Ureteral stent discomfort: Etiology and management

Outcomes of a non-randomised audit of single pigtail suture stents in urolithiasis management of Asian patients in Singapore

Objective

Double-J (DJ) ureteric stents are commonly placed perioperatively for semirigid or flexible ureteroscopic renal surgery. It is believed that lesser stent material within the bladder mitigates stent-related symptoms. This study aimed to evaluate the J-Fil ureteral stent, a single pigtail suture stent compared with conventional DJ stent in relation to stent symptoms in an Asian population undergoing ureterorenal intervention.

Methods

Based on internal audit committee recommendation approval, the records of 50 patients retrieved, available data of 41 patients who were prospectively enrolled into two groups (Group 1 [J-Fil stent group], n=21 and Group 2 [DJ stent group], n=20) between August 2020 to January 2021, were analysed. Parameters compared were nature of procedure, stone location and size, ease of deployment or removal, and complications. A modified universal stent symptom questionnaire was used to assess morbidity of stent symptoms within 48 h of insertion and at removal.

Results

Both groups had similar median age, distribution in male to female ratio, and stone size. The overall median universal stent symptom questionnaire score at insertion was similar for bladder pain, flank or loin pain, and quality of life between Group 1 and 2; however, at removal Group 1 fared significantly better than Group 2, especially for flank or loin pain and pain at voiding. Both groups had similar ease in insertion with no hospital readmissions.

Conclusion

Our audit favoured the single pigtail suture stent in Asian ureters in mitigating stent-related issues. It showed a good safety profile with easy deployment and removal. It promises a new standard in stenting.

Factors associated with unplanned clinical encounters for ureteral stent-related symptoms

BACKGROUND, INTRODUCTION AND AIM

Ureteral stent-related symptoms (USRS) often result in unplanned phone calls and ER visits. We hypothesize that patient factors can be identified to predict these unplanned encounters.

METHODS AND MATERIALS

Retrospective analysis of indwelling ureteral stent placements from 2014 to 2019 at a single institution by CPT code was performed. Patient demographics, discharge medications, and clinical factors were evaluated using multiple logistic regression with respect to postoperative telephone and emergency room (ER) encounters for USRS.

RESULTS

Of 374 patients, 75 (20.1%) had one or more encounters for USRS: 48 (12.8%) called the clinic and 39 (10.4%) returned to the ER. Chronic opioid use was predictive of calls to clinic and ER visits (OR 3.21 [CI 1.42-6.97], p < 0.01 and OR 3.64 [CI 1.45-8.98], p < 0.01). Survival analysis stratified by history of chronic opioid use and discharge opioid prescriptions demonstrated that opioid naïve patients receiving opioids at discharge had unplanned encounters sooner and more often [Calls p = 0.025, ER p = 0.041]), whereas patients with chronic opioid use returned to the ER sooner and more frequently when prescribed additional opioids (Calls p = 0.4, ER p = 0.002).

CONCLUSION

Patients with a history of chronic opioid use may experience more intense USRS or have a lower threshold to seek medical care than opioid naïve patients and tend to bypass calling the clinic for the ER. Given that none of the studied medications reduced unplanned patient contact for USRS, urologists should consider upfront definitive management of urinary obstruction when appropriate.

Triangular prismatic JJ stent does not cause more discomfort than tubular ones: a randomised controlled trial comparison

OBJECTIVE

To compare the stent-related symptoms (SRS) of three commonly used, readily accessible ureteric JJ stents after uncomplicated flexible ureteroscopic lithotripsy (FURL), in a prospective randomised controlled single-blind parallel-group study, in order to see whether structural difference might influence SRS.

PATIENTS AND METHODS

Patients undergoing FURL were randomised into three groups: the Cook Group received conventional 6 F Cook Universa Soft JJ stents as control, the Kang Yi Bo (KYB) Group received 6 F KYB anti-reflux JJ stents, and the Urovision Group received 7 F Urovision Visiostar ESWL JJ stents. The ureteric stent symptom questionnaire (USSQ) was administered at 1 week, 4 weeks (before stent removal), and 5 weeks (one week after stent removal as baseline evaluation) after stent insertion. Both raw and baseline-adjusted USSQ domain subscores at 1 week and 4 weeks were compared.

RESULTS

A total of 146 patients were included in the analysis. The KYB Group showed significantly lower P6&7 subscore yet higher urinary symptoms score 1 week and 4 weeks after stents insertion than both Cook and Urovision, whilst the Urovision Group achieved similar scores in most domains with Cook.

CONCLUSIONS

Although the KYB anti-reflux JJ stent might prevent vesicoureteral reflux, it induces significantly stronger urinary symptoms, both at 1 week or 4 weeks after stent insertion, with or without baseline correction. Despite the unique triangular prismatic shape, the Urovision Visiostar stent does not cause heavier urinary symptoms or pain compared to the conventional cylinder shape counterparts.

The Impact of the Double J Stent on Health and Sexual Life

Double J stents are commonplace tools used in modern urology, serving as a vital aid in the drainage of the upper urinary system. Along with the numerous advantages of these catheters, numerous negative consequences have also been addressed throughout time. Among the most common symptoms associated with ureteral catheters are those associated with LUTS (lower urinary tract symptoms), such as dysuria, urinary urgency, pollakiuria, the feeling of incomplete emptying of the bladder, urinary incontinence, or even urinary tract infections (UTIs). Complications associated with sexual dysfunction, including dyspareunia and pain during sex, which can lead to erectile dysfunction or loss of orgasm, are less discussed in the literature. This small review tries to focus on the most important aspects of low urinary symptoms that affect the general quality of life and those related to the quality of sexual life, which are less discussed but of particular importance in the lifestyle of any patient with such ureteral device.

Efficacy of combination therapy tadalafil plus tamsulosin in ureteral stents-related symptoms relief

Introduction

Ureteral stents-related symptoms (USRs) are the common complications of ureteral stenting. Tamsulosin a selective alpha-1 blocker and Tadalafil a PDE-5 inhibitor are one of drugs have been used for USRs relief. In this study we aimed to evaluate the effectiveness and safety of combination therapy Tamsulosin+Tadalafil for treating USRs comparing it with the efficacy of either Tamsulosin or Tadalafil monotherapies.

Material and methods

279 patients with indwelled unilateral ureteral stents were randomized to Tamsulosin 0.4 mg + Tadalafil 5 mg once a day (Group 1, n = 67), Tamsulosin 0.4 mg once a day (Group 2, n = 71), Tadalafil 5 mg once a day (Group 3, n = 69) and Placebo once a day (Group 4, n = 72). USRs severity was registered and calculated by using the Ureteral Symptoms Score Questionnaire (USSQ) at the 14th day of treatment. Side-effects and total analgesic use were recorded and compared.

Results

At the endpoint in patients with unilateral ureteral stents the combination therapy Tamsulosin + Tadalafil led to statistically lower intensity of urinary symptoms comparing with Tamsulosin (15.2 ±4.3 vs 21.8±3.6, p = 0.0003) or Tadalafil (15.2 ±4.3 vs 20.6 ±2.8, p = 0.0004) monotherapy. All groups of treatment demonstrated significant relief of USRs comparing with Placebo mostly beneficial in the combined therapy group. Body pain and analgesic need in Group 1 was lower than in Groups 2, 3 or 4. Side-effects were registered rarely without statistical differences in frequency between groups.

Conclusions

Combination therapy with Tamsulosin + Tadalafil is an effective and safe option that achieves the statistically more significant relief of USRs comparing with Tadalafil or Tamsulosin monotherapies.

