A randomized trial investigating clinical outcomes and stent-related symptoms after placement of a complete intra-ureteric stent on a string versus conventional stent placement

Patients undergoing double J substitution with a pigtail suture stent report a significant decrease of stent-related symptoms. Results from a prospective multicenter longitudinal trial

PURPOSE

To compare stent-related symptoms (SRS) in patients with double J (DJ) undergoing substitution with a pigtail suture stent (PSS) after ureteroscopy (URS), through the Ureteral Stent Symptom Questionnaire (USSQ).

MATERIALS AND METHODS

Patients with DJ undergoing URS for stone treatment were enrolled in this prospective multicenter longitudinal study. The USSQ was submitted thrice: 2 weeks after DJ, 2 weeks after PSS and 4 weeks after PSS removal (baseline).

PRIMARY ENDPOINT

to compare Urinary Symptom Index Score and the rate of patients with pain 2 weeks after DJ and PSS. Secondary endpoints: to compare other USSQ scores and single answers 2 weeks after DJ and PSS, and DJ and PSS USSQ scores with baseline.

RESULTS

93 patients were enrolled. 2 weeks Urinary Symptom Index Score (p < 0.001) and the percentage of patients complaining of pain (60.2% vs 88.2%, p < 0.001) were significantly in favour of PSS compared to DJ. 2 weeks scores were significantly improved with PSS compared to DJ: Pain Index (p < 0.001), VAS (p < 0.001), General Health Index (p < 0.001) and Work Performance Index (p < 0.001). All urinary symptoms were significantly decreased with PSS, including renal pain during micturition and pain interfering with life. Pain Index Score (p = 0.622) and VAS (p = 0.169) were comparable to baseline with PSS, while differed with DJ.

CONCLUSIONS

Patients undergoing DJ substitution with PSS after URS report a significant decrease of SRS. Urologists may consider positioning PSS after URS in pre-stented patients to reduce the impact of SRS.

Is Stent on a String the New Gold Standard for Postureteroscopy Ureteral Drainage? Evidence from a Systematic Review

Introduction: Ureteral stents are widely used throughout urologic surgery, most commonly following ureteroscope (URS) procedures. This systematic review aims to assess the current evidence concerning stent on string (SOS) placed after URS and compare it with stents without strings (SWOSs). Methods: A systematic review was conducted on several databases using the preferred reporting items for systematic review and meta-analysis (PRISMA) methodology for studies in English language, for patients of all age groups, who had an SOS after URS for stone disease. Results: Of 1210 records identified, a total of 22 studies (20 adult and 2 pediatric studies) were included, with a total of 8382 patients. Of these, 3427 (40.9%) had SOSs inserted and 434 (11%) were in the pediatric age group. Our results show that SOS provides several advantages, and compared with SWOS, they were in situ for less time, with no difference in complications such as urinary tract infection or urinary symptoms. Furthermore, significant cost savings, less pain on removal, and high rates of safe home removal were reported in SOS, with >90% patients reporting that they would be happy to remove their SOSs at home. However, a small risk of stent dislodgment must be considered when making decisions regarding SOS placement after URS. Conclusion: SOS provides an excellent option after URS, especially in those patients with no intraoperative complication, and their placement is done as a routine insertion based on surgeon preference. These stents reduce dwell time, pain, cost, risks, and suffering involved from prolonged stenting, and majority of patients are happy to remove it themselves at home. Although their use seems to be still restricted in the current endourology practices, they are likely to become the new gold standard for routine URS in future, with more shared decision making and patient-reported outcome measures coming into the mainstream.

Complete Intraureteral Stents Decrease Urinary Symptoms Compared with Conventional Ureteral Stents: A Systematic Review and Meta-Analysis

