Ureteroscopy for Urinary Calculi with or Without Ureteral Stents

Ureteroscopy for Urinary Calculi with or Without Ureteral Stents

Ureteroscopy for Urinary Calculi with or Without Ureteral Stents

REVIEW QUESTION

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Is routine ureteral stent placement or no stent placement preferable following ureteroscopy for renal or ureteral calculi?

TYPE OF REVIEW

A systematic review of 23 studies, including 2,656 participants.

RELEVANCE FOR NURSING

The presence of urinary system calculi, both ureteral and intrarenal, is a common urological condition. These calculi can cause flank pain and nausea and can obstruct urinary flow as they migrate from the renal pelvis to the bladder. Calculi measuring more than 1 cm or requiring more than four to six weeks to pass often necessitate medical intervention.

Ureteroscopy is one of the most common procedures for the treatment of urinary calculi. The flexibility of the scope allows access to the entire collecting system and provides a means for either retrieval or degradation of the stone. Although the 2016 American Urological Association–Endourological Society guidelines do not recommend routine ureteral stenting following ureteroscopy, 60% to 80% of patients still receive stents. While they are thought to prevent postoperative obstruction due to stone fragments or ureteral edema, stents are also believed to cause dysuria, flank pain, and urinary frequency.

CHARACTERISTICS OF THE EVIDENCE

This review evaluated 23 randomized controlled trials involving 2,656 adult patients who had undergone ureteroscopy for renal or ureteral calculi and were then randomized to either stent or no stent placement.

The primary outcomes of interest were unplanned return visits to urgent or emergent care, postoperative pain, and required secondary interventions (such as repeated ureteroscopy or stent placement or exchange). Secondary outcomes of interest included postoperative ureteral stricture, urinary tract infection, and need for hospital admission. Data on ureteral stricture were included if the stricture occurred within the first 90 days following ureteroscopy. Pain was assessed using a visual analog scale and was evaluated on postoperative day (POD) 0, 1 to 3, and 4 to 30.

Sixteen studies involving 1,970 patients reported on unplanned postoperative visits to urgent or emergent care. The authors’ analysis suggested that stent placement may reduce the number of these visits (very low-certainty evidence).

Pain was evaluated by four studies on POD 0 (346 patients) and by eight studies on PODs 1 to 3 (683 patients) and 4 to 30 (903 patients). The authors found no statistical difference in pain between the two groups on POD 0 (moderate-certainty evidence) or between the two groups on PODs 1 to 3 (low-certainty evidence). The authors reported that pain might be greater in stented participants on PODs 4 to 30; however, forest plot analysis showed that unstented patients experienced significantly greater discomfort (very low-certainty evidence).

Ten studies involving 1,435 patients evaluated the need for secondary interventions such as stent exchange or secondary ureteroscopy; the authors found no statistical significance in the number of secondary interventions between them (low-certainty evidence).

BEST PRACTICE RECOMMENDATIONS

This review found that stented patients tended to have fewer unplanned postoperative visits than unstented patients, and that ureteral stricture and hospital readmission occurred less often in stented patients; however, its results are inconclusive. The authors noted low to very low certainty in their results because of small sample sizes, publication bias, “major imprecision,” and other study limitations.

There is insufficient data to recommend the routine stenting or nonstenting of patients undergoing ureteroscopy for urinary system calculi. Health care providers should consider related patient and/or procedural complications when deciding whether a ureteral stent is warranted.

SOURCE DOCUMENT
Ordonez M, et al. Ureteral stent versus no ureteral stent for ureteroscopy in the management of renal and ureteral calculi. Cochrane Database Syst Rev 2019;2:CD012703.

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