Antireflux Ureteral Stents Prevent Stent-Related Symptoms: A Meta-Analysis of Randomized Controlled Trials

Ureteral stents are widely used in urological care, but they are often associated with adverse stent-related symptoms (SRS), such as painful urination, elevated urinary frequency, and abdominal discomfort. Antireflux ureteral stents have been developed to reduce stent-related pain and reflux by minimizing vesicoureteral reflux (VUR). This systematic review and meta-analysis of randomized controlled trials (RCTs) was undertaken to assess the efficacy of antireflux ureteral stents in mitigating SRS compared to conventional urethral stents. Our study included a total of 269 cases from three RCTs. The meta-analysis showed that antireflux ureteral stents were significantly more effective than standard stents in reducing SRS, including stent-related pain (odds ratio (OR): 4.80, 95% CI: 2.77, 8.31, p <0.00001), severe stent-related pain (OR: 8.35, 95% CI: 2.12, 32.89, p=0.002), flank pain while urinating (OR: 5.98, 95% CI: 3.35, 10.68, p <0.00001), and severe flank pain while urinating (OR: 15.79, 95% CI: 2.91, 85.57, p=0.001). There was no significant difference in the rates of postoperative creatinine abnormality or postoperative hydronephrosis between the two groups. Therefore, antireflux ureteral stents are more effective than standard stents in reducing SRS. This suggests that antireflux ureteral stents should be considered for patients undergoing ureteral stenting.

Double J Stents and Reno-Ureteral Lithiasis: Dynamic Changes in Management during the COVID-19 Pandemic

PURPOSE

To provide an evidence-based review of the use of ureteral stents in managing reno-ureteral lithiasis during the COVID-19 pandemic.

MATERIALS AND METHODS

A literature search was conducted between 2020 and 2023 using the PubMed and SCOPUS databases. As a part of the search query, we entered "ureteral stents" OR "double J stent" AND "renal colic" OR "ureteral obstruction" OR "reno-ureteral lithiasis" AND "COVID-19 Pandemic" OR "SARS-CoV-2 infection".

RESULTS

Patients with lithiasis should be categorized into low priority, intermediate priority, high priority, and emergency under the COVID-19 pandemic scenario to manage their delay and save resources, including healthcare professionals, beds, and ventilators. However, immediate interventions are necessary for individuals at risk of life-threatening septic complications. During the COVID-19 pandemic, the feasibility of conducting or resuming elective activity depended on local circumstances, the accessibility of beds and ventilators, and the execution of screening protocols. If lithiasis surgery is delayed, consequences and increased effort will be inevitable. It is possible that teleconsultation could help guide these patients and cut down on unnecessary visits and exposure.

CONCLUSIONS

COVID-19 has shifted treatment options for urinary stones, with ureteral stents being a safe, efficient, and cost-effective option for managing urolithiasis. Decompression is essential in emergency situations, while ureteral stents reduce the risk of infection and hospital visits.

Lower urinary tract effects of ureteral stent length and intravesical position

PURPOSE

Ureteral stents can cause lower urinary tract problems such as stent-related irritative symptoms and urinary tract infections. This study aimed to determine the lower urinary tract effects of ureteral stent length and intravesical position in children.

METHODS

Patients who underwent double-J stenting after urological procedures between January 2017 and January 2022 were included in the study. The patients were assessed in terms of age, irritative symptoms, urinary tract infections, and stent length. The intravesical position of the ureteral stents was grouped as cross-trigonal and ipsilateral. The distribution of irritative symptoms, frequency of urinary tract infections and stent length were analyzed according to intravesical location.

RESULTS

A total of 47 patients were included in the study. The median age was 5 years (range: 1-16). Cross-trigonal stent position was significantly associated with symptoms of urgency (p = 0.046), suprapubic pain (p = 0.002), and lower mean age (p = 0.004). Urinary tract infections were more frequent in patients whose placed stents were longer than recommended (p < 0.001) or were in cross-trigonal position (p = 0.043).

CONCLUSION

Our results suggest that stent-related irritative symptoms and urinary tract infections can be reduced in pediatric patients using a suitably sized ureteral stent and considering its intravesical position.

Comparison of Ureteral Stent Biomaterials: Encrustation Profile in Lithogenic Artificial Urine Models

Ureteral stent encrustation significantly limits indwelling time and can lead to downstream urological problems. However, no ideal polymeric biomaterials have been shown to completely resist encrustation in long-term urine exposure. Recently, 2-hydroxyethyl methacrylate (HEMA)-coated Pellethane was reported as a promising biomaterial resistant to encrustation. This study compared HEMA-coated Pellethane to commercially available stents under two different artificial urine environments. To evaluate the degree and composition of encrustation on HEMA-coated Pellethane, Boston Scientific Tria, Bard InLay Optima, Cook Universa Hydrogel, and Cook Black Silicone stents were used at various dwelling times in two different artificial urine environments. In a batch-flow model, samples of stents were suspended in an artificial urine solution (AUS) at 37 °C. Every 24 h for 11 weeks, 50% of the AUS would be replaced with fresh components using a programmable peristaltic pump system. The stent materials were removed at suitable time intervals and air-dried for 24 h under sterile conditions before follow-up analysis. SEM was used to assess the degree of encrustation, and inductively coupled plasma mass spectrometry (ICP-MS) was employed to quantify the encrusted compositions, specifically for calcium, magnesium, and phosphorus. We measured the weight gain over time due to encrusted deposits on the stents and quantified the amount of Ca, Mg, and P deposited on each encrusted stent. After the 11 week trial, HEMA-coated Pellethane showed the most average mass change. SEM showed that HEMA-coated Pellethane was fully encrusted in just 2 weeks in the AUS environments, and ICP-MS showed that Ca is the most abundant deposit. Among all the tested stents, Black Silicone performed the best. The two AUSs were formulated to encrust more rapidly than physiological conditions. HEMA-coated Pellethane is not an ideal stent material, while silicone is a promising material for advancing ureteral stents.

Comparison of the Removal Efficiency and Safety of Magnetic Versus Conventional Ureteral Stents: A Systematic Review and Meta-analysis

Context

The incidence of urolithiasis is increasing year by year. Ureteral stents are a popular treatment option for this condition. Efforts to improve the material and structure of stents to increase comfort and reduce complications have led to the introduction of magnetic stents.

Objective

To evaluate differences in removal efficiency and safety for magnetic and conventional stents.

Evidence acquisition

This study was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Data were extracted according to the PRISMA principles. We collected and combined data from randomized controlled trials on magnetic versus conventional stents to evaluate the efficiency of their removal and the associated effects. Data synthesis was performed using RevMan 5.4.1 and heterogeneity was evaluated using I² tests. A sensitivity analysis was also performed. Key metrics included the stent removal time, Visual Analog Scale (VAS) pain scores, and Ureteral Stent Symptom Questionnaire (USSQ) scores for various domains.

Evidence synthesis

Seven studies were included in the review. We found that magnetic stents had a shorter removal time (mean difference [MD] -8.28 min, 95% confidence interval [CI] -15.6 to -0.95; p = 0.03) and their removal was associated with less pain (MD -3.01 points, 95% CI -3.83 to -2.19; p < 0.01) in comparison to conventional stents. USSQ scores for urinary symptoms and sexual matters were higher for magnetic than for conventional stents. There were no other differences between the stent types.

Conclusions

Magnetic ureteral stents have the advantages of a shorter removal time, less pain during removal, and low cost in comparison to conventional stents.

Patient summary

For patients undergoing treatment of urinary stones, a thin tube called a stent is often temporarily inserted in the tube between the kidney and the bladder to allow stones to pass. Magnetic stents can be removed without any need for a second surgical procedure. Our review of studies comparing two types of stents suggests that magnetic stents are superior to conventional stents in terms of efficiency and comfort during removal.

Distal end of Double-J ureteral stent position on ureteral stent-related symptoms: A systematic review and meta-analysis

Background

Most patients suffer from ureteral stent-related symptoms (USRS) caused by indwelling ureteral stents. Nevertheless, various medications to alleviate discomfort as well as novel stents are continually being developed, and in recent years, some researchers have believed that proper intravesical stent placement can relieve USRS.

