Multi-length or 24 cm ureteric stent? A multicentre randomised comparison of stent-related symptoms using a validated questionnaire

Can ureteral stents with a different format reduce patients' symptomatology? A single-blinded, randomized, controlled study comparing smooth-walled and grooved ureteral stents

INTRODUCTION

The true benefits of perioperative JJ stent placement are being widely studied due to its known side effects. However, no consensus has been reached in the literature regarding the best type of stent. This prospective, randomized, single-blinded study therefore aimed to compare the symptomatology associated with two JJ stent designs: smooth-walled and grooved.

MATERIALS AND METHODS

The study prospectively recruited 42 patients who underwent JJ stent placement between July 2019 and August 2020. The patients were randomly divided into two groups according to the JJ stent design used: the smooth-walled stent (control) and grooved stent (intervention) groups. After surgery, all patients completed the Portuguese-validated Ureteral Stent Symptom Questionnaire at three timepoints (days 7 and 30 post-surgical procedure, and day 30 post-stent removal).

RESULTS

No significant differences in gender, age, median body mass index, laterality, type of surgical procedure (flexible, semi-rigid or mixed ureteroscopy) were found. Smooth-walled JJ stents were associated with a higher incidence of flank pain (52.38% vs. 10%, P = .006) and suprapubic pain (57.14% vs. 30%, P = .04) on the 7th post-procedure day. Linear mixed regression showed significantly lower flank (P < .001) and suprapubic pain (P < .01), and significantly better sexual performance in the intervention group (P = .03).

CONCLUSIONS

Ureteral stent with a grooved format are associated with a lower incidence of flank and suprapubic pain and had less impact on the sexual performance of patients.

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.

New Stent Technologies

Ureteral stents are an indispensable part of any (endo-) urologic practice. Despite the widely demonstrated advantages of stents, they also carry a considerable risk of side effects and complications, such as urinary symptoms, pain, hematuria, decreased quality of life, stent-related infection, and encrustation. Multiple pathways in preventing or mitigating these side effects and complications and improving stent efficacy have been and are being investigated, including stent architecture and design, biomaterials, and coatings. This article provides an update on currently researched and available stents as well as future perspectives.

Magnetic double-J stent: Evaluation of tolerance and impact on quality of life compared to traditional double-J stent

INTRODUCTION

The placement of a ureteral stent is one of the most widely performed procedures in urology. It can have a negative impact on the patients' quality of life, requiring a cystoscopy for its removal. The objective of this study is to evaluate the symptoms and impact on quality of life derived from the use of a magnetic double-J stent (Black Star®) and compare them to those presented in patients with a traditional double-J stent (OptiMed®).

MATERIAL AND METHODS

We conducted a comparative, prospective, randomized study in 46 patients who underwent ureterorenoscopy with double-J stent placement between August 2019 and June 2020. Of all patients included, 23 had a traditional double-J stent placed (group A) and 23 had a magnetic double-J stent (group B) placed. We evaluated the results of the Ureteral Stent Symptom Questionnaire (USSQ) in both groups, assessed the technical difficulty related to stent removal and the pain during the procedure using the Visual Analogue Scale (VAS). We also reviewed the need for medical attention due to problems related to the stent or after its removal.

RESULTS

There were no statistically significant differences between groups regarding the answers in the USSQ and the complications related to the use of the stent. Group B showed less pain (1.52 vs. 4, VAS, p = 0.001) and less difficulty during removal (1.61 vs. 3, p < 0.001) associated with a shorter procedure duration (11.65 min vs. 22.17 min p < 0.001).

CONCLUSIONS

The tolerance shown by the use of magnetic double-J is comparable to the tolerance of traditional stent, since it does not cause an increase in urinary symptoms nor worsens the quality of life of patients during its use.

Magnetic double-J stent: evaluation of tolerance and impact on quality of life compared to traditional double-J stent

INTRODUCTION

The placement of a ureteral stent is one of the most widely performed procedures in urology. It can have a negative impact on the patients' quality of life, requiring a cystoscopy for its removal. The objective of this study is to evaluate the symptoms and impact on quality of life derived from the use of a magnetic double-J stent (Black Star ®) and compare them to those presented in patients with a traditional double-J stent (OptiMed®).