Introduction: Up to 80% of stent patients report urinary discomfort, negatively impacting their daily activities and quality of life. Conventional Double-J ureteral stents (DJSs) can cause adverse kidney and bladder-related symptoms. Complete intraureteral stents (CISs) may reduce bothersome bladder symptoms by reducing foreign material in the bladder. We sought to aggregate and analyze ureteral stent symptom questionnaire (USSQ) data from the available randomized controlled trials comparing CISs with conventional ureteral stents. Methods: In February 2023, a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review was performed to identify studies that evaluated the use of CISs and reported outcomes using the USSQ score. Two authors (D.E.H.-G. and G.S.) independently extracted and analyzed data using Review Manager 5.41. Heterogeneity was assessed using Higgins I2%, with values >50% considered heterogeneous and analyzed with a random effects model; otherwise, a fixed effects model was used. The results are presented as the mean difference (MD) with 95% confidence intervals (CIs). We set our significance level at p = 0.05. Results: Six randomized controlled clinical trials compared CISs with DJSs, but only five trials reported the USSQ score. Among these patients, 235 had CISs, whereas the remaining 259 had DJSs or loop-tail stents and served as controls for 494 patients. Urinary symptoms scores were lower in the CIS group (MD -5.19, 95% CI: [-5.89 to -4.50], p < 0.0001). Pain scores were also lower in the CIS group (MD -1.90 [-2.63 to -1.16] p < 0.00001). General health and work performance domains were similar between the groups. A 2.5% stent failure or migration rate requiring endoscopic intervention was reported in the CIS group compared with 0.3% in the DJS group (odds ratio 4.01 [0.96-16.76] p = 0.06). Conclusions: CISs significantly decrease urinary symptoms and pain associated with conventional indwelling ureteral stents. However, further trials are needed to determine the optimal patient selection for this type of stent.

Comparation of intraureteral stent and conventional stent at different stages: a systematic review with meta-analysis

INTRODUCTION

Stent related symptom (SRS) is the most common adverse effect of ureteral stenting. In recent years, many efforts have been made to develope modified ureteral stents to ameliorate SRS. It has been reported that intraureteral stents have the potential to improve the tail end adverse effect of the bladder and alleviate SRS. However, there still lack of evidence for the efficacy and the safety of clinically applying intraureteral stents. The aim of this work is to investigate the efficacy and safety of intraureteral stents.

EVIDENCE ACQUISITION

A systematic review was performed by using the PubMed, Web of Science, Medline, Embase, and Cochrane library. The studies published before February 2023 were included. The study selection was following the guideline from Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). The searching strategy was: "Pigtail suture stent" OR "Intra-ureteric stent" OR "Suture Stent" OR "Intraureteral stent" AND "Ureteroscopy" OR "Urinary calculi" OR "Stent-related symptoms" OR "Lower urinary tract symptoms". The data from randomized clinical trials which meet the selection criteria were extracted. Revman 5.4 was employed to proceed the meta-analysis.

EVIDENCE SYNTHESIS

A total of six randomized clinical trials of intraureteral stents were included in this systematic review and meta-analysis. According to the different investigation time, the results could be divided into four stages: early-stage, middle-stage, late-stage, and long-term evaluation. Urinary symptoms, pain score, and general health were significantly improved in intraureteral stents group at middle stage. For late-stage, intraureteral stent achieved better outcomes in urinary symptoms index, VAS score, quality of life, general health, and pain score. However, for early-stage and long-term evaluation, there was no significant difference between two groups.

CONCLUSIONS

This systematic review and meta-analysis reveal that regardless of the stage of treatment, the efficacy and safety of intraureteral stent are no worse than that of conventional stent. During 7-14 days postoperation, which is the most commonly time for clinically using ureteral stent, most of the outcomes of intraureteral stent are better than those of conventional stent. Hence, it is confirmed that intraureteral stent is worth for more clinical study and application.

A randomized controlled study of ureteral stent extraction string on patient's quality of life and stent-related complications after percutaneous nephrolithotomy in the prone position

To demonstrate the Tianjin Institute of Urology (TJIU) technique to place and remove the ureteral stent with extraction string after percutaneous nephrolithotomy (PCNL). Additionally, we aim to compare the pain experienced during stent removal, quality of life during stent retention, and stent-related complications between patients with and without extraction string. 65 patients were included in the final analysis in the string group constructed by the TJIU technique and 66 patients in the conventional double-J ureteral stent (non-string) group. All patients underwent the surgery in a prone position under general anesthesia. They completed the Ureteral Stent Symptom Questionnaire (USSQ) on postoperative days (POD) 7, as well as before their ureteral stent was removed. The visual analogue scale (VAS) pain score (0-10) was completed immediately after the removal of the ureteral stent. Moreover, a specialized person was responsible for recording stent-related complications. All patients completed the USSQ on POD 7, and we did not find a difference in scores in each field. However, there was a significant difference in the "sex" domain before removing the ureteral stent (4.34 vs 3.23; p = 0.01). Notably, the use of extraction string after PCNL could decrease the pain associated with stent removal significantly (mean VAS scores 1.45 vs 2.76; p < 0.01). Extraction string did not increase the incidence of stent-related complications. We concluded that placing a ureteral stent with an extraction string after PCNL reduces the pain of ureteral stent removal without increasing complications such as accidental removal of the stent, febrile urinary tract infection (UTI).

