra procedure. Handling of this complication will also be highlighted.

MATERIALS AND METHODS

319 cases of UURS cases were selected out of 903 patients, who were admitted for URS stone treatment at King Abdullah University Hospital during the period from May, 2003 to December, 2010. Thirty-eight of them (11.9%) had emergency post-URS DJ stenting within 24 hours of discharge. The medical records of all UURS cases were retrospectively reviewed. Comparison in demographic and stone-related variables was made using 2-paired t-test with P < 0.05. Operative findings of 38 stented patients were outlined.

RESULTS

Significant risk factors for emergency stenting were noted in males with larger (> 1.5 cm) and proximal stones (38 stented vs. 281 unstented). Operative risk factors among the 38 patients were: initial procedure time > 45 minutes (42.1%), ureteral wall edema (21.1%), repeated access for stones > 1.5 cm (21.1%), impacted stone (10.5%) and ignored or missed stones/fragments (4.6%).

CONCLUSIONS

The need for emergency DJ stenting following UURS stone treatment is not uncommon. The routine insertion is impractical and weakly-supported. With risk-factor stratification, selective and individualized DJ stenting policy is recommended.

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.

Immediate unplanned hospital admission after outpatient ureteroscopy for stone disease

PURPOSE

Medicare recently changed reimbursement for ureteroscopy, encouraging migration to ambulatory surgical centers. To our knowledge the risk of immediate unplanned hospital admission, which may discourage ureteroscopy at ambulatory surgical centers, is unknown. We determined the rate of immediate unplanned hospital admission, identified factors associated with admission and developed a risk stratification tool to assist with location selection for outpatient ureteroscopy.

MATERIALS AND METHODS

We retrospectively reviewed the records of 1,798 consecutive outpatient ureteroscopic procedures for urolithiasis performed from 1998 to 2008 at our institution. Patients requiring immediate hospital admission were matched 1 to 3 by provider, gender and date with controls who did not require admission. Patient demographics, comorbid conditions, stone history and burden, and operative technique were assessed for impact on admission by bivariate and multivariate logistic regression. A scoring system was developed and estimated admission rates were calculated.

RESULTS

There were 70 immediate unplanned admissions (3.9%). Based on multivariate analysis the factors associated with unplanned admission were any previous admission related to stones (p <0.001), history of psychiatric illness (p = 0.016) and bilateral procedure (p = 0.019). Patients with distal ureteral stones were less likely to require admission (p = 0.026). One point was added for each positive factor and 1 was subtracted for a distal ureteral stone. A risk factor score of 2 or greater in 9% of the cohort was associated with an estimated 20.0% admission rate while lower scores in 91% of the cohort were associated with a 2.9% admission rate.

CONCLUSIONS

Readily identifiable factors can stratify the risk of unplanned hospital admission and help guide the selection of the most appropriate facility for outpatient ureteroscopy.

SWL is More Cost-Effective than Ureteroscopy and Holmium:YAG Laser Lithotripsy for Ureteric Stones: A Comparative Analysis for a Tertiary Referral Centre

Background:

To identify the most cost-effective treatment for ureteric stones ≤15 mm in our department, by using an economic model to compare the total cost of shockwave lithotripsy (SWL) versus ureteroscopy with Holmium:YAG laser lithotripsy (URSL).

Patients and methods:

Data for patients treated with the same lithotriptor were retrospectively analyzed. The financial department provided data about the cost of procedures. This model accepted a 100% stone-free rate for URSL in outpatients, and a 50% rate of insertion of a ureteric stent. The cost for each procedure to render a patient stone-free was estimated by the following equations: costSWL = cost(initial SWL session) + [cost(SWL session) × retreatment rate] + [cost(URSL) × SWL failure rate] + [cost(stent insertion and removal) × rate] + [cost(KUB film) × 4] costURSL = cost(URSL) + [cost(stent removal) × 50%] + [cost(KUB film) × 2]

Results:

Records of 228 patients with previously untreated solitary radiopaque ureteric stones ≤15 mm were reviewed. The total cost for SWL (cSWL) was £1491/patient, while the total cost for URSL (cURSL) was £2195/patient. The difference was highest in the upper ureter (over £1000), and lowest in the distal part (URSL about 40% more expensive). For lower ureteric stones >10 mm, SWL was over £500 more expensive than URSL.

Conclusion:

Using data from the department to calculate cost-effectiveness for ureteric stones ≤15 mm a difference in favour of SWL versus URSL was found. Uniform guidelines incorporating cost are impossible considering differences between countries; each centre should probably assess their data individually.

Prestenting improves ureteroscopic stone-free rates

PURPOSE

Although the use of stents after ureteroscopy has been studied extensively, relatively little has been published about stent placement before complicated ureteroscopic procedures. In this study, we examined our experience with stent placement before ureteroscopic management of renal and ureteral stone disease.

