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Article of the Week: Preoperative JJ stent placement to treat ureteric and renal stones

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Marianne Schmid and Dr. Atiqullah Aziz, discussing their Editorial.

If you only have time to read one article this week, it should be this one.

Preoperative JJ stent placement in ureteric and renal stone treatment: results from the Clinical Research Office of Endourological Society (CROES) ureteroscopy (URS) Global Study

Dean Assimos, Alfonso Crisci*, Daniel Culkin, Wei Xue, Anita Roelofs§, Mordechai Duvdevani, Mahesh Desai** and Jean de la Rosette†† on behalf of the CROES URS Global Study Group

 

Department of Urology, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA, *Department of Urology, Careggi Hospital, Florence, Italy, Department of Urology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA, Department of Urology, Renji Hospital, Shanghai, China, §Department of Urology, Rijnstate Hospital, Arnhem, The Netherlands, ††Department of Urology, AMC University Medical Centre, Amsterdam, The Netherlands, Department of Urology, Hadassah Ein-Kerem University Hospital, Jerusalem, Israel, and **Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India

 

Objective

To compare outcomes of ureteric and renal stone treatment with ureteroscopy (URS) in patients with or without the placement of a preoperative JJ stent.

Patients and Methods

The Clinical Research Office of the Endourological Society (CROES) URS Global Study collected prospective data for 1 year on consecutive patients with ureteric or renal stones treated with URS at 114 centres around the world. Patients that had had preoperative JJ stent placement were compared with those that did not. Inverse-probability-weighted regression adjustment (IPWRA) was used to examine the effect of preoperative JJ stent placement on the stone-free rate (SFR), length of hospital stay (LOHS), operative duration, and complications (rate and severity).

Results

Of 8 189 patients with ureteric stones, there were 978 (11.9%) and 7 133 patients with and without a preoperative JJ stent, respectively. Of the 1 622 patients with renal stones, 590 (36.4%) had preoperative stenting and 1 002 did not. For renal stone treatment, preoperative stent placement increased the SFR and operative time, and there was a borderline significant decrease in intraoperative complications. For ureteric stone treatment, preoperative stent placement was associated with longer operative duration and decreased LOHS, but there was no difference in the SFR and complications. One major limitation of the study was that the reason for JJ stent placement was not identified preoperatively.

AprAOTW5

Conclusions

The placement of a preoperative JJ stent increases SFRs and decreases complications in patients with renal stones but not in those with ureteric stones.

Editorial: Some like it safe

Since the implementation of ureteroscopy (URS) about 100 years ago, technological as well as peri-operative management improvements have made URS the treatment of choice for ureteric and renal stones. Depending on stone location and size, stone-free rates of up to 100% have been reported in combination with low peri-operative complications and short hospital stay. Endoscopic therapy of stone disease, e.g. (primary) URS, reflects the zeitgeist: minimally invasive, fast, efficient and economic. There is, however, still a lack of consensus on the question of preoperative stenting in stone management strategies. The underlying aim of preoperative stenting is to cause passive dilation of the ureter, allowing easier access to the upper urinary tract during a secondary URS.

In the current issue of the BJUI, Assimos et al. [1] report higher stone-free rates, as well as fewer complications, with the use of a JJ stent before URS in patients with renal stones, and their article, therefore, supports the previously reported findings of retrospective series with observational, multicentre evidence [2]. Their findings do not, however, corroborate improved outcomes for prestented patients with ureteric stones [1]. Notably, more stents overall were placed in the presence of renal stones compared with ureteric stones (36.4 vs 11.9%). Primary URS may not always be feasible because of anatomical abnormalities, a narrow ureteric lumen, complex ureteric path or previous instrumentation [3]. In such cases, further manipulation risking trauma and potentially long-term stricture formation should be avoided and ureteric stent placement is necessary before further therapy. Indeed, it is possible that renal stone treatment may be associated with increased ureteric manipulation; therefore, passive ureteric dilation might be helpful and facilitate endocopic access to the renal pelvis. A direct elective prestenting in these patients followed by a secondary URS, therefore, warrants discussion. Although prestenting is an additional procedure, it has the potential to lower healthcare costs by decreasing complications rates, operating time and re-operation rates, especially for large proximal stones [4].