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.

Complete intraureteral stent placement reduces stent-related symptoms: Systemic review and meta-analysis

PURPOSE

The distal coil of a double-J ureteral stent is considered the major cause of stent-related symptoms. We noticed that some recent studies investigated whether complete intraureteral stent placement (CIU-SP) reduced these symptoms. The current systemic review and meta-analysis aimed to evaluate the safety and the effectiveness of CIU-SP, as compared to conventional stent placement (C-SP).

METHODS

We retrieved relevant trials published before December 2021 from three databases, including PubMED, Embase, and Web of Science. The following medical subject heading were used ((complete intraureteral stent) OR (suture stent)) AND (symptom OR pain) AND (randomized OR randomised). The above search was limited to English language publication.

RESULTS

We identified six prospective randomized trials, all of which investigated a short-term (1-2 weeks) stent placement following uncomplicated ureteroscopic lithotripsy. The meta-analysis revealed that CIU-SP significantly reduced stent-related symptoms: CIU-SP had lower USSQ (Ureteral Stent Symptom Questionnaire) Urinary Symptom Index score (MD -5.13; 95%CI [-5.82,-4.44]; P < 0.00001), lower USSQ Pain Index score (MD -4.21; 95%CI [-5.25,-3.17]; P < 0.00001), and lower VAS pain scale (MD -1.93; 95%CI [-2.17,-1.69]; p < 0.00001). Besides, patients with CIU-SP were less likely to have pain (RR 0.78; 95%CI [0.67,0.91]; p = 0.001). There was no significant difference regarding the USSQ General Health and Work Performance. Both CIU-SP and C-SP had similarly few complications of Clavien-Dindo grade ≥2.

CONCLUSION

This meta-analysis reveals that CIU-SP significantly decreases stent-related urinary symptoms and pain. Based on the current evidence, CIU-SP is ready to be applied in clinical practice, at least in those requiring short-term stent placement following uncomplicated ureteroscopic lithotripsy.

The intraureteral placement of the stent's distal end decreases stent-related urinary symptoms: a prospective randomized clinical trial

PURPOSE

We compared intraureteral stent placement (CIU-SP) with conventional stent placement (C-SP) regarding the stent-related symptoms.

METHODS

We randomized patients who underwent ureteroscopic lithotripsy into two groups. In CIU-SP group, a 16-cm or 18-cm stent was placed with its distal end above the ureterovesical junction. In C-SP group, a 22-cm or 24-cm stent was placed in a conventional method. Stent-related symptoms were assessed with the Ureteral Stent Symptom Questionnaire (USSQ) before the stent was removed, around 7 days after the operation. The primary outcome was the urinary symptoms; the secondary outcomes included postoperative pain and quality of life.

RESULTS

We randomized 103 patients, of which 91 (45 in CIU-SP and 46 in C-SP) entered the final analysis. Regarding the primary endpoint, the CIU group had less urinary symptoms; the mean USSQ urinary symptom score was significantly lower in the CIU-SP versus C-SP group (25.5 ± 6.3 vs 31.7 ± 5.9, P < 0.001). The CIU-SP group also had more favorable profiles in the following outcomes: lower USSQ body pain score (15.5 ± 5.3 vs 20.1 ± 5.2, P < 0.001), lower overall pain score (3.2 ± 2.2 vs 5.7 ± 2.3, P < 0.001), less number of pain site (1.0 ± 0.9 vs 1.7 ± 0.9, P = 0.001, lower USSQ general health score (10.4 ± 3.7 versus 13.9 ± 3.4, P < 0.001), and lower USSQ work performance score (5.2 ± 3.3 versus 6.7 ± 2.8, P = 0.033). In either group, there was no complication of Clavien-Dindo Class 2 or greater.

CONCLUSION

The complete intraureteral placement significantly decreases stent-related urinary symptoms and pain. It is also associated with better postoperative general health condition and is less likely to limit physical activity and work ability.