Objective

To determine appropriate intravesical ureteral stent position may alleviate USRS.

Methods

Up to May 1, 2022, the PubMed, Embase, Scopus and Web of Science databases were thoroughly searched, and two independent reviewers included relevant studies that met the PICO (Patient, Intervention, Comparison, Outcome) criteria. Studies methodological quality were assessed by ROB2 and ROBINS-I. Ureteral stent symptom questionnaire (USSQ), international prostate symptom score (IPSS) and quality of life (QoL) was used to quantify the USRS. According to intravesical ureteral stent position, Group A was defined as the contralateral group, that is distal end of ureteral stent crossed the bladder midline, whereas Group B was classified as ipsilateral group, meaning stent end did not cross the midline.

Results

Six studies incorporating a total of 590 patients were eligible. In terms of USSQ score, the meta-analysis showed that contralateral group was associated with a significant increase in USSQ total (MD, 17.55; 95% CI, 12.04 to 23.07; P < 0.001), urinary symptoms (MD, 2.74; 95% CI, 0.48 to 5.01; P = 0.02), general health (MD, 4.04; 95% CI, 2.66 to 5.42; P < 0.001), work performance (MD, 1.36; 95% CI, 0.75 to 1.98; P < 0.001) and additional problems (MD, 0.89; 95% CI, 0.47 to 1.32; P < 0.001) scores while not associated with a significant increase in body pain (MD, 3.13; 95% CI, −0.19 to 6.44; P = 0.06) and sexual matters (MD, 1.01; 95% CI, −0.03 to 2.06; P = 0.06). As for IPSS, although no significant differences in IPSS total (MD, 2.65; 95% CI, −0.24 to 5.54; P = 0.07) or voiding symptoms (MD, −0.84; 95% CI, −3.16 to 1.48; P = 0.48) scores were found, ipsilateral group was associated with a significant decrease in storage symptoms (MD, 1.92; 95% CI, 0.91 to 2.93; P = 0.0002). Furthermore, ipsilateral group was linked to a significant decrease in QoL score (MD, 1.00; 95% CI, 0.18 to 1.82; P = 0.02).

Conclusion

This meta-analysis proven that correct intravesical stent position was critical, and patients with stents crossing the midline experienced more severe USRS than those who did not. Further high-quality randomized controlled trials are needed to corroborate our findings.

Primary versus delayed ureteroscopy for ureteric stones: A systematic review and meta-analysis

Background:

Ureteric colic is a major clinical and economic burden on the National Health Service. There has been a recent paradigm shift to consider definitive surgery as the primary intervention at the time of initial presentation.

Objective:

To systematically evaluate the outcomes of primary/emergency ureteroscopy versus delayed/elective ureteroscopy.

Methods:

We performed a critical review of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials–CENTRAL, CINAHL, Clinicaltrials.gov, Google Scholar and individual urological journals in April 2020. A robust database search was performed using a combination of the terms ‘primary ureteroscopy’, ‘immediate ureteroscopy’, ‘delayed ureteroscopy’ and ‘emergency ureteroscopy’. Adult patients (> 16 years) with ureteric stones presenting as an emergency were included.

Results:

Twelve studies met the inclusion criteria, with 4 studies directly comparing primary/emergency to delayed/elective ureteroscopy for an acute presentation of ureteric colic. Across the studies, 1708 patients underwent primary/emergency ureteroscopy for ureteric calculi and 990 underwent delayed ureteroscopy. No significant differences in stone-free rates were found between both groups with primary/emergency achieving 85% and delayed/elective 91% ( p = 0.68). The majority of stones treated were located in the distal ureter in both groups. Overall, there were no differences in complications between the groups ( p = 0.42) or major complications (0.17). However, there were fewer minor complications in the primary URS group ( p = 0.02). Ureteral catheter or double-J stent insertion was used in 71% of delayed/elective ureteroscopy cases, compared to 46.8% of primary/emergency cases (p = 0.001). For patients undergoing primary/emergency ureteroscopy, 6.4% patients required auxiliary procedures. In the delayed/elective group, 7.6% required further definitive treatment (NS).

Conclusion:

Primary ureteroscopy is a safe and feasible procedure, when performed in suitable patients in the acute setting. It is associated with significantly lower stent usage, equivalent stone clearance, no increase in overall or major complications including sepsis, and fewer minor complications when compared to delayed/elective ureteroscopy. Prospective studies will do well to explore this area further but on current evidence, primary ureteroscopy is the safe procedure.

Level of evidence:

Not applicable

Comparative efficacy and safety between Micro-Percutaneous Nephrolithotomy (Micro-PCNL) and retrograde intrarenal surgery (RIRS) for the management of 10–20 mm kidney stones in children: A systematic review and meta-analysis

Objectives

Kidney stone in children is a recurring problem that requires multiple interventions over time. Minimally-invasive approach, such as Extracorporeal Shockwave Lithotripsy (ESWL) is recommended for moderately-sized stones. However, since ESWL is associated with multiple interventions, Micro-Percutaneous Nephrolithotomy (Micro-PCNL) and Retrograde Intrarenal Surgery (RIRS) can also be considered to treat kidney stones in pediatric patients. Both approaches have their respective advantages and disadvantages. In this study, we aimed to compare the efficacy and safety of Micro-PCNL and RIRS in pediatric patients with kidney stones.

Methods

This systematic review and meta-analysis adhered to the PRISMA guideline and Cochrane Handbook of intervention. The included studies were obtained from the PubMed and ScienceDirect databases. The protocol of this review has been registered in PROSPERO (CRD42021265894). The quality of the studies was assessed using the Newcastle-Ottawa Scale, outcomes were analyzed using STATA®16, and certainty of evidence was evaluated using GRADE.

Results

A total of 239 participants were included in this study, divided into the Micro-PCNL (n = 112) and RIRS (n = 127) procedure groups. Statistical analysis revealed a significantly lower requirement of postoperative stenting procedure in Micro-PCNL compared to RIRS (OR 0.09; 95%CI 0.02, 0.47; p < 0.01). However, no significant difference was found in stone-free rate (p = 0.86), operative time (p = 0.09), UTI incidence (p = 0.67), blood transfusion requirement (p = 0.95), and length of stay (p = 0.77).

Conclusion

Micro-PCNL is superior to RIRS in managing pediatric kidney stones,10–20 mm in size based on their comparable SFR and fewer requirements of additional stenting procedures.

•

Micro-PCNL had a comparable SFR to RIRS in managing pediatric kidney stones,10–20 mm.

•

Micro-PCNL had less requirement of stenting procedure than RIRS in managing pediatric kidney stones,10–20 mm.

•

Micro-PCNL is superior to RIRS in managing pediatric kidney stones,10–20 mm.

Role of pre-operative ureteral stent on outcomes of retrograde intra-renal surgery (RIRS): systematic review and meta-analysis of 3831 patients and comparison of Asian and non-Asian cohorts

PURPOSE

To evaluate the outcomes of pre-stented (PS) versus non-pre-stented (NPS) patients who have undergone retrograde intrarenal surgery (RIRS) for renal calculi with subgroup analysis of Asian and non-Asian cohorts.

METHODS

Protocol is registered in PROSPERO, CRD42021261123. Eligible studies identified from four electronic databases. Meta-analysis was done to enumerate the outcomes of RIRS in between PS and NPS. Secondary sub-analysis was done to look for differences in outcomes in Asian and non-Asian cohorts.