PATIENTS AND METHODS

A total of 90 patients underwent ureteroscopic surgery on 115 renal units by a single surgeon from 2001 to 2006. All patients had documented follow-up with imaging either by CT or intravenous urography (IVU) with tomography. Patients were classified into two groups depending on whether they had a stent placed before ureteroscopy. Baseline characteristics, operative indications for stent placement, stone-free rates, and complications were compared between groups.

RESULTS

Baseline characteristics were similar between the groups. The majority of patients received stents before stone management because of technical considerations during surgery (17/36, 47%) or infection (13/36, 37%). Strict stone-free rates after ureteroscopic treatment were 47% in the 79 procedures without previous stents, compared with 67% in the 36 procedures with prestenting (P < 0.05). Including small fragments (2 mm or smaller), stone-free rates improved to 54% v 78%, respectively (P < 0.02). Complications were not significantly different in the two groups (P = 0.70).

CONCLUSION

Although routine stent placement is not necessary before all ureteroscopic procedures, we demonstrate that it is associated with good stone-free rates and few complications. In this retrospective cohort, prestenting was associated with significantly higher stone-free rates. Prestenting should be considered in challenging cases.

Anuric renal failure after same-session bilateral atraumatic flexible ureteroscopy

We report the first known case of anuric renal failure after same-session bilateral atraumatic flexible ureteroscopy for renal calculi. Although, there is no consensus about stenting patients who undergo same-session bilateral ureteroscopy due to the lack of prospective randomized studies; strong consideration should be given to stenting the ureter at least one side to avoid this complication.

The role of stenting in relieving loin pain following ureteroscopic stone therapy for persisting renal colic with hydronephrosis

OBJECTIVE

To prospectively define the role of the double J-stent placement following ureteroscopic stone therapy in providing a pain-free postoperative period for patients with persisting loin pain and documented hydronphrosis.

MATERIAL AND METHODS

The study cohort consisted of 27 patients (mean age: 38.59 years; range: 22-60 years) who had undergone ureteroscopic intervention due to ureteral stone. All of the patients reported loin pain which did not respond to medical therapy associated with various degrees of hydronephrosis documented by ultrasound and/or an excretory urogram. The patients were randomized to either a stented (18 patients) or stentless (nine patients) group following semirigid ureteroscopy (7.5/12 Fr) for the treatment of ureteral calculi (pneumatic lithotripsy). The mean diameter of the stones was 7.7 mm (range: 3-13 mm). Intra-operative balloon ureter orifice dilatation was routinely performed. All patients were evaluated between 0 and 6 days postoperative for loin pain and lower urinary tract symptoms.

RESULTS

Nine patients had loin pain in the first few days following the operation and were in need of intramuscular and/or intravenous analgesics. Of these, four were stented patients (4/18; 22.2%) and five were stentless patients (5/9; 55.5%). Lower urinary tract symptoms were not clinically significant and did not affect the quality of life in terms of loin pain, with the exception of one patient in whom the stent had dropped into the bladder.

CONCLUSION

We believe that stenting in patients with documented hydronephrosis manifesting in persisting renal colic is recommended. As ureteroscopic therapy may aggregate the edema of ureter mucosa, double J-stent placement may play an important role in offering patients a postoperative period free of loin discomfort. However, further prospective trials should be designed to evaluate the criteria for stentless ureterorenoscopy.

Stenting versus non-stenting after non-complicated ureteroscopic manipulation of stones in bilharzial ureters

BACKGROUND

Stents were used routinely after ureteroscopy to prevent postoperative ureteral obstruction. However, because of the recognized complications of stents, non-stenting is the new trend after uncomplicated ureteroscopy. The wall of the bilharzial ureter is characteristically thick and may be calcified. The aim of this study is to see if the non-stenting trend could be applied to ureteroscopic manipulation of stones in bilharzial ureters.

PATIENTS AND METHODS

In this prospective study, 56 patients, with evidence of bilharzial lesions in the urinary tract, undergoing ureteroscopy for distal ureteral stones were included. After successful uncomplicated stone fragmentation and extraction, patients were randomized into two groups. Group A includes 28 patients in whom double J 6-Fr polyurethane stents were placed for 3 weeks. Group B includes 28 non-stented patients. Postoperative fever, loin pain, lower urinary tract symptoms and change in the degree of hydronephrosis were reported.

RESULTS

There was no significant difference in the mean age of patients and stone size in both groups. The mean operative time was 43 +/- 14 min in group A and 38 +/- 11 in group B. There was no significant difference in the mean loin pain score, in the first postoperative 48 h, in both groups (4.4 +/- 0.8 in group A and 4.9 +/- 0.5 in group B). Patients in group A had, significantly, more flank pain with voiding (P < 0.01), voiding pain (P = 0.04), frequency (P = 0.01) and urgency (P = 0.04). Radiologic follow-up was available for 24 patients in group A and 23 patients in group B at the 3-month visit. Hydronephrosis had improved in all patients, in both groups, with no evidence of ureteral stricture.