Routine preoperative stenting is not necessarily recommended by current guidelines [5]; however, the management of pre-URS stent placement is left to institutional and international practice patterns. Indeed, as shown in Figs 1 and 2 of the present paper [1], the incidence of preoperative JJ stenting varied tremendously by country. Whereas the large majority of patients with ureteric (88.1%) as well as renal (63.6%) stones were treated without a stent, in Germany, for example, >50% of patients were stented before URS. Also in China, Chile, Egypt and Israel, a higher percentage of patients with ureteric stones primarily received a JJ stent.

The use of stents is known to cause discomfort, pain and urinary symptoms, and therefore can represent significant health problems for the patient. These negatively affect daily activities, work capacity and quality of life [6]. Other disadvantages of a stenting may be higher costs associated with the need for interval procedure(s) and additional hospital stay(s). In addition, as recently reported, preoperative ureteric stent placement was not an independent predictor of stone-free status after flexible URS for renal stone removal [7].

Although there is no consensus or definite recommendation for pre-URS stenting, it should be considered and discussed with the patient when obtaining preoperative consent, especially for purely elective, non-urgent cases and in the presence of renal stones.

Long-term outcomes will show whether or not pre-URS stenting makes a difference with regard to the formation of ureteric strictures. Finally, surgical strategies need to weigh carefully the benefits to the patients and improved outcomes against cost-effectiveness.

Atiqullah Aziz, and Marianne Schmid
Department of Urology, University Medical Centre Hamburg- Eppendorf, Hamburg, Germany

 

References

 

 

 

3 Cetti RJ, Biers S, Keoghane SR. The difcult ureter: what is the incidence of pre-stenting? Ann R Coll Surg Engl 2011; 93: 313

 

4 Chu L, Farris CA, Corcoran AT, Averch TD. Preoperative stent placement decreases cost of ureteroscopy. Urology 2011; 78: 30913 

 

5 Turk C, Petřík A, Sarica K et al. EAU guidelines on interventional treatment for urolithiasis. Eur Urol 2015; doi: 10.1016/j.eururo.2015. 07.041. [Epub ahead of print]

 

6 Joshi HB, Newns N, Stainthorpe A, MacDonagh RP, Keeley FX JrTimoney AG. Ureteral stent symptom questionnaire: development and validation of a multidimensional quality of life measure. J Urol 2003; 169: 10604

 

 

Video: Some like it safe

Preoperative JJ stent placement in ureteric and renal stone treatment: results from the Clinical Research Office of Endourological Society (CROES) ureteroscopy (URS) Global Study

Dean Assimos, Alfonso Crisci*, Daniel Culkin, Wei Xue, Anita Roelofs§, Mordechai Duvdevani, Mahesh Desai** and Jean de la Rosette†† on behalf of the CROES URS Global Study Group

 

Department of Urology, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA, *Department of Urology, Careggi Hospital, Florence, Italy, Department of Urology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA, Department of Urology, Renji Hospital, Shanghai, China, §Department of Urology, Rijnstate Hospital, Arnhem, The Netherlands, ††Department of Urology, AMC University Medical Centre, Amsterdam, The Netherlands, Department of Urology, Hadassah Ein-Kerem University Hospital, Jerusalem, Israel, and **Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India

 

Objective

To compare outcomes of ureteric and renal stone treatment with ureteroscopy (URS) in patients with or without the placement of a preoperative JJ stent.

Patients and Methods

The Clinical Research Office of the Endourological Society (CROES) URS Global Study collected prospective data for 1 year on consecutive patients with ureteric or renal stones treated with URS at 114 centres around the world. Patients that had had preoperative JJ stent placement were compared with those that did not. Inverse-probability-weighted regression adjustment (IPWRA) was used to examine the effect of preoperative JJ stent placement on the stone-free rate (SFR), length of hospital stay (LOHS), operative duration, and complications (rate and severity).

Results

Of 8 189 patients with ureteric stones, there were 978 (11.9%) and 7 133 patients with and without a preoperative JJ stent, respectively. Of the 1 622 patients with renal stones, 590 (36.4%) had preoperative stenting and 1 002 did not. For renal stone treatment, preoperative stent placement increased the SFR and operative time, and there was a borderline significant decrease in intraoperative complications. For ureteric stone treatment, preoperative stent placement was associated with longer operative duration and decreased LOHS, but there was no difference in the SFR and complications. One major limitation of the study was that the reason for JJ stent placement was not identified preoperatively.

AprAOTW5

Conclusions

The placement of a preoperative JJ stent increases SFRs and decreases complications in patients with renal stones but not in those with ureteric stones.

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