RESULTS

Fourteen studies involving 3831 patients (4 prospective, 10 retrospective studies) were included. PS patients experienced higher success rates of ureteral access sheath (UAS) insertion than NPS (RR 1.09, 95% CI 1.05-1.13, p < 0.00001). PS patients had lower risk of ureteral injuries from UAS placement (RR 0.69, 95% CI 0.50-0.96, p = 0.03). No significant differences in intra- and postoperative complications between two groups were found. Stone-free rate (SFR) outcomes for residual fragment (RF) cut-off of < 1 mm and < 4 mm favoured the PS patients (RR 1.10, 95% CI 1.04-1.17, p = 0.002 for < 4 mm, RR1.10, 95% CI 1.02-1.19, p = 0.02 for < 1 mm). In the subgroup analysis, PS Asian patients had similar SFR as NPS patients for SFR(< 4 mm) but non-Asian population showed better outcomes in the PS patients for SFR(< 4 mm) (RR 1.31, 95% CI 1.13-1.52, p = 0.0005).

CONCLUSIONS

This meta-analysis suggests that pre-stenting results in a higher success for UAS placement, minimising intraoperative ureteric injury, with higher overall SFR for any RF cut-off in PS cohorts. In non-Asian cohort, significant differences occurred at SFR < 4 mm but not for SFR < 1 mm. No difference was seen in our Asian cohort for any SFR cut-off in both PS and NPS patients.

A systematic review of magnetic versus conventional ureteric stents for short term ureteric stenting

Ureteric stents play an essential role in urology. However, patients can suffer a range of stent-related symptoms with stent in situ and during removal. Conventional ureteric stents are removed using a flexible cystoscopy, whereas magnetic stents may be rapidly removed with a smaller catheter-like retrieval device. The primary aim of this systematic review was to compare the morbidity including pain associated with conventional versus magnetic ureteric stents. The secondary aim was cost comparison. Searches were performed across databases, including Medline, Scopus, Embase and Cochrane. This review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The search from the 5 databases returned a total of 358 articles. After duplicates were removed as well as the inclusion and exclusion criteria applied, a total of 6 studies were included in the final review. Ureteric Stent Symptoms Questionnaire (USSQ) and Visual Analogue Score (VAS) were used in most of the studies. All the studies reported that magnetic ureteric stents resulted in a reduction in the pain on the removal of magnetic ureteric stents, and no statistically significant difference with indwelling ureteric stents. Furthermore, majority of the studies reported a reduction in the cost associated with magnetic ureteric stents. There is no significant difference in pain from indwelling ureteric stents. There is a reduction in pain with the removal of magnetic ureteric stents compared to conventional removal via cystoscopy and an associated reduction in cost.

Free interactive counselling program in a mobile communication application for improving health education on indwelling ureteric stents after ureterorenoscopic lithotripsy: An observational study

Objective

This study examines the potential benefit of an interactive counselling program via a mobile application (app), which can instantly provide patients with the necessary information and correct response regarding their condition.

Methods

We designed a free ‘Ureteric Stent Interactive Program’ for patients receiving ureterorenoscopic lithotripsy and provided the program to interested patients. Patient data were collected from medical records and depending on whether patients used our program, they were divided into two groups: ‘program-user’ and ‘non-user’. The differences between the groups were analysed using Fisher’s exact tests.

Results

Of the 70 patients, 50 elected to use the program. The program-user group was significantly younger (<60 years: 74% vs 15%, P<0.001) and had higher education levels (40% vs 5%, P = 0.004). All 50 patients in the program-user group reported being satisfied (32%) or very satisfied (68%) with the program. Patients over 60 years were significantly more satisfied with program (35.5% vs 6.3%, P = 0.04).

Conclusions

Younger patients with high education levels were more likely to use the app and improve their health knowledge. Using the program resulted in high satisfaction, especially among older patients. This study demonstrates the benefits of interactive application for educating patients regarding their health.

Clinical Significance of Renal Allograft Urothelial Thickening Identified by Ultrasound

OBJECTIVES

To assess the etiology and clinical implications of ultrasound (US)-diagnosed urothelial thickening (UT) in renal transplants.

METHODS

Patients with renal transplants who had UT diagnosed by US from January 2000 to December 2018 were retrospectively identified and compared to patients with transplants without UT scanned during the study period. Medical records were reviewed for demographics, US findings, pathologic results, laboratory values, and clinical outcomes and compared between groups by Fisher exact and t tests.

RESULTS

A total of 143 patients with UT and 128 controls comprised our cohorts. The patient age in the UT group versus controls (mean ± SD, 50.2 ± 16.5 versus 51.2 ± 15.3 years) and the time since transplant (2.9 ± 4.2 versus 2.4 ± 5.8 years) were similar. Patients with UT were more likely to be female than controls (76 of 143 [53.1%] versus 53 of 128 [41.4%]; P = .07), but the difference was not statistically significant, and patients with UT were more likely to have indwelling stents (31 of 143 [21.7%] versus 9 of 128 [7.0%]; P = .001) and hydronephrosis (25 of 143 [17.4%] versus 11 of 128 [8.6%]; P = .03). At biopsy, rejection and vascular sclerosis were more likely in patients with UT compared to controls (24 of 25 [49.0%] versus 11 of 43 [25.6%]; P = .031; 42 of 49 [85.7%] versus 22 of 43 [51.2%]; P = .0005, respectively), whereas acute tubular necrosis was similar. The sensitivity (50.0%) and specificity (74.4%) of UT for rejection were low.

CONCLUSIONS

Urothelial thickening correlates with US findings of urinary obstruction and indwelling stents, suggesting a possible mechanical component to UT's etiology. Although transplant rejection and vascular sclerosis were more frequent at biopsy in the UT group than controls, UT had low sensitivity and specificity for rejection.

The efficacy and safety of mirabegron in treating ureteral stent-related symptoms: A systematic review and meta-analysis

OBJECTIVES

This meta-analysis aimed to assess the efficacy and safety of mirabegron in treating ureteral stent-related symptoms.

METHODS

MEDLINE, EMBASE, and the Cochrane Controlled Trials Register were searched to identify randomized controlled trials (RCT) of mirabegron in treating ureteral stent-related symptoms. We conducted a systematic review and meta-analysis based on the eligible RCT.

RESULTS

Five RCT including 546 patients and comparing mirabegron with placebo or blank control were involved in the present research. Regarding efficacy, mirabegron was superior to controls in urinary symptom score (P = .0006) and general health score (P < .0001) of the Ureteral Stent Symptom Questionnaire, total International Prostate Symptom Score (P < .00001), quality of life (P < .0001), analgesic use (P = .008), and readmission or visit to hospital due to discomfort (P = .001). Safety assessments including adverse events (P = .40) suggested that mirabegron was well tolerated.

CONCLUSIONS

The present meta-analysis shows that mirabegron is an effective and safe treatment for relieving ureteral stent-related symptoms with a low occurrence of adverse events.

Assessment of encrustation and physicochemical properties of poly(lactide-glycolide) - Papaverine hydrochloride coating on ureteral double-J stents after long-term flow of artificial urine

Implantation of ureteral stents is associated with inconvenience for the patient, which is related to the natural ability of the ureter to contract. The most frequently used solution is the systemic administration of a diastolic drug, which has a relaxing effect on smooth muscle cells and decreases inconvenience. Current interdisciplinary research aimed at reducing the complications after the implantation of ureteral stents used in the treatment of upper urinary tracts with regard to infection, initiation of encrustation, and fragmentation of stents, and patient pain has not been resolved. This study presents the results of research regarding the impact of a biodegradable coating with the active substance on the physical and chemical properties of ureteral stents used in the treatment of the upper urinary tract. The surface of polyurethane double-J stents was coated with poly(lactide-glycolide) (PLGA) 85/15 loaded with papaverine hydrochloride (PAP) with diastolic properties. The coating for ureteral stents has been designed for short-term implantation. The effect of the coating on the process of encrustation and PAP release by the dynamic in vitro model with artificial urine (AU) up to 30 days was evaluated. The influence of AU on the physical and chemical properties of ureteral stents was determined. As part of the study, surface structure and topography researches; chemical composition analyses using X-ray photoelectron spectroscopy, Fourier transform infrared spectroscopy, and wetting; and surface roughness studies of both PUR stents and coated stents were carried out. The proposed biodegradable PLGA+PAP coating is characterized by controlled drug release, while optimal physicochemical properties does not increase the encrustation process.

