Abstract
ABSTRACTObjectives: To report on our experience with the use of an evidence-based algorithm defining specific indications for stent omission (SO) after ureteroscopic lithotripsy (URSL), as stent placement has been associated with increased cost and morbidity and indications for SO in the setting of uncomplicated ureteroscopy have been proposed but remain vague.Patients and methods: Indications for SO were defined as per the attached figure, data from URSL procedures performed from January 2016 to September 2017 were collected. For procedures eligible for SO, preoperative and intraoperative factors were recorded including: stone burden, presence of preoperative stent, procedure time, access sheath use, and whether SO was performed. Morbidity data were reviewed including: postoperative events, patient telephone calls for bothersome symptoms, unplanned return visits, and admissions within 30 days.Results: In all, 250 URSL procedures were performed during the study period, and 106 (42.4%) were eligible for SO. SO was performed in 60 (24.0%) cases reflecting a 56.7% compliance with the algorithm. There were no readmissions or re-operations within 30 days for the SO group. Lower postoperative event rates were noted in the SO group (16.7% vs 34.8%, P = 0.03), unplanned return visits (8.3% vs 17.4%, P = 0.16) and 30-day readmission rates (0.0% vs 6.5%, P = 0.08) were also lower in the SO group, although they did not reach statistical significance. Analysis also demonstrated a protective effect of SO on unplanned return visits (odds ratio 0.43, 95% confidence interval 0.13–1.42, P = 0.17), although this was not statistically significant. No statistically significant associations were noted between postoperative events and stone burden, procedure time, or presence of preoperative stent.Conclusions: We provide an algorithm defining indications for SO. SO is safe in a significant portion of URSL procedures, and SO appears to decrease postoperative events when performed judiciously.Abbreviations: IQR: interquartile range; LUTS: lower urinary tract symptoms; OR, odds ratio; SO: stent omission; URSL: ureteroscopic lithotripsy; YAG: yttrium-aluminium-garnet
Highlights
Ureteric stents have been associated with significant postoperative morbidity [1] and increased cost when placed unnecessarily [2]
AUA guidelines state stents may be omitted for uncomplicated ureteroscopic lithotripsy (URSL), specific indications to guide urologists remain elusive [3]
A total of 126 URSLs were identified from January to September 2016, and 67 (53.2%) patients met the criteria of stent omission (SO)
Summary
Ureteric stents have been associated with significant postoperative morbidity [1] and increased cost when placed unnecessarily [2]. AUA guidelines state stents may be omitted for uncomplicated ureteroscopic lithotripsy (URSL), specific indications to guide urologists remain elusive [3]. Randomised controlled trials have shown that stent omission (SO) yields decreased postoperative pain and symptoms in uncomplicated URSL, but these reports have not translated into lower rates of stent placement in the USA. Data has been largely limited to ureteric stones without the use of ureteric access sheaths [4,5,6,7], and a recent meta-analysis showed a possible increase in unplanned postoperative visits for patients where SO was performed [8]. Stent use varies widely internationally, it remains nearly ubiquitous in the USA, with stents being placed after 93% of URSL procedures [9]. That difference may be driven by fear of unplanned follow-