Tag Archive for: ureteroscopy

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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.

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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.

Article of the week: Stent QOL comes with strings attached

Every week the Editor-in-Chief selects the 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. Barnes and colleagues summarising their paper on stent extraction strings.

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

Do ureteric stent extraction strings affect stent-related quality of life or complications after ureteroscopy for urolithiasis: a prospective randomised control trial

Kerri T. Barnes, Megan T. Bing and Chad R. Tracy

Department of Urology, University of Iowa, Iowa City, IA, USA

OBJECTIVE

• To determine whether ureteric stent extraction strings affect stent-related quality of life (QoL) or increase complications after ureteroscopy (URS) for stone disease.

PATIENTS AND METHODS

• In all, 68 patients undergoing URS (October 2011 to May 2013) for stone disease were randomised to receive a ureteric stent with or without an extraction string.

• Patients completed the Ureteric Stent Symptom Questionnaire (USSQ) on postoperative days 1 and 6, and 6 weeks after stent removal.

• Pain was assessed at stent removal.

• Adverse events, including early stent removal, stent migration, retained stent, urinary tract infection (UTI), emergency room (ER) visits and postoperative phone calls were monitored.

RESULTS

• There was no difference in stent-related QoL as measured by the USSQ between those with and without a stent extraction string, pain at stent removal between those who pulled their stent independently vs those who underwent cystoscopy for stent removal, or in the rate of UTIs, ER visits or phone calls between groups.

• Five patients (four female, one male) removed their stent early by inadvertently pulling the string; none required replacement.

• Patients without a string had a significantly longer period with the postoperative ureteric stent (10.6 vs 6.3 days, P < 0.001).

• One patient without a stent string retained her ureteric stent for 6 months, which was removed by cystoscopy without incident.

CONCLUSION

• Ureteric stent extraction strings may offer several advantages without increasing stent-related urinary symptoms, complications, or postoperative morbidity.

 

Editorial: Tether your stents!

Ureteric stents are commonly placed after ureteroscopy to protect the ureter and to facilitate subsequent stone fragment passage. They are known to be a cause of significant morbidity as judged by standardised validated questionnaires [1]. Whether placement of a stent is required at all is debatable, with randomised studies suggesting they are unnecessary after routine ureteroscopy [2]. The European Association of Urology (EAU) guidelines recommend stent insertion only ‘in patients who are at increased risk of complications’ and ‘in all doubtful cases to avoid stressful emergency situations’. Despite this, available evidence would suggest that we continue to commonly place stents [3].

If a stent is placed, the principal means of reducing morbidity is by minimising the stent dwell-time. One of the ways of doing this is to leave a stent with extraction strings/tether. This obviates the delay associated with scheduling cystoscopic extraction, the morbidity of cystoscopy and potentially reduces additional hospital visits if the patient is able to remove the stent at home.

Tethered stents are not widely used due to preconceptions about their tolerability, increased risk of complications (e.g. infection, migration) and accidental removal. Perhaps for this reason there have been few studies into the effectiveness of tethered stents in minimising stent-related morbidity to date, with only a handful in the past 30 years that have specifically addressed this issue.

In this issue of BJUI, Barnes et al. [4] report on the results of a prospective randomised trial analysing stented patients with or without the extraction strings attached, for both quality of life and postoperative complications after ureteroscopy for stone disease. This follows on from a retrospective series previously reported by the same group [5]. It is pleasing to see the authors, who originally concluded that randomised trials are needed in this area, actually get on and do the trial!

Two aspects of the trial methodology are worth highlighting: (i) the surgeons were not told that the patient was part of the study until they had made the decision to stent to minimise selection bias; (ii) patients completed the Ureteric Stent Symptom Questionnaire (USSQ) 6 weeks after stent removal as a control for their USSQ scores at postoperative days 1 and 6.

The headline results showed that there was no difference in quality of life and stent-related symptoms between patients with and without the extraction strings. There was also no difference in postoperative complications, emergency room visits or phone calls between the groups. What is surprising is that they found no difference in pain scores between self-removal and cystoscopic removal. This has not been our experience with tethered stents and may be due to the few men in the study. However, stent dwell-time was significantly less for patients with tethers compared with those without (10.6 vs 6.3 days, P < 0.001).

For urologists planning on using this technique it should be noted that the authors removed the original knot and shortened the string considerably to reduce the risk of accidental removal. For this reason the string was not attached to the patient’s skin.

This trial addresses many of the reservations urologists have about the use of tethered stents. Furthermore, reducing accidental removal and encouraging self-removal should be possible with improved patient education and selection. This was addressed by a study in New Zealand [6], which showed the feasibility of self-removal of stents.

The authors also acknowledged weaknesses in their study, which included failure to reach target enrolment, a 68% completion of trial surveys and a larger proportion of women in the study group due to male anxiety about self-removal of stents. In all, 15% of stents were inadvertently removed early and thus this technique should be used with caution in patients where early removal may be detrimental, e.g. in single kidneys. This does of course prompt the question: ‘If you are going to place a stent, how long does the stent need to stay for?’ and hopefully future trials may address this unanswered question.