The role of mirabegron in relieving double-J stent-related discomfort: a randomized controlled clinical trial

Introduction

The aim of this study was to investigate the effect of 50 mg mirabegron once daily in relieving ureteral double-J (DJ) stent-related discomfort after ureteroscopy (URS) or retrograde intrarenal surgery (RIRS).

Material and methods

A total of 210 patients who underwent DJ ureteral stent insertion after URS or RIRS were randomized 1:1 to receive either no treatment (Group B) or mirabegron 50 mg once daily (Group A) during the stenting period. At time of stent removal, all patients were evaluated for stent-related symptoms using the Arabic translated and validated ureteral stent symptom questionnaire (USSQ). The severity of stent-related symptoms (SRS) was compared between the two groups.

Results

The mean age was 46.6 ±8.2 years in Group A and 44.7 ±9.4 (26-64) years in the control group (p = 0.13). The stone characteristics, stent size, and position were similar in both groups. Compared to the control group, the mirabegron group had significantly lower daytime frequency, nocturia and urgency (p = 0.028, p = 0.008 and p = 0.012, respectively). As for stent-related pain, Group A had significantly less flank and abdominal pain (p = 0.007 and p = 0.001, respectively). The mirabegron versus control group showed significant difference in mean analgesics use and quality of life (QoL) scores during the stenting period (p = 0.005 and p = 0.003, respectively). Three patients (2.9%) in Group A encountered minor adverse effects (two experienced dry mouth and one presented with constipation).

Conclusions

For patients with indwelling DJ stent, postoperative mirabegron 50 mg use was effective and well-tolerated for the treatment of lower urinary tract symptoms and stent-related pain.

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.

Ureteral stent complications - experience on 50,000 procedures

Double J stent is an essential tool in urology, being a basic part of many urological procedures. However, some issues related to their use still occur. Our study aimed to evaluate an important number of procedures, the complications of ureteral stents, and their prevention and treatment retrospectively. We evaluate 50,000 procedures performed between 1996 and 2021 on 36,688 patients. According to the stenting duration, the cases were divided into short-term (less than 6 weeks – 34,213 procedures), respectively long-term stenting (more than 6 weeks – 15,757 procedures). The indications of stenting for both groups were noted. The total number of complications was 41,369. We encountered 153 cases (0.3%) of JJ stent malposition, of which 3 cases were into the retroperitoneum, one case with parenchymal perforation and hematoma. Considering the double J migrations, we found proximal migration in 427 cases (0.9%) and distal double J migrations in 352 (0.7%) cases. The obstruction of the ureteral stent, causing inefficient drainage, was encountered in 925 cases, while irritative bladder symptoms occurred in 16,326 cases (32.7%). Hematuria was observed in 5,213 cases, in 7 cases blood transfusion being necessary. Urinary tract infection was diagnosed in 7,436 cases (14.8%). Stent encrustation and calcification occurred in 832 cases, while stent fragmentation was noted in 52 cases. Double J stent complications should be promptly evaluated and treated. Encrustation and stone formation in forgotten stents often lead to serious complications and should be managed with stent removal and combined endourological techniques.

Sexual dysfunction in Indian men undergoing Double J ureteral stenting following ureteroscopy-A prospective analysis

This prospective study was aimed to evaluate the impact of an indwelling ureteral double-J stent on the sexual health of Indian men undergoing ureteroscopy. The first phase of the study included 30 men who were not counselled prior to stenting about possible sexual dysfunction, while in the next phase, 60 men were counselled about this. These 60 patients were assessed by a 6-point questionnaire: five questions from the International Index of Erectile Function-5 (IIEF-5) and an additional 6th question to assess pain during erection/ejaculation. Patients answered the questionnaire prior to ureteroscopy, at the time of stent removal and then 4 weeks after stent removal. A higher proportion of men in the second phase attempted sexual activity (68.3% vs. 26.7%; p < .001). Significant changes were noted in the total IIEF-5 score (mean 23.16 before vs. 15.65 after, p < .001) and individual IIEF-5 components: erection confidence (4.59 vs. 2.76, p = .017), maintenance ability (4.67 vs. 2.43, p = .006) and intercourse satisfaction (4.61 vs. 2.31, p < .001) and also the 'pain' question (2.83 post-stenting vs. 0.37 pre-stenting, p < .001). Most patients had a recovery of scores at 4 weeks after stent removal. Thus, ureteral DJ stenting leads to significant but temporary sexual dysfunction and patients need to be counselled regarding this.

Clinical Effectiveness of Single Pigtail Suture Stent on Patient Comfort: A Double-Blind Prospective Randomized Trial

Background: A double-pigtail ureteral stent (DPUS) can cause untoward symptoms, such as urgency, frequency, urinary incontinence, hematuria, and body pain that are bothersome to patient's quality of life (QoL). By reducing the quantity of material in the bladder, it could be reasonable to decrease stent-related symptoms (SRSs). We aimed to evaluate the tolerability of single pigtail suture stent (SPSS) with a validated questionnaire after uncomplicated retrograde semirigid ureteroscopic lithotripsy (URSL). Materials and Methods: A total of 130 patients who underwent ureteral stent placement after URSL for unilateral symptomatic ureteral stones with <15 mm diameter were randomized prospectively into two groups. Polyurethane ureteral stent (6 Fr, 24 or 26 cm) was placed in all patients, which was removed postoperatively with a mean of 14 days. There were 65 patients in both groups. All subjects completed the ureteral stent symptoms questionnaire (USSQ), which explores the SRSs. The questionnaires were conducted on the day of stent removal (at week 2) with the stent in situ and 4 weeks after removal (at week 6, poststent). The severity of SRSs and QoL were compared between the two groups. Results: SPSS was associated with perfect effect on all domains of USSQ, except from sexual and general health index scores. Pain index scores, visual analog scores (VAS), and analgesic requirements in SPSS group were found significantly low compared with those in the DPUS group. The QoL scores were significantly better in patients indwelling SPSS. Conclusion: SPSS is a potentially beneficial option to minimize ureteral SRSs after uncomplicated URSL.

Comparison of silicone versus polyurethane ureteral stents: a prospective controlled study

BACKGROUND

Approximately 80% of patients with indwelling ureteral stents experience stent related symptoms (SRS). We believe SRS can be reduced through altering the composition of ureteral stents to a less firm material. Therefore, we aim to compare modern silicone and polyurethane ureteral stents in terms of SRS intensity and safety.

METHODS

From June 2018 to October 2018, patients from two distinct clinical centers were prospectively enrolled in the study and stratified (non-randomly) into either control group A, patients who received polyurethane stents (Rüsch, Teleflex), or experimental group B, patients who received silicone stents (Cook Medical). Each participant completed a survey 1 h after stent insertion, in the middle of the stent dwelling period, and before stent removal or ureteroscopy noting body pain and overactive bladder via the visual analog scale pain (VASP) and overactive bladder (OAB) awareness tool, respectively. Additionally, successfulness of stent placement, hematuria, number of unplanned visits, and stent encrustation rates were assessed within each group.

RESULTS

A total of 50 patients participated in the study, control group A consisted of 20 patients and experimental group B consisted of 30 patients. Participants in group B, silicone ureteral stents, demonstrated significantly lower mean values of VASP 2 weeks prior to stent removal and promptly before stent removal (p = 0.023 and p = 0.014, respectively). No other comparisons between the two groups were statistically significant.