MATERIAL AND METHODS

We conducted a comparative, prospective, randomized study in 46 patients who underwent ureterorenoscopy with double-J stent placement between August 2019 and June 2020. Of all patients included, 23 had a traditional double-J stent placed (group A) and 23 had a magnetic double-J stent (group B) placed. We evaluated the results of the Ureteral Stent Symptom Questionnaire (USSQ) in both groups, assessed the technical difficulty related to stent removal and the pain during the procedure using the Visual Analogue Scale (VAS). We also reviewed the need for medical attention due to problems related to the stent or after its removal.

RESULTS

There were no statistically significant differences between groups regarding the answers in the USSQ and the complications related to the use of the stent. Group B showed less pain (1,52 vs. 4, VAS, p = 0.001) and less difficulty during removal (1,61 vs. 3, p < 0,001) associated with a shorter procedure duration (11,65 min vs. 22,17 min p < 0,001).

CONCLUSIONS

The tolerance shown by the use of magnetic double-J is comparable to the tolerance of traditional stent, since it does not cause an increase in urinary symptoms nor worsens the quality of life of patients during its use.

Effects of mirabegron on JJ stent-related symptoms: A multicentric study

AIMS OF THE STUDY

To investigate the effect of mirabegron 50 mg/daily for JJ stent-related symptoms after ureteroscopic stone surgery.

METHODS

Medical records of 145 patients who were given a single daily oral dose of 50 mg of mirabegron for relieving stent-related symptoms were retrospectively analysed. Demographic and clinical data and stone parameters were recorded. All participants completed the Turkish version of the Ureter Symptom Score Questionnaire (USSQ-T) on the postoperative 7th day, and again after at least 3 weeks, before JJ stent removal. The severity of stent-related symptoms was statistically compared before and after the mirabegron treatment.

RESULTS

The mean urinary symptoms score decreased significantly from 30.87 ± 9.43 to 22.61 ± 6.78 (P < .0001), mean body pain score decreased significantly from 21.82 ± 11.22 to 14.03 ± 7.52 (P < .0001), mean work performance score decreased from 10.50 ± 8.61 to 7.02 ± 6.51 (P < .0001) and mean general health score decreased significantly from 15.43 ± 6.50 to 11.12 ± 3.70 (P < .0001). The mean sexual matters score significantly decreased from 3.88 ± 3.40 to 2.48 ± 2.03 (P < .0001), the additional problem score decreased from 9.31 ± 4.61 to 6.51 ± 2.83 (P < .0001) and the overall quality of life (QoL) score decreased from 5.18 ± 1.94 to 4.23 ± 1.71 after mirabegron use (P < .0001).

CONCLUSION

Daily use of 50 g of mirabegron significantly improved stent-related symptoms, sexual matters and quality of life.

Evaluation of Patient Factors That Influence Predictive Formulas for Determining Ureteral Stent Length When Compared to Direct Measurement

Objectives: To compare direct ureteral length measurements with predictive formulas used for the preoperative assessment of ureteral length, and to evaluate patient factors that impact the accuracy of these predictive formulas. Methods: Patients undergoing ureteral stenting for benign and malignant indications were included. Clinical factors analyzed were gender, race, height, weight, prior abdominal or pelvic surgery, radiation therapy, pelvic organ prolapse (POP), laterality, hydronephrosis, and pre-existing ureteral stent. Three predictive formulas and a common height-based formula were used. Direct ureteral measurements were obtained with a ruled 5F ureteral catheter. Predictive formulas were compared with direct ureteral measurements using scatterplot and Spearman's correlation coefficient. Univariate and multivariate logistic regressions were used to evaluate patient factors associated with ≥2 cm deviation from direct ureteral measurements. Results: A total of 108 patients (134 ureters) were analyzed. All predictive formulas correlated poorly with direct ureteral measurements, although as much as 60% of ureteral stent lengths were accurately predicted. Several patient factors significantly impacted accuracy of formulas: male gender (p = 0.04), POP (p = 0.05), body mass index (BMI) ≥25 (p = 0.03), and pre-existing ureteral stent (p = 0.05). Conclusion: Our study suggests that predictive formulas for ureteral stent length have poor accuracy when compared to direct measurement, especially for patients with elevated BMI and POP. Our institution considers direct ureteral measurement the gold standard for determining ureteral stent length-a method that is universally applicable and independent of patient factors.

