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

The optimal stent pusher position to achieve successful ureteral stent insertion under fluoroscopic guidance

Objective

To examine factors to predict the optimal stent pusher position when inserting ureteral stents under fluoroscopy.

Methods

We retrospectively reviewed 327 patients who underwent ureteral stent insertion. We considered the pubic bone as a useful anatomical landmark to insert ureteral stents under fluoroscopic guidance. Thus, we categorized patients into three groups (proximal, middle, and distal groups) according to the position of the radiopaque tip of the push catheter when inserting the ureteral stent. Success was defined as a completely curled ureteral stent tail. We compared stent insertion success rates among the three groups. A multivariate analysis was performed to identify the factors affecting stent insertion success.

Results

In men, 36 (63.2%) cases were deemed successful in the proximal group compared with 40 (80.0%) cases in the middle group and 12 (20.7%) cases in the distal group (p<0.001). In women, 26 (45.6%) cases were deemed successful in the proximal group compared with 54 (98.2%) cases in the middle group and 38 (76.0%) cases in the distal group (p<0.001). With the multivariate analysis, the stent pusher position was the most significant factor influencing successful stent insertion (men: odds ratio 6.00, 95% confidence interval 2.66-13.51, p<0.001; women: odds ratio 37.80, 95% confidence interval 4.94-289.22, p<0.001).

Conclusion

The position of the stent pusher affects stent insertion success. The middle of the pubic symphysis is the optimal position for the radiopaque tip of the pusher when inserting ureteral stents under fluoroscopic guidance.

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.

Prospective randomized controlled trial comparing a ureteral stent crossing versus not crossing the bladder midline

PURPOSE

To evaluate the correlation between the position of a ureteral stent and stent-related symptoms in a single-center randomized study.

METHODS

A total of 113 patients who required ureteral stent placement after lithotripsy were randomized at a 1:1 ratio into groups with stents crossing and not crossing the bladder midline. The ureteral stent remained in place until postoperative day 14, when we obtained each patient's International Prostate Symptom Score (IPSS), overactive bladder symptom score (OABSS), and visual analog scale (VAS) pain score.

RESULTS

Comparing changes from baseline IPSS and OABSS scores between the two groups, the midline crossing group had a worse OABSS total score than the not crossing group (3.0 ± 2.8 vs. 2.0 ± 3.3; p = 0.032). There was no significant difference between the crossing and not crossing groups in IPSS total score (6.8 ± 7.6 vs. 5.1 ± 8.5; p = 0.14). The OABSS urgency mean score was significantly lower in the not crossing than in the crossing group (1.1 ± 1.8 vs. 1.6 ± 1.8; p = 0.042). However, there was no significant difference between groups for remaining items of the IPSS and OABSS and the mean VAS total pain score (1.9 ± 2.7 vs. 1.2 ± 1.9; p = 0.14).

CONCLUSION

A ureteral stent that crossed the bladder midline led to worse urinary symptoms. Choosing the appropriate stent length for each patient is important to minimize stent-related symptoms.

TRIAL REGISTRATION DATE

1 October 2018; number: UMIN000034067.

Stent diameter and stent-related symptoms, does size matter? A systematic review and meta-analysis

The ureteral insertion of a silicone tube was first performed in 1967. A validated ureteral stent symptom questionnaire (USSQ) is used for an objective assessment of patient-reported stent-related symptoms. As the impact of stent diameter on the incidence of stent-related symptoms is unclear, we aimed to perform a systematic review and meta-analysis comparing USSQ reported outcomes when using a 6 Fr diameter ureteric stent, versus smaller diameter stents (4.7-5 Fr) when inserted for ureteric stones. All randomized control trials and comparative studies of 6 Fr versus 4.7-5 Fr ureteric stents were reviewed. The USSQ outcomes were considered as the primary outcome measures while stent migration was considered as a secondary outcome measure. A total of 61 articles were identified of which four studies met the eligibility criteria. There was a statistically significant association between the use of wider (6 Fr) diameter stents and the incidence of urinary symptoms as measured by the urinary index score. Larger stent diameters were associated with a statistically significant increase in the pain index score. There was no statistically significant difference in the scores between the compared stent diameters with regard to work performance score, general health index score, additional problems index score, and stent migration. There were insufficient reported outcomes to perform a meta-analysis of sexual matters index score. Our meta-analysis shows that using smaller diameter ureteric stents is associated with reduced urinary symptoms and patient-reported pain. Other USSQ parameter outcomes are statistically similar in the 6 Fr ureteric stent cohort versus the 4.7-5 Fr ureteric stent cohort. Our meta-analysis was limited due to the limited number of studies and gross heterogeneity of reporting parameters in various studies. We hope a large-scale homogeneous randomized control trial will further shed more insight into the stent symptoms response to stent diameter.