CONCLUSIONS

Compared to polyurethane ureteral stents, silicone ureteral stents are associated with lower body pain intensity assessed by VASP 2 weeks before stent removal and at the time of stent removal.

TRIAL REGISTRATION

Current Controlled Trials NCT04000178. Retrospectively registered on June 26, 2019.

Linguistic and cultural validation of Ureteral Stent Symptom Questionnaire in Hindi

Introduction:

In the year 2003, Joshi et al. developed a validated outcome assessment tool to measure the ureteral stent-related symptoms. The original English language Ureteral Stent Symptom Questionnaire (USSQ) has been validated in various languages worldwide. Our objective was to develop the USSQ in Hindi, a commonlyused language in India, by validating it in patients undergoing ureteroscopic lithotripsy.

Materials and Methods:

A final Hindi version of the USSQ was derived from the original English version to apply to the study population by translation, back translation, and face-to-face interviews. The Hindi and English versions were completed by 70 patients undergoing ureteroscopic lithotripsy with stent in situ, on postoperative days 7 and 8, and 4 weeks after stent removal. Similarly, discriminant validity was checked among 50 healthy individuals. A detailed statistical analysis was used to correlate results (Cronbach's α coefficient, Spearman's correlation, and Mann–Whitney U-test).

Results:

A total of 70 patients were enrolled in the study and 61 completed the final assessment. The median age was 35 years (range: 18–60 years). The USSQ domain scores with the stent in situ were higher than poststent status. The test–retest reliability checked by Cronbach's α coefficient (>0.44) and Spearman's correlation coefficient (>0.44) were acceptable to good. We found high discriminant validity of the questionnaire between patients with stent and the healthy controls (P < 0.05).

Conclusion:

Our results demonstrate satisfactory validity for the Hindi version of the USSQ for the assessment of quality of life in patients with stent. This is ready for application in the clinical studies and the future stent-related research in Hindi language.

Fluoroscopy-free double-J stent placement through ureteroscope working channel postuncomplicated ureteroscopic laser lithotripsy: A novel technique

Objectives:

To report a technique for ureteroscopic laser lithotripsy (URSL) and retrograde placement of a double-J (DJ) stenting through the ureteroscope working channel without the use of a fluoroscope compared to the conventional technique.

Patients and Methods:

Between June 2015 and December 2017, 170 patients selected for URSL for treatment of ureteral stones and DJ insertion was evaluated. Patients are divided into two groups according to the use of fluoroscopy. In Group A (100 patients), fluoroscope is used and group B (70 patients) without fluoroscopy guidance. In group B, URSL is performed first and followed by DJ insertion by the semi-rigid ureteroscope 8.5-11 Fr under vision without fluoroscopy.

Results:

Stone free rate in 96% versus 94.3% for groups A and B respectively. This technique was successful in all the included patients: 166 retrograde DJ stenting post URSL for ureteric calculi and 4 cases for anuria. Group A are exposed to radiation with mean 26.6 seconds in URSL procedure and 4.8 seconds for DJ stenting. Group B was exposed to zero dose. For group A, the stents size was 6 Fr for 70% of patients and 15 % for 4.7 Fr and 15% for 7 Fr stenting. In Group B, stents of 4.7 Fr and length 24-26 cm were used in all patients. Failure of DJ insertion is reported in 9% for group A and 13 (18.5%) patients for group B.

Conclusions:

This study report the feasibility and efficacy of the completely fluoroscopy free URSL and DJ stenting to treat ureteric stones.

Comparison of safety and efficacy of silodosin, solifenacin, tadalafil and their combinations in the treatment of double-J stent- related lower urinary system symptoms: A prospective randomized trial

OBJECTIVE

To evaluate the efficacy and safety of silodosin, solifenacin, tadalafil and their combinations in reducing double J (DJ) stent-related symptoms (SRS).

MATERIAL AND METHODS

A total of 335 patients who underwent DJ stenting and develop SRS at 1^st week were randomized into eight groups. Ureteral stent symptom questionnaire (USSQ) and Quality of life (QOL) scores were noted in each group: Group A-Silodosin (8 mg OD)+ Solifenacin (10 mg OD)+ Tadalafil (5 mg OD), B - Silodosin 8 mg OD, C - Solifenacin 10 mg OD, D- Tadalafil 5 mg OD, E- Silodosin (8 mg OD) + Solifenacin (10 mg OD), F- Silodosin (8 mg 0D)+ Tadalafil (5 mg OD), G- Solifenacin (10 mg OD)+ Tadalafil (5 mg OD) and H-placebo. Analgesic (diclofenac 50 mg) was given as per requirement. All groups received the drugs for 14 days and again USSQ, QOL score with analgesic requirement were noted in each group.

RESULTS

USSQ score was similar in all groups at 1^st week but all groups (Groups A-G) led to significant decrease in USSQ score at 3^rd week as compared to Group H with less requirement of analgesic. However when we compared groups with each other we found that mean USSQ score and analgesic requirement was favoring Group E as compared to other groups. Quality of life score was also best in Group E (mean 1.5) (p<0.05).

CONCLUSION

Combination therapy with silodosin and solifenacin (group E) was effective for relieving SRS with improved quality of life and less requirement of analgesic than any other groups and should be considered in patients who develop SRS.

A ureteral stent crossing the bladder midline leads to worse urinary symptoms

Introduction

To investigate the correlation between the position of a ureteral stent and stent-related symptoms, excluding the influence of ureteroscopic maneuvers.

Material and methods

From January 2016 to December 2016, we analyzed 130 patients who placed a ureteral stent before ureteroscopic lithotripsy (URSL). A total of 108 patients were enrolled, including 77 (71.3%) men and 31 (28.7%) women, and the mean age was 58.9 ±14.3 years. On the day before URSL, plain radiography (kidney, ureter, bladder X-ray [KUB]) was used to confirm the stone location and ureteral stent position. According to KUB, we defined the crossing midline group as when the distal loop of the ureteral stent was crossing the bladder midline, and the not crossing midline group as when the distal loop of the ureteral stent was not crossing the bladder midline. We assessed urinary symptoms of the two groups using the overactive bladder symptom score (OABSS) on the day before URSL.

Results

The crossing midline group had a worse total OABSS (p <0.001) and worse scores for each item of daytime frequency (p = 0.047), nocturia (p <0.001), urgency (p = 0.002), and urgency incontinence (p = 0.045) than did the not crossing group. In multivariate analysis, stent position had the strongest association with the total OABSS (p = 0.002) among the other factors of age, sex, body mass index, stent side, stent diameter, stent length and stent indwelling time.

Conclusions

This study shows that a ureteral stent crossing the bladder midline leads to worse urinary symptoms. Choosing the appropriate stent length for each patient is important for improving stent-related symptoms.

Comparison between double-pigtail ureteral stents and ureteral bypass devices for treatment of ureterolithiasis in cats

OBJECTIVE To compare the complication rates and outcomes in cats with ureteral obstruction treated by placement of double-pigtail ureteral stents or ureteral bypass (UB) devices. DESIGN Retrospective cohort study. ANIMALS Cats with unilateral or bilateral ureterolithiasis that received double-pigtail ureteral stents (30 stents in 27 cats; stent group) or UB devices (30 devices in 23 cats; UB group). PROCEDURES Medical records were reviewed to collect data on signalment, clinical signs, serum biochemical data, surgical procedure, duration of hospitalization, complications, and follow-up (≥ 6 months after placement) information. Outcomes were compared between device types. RESULTS Median durations of surgery and hospitalization were significantly longer in the stent versus UB group. Perioperative mortality rate was 18% (5/27) in the stent group and 13% (3/23) in the UB group. Median survival time was shorter in the stent versus UB group. Stent placement was associated with a greater risk of lower urinary tract-related signs, such as hematuria (52% [14/27]) and pollakiuria or stranguria (48% [13/27]). The risk of device occlusion was also greater in the stent (26% [7/27]) versus UB (4% [1/23]) group. The percentage of cats requiring additional procedures to treat complications was greater in the stent (44%; complications included uroabdomen, stent occlusion, and refractory cystitis) versus UB (9%; complications included UB occlusion and urethral obstruction) group. CONCLUSIONS AND CLINICAL RELEVANCE Although the benefits of stent placement in the treatment of ureteral obstruction in cats have been established, results suggested that cats treated with UB devices had a lower risk of complications and a longer survival time than those treated with double-pigtail ureteral stents.