A New Customized Ureteral Stent with Nonrefluxing Silicone End-piece to Alleviate Stent-related Symptoms in Malignant Diseases

OBJECTIVE

To evaluate the stent-related symptoms using a new customized ureteral stent with a nonrefluxing silicone end-piece.

METHODS

By decreasing the amount of material within the bladder, it should be possible to attenuate the stent-related symptoms. To minimize the amount of material, 17 consecutive patients already fitted with a double-pigtail stent for malignant ureteral obstruction agreed to be fitted with a customized stent where the bladder loop was replaced by a nonrefluxing silicone end-piece. The ureteral stent symptom questionnaire was prospectively administered to patients at baseline with double-pigtail stent and Day 15 after customized stent placement.

RESULTS

No difficulty in the placement of the customized stent was encountered. No stent failure, no dislodgment and no calcification were observed 6 months after stenting. The scores for the main domain "Urinary symptoms" (34.4 ± 3.6 vs 23.0 ± 7.0; P = .0004) and the question "Global quality of life" (4.4 ± 2.0 vs 2.4 ± 2.1; P = .01) were significantly decreased by the replacement of the double-pigtail stent by the customized stent.

CONCLUSION

The customized ureteral stent may constitute an improvement in the field of stent-related symptoms and seems fit for use in its current shape. Studies exploring and exploiting new concepts are greatly required to reduce stent-related symptoms in all patients including those with cancer.

Challenges To Attenuate Ureteric Stent-Related Symptoms: Reflections On The Need To Fashion A New Dynamic Stent Design Consequent Upon A Case Report

Double-pigtail stent has been widely used in urology for half a century now, but this device reduces the patient’s quality of life. Moreover, indwelling stent-related symptoms induce additional suffering to the pre-existing bladder disease. Novel concepts to prevent stent-related symptoms are greatly required. It has been suggested that changes in the size, form and stent positioning could ease discomfort. By decreasing the amount of material within the bladder, it should be possible to attenuate the stent-related symptoms. A customized stent has been developed to alleviate bladder symptoms. The major characteristic of this stent was in the replacement of the bladder part of the double-pigtail stent by a nonrefluxing silicone end-piece. Three months after stenting, the patient complained of sudden discomfort in the bladder area. On the X-ray, the end-pieces of the customized stents seemed to have slipped in the bladder. The customized stents were replaced by new ones after truncating and adjusting their lengths to the exact ureteric length and stent-related symptoms were then improved again. In the field of stent-related symptoms, stent mobility needs more attention than its intravesical position. The case hereby reported illustrates the variations of the symptoms which seem related to the stent mobility, the necessary shaping of the stent and, the possible research avenues for an innovative dynamic ureteric stent.

Ureteral stents in urolithiasis

Ever since the ureteral stent design was fitted with a curl on both sides to prevent it from migrating up or down the ureter some 40 years ago, its use has gained tremendous momentum, aiding in the rise and evolution of endourology and has confidently kept its place in modern time urology. Over the past four decades, several designs, coating and biomaterials have been developed, trying to reduce infection, encrustation and other stent related symptoms. As the ideal stent has not yet been discovered, different ways of helping patients with their complaints have been researched. This review will cover these aspects of stent use in urolithiasis.

Impact of loop-tail ureteral stents on ureteral stent-related symptoms immediately after ureteroscopic lithotripsy: Comparison with pigtail ureteral stents

Purpose

To evaluate urination-related quality of life (QoL) in patients with an indwelling ureteral stent immediately after ureteroscopic lithotripsy (URSL) for upper urinary calculi. We compared the effects of loop-tail and pigtail ureteral stents on urination-related QoL.

Materials and Methods

Of 135 patients who underwent URSL between May 2014 and March 2015 at our hospital, we retrospectively analyzed the records of 70 patients (42 men, 28 women; median age, 63 years) in whom the stent tail was positioned inside the bladder without crossing the midline and who completed the core lower urinary tract symptoms score (CLSS) questionnaire pre- and postoperatively.

Results

There were significant differences in incomplete emptying (p=0.048) and bladder pain (p=0.041) between patients with loop-tail versus pigtail ureteral stents after URSL. In the multivariate analysis, stent type had a stronger association with incomplete emptying (p=0.022) and bladder pain (p=0.018) than age, sex, body mass index, stent side, operation time, diameter of ureteral access sheath, and stent type.