CONCLUSION

Routine placement of stents after uncomplicated ureteroscopy for distal ureteral stones is unnecessary in bilharzial ureters. Moreover, it might be unadvisable because lower urinary tract symptoms and voiding loin pain are more in patients with ureteral stents and hydronephrosis is equally improved in stented and non-stented patients.

Incontinence after radical prostatectomy: surgical treatment options

PURPOSE OF REVIEW

Stress urinary incontinence is an uncommon finding in healthy men. Following radical prostatectomy, however, stress urinary incontinence is the most important complication influencing patient morbidity following surgery and influencing satisfaction, regardless of the surgical technique applied. Conservative treatment options centre at early restoration of bladder and pelvic floor function. When significant and bothersome stress urinary incontinence persists, even after six to 12 months active treatment follow-up, surgical restoration of continence seems advisable.

RECENT FINDINGS

Two themes emerge in reviewing the recent publications in this field. Implantation of the hydraulic artificial urinary sphincter is still the gold standard, particularly in severe cases. Alternatively, new techniques and other artificial materials are gaining favour, aiming at a large cohort of patients with less severe incontinence, which have been not treated or overtreated so far. Advances in both areas are covered within this review article in detail.

SUMMARY

For treatment of incontinence following prostatectomy, a large variety of surgical techniques are readily available and have proven to be helpful tools in making patients' uncomfortable lives much easier. In addition, the wide armamentarium of artificial materials and techniques may help to choose the proper surgical technique for every patients' needs.

The evolution of ureteroscopy: a modern single-institution series

OBJECTIVES

To evaluate a modern ureteroscopy series, including the use of new technological advances, operative procedures, and potential complications, at a single institution and to compare our current experience with our prior published series and the current literature.

MATERIAL AND METHODS

We retrospectively reviewed 1000 consecutive ureteroscopies performed in 961 patients from December 1999 to February 2003 at our institution.

RESULTS

Semirigid and flexible ureteroscopes were used in 60.3% and 37.0% of the cases, respectively. In 2.6% of cases, a combination of both rigid and flexible ureteroscopes was required. The most common indications for ureteroscopy were as follows: stone, 57.9%; diagnostic, 20.6%; and urothelial carcinoma, 12.6%. Of the stones treated, 31.8% were proximal or middle and 59.1% distal. The overall, proximal, and distal stone-free rates were 91.7%, 87.3%, and 94.2%, respectively. Average operative time was 81 minutes (range, 5-280 minutes). Average follow-up was 2.36 months (range, 1-24 months). The overall complication rate was 1.9% (18/961), including a 0.2% (2/961) incidence of ureteral strictures.

CONCLUSION

Current practice trends have shifted to an increased use of flexible ureteroscopes and more frequent ureteroscopic treatment of proximal calculi. Our single treatment stone-free rates are competitive with quoted shock wave lithotripsy success. In addition, there has been a decrease in ureteroscopic-associated complications in our series, with no ureteral avulsions. The improvements in treatment success and decrease in complications may be secondary to advances in ureteroscopic technology.

Stent Positioning after Ureteroscopy for Urinary Calculi: The Question Is Still Open

OBJECTIVES

We conducted a study to assess the need for routine ureteral stenting after ureteroscopic stone removal using Lithoclast pneumatic intracorporeal lithotripsy.

MATERIALS AND METHODS

A total of 104 patients, prospectively divided in two groups to receive (group A, 52 patients) or not (group B, 52 patients) a stent after stone removal, underwent ureteroscopy for the treatment of ureteral lithiasis. The procedure was performed with the patient under either general or epidural anesthesia. A semirigid ureteroscope (Wolf 8.9 Fr) was used in all cases and intracorporeal lithotripsy with ballistic energy was performed. In group A a double pigtail ureteral 4.8 or 6 Fr polyurethane stent was placed following ureteroscopy. All patients were closely evaluated on follow-up examinations. The outcomes measured were postoperative patient pain, lower urinary tract symptoms, the need for hospital care as a result of the postoperative pain and late postoperative complications.

RESULTS

The two patient groups were comparable with respect to the baseline variables of patient gender and age, stone location and mean stone size. Mean operative time plus or minus standard deviation (S.D.) in group A was 42 +/- 15 minutes (range 20-65) compared to 37 +/- 20 (range 15-60) in group B. Operative time was not significantly longer when a stent was placed (p = 0.17). At day 3 the mean visual analog pain score in group B was much higher than in group A (p = 0.01). Dysuria, hematuria and frequency/urgency were more prevalent in the stented group, although without statistically significant difference. Readmission to the hospital for unremitting pain was necessary in 12 of 104 patients (11.5%) all being in unstented group (p < 0.05). The incidence of anatomical ureteral narrowing on IVP at 6 months follow-up was not statistically different between the two groups.

CONCLUSIONS

In our experience, using Swiss Lithoclast ballistic energy to fragment stones, routine stent placement is advisable also after uncomplicated ureteroscopic lithotripsy without ureteral dilation. Further prospective randomized studies are needed to assess the role of stenting after ureteroscopic lithotripsy, considering different energies sources, scopes, diameter and site of the stones in the ureter.