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.

Intraureteral lidocaine for ureteral stent symptoms post-ureteroscopy: A randomized, phase 2, placebo-controlled trial

INTRODUCTION

Ureteral stent and ureteral manipulation-related pain is a significant complication for patients undergoing ureteroscopy. Herein, we report a phase 2, randomized trial to assess efficacy of direct instillation of intraureteral lidocaine in reducing postoperative pain and ureteral stent symptoms.

METHODS

We performed a randomized, double-blinded trial of patients undergoing elective ureteroscopy for ureteral calculi. Patients were randomized to direct instillation of 2% lidocaine plus bicarbonate, or to normal saline as control. The primary outcome of interest was early postoperative pain scores. Patients completed10-point visual analog pain scale at one-hour, two-hour, four-hour, 24-hours, four- and seven-day time points. Other outcome measurements collected included a medication diary and voiding questionnaire.

RESULTS

A total of 41 patients were randomized in the study. Mean flank pain scores at one hour were 2.2 (±2.9) vs.1.9 (±2.4) in the intervention and placebo group, respectively (p=0.84). There was no significant difference at any time point between the intervention and placebo groups in patient-reported pain scores. Patients reported lower dysuria scores at all time points in the lidocaine group, however, none reached statistical significance. There was no difference in complication rates or adverse effects between groups.

CONCLUSIONS

In this randomized, phase 2 study, direct instillation of lidocaine into the ureter did not appear to significantly improve pain or voiding symptoms following stented ureteroscopy.

Efficacy of Tamsulosin, Oxybutynin, and their combination in the control of double-j stent-related lower urinary tract symptoms

Introduction and objective

Indwelling double J ureteral stents are used routinely in the resolution of ureteral obstruction caused by different etiologies. Evaluation of urinary symptoms related to double-J stent, indicate that these affect 73-90% of patients. We conducted a prospective, randomized study, to evaluate the efficacy of tamsulosin, oxybutinin and combination therapy in improving the urinary symptoms.

Methods

Patients who underwent ureteral stent placement after ureterolithotripsy (total 51), were randomized into three groups: Group I: Tamsulosin 0.4 mg. once per day(17 patients), Group II: Oxybutinin 5 mg. once per day (17 patients), Group III: Tamsulosin+ oxybutynin once per day (17 patients). All the groups received the drugs for three weeks and completed a Spanish validated Ureteral Stent Symptom Questionnaire (USSQ) at day 7 and 21.

Results

Repeated measures ANOVA showed mean urinary symptom index score was 22.3 vs. 15.5 in group three (p<0.001) at day 7 and 21 respectively. The mean work performance index was 6.6 vs 8.1 (p=0.049) favoring tamsulosin group, the mean sexual score was 0.5 vs 1.5 (p=0.03). Among additional problems the mean was 7.2 vs 6.2 (p=0.03). No significant difference was noted among pain and general health index. No side effects were reported.

Conclusions

Combination therapy with tamsulosin and oxybutynin improved irritative symptoms and work performance as well as sexual matters. Combination therapy should be considered for patients who complained of stent related symptoms.

Correlation of Bladder Histopathologic Changes Due to Double-J Stenting to the Period of Stenting: A Preliminary Study

OBJECTIVES

To study the histopathologic changes in the urinary bladder associated with Double-J (DJ) stenting and the correlation between these changes and the period of stenting.

METHODS

In a 2-year period, a retrospective study was carried out on 30 patients indicated for DJ stenting. These patients underwent cold-cup cystoscopic biopsies from the ipsilateral ureteral orifice at the time of removal of DJ stents.

RESULTS

The mean age of the 30 patients included in our study was 43.6 ± 8.6 years (range 26-74 years). The stent size used was 4.7 and 6F. The stent duration was 2 weeks in 2 patients, 4 to 6 weeks in 18 patients, 6 to 12 weeks in 6 patients, and more than 12 weeks in the remaining 4 patients. Stent placement was optimum in all patients. The histopathologic study of 30 biopsies showed mild, acute eosinophilic inflammatory reactions with edema in patients with stenting less than 14 days. Acute lymphocytic eosinophilic cystitis with edema was found with stents of 2 to 6 weeks. Brunn's nests were reported with stents more than 6 weeks. Cystitis cystica was seen in those who had stents more than 12 weeks.

CONCLUSIONS

Our study shows that acute and chronic allergic inflammatory changes can be seen around the bladder coil of the DJ stents. It is of major importance for the urologist to limit the use of DJ stents to highly indicated cases only and for a short interval.

Effects of Tamsulosin and Tolterodine on double J stent-related symptoms: A double-blind, randomized, placebo-controlled trial

Background:

Ureteral double J stent are routinely applied for urologic patients although stent-related symptoms are common. Several attempts have been reported to minimize these symptoms.

Objective:

To compare Tolterodine, Tamsulosin, and placebo effects on double J stent–related symptoms.

Material and method:

In all, 125 patients (82 males and 43 females) with double J stent were randomly divided into three groups (group 1, n: 42, group2, n: 40 and group 3, n: 43). Each patient randomly received one pack of drug in different colors by a nurse unaware of the content to take Tamsulosin 0.4 mg before sleep (MODALUSINE), Tolterodine 2 mg twice a day or placebo once daily (capsules filled with starch): group 1 received placebo, group 2 Tamsulosin and group 3 Tolterodine for 1 month in a double-blind manner. Ureteral stent-related morbidity indices which analyzed include urinary symptom, pain, general health, quality of work and sex scores. All of indices measured by Ureteral Symptom Score Questionnaire for first and fourth weeks after drug consumption and the first week after double J stent removal (labeled as w1, w4, and w5, respectively).

Result:

The mean age was 44.8 years (range: 15–83 years). There was no statistically significant difference in background characteristics between groups (p value > 0.05). The most important and statistically significant results were Tolterodine-reduced urinary symptom score (p value = 0.001) and improved general health score (p value = 0.007) of the fourth week. The pain score in groups of Tamsulosin and Tolterodine significantly reduced between weeks 4 and 1 and 5 and 1 (both with the p value < 0.05), but in other indices, there was no significant difference between them.

Conclusion:

According to our results, we suggest Tolterodine to minimize stent-related urinary symptom and improve general health in patients with double J stent.

Factors Predicting Catheter-Related Bladder Discomfort in Surgical Patients

PURPOSE

The study was conducted to identify the factors predicting catheter-related bladder discomfort (CRBD) in the postanesthesia care unit, to assess the level of CRBD and urinary catheter-related pain for the first 24 hours postoperatively, and to compare UCRP with the postoperative pain in the surgical site.

BACKGROUND

About 20% of hospitalized patients receive an indwelling urinary catheter, and more than half of these patients complain of CRBD or urinary catheter-related pain.

DESIGN

This prospective descriptive study conducted in an 800-bed university hospital involved 160 patients who had undergone elective surgery from February 5, 2012 to June 5, 2012.

METHODS

Demographic data including gender, age, American Society of Anesthesiologists class, weight, and height were collected on the preoperative visit. Factors predicting CRBD were identified by multiple logistic regression analysis. Comparison of the UCRP and postoperative pain was analyzed using the Mann-Whitney U test.