Conclusions

Patients with loop-tail ureteral stents had better urination-related QoL in the immediate post-URSL stage than patients with pigtail stents.

Intraoperative Radiographic Determination of Ureteral Length as a Method of Determining Ideal Stent Length

INTRODUCTION

Accurate determination of ureteral length (UL) and appropriate stent length remains a challenge. The objective of this study was to describe an intraoperative technique to measure UL and determine appropriate stent length, and to compare this technique with other methods of determining appropriate stent length.

METHODS

Patients undergoing ureteroscopy requiring postoperative stenting and who had a preoperative CT were prospectively identified. Gender, age, height, body mass index, L1 to L5 lumbar height on CT, and surgeon's estimate of UL were recorded. UL was measured using four methods: direct measurement with a ureteral catheter, ureteropelvic junction (UPJ) to ureterovesical junction distance on axial and coronal CT, and using a novel intraoperative radiographic technique. Radiographic measurement was performed using a radiographic nipple marker affixed to the skin over the ureteral orifice (UO) and an angiographic catheter with radiopaque markings at 1 cm intervals. UL was the distance from the UPJ to the marker at the UO measured using the catheter markers. Correlation between direct measurement and the recorded variables and methods of ureteral measurement were calculated. Stent length was chosen based on radiographic measurement. Stents were deemed of appropriate length if they showed a proximal coil in the renal pelvis and a distal coil in the bladder without crossing midline.

RESULTS

Twenty-five ureters from 23 patients were included. Radiographically measured UL was strongly correlated with direct measurement. (r = 0.873, p < 0.01). Coronal and axial CT ULs were significantly associated with direct measurement (p < 0.05). Height, lumbar height, and surgeon's estimate of UL were not. Stents were deemed of appropriate length in 23/25 cases (92%).

CONCLUSIONS

This new method for radiographic UL measurement is strongly correlated with directly measured UL. A length of stent chosen based on radiographic UL resulted in an appropriate stent length.

Best Stent Length Predicted by Simple CT Measurement Rather than Patient Height

INTRODUCTION AND OBJECTIVES

Ureteral stent length is important, as stents that are too long might worsen symptoms and too short are at higher risk of migration. The purpose of this study was to determine if patient or radiologic parameters correlate with directly measured ureteral length and if directly measured ureteral length predicts proper stent positioning.

METHODS

During stent placement, ureteral length (ureteropelvic junction to ureterovesical junction distance) was directly measured by endoscopically viewing a ureteral catheter (with 1-cm marking) emanating from the ureteral orifice. A 22, 24, or 26 cm stent was chosen to be closest to the measured ureteral length. For ureters >26 cm, a 26 cm stent was chosen. Ends of an "ideally positioned" stent were fully curled in the renal pelvis and bladder, without crossing the bladder midline. Rates of ideal stent position were compared between patients with matching stent and ureteral lengths and those with stent lengths differing by ≥1 cm (mismatched). The measured ureteral length was correlated with patient height, L1-L5 height, and length measured on CT.

RESULTS

Fifty-nine ureters from 57 patients were included. Height was reasonably correlated with L1-L5 height (Spearman correlation coefficient [rho] = 0.79), although both were poorly correlated with directly measured ureteral length (rho = 0.18 for height and 0.32 for lumbar height). Ureteral lengths measured on CT correlated well with direct measurement (rho = 0.63 for axial cuts and rho = 0.64 for coronal cuts). Matched stent length was associated with higher rates of ideal stent position than mismatched (100% vs 70.9%, p = 0.006).

CONCLUSIONS

CT measurements, rather than height, correlate well with measured length and could be used to choose the appropriate stent length. Stents matching directly measured ureteral lengths are associated with high rates of ideal stent position.

Efficacy and safety of tamsulosin oral-controlled absorption system, solifenacin, and combined therapy for the management of ureteric stent-related symptoms

Objectives

To evaluate the efficacy of solifenacin, tamsulosin oral-controlled absorption system (OCAS), and the combination of both drugs on JJ stent-related symptoms using the validated Arabic version of the ureteric stent symptom questionnaire (USSQ).

Patients and methods

In all, 260 patients who had undergone JJ stenting of the ureter for different endoscopic urological procedures were postoperatively randomly assigned into four equal groups. Patients in Group I received no treatment and served as the control group, Group II patients received tamsulosin OCAS 0.4 mg daily, Group III patients received solifenacin 5 mg daily, and Group IV patients received a combination of both drugs. Before stent removal, all patients completed the Arabic version of the USSQ.

Results

In all, 234 patients completed the study, comprised of 56 in Group I, 59 in Group II, 58 in Group III, and 61 in Group IV. Baseline characteristics and indications for JJ stenting were comparable in the four groups. There were highly significant differences in all items of the USSQ between the treatment groups and the controls, while Group II and III were comparable. The USSQ score was significantly lower in Group IV vs Groups II and III. Crossing of the distal curl of the stent to the midline had a significant positive correlation with the severity of the urinary symptoms, body pain, general health, and work performance in the medicated groups.

Conclusions

Combined therapy with tamsulosin OCAS 0.4 mg daily and solifenacin 5 mg daily is a safe and well-tolerated management for stent-related symptoms. However, stent position remains a significant factor affecting response to medical therapy and patients’ health-related quality of life.

Predicting female ureteral length: a mathematical model

Aim:

Ureteral double J stent placement is a common urological procedure. A stent placement is performed for multiple conditions but some of them are contraindicated, mainly in pregnant female patients, because of X-rays. This work aims to suggest a mathematical model to predict female ureteral length by finding a link among different physical data.

Materials and methods:

Between June 2007 and July 2009, 100 female patients who had undergone ureteral stent placement were enrolled in the present study with the exception of those with septic conditions, history or evidence of TCC, congenital and acquired kidney or ureteral malformations, and previous ureteral surgery. The physical data of each patient were collected (mean age 55.8 years, range 18–89 SD 15.27, mean height 173 cm, range 160–182 SD 6.31, mean weight 75.33 kg, range 62–94 SD 8.81). A previous ureteral retrograde pyelography was performed during the procedure to individualise the pyeloureteral junction. Ureteral length was estimated through a graduated ureteral catheter with a final result between 24 and 27 cm. The length was read in cystoscopy examining the ureteral orifice while the catheter tip reached the pyeloureteral junction. The collected data were then analysed.

Results:

A link between the female patients’ ureteral length and height was observed. The following mathematical model can predict female ureteral length starting from the patient’s height: Result: y = 0.151712487 (height expressed in cm) ± 0.12; correlation coefficient: r = 0,973, residual sum of squares: rss = 5.285. No link was found between ureteral length and patients’ age and weight.

Conclusions:

A good estimation of the length of the ureter to be cannulated enables us to choose in advance the proper one to use. Female patient height correlates with ureteral length. A cost reduction can also be obtained, avoiding an intra-operative X-ray control. An X-ray-free ureteral stenting procedure can be described simply through an ultrasound control mainly in pregnant women. Further studies are needed to obtain a similar mathematical model for male patients.

Do ureteric stent extraction strings affect stent-related quality of life or complications after ureteroscopy for urolithiasis: a prospective randomised control trial

OBJECTIVE

To determine whether ureteric stent extraction strings affect stent-related quality of life (QoL) or increase complications after ureteroscopy (URS) for stone disease.

PATIENTS AND METHODS

In all, 68 patients undergoing URS (October 2011 to May 2013) for stone disease were randomised to receive a ureteric stent with or without an extraction string. Patients completed the Ureteric Stent Symptom Questionnaire (USSQ) on postoperative days 1 and 6, and 6 weeks after stent removal. Pain was assessed at stent removal. Adverse events, including early stent removal, stent migration, retained stent, urinary tract infection (UTI), emergency room (ER) visits and postoperative phone calls were monitored.

RESULTS

There was no difference in stent-related QoL as measured by the USSQ between those with and without a stent extraction string, pain at stent removal between those who pulled their stent independently vs those who underwent cystoscopy for stent removal, or in the rate of UTIs, ER visits or phone calls between groups. Five patients (four female, one male) removed their stent early by inadvertently pulling the string; none required replacement. Patients without a string had a significantly longer period with the postoperative ureteric stent (10.6 vs 6.3 days, P < 0.001). One patient without a stent string retained her ureteric stent for 6 months, which was removed by cystoscopy without incident.

CONCLUSION

Ureteric stent extraction strings may offer several advantages without increasing stent-related urinary symptoms, complications, or postoperative morbidity.