Archana Fernando and Matthew Bultitude
Urology Department, Guy’s and St Thomas’ NHS Trust, London, UK

References

  1. Joshi HB, Newns N, Stainthorpe A et al. Ureteral stent symptom questionnaire: development and validation of a multidimensional quality of life measure. J Urol 2003; 169: 1060–1064
  2. Song T, Liao B, Zheng S, Wei Q. Meta-analysis of postoperatively stenting or not in patients underwent ureteroscopic lithotripsy. Urol Res 2012; 40: 67–77
  3. Mangera A, Parys B. BAUS Section of Endourology national ureteroscopy audit: setting the standards for revalidation. J Clin Urol 2012; 6: 45–49
  4. Barnes KT, Bing MT, Tracy CR. Do ureteric stent extraction strings affect stent-related quality of life or complications after ureteroscopy for urolithiasis: a prospective randomised control trial. BJU Int 2014; 113: 605–609
  5. Bockholt N, Wild T, Gupta A et al. Ureteric stent placement with extraction strings: no strings attached? BJU Int 2012; 110: 1069–1073
  6. York N, English S. Self-removal of ureteric JJ stents: analysis of patient experience. Presented at AUA 2013, May 7; San Diego, CA, USA. Abstract no. 1979. J Urol 2013; 189 (Suppl. 4): e812

 

Video: Stent extraction strings after ureteroscopy

Do ureteric stent extraction strings affect stent-related quality of life or complications after ureteroscopy for urolithiasis: a prospective randomised control trial

Kerri T. Barnes, Megan T. Bing and Chad R. Tracy

Department of Urology, University of Iowa, Iowa City, IA, USA

OBJECTIVE

• To determine whether ureteric stent extraction strings affect stent-related quality of life (QoL) or increase complications after ureteroscopy (URS) for stone disease.

PATIENTS AND METHODS

• In all, 68 patients undergoing URS (October 2011 to May 2013) for stone disease were randomised to receive a ureteric stent with or without an extraction string.

• Patients completed the Ureteric Stent Symptom Questionnaire (USSQ) on postoperative days 1 and 6, and 6 weeks after stent removal.

• Pain was assessed at stent removal.

• Adverse events, including early stent removal, stent migration, retained stent, urinary tract infection (UTI), emergency room (ER) visits and postoperative phone calls were monitored.

RESULTS

• There was no difference in stent-related QoL as measured by the USSQ between those with and without a stent extraction string, pain at stent removal between those who pulled their stent independently vs those who underwent cystoscopy for stent removal, or in the rate of UTIs, ER visits or phone calls between groups.

• Five patients (four female, one male) removed their stent early by inadvertently pulling the string; none required replacement.

• Patients without a string had a significantly longer period with the postoperative ureteric stent (10.6 vs 6.3 days, P < 0.001).

• One patient without a stent string retained her ureteric stent for 6 months, which was removed by cystoscopy without incident.

CONCLUSION

• Ureteric stent extraction strings may offer several advantages without increasing stent-related urinary symptoms, complications, or postoperative morbidity.

 

Article of the Week: Pain relief after ureteric stent removal: think NSAIDs

Every week the Editor-in-Chief selects the 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 blog 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. QC Kinetix’s charleston pain management relief center has decades of collective experience treating patients with all kinds of conditions. We make a concerted effort to treat each patient with professionalism and dignity as they work their way back to a pain-free life. We do everything in our power to earn the trust of each person that walks through our doors for treatment. Regenerative medicine is the future of medical care. QC Kinetix is offering non-invasive treatments that allow people to avoid going under the knife, while accelerating their recovery times and minimizing side effects. Discover why people across the state of South Carolina trust QC Kinetix when it comes to pain relief. At our clinic for pain management in Mt. Pleasant, SC, our specialists take the time to understand each patient’s needs and symptoms. We go out of our way to understand each person’s unique situation and how we can best treat their condition. Then, we very carefully formulate a plan to get them back to an active and healthy lifestyle. One of our most common treatments is laser therapy. We use non-invasive laser energy to target the affected area and reduce inflammation and pain. This triggers a photochemical response that initiates tissue repair and quickly improves a patient’s range of motion and functionality. Laser therapy is often the first step in our pain management plan before moving onto stem cell-based treatments.

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 of  Michael Conlin discussing his paper.

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

A single dose of a non-steroidal anti-inflammatory drug (NSAID) prevents severe pain after ureteric stent removal: a prospective, randomised, double-blind, placebo-controlled trial

Nicholas N. Tadros, Lisa Bland, Edith Legg, Ali Olyaei and Michael J. Conlin

OBJECTIVES

• To determine the incidence of severe pain after ureteric stent removal.

• To evaluate the efficacy of a single dose of a non-steroidal anti-inflammatory drug (NSAID) in preventing this complication.

 PATIENTS AND METHODS

• A prospective, randomised, double-blind, placebo-controlled trial was performed at our institution.

• Adults with an indwelling ureteric stent after ureteroscopy were randomised to receive either a single dose of placebo or an NSAID (rofecoxib 50 mg) before ureteric stent removal.