FINDINGS

Multiple logistic regression analysis showed that the factors predicting CRBD ≥2 30 minutes after arrival to the postanesthesia care unit were age <50 years (odds ratio [OR], 4.79; P = .005), male gender (OR, 7.07; P = .015), obstetric and gynecological surgery (OR, 11.07; P = .045), and UCRP (OR, 132.3; P < .015). Postoperative pain (P < .001) was significantly greater than UCRP.

CONCLUSIONS

Age <50 years, male gender, open abdominal surgery, and UCRP ≥4 predict CRBD.

CLINICAL RELEVANCE

Perioperative care providers should screen surgical patients for risk factors of CRBD during the first postoperative 12 hours.

Preoperative Belladonna and Opium Suppository for Ureteral Stent Pain: A Randomized, Double-blinded, Placebo-controlled Study

OBJECTIVE

To investigate whether the use of a belladonna and opium (B&O) rectal suppository administered immediately before ureteroscopy (URS) and stent placement could reduce stent-related discomfort.

METHODS

A randomized, double-blinded, placebo-controlled study was performed from August 2013 to December 2014. Seventy-one subjects were enrolled and randomized to receive a B&O (15 mg/30 mg) or a placebo suppository after induction of general anesthesia immediately before URS and stent placement. Baseline urinary symptoms were assessed using the American Urological Association Symptom Score (AUASS). The Ureteral Stent Symptom Questionnaire and AUASS were completed on postoperative days (POD) 1, 3, and after stent removal. Analgesic use intraoperatively, in the recovery unit, and at home was recorded.

RESULTS

Of the 71 subjects, 65 had treatment for ureteral (41%) and renal (61%) calculi, 4 for renal urothelial carcinoma, and 2 were excluded for no stent placed. By POD3, the B&O group reported a higher mean global quality of life (QOL) score (P = .04), a better mean quality of work score (P = .05), and less pain with urination (P = .03). The B&O group reported an improved AUASS QOL when comparing POD1 with post-stent removal (P = .04). There was no difference in analgesic use among groups (P = .67). There were no episodes of urinary retention. Age was associated with unplanned emergency visits (P <.00) and "high-pain" measure (P = .02) CONCLUSION: B&O suppository administered preoperatively improved QOL measures and reduced urinary-related pain after URS with stent. Younger age was associated with severe stent pain and unplanned hospital visits.

Efficacy of α-blocker in improving ureteral stent-related symptoms: a meta-analysis of both direct and indirect comparison

Objective

To critically evaluate the efficacy of an α-blocker in improving ureteral-stent-related symptoms and preliminarily investigate the difference between different types of α-blockers.

Methods

Relevant randomized controlled trials were identified through searching PubMed, the Cochrane Library, Embase, and other sources. After quality assessment and data abstraction, direct comparison based on the Ureteral Stent-related Symptom Questionnaire (USSQ) between α-blockers and control was performed by RevMan 5.3. Indirect comparison between different types of α-blockers was performed by ITC 1.0. Sensitive and subgroup analyses were used to handle important clinical factors.

Results

Sixteen randomized controlled trials containing 1,489 cases were included. Compared with control, α-blockers significantly reduced the overall urinary symptom, pain index, general health index, and scores related to sexual matters, while no significant difference was found in work performance and additional problem scores. Subgroup analysis showed that the duration of stent insertion, patient’s age, stent size, and the type of α-blocker had the potential to influence the outcomes. Through indirect comparison, we found alfuzosin and terazosin to be better than tamsulosin in pain relief and general health improvement.

Conclusion

α-Blocker was effective in treating ureteral stent-related symptoms, as it improved the major indexes of USSQ post-insertion or post-removal. Alfuzosin and terazosin seemed to be better than tamsulosin, which needs further verification because of the lack of direct comparison currently.

Prevention of iatrogenic ureteral injuries during robotic gynecologic surgery: a review

Iatrogenic ureteral injuries, more than half of which occur during gynecologic surgery, may have devastating consequences for both patients and physicians. Gynecologists have employed various techniques such as cystoscopy, ureteral stents, and lighted ureteral stents to prevent ureteral injuries. The emergence and increasing prevalence of robotic surgery necessitates that we not only reevaluate the utility of these techniques, but also develop new ones specific for the robotic modality. In the robotic setting, the surgeon lacks tactile feedback and must rely primarily on visual cues. The use of intraureteral indocyanine green and subsequent visualization under near-infrared fluorescence appears to be a promising technique to primarily and secondarily prevent ureteral injuries during robotic gynecologic surgery.

Risks associated with drug treatments for kidney stones

INTRODUCTION

Renal stones are one of the most painful medical conditions patients experience. For many they are also a recurrent problem. Fortunately, there are a number of drug therapies available to treat symptoms as well as prevent future stone formation.

AREAS COVERED

Herein, we review the most common drugs used in the treatment of renal stones, explaining the mechanism of action and potential side effects. Search of the Medline databases and relevant textbooks was conducted to obtain the relevant information. Further details were sourced from drug prescribing manuals. Recent studies of drug effectiveness are included as appropriate.

EXPERT OPINION

Recent controversies include medical expulsive therapy trials and complex role of urinary citrate in stone disease. Future directions in research will involve new medical therapies for stone prevention, for example new drugs for hyperoxaluria.

Evaluation of sexual function in patients submitted to ureteroscopic procedures

Objective:

We aimed to evaluate the possible effects of ureteroscopic procedures on the sexual function of both genders.

Materials and Methods:

A total of 102 sexually active cases (60 male, 42 female) undergoing ureteroscopic procedures were included in this study. Sexual function has been evaluated in detail by using International Index of Erectile Function (IIEF) in male and Female Sexual Function Index (FSFI) forms in female cases both before and 1-month after the procedures. Pre-and postoperative data were evaluated in a comparative manner.

Results:

The pre-and postoperative mean IIEF scores were 57.86±2.26 and 54.57±2.48 (p=0.19) in males and the mean FSFI scores were 13.58±1.46 and 14.46±1.52 (p=0.41), respectively in females. Evaluation of these values showed that regarding the effects of this procedure on male cases although the total scores for sexual function were not influenced it was observed a significant reduction in the intercourse satisfaction sub-domain (IIEF-IS) in males (p<0.05). In female cases however, unlike the male cases no statistically significant alterations with respect to these scores were noted (p=0.418).

Conclusion:

Ureteroscopic interventions could have some adverse effects on the sexual function particularly in male cases. However, it is clear that further prospective studies in both genders with large population of cases are certainly needed in order to outline this unresolved but important subject.

Morbidity and impact on quality of life in patients with indwelling ureteral stents: A 10-year clinical experience

Objective:

Prospective analysis of the prevalence of symptoms, tolerability and complications associated with ureteral stents and their impact on quality of life based on the Flanagan Quality of Life Scale and a not-validated questionnaire from our clinic.

Methods:

A total of 2200 adult patient participated to this study in a period of 10 years (2003-2012). Those patients were asked to complete the QOLS and a not-validated questionnaire from our clinic, before ureteral indwelling, 7 day after ureteral indwelling and 14 days after removal of the stent.

Results:

Total 1520 patient aged between 18 and 84 years completed the study. The analysis of data showed that the unpleasant symptoms caused by stent were encountered more frequently at 7 days after stent insertion, in terms of urinary frequency, dysuria, urgency and macroscopic haematuria, this difference being statistically significant (p<0.05). After analysis the responses to QOLS questionnaire, at 7 days after stent placement, mean scores show a clear reduction in the QoL of those patients, in all cases the standard deviation being at a great value, indicating a high variability of responses, but at 14 days after its suppression of stent the average scores are somewhat closer to the baseline.

Conclusions:

Our study brings many elements that shows a statistically significant increase in the incidence of numerous side effects and impaired quality of life. It contributes to existing data from the literature as regards the knowledge of the pathology determined by the presence of foreign body in the urinary tract and in providing patient counseling.