Feasibility and safety of magnetic-end double-J ureteral stent insertion and removal in children

PURPOSE

The need for surgical removal of a double-J ureteral stent (DJUS) is considered one of its disadvantages. Apart from increased cost, repeated exposure to general anesthesia is a concern in children. Alternative techniques have been described, all failing to become integrated into mainstream practice. Stents with a distal magnetic end, although introduced in the early 1980s, have only recently gained acceptance. We report the feasibility and safety of insertion and removal of a magnetic-end double-J ureteral stent (MEDJUS) in a pediatric population.

MATERIALS AND METHODS

We retrospectively analyzed the use of the Magnetic Black-Star Urotech^® MEDJUS between 11/2016 and 12/2019 in children. Stents were removed in the outpatient clinic using a transurethral catheter with a magnetic tip.

RESULTS

MEDJUS insertion was attempted in 100 patients (65 boys). Mean age was 7.8 years (0.5-18). The stent was placed in an antegrade procedure (n = 47), by a retrograde route (n = 10), and during open surgery (n = 43). Stent insertion was successful in 84 cases (84%). All 16 failures occurred during the antegrade approach in laparoscopic pyeloplasty, with inability to push the stent and its magnet through the ureterovesical junction in 14. Magnetic removal was attempted in 83 patients, successful in 81 (98%). There was no added morbidity with the MEDJUS.

CONCLUSIONS

The use of MEDJUS is a safe and effective strategy that obviates the need for additional general anesthesia in children. Its insertion is similar to that with regular DJUS, and its easy and less time-consuming removal benefits both the patient and the hospital and validates its clinical use.

Double J stent removal in paediatric patients by Vellore Catheter Snare technique: a randomised control trial

BACKGROUND

Double J (DJ) stents placed at the end of paediatric urological procedures require another cystoscopy under general anaesthesia for removal. The second author developed a reproducible technique for snaring the DJ stent using an infant feeding tube (6-Fr or 8-Fr) and a 3-0 polypropylene suture per urethra. Having demonstrated the proof of concept, ethical clearance was obtained for an institutional randomised controlled trial.

OBJECTIVE

The aim of the study was (1) to describe the Vellore Catheter Snare (VeCS) technique for DJ stent removal, (2) to study the efficacy of the technique and (3) to compare the costs of VeCS technique with cystoscopy on an intention-to-treat basis.

STUDY DESIGN

The study design was that of a randomised control trial with parallel groups as a non-inferiority study.

RESULTS

Forty children with unilateral indwelling DJ stents were enrolled from January to August 2018. They were randomised by unequal allocation (1:3) to cystoscopic and VeCS technique removal arms. The VeCS technique and cystoscopy were successful in 86.67% (26/30) and in 100% (10/10) cases, respectively, with no statistically significant difference in the outcome (p = 0.223). The average cost for cystoscopic removal of the stent was INR 14,579 and was INR 5636.5 for the VeCS technique (on an intention-to-treat basis).

DISCUSSION

While per-urethral catheterisation is an outpatient/ward procedure in children, cystoscopy is not. Other techniques such as extraction strings and magnetic stents with their extraction device were found to have certain disadvantages. The VeCS technique, using common disposables, circumvented the need for inpatient admission, disinfected equipment usage and operation theatre time in 87% children, thereby reducing the costs incurred by the patient.

CONCLUSION

The VeCS technique for DJ stent removal is a practical low-cost safe alternative to cystoscopic removal of DJ stents in children. Although the technique has a high success rate, it still needs the backup option of cystoscopy under general anaesthesia.

Clinical Utility of the Modified Snare Technique for Percutaneous Antegrade Removal of Double J Ureteral Stents

Although a snare is the commonly used device for antegrade double J (DJ) stent removal, there are some cases in which DJ stent removal using only a snare is particularly difficult. In the present study, an unfavorable positioning of the proximal DJ stent tip and tip embeddedness were significantly associated with a simple snare technique failure; thus, present the modified snare technique to overcome the simple snare technique failure. By applying these 2 techniques together, we can increase the overall technical success rate up to 97% (196/202). The modified snare technique is safe and effective in cases of simple snare technique failure.

Prospective trial of single-use, flexible cystoscope for ureteric double-J stent removal: Cost and utility analysis

Objective:

The objective of this study is to evaluate the costs and benefits of Isiris (Coloplast, Denmark), a mobile, single-use, flexible cystoscope with a built-in stent grasper.

Methods:

A prospectively collected database was reviewed to define procedural outcomes for Isiris ureteric stent removal. Variables assessed included stent duration and location of removal. A cost assessment was performed evaluating the impact on costs, funding and facility use.