• Pain was measured using a visual analogue scale (VAS) just before and 24 h after stent removal.

• Pain medication use after ureteric stent removal was measured using morphine equivalents.

RESULTS

• In all, 22 patients were enrolled and randomised into the study before ending the study after interim analysis showed significant decrease in pain level in the NSAID group.

• The most common indication for ureteroscopy was urolithiasis (14 patients).

• The proportion of patients with severe pain (VAS score of [1]7) during the 24 h after ureteric stent removal was six of 11 (55%) in the placebo group and it was zero of 10 in the NSAID group (P < 0.01).

• There were no complications related to the use of rofecoxib.

 CONCLUSIONS

• We found a 55% incidence of severe pain after ureteric stent removal.

• A single dose of a NSAID before stent removal prevents severe pain after ureteric stent removal.

Read Previous Articles of the Week

Editorial: Stent removal need not be painful

Matthew Bultitude

Matthew Bultitude
Urology Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Ureteric stents are undoubtedly a significant cause of morbidity while in situ [1].Whilst there are different options for removal, they are usually removed under local anaesthetic with the aid of a flexible cystoscope. This is an uncomfortable procedure and a proportion of patients seem to get fairly severe pain afterwards, which may be attributable to ureteric spasm. The pain after stent removal has not been well reported in the literature. In this issue of the BJUI we present a randomised controlled trial of a non-steroidal anti-inflammatory (NSAID) to dramatically reduce pain after stent removal.

This beautifully simple study by Tadros et al. [2] had simple aims: to determine the incidence of pain after stent removal and whether this could be reduced using a single oral dose of a NSAID given before the procedure. In a prospective randomised double-blind placebo controlled trial, the authors have shown a clear advantage to the use of active medication over placebo, such that the trial was stopped after an interim analysis. Using a visual analogue scale (VAS) the mean pain after stent removal was 2.7 in the NSAID group compared with 5.5 with placebo.More impressively the proportion of patients with severe pain (as defined as aVAS >=7) within 24 hours of stent removal was 0% vs. 55%. A corresponding reduction in narcotic use was seen (1.67 mg vs. 4.77 mg).

With increasing healthcare pressures on emergency departments and beds, and in the UK with financial penalties for re-admissions, this simple intervention has the potential to improve our own patients pain ratings and satisfaction and also reduce emergency consultations and even re-admissions. It should be noted that in this trial, there were two visits to the emergency department and one re-admission, all in the placebo group.

NSAIDs are thought to work through a number of mechanisms such as direct effect on pain pathways, reduced ureteric contractility and renal blood flow. This is thought to be a class effect for all NSAIDs. The drug used in this trial (rofecoxib) has subsequently been withdrawn from the market, although one would expect similar outcomes with other NSAID medications.

References
1 Joshi HB, Stainthorpe A, MacDonagh RP et al. Indwelling ureteral stents: evaluation of symptoms, quality of life and utility. J Urol 2003; 169: 1065–9
2 Tadros NN, Bland L, Legg E et al. A single dose of a non-steroidal anti-inflammatory drug (NSAID) prevents severe pain after ureteric stent removal: a prospective, randomised, double-blind, placebo-controlled trial. BJU Int 2013; 111: 116–20

Michael Conlin’s commentary on NSAIDs

Pain relief after ureteric stent removal: think NSAIDs

Nicholas N. Tadros, Lisa Bland, Edith Legg, Ali Olyaei and Michael J. Conlin*
Oregon Health & Science University and *Portland Veterans Administration Medical Center, Portland, OR, USA

OBJECTIVES

• To determine the incidence of severe pain after ureteric stent removal.

• To evaluate the efficacy of a single dose of a non-steroidal anti-inflammatory drug (NSAID) in preventing this complication.

PATIENTS AND METHODS

• A prospective, randomised, double-blind, placebo-controlled trial was performed at our institution.

• Adults with an indwelling ureteric stent after ureteroscopy were randomised to receive either a single dose of placebo or an NSAID (rofecoxib 50 mg) before ureteric stent removal.

• Pain was measured using a visual analogue scale (VAS) just before and 24 h after stent removal

• Pain medication use after ureteric stent removal was measured using morphine equivalents.

RESULTS

• In all, 22 patients were enrolled and randomised into the study before ending the study after interim analysis showed significant decrease in pain level in the NSAID group.

• The most common indication for ureteroscopy was urolithiasis (14 patients).

• The proportion of patients with severe pain (VAS score of ≥7) during the 24 h after ureteric stent removal was six of 11 (55%) in the placebo group and it was zero of 10 in the NSAID group (P < 0.01).

• There were no complications related to the use of rofecoxib.

CONCLUSIONS

• We found a 55% incidence of severe pain after ureteric stent removal.

• A single dose of a NSAID before stent removal prevents severe pain after ureteric stent removal.

Tadros NN, Bland L, Legg E, et al. A single dose of a non-steroidal anti-inflammatory drug (NSAID) prevents severe pain after ureteric stent removal: a prospective, randomised, double-blind, placebo-controlled trial. BJU Int 2013, 111: 101–105.

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