Indian Journal of Urology
EVIDENCE BASED UROLOGY
Year
: 2005  |  Volume : 21  |  Issue : 2  |  Page : 116--117

Ureteroscopic lithotripsy - skip the stent and spare the patient


S Kumar 
 Department of Urology, Christian Medical College, Vellore, Tamil Nadu, India

Correspondence Address:
S Kumar
Department of Urology Unit 2, Christian Medical College and Hospital, Vellore - 632 004,Tamil Nadu
India




How to cite this article:
Kumar S. Ureteroscopic lithotripsy - skip the stent and spare the patient.Indian J Urol 2005;21:116-117


How to cite this URL:
Kumar S. Ureteroscopic lithotripsy - skip the stent and spare the patient. Indian J Urol [serial online] 2005 [cited 2020 Oct 20 ];21:116-117
Available from: https://www.indianjurol.com/text.asp?2005/21/2/116/19634


Full Text

Ureteroscopy has been recognized as a major method for treating ureteric calculi. Although invasive, the development of smaller and more flexible ureteroscopes, and a new generation of various intracorporial lithotripters, has made this procedure safer and more effective. Recently ureteroscopy has been used to treat stones in the lower urinary tract as well as those in the upper tract. Stenting has been primarily used to treat urinary obstruction and the frequency of this use is increasing with the increase in ureteroscopic management. In cases of acute obstruction, a stent is used temporarily to stabilize the patient until definitive therapy. The stent is generally placed if there is accompanying ureteric injury or in those with a residual stone after ureteroscopic lithotripsy. Placing a ureteric stent after ureteroscopy with stone extraction is done by some urologists routinely to prevent possible stenosis or to decrease secondary pain caused by mucosal oedema. However, routinely placing a stent to prevent late complications or to relieve flank pain from a ureteric stricture or mucosal oedema after surgery is questionable. No study has examined whether stenting can actually prevent a ureteric stricture. Indeed, stents may cause complications, e.g. haematuria, urination, urgency, flank pain, lower abdominal pain, bacteriuria, infection, or it may migrate; these symptoms can last for 3 days after removing the stent. Moreover, if a stent is placed for a long time it can cause stone formation or denudation of the stent.[1],[3] The severity of these complications is related to the mean diameter of the stent, patient characteristics and the stent material.[1],[4],[5] The other problems associated with stents are that it extends the operative duration and causes inconvenience to patients in cases of ureteroscopic lithotripsy under intravenous anaesthesia [6],[7],[8] and increases the cost.[9]

The practice of routine ureteric stenting after uncomplicated ureteroscopy has been questioned. There are ten randomized controlled trials, two of which were multi institutional, to address the issue of placing an indwelling ureteral stent following 'uncomplicated' ureteroscopic stone removal. Placement of an indwelling ureteral stent after 'uncomplicated' ureteroscopic stone manipulation is a costly procedure of no value to the patient. Stent placement in these patients results in more statistically significant severe and prolonged haematuria. In addition, frequency, dysuria and nocturia all tended to be more common among the patients with a stent. The key question is the definition of the word 'uncomplicated,' as the indication not to place a stent. In two trials only frank perforation of the ureter constituted a cause for exclusion from the study,[8],[10] while in others stone impaction or the perception of mucosal injury prompted stent placement and elimination from randomization. In some series balloon dilation of the ureter was sufficient cause to place a stent.[11] However, despite the differences in patient selection among trials, patients left unstented had few complications, regardless of the appearance of the ureteric mucosa after the procedure, provided there was no frank perforation.

Despite these encouraging results suggesting that patients can be spared the discomfort and morbidity of a ureteric stent after uncomplicated ureteroscopy, a word of caution is advised. The decision to place a ureteric stent after a difficult ureteroscopy, particularly if the mucosa is traumatized, will never be questioned, and the action can be simply undone by removing the stent. However, the decision to leave a questionable ureter unstented may lead to serious morbidity. As such, to err on the side of judicious stenting in such cases should be the rule.

The problem is defining what constitutes 'uncomplicated ureteroscopy' and who can be safely left unstented? Unfortunately, the inclusion criteria for patient enrolment in these studies were not uniform. Likewise, fragment retrieval was excluded in some but allowed in others. Most trials involved primarily distal ureteric stones, although some investigators reported similar results irrespective of stone location. Despite these shortcomings all series except one[12] came to the same conclusion of not placing a stent. Perhaps it is time for us all to pay attention to what the science is clearly telling us-skip the stent and spare the patient!

References

1Pryor JL, Langley MJ, Jenkins AD. Comparison of symptom characteristics of indwelling ureteral catheters. J Urol 1991;145: 719-22.
2Bregg K, Riehle RA Jr. Morbidity associated with indwelling internal ureteral stents after shock wave lithotripsy. J Urol 1989; 141:510-2.
3Pollard SG, Macfarlane R. Symptoms arising from double-J ureteral stents. J Urol 1988;139:7-8.
4Lennon GA, Thornhill JA, Sweeney PA, Grainger R, TE, Butler MR. 'Firm' versus 'soft' double pigtail ureteric stents: a randomized blind comparative trial. Eur Urol 1995;28:1-5.
5Irani J, Siquier J, Pires C, Lefebvre O, Dore B, J. Symptom characteristics and development of tolerance with in patients with indwelling double-pigtail ureteric stents. BJU Int 1999;84: 276-9.
6Chen YT, Chen J, Wong WY, Yang SS, Hsieh CH, Wang CC. Is ureteral stenting necessary after uncomplicated ureteroscopic lithotripsy? A prospective, randomized controlled trial. J Urol 2002;167:1977-80
7Netto NR Jr, Ikonomidis J, Zillo C. Routine ureteral stenting after ureteroscopy for ureteral lithiasis: is it really necessary? J Urol 2001;166:1252-4.
8Jeong H, Kwak C, Lee SE.Ureteric stenting after ureteroscopy for ureteric stones: a prospective randomized study assessing symptoms and complications. BJU Int 2004;93:1032-4.
9Srivastava A, Gupta R, Kumar A, Kapoor R, Mandhani A. Routine stenting after ureteroscopy for distal ureteral calculi is unnecessary: results of a randomized controlled trial. J Endourol 2003;17:871-4.
10Cheung MC, Lee F, Leung YL, Wong BB, Tam PC. A prospective randomized controlled trial on ureteral stenting after ureteroscopic holmium laser lithotripsy. J Urol 2003;169:1257-60.
11Byrne RR, Auge BK, Kourambas J, Munver R, Delvecchio F, Preminger GM. Routine ureteral stenting is not necessary after ureteroscopy and ureteropyeloscopy: a randomized trial. J Endourol 2002;16:9-13.
12Damiano R, Autorino R, Esposito C, Cantiello F, Sacco R, de Sio M, D'ArmientoM. Stent positioning after ureteroscopy for urinary calculi: the question is still open. Eur Urol 2004;46:381-7.