Results:

Seventy-five procedures were performed using Isiris between April and September 2017. There were no complications. Two procedures failed because of encrustation and poor visibility secondary to haematuria. The mean (SD), median (interquartile range) and range of delay were 2.1 (0–5.3), 0 (0–2) and 0–40 days, respectively. Only one patient was delayed more than two weeks; this occurred because he was placed on a theatre waiting list, which resulted in the 40-day delay. Overall, the cost benefit for our department with the introduction of the Isiris system has been a surplus of $104,434, with an extra 65 elective spaces free for diagnostic flexible cystoscopy cases.

Conclusion:

Isiris flexible stent removal offers our patients a rapid stent-removal service with low rates of removal delay. Savings have been made in scope repair costs, sterilisation and scope maintenance, as well as optimisation of theatre and procedure room space. Level of evidence: 1c

A prospective and randomized comparison of rigid ureteroscopic to flexible cystoscopic retrieval of ureteral stents

Background

Flexible cystoscopy has become an accepted alternative for stent retrieval. However, it is associated with higher cost. Some reports have described experiences of using rigid ureteroscope to retrieve ureteral stents. We compared rigid ureteroscopic to flexible cystoscopic retrieval of ureteral stents in a prospective and randomized clinical trial.

Methods

Three hundred patients treated with ureteral stents between July 2012 and July 2013 were accrued in this study. These patients were divided into two groups using the random number table method. Group A, with 162 patients, had stents removed with a flexible cystoscope and Group B, with 138 patients, had stents removed with a rigid ureteroscope. All procedures were performed under topical anesthesia by the same urologist. Patients in each group were compared in terms of preoperative, perioperative, and postoperative data. Postoperative data were collected using telephone interview on the postoperative day two. The postoperative questionnaire used included three items: hematuria, irritable bladder symptoms, and pain scores.

Results

All the stents were retrieved successfully. No statistical differences were noted between the two groups in terms of gender, age, laterality and duration of the stents, operative time, postoperative hematuria, irritable bladder symptoms, and pain scores. The per-use cost of instrument was much higher for the flexible cystoscopic group, RMB 723.1 versus 214.3 (USD 107.9 versus 28.2), P < 0.05.

Conclusion

Ureteral stent retrieval using rigid ureteroscope under topical anesthesia is as safe and effective as flexible cystoscope but with a much lower cost to patients.

Trial registration

This study was registered with Chinese Clinical Trial Registry on March 27, 2017 (retrospective registration) with a trial registration number of ChiCTR-IOR-17010986.

Rethinking of ureteral stent removal using an extraction string; what patients feel and what is patients' preference? : a randomized controlled study

BACKGROUND

Ureteral stent removal using an extraction string is advantageous because it can obviate an invasive cystoscopy, but there is a paucity of data on how patients feel about it, and how bothersome or beneficial it is. We performed this study to evaluate patients' preference for stent removal using an extraction string and which parameters could affect it.

METHODS

In total, 114 consecutive patients undergoing ureteral stent insertion after ureteroscopic stone removal (URS) for unilateral recurrent ureter stones were enrolled. Patients were randomized to a string group or a no string group. Stent removal was performed on the first visit within 7 days postoperatively. All patients were asked to complete the ureteral stent symptom questionnaire, to rate the degree of pain during stent removal using a visual analog scale (VAS) and to answer to questions regarding their preference.

RESULTS

No significant differences were found in domain total scores including urinary symptoms (p = 0.17), pain (p = 0.62), general health (p = 0.37), work performance (p = 0.41). However, regarding separate questions for 'dysuria' and 'difficulties with heavy physical activity', there were significant intergroup differences (p = 0.03 and p = 0.04, respectively). Particular, a significantly higher proportion of patients in the string group checked 'stoppage of sexual intercourse due to stent-related problems' than in the no string group (p = 0.03). VAS score on stent removal was significantly higher in the no string group than the string group (p = 0.005). Among the patients who remember the experience of an indwelling ureteral stent in the past, 85% (17/20) of the no string group answered 'No' to the question of 'difference between the methods used in this time and in the past'. On the contrary, 84.2% (16/19) answered 'Yes' to the same question in the string group. And, all 16 patients of the string group who noted differences between the methods preferred ureteral stent removal using an extraction string to the past method.

CONCLUSIONS

Despite of minor increased morbidity related to the extraction string, patients preferred ureteral stent removal using the extraction string after URS. The patients with the extraction string felt less pain on stent removal than flexible cystoscopic stent removal.

TRIAL REGISTRATION

KCT0001700 . The trial was registered in the Clinical Research Information Service (CRiS), Republic of Korea; registration date: 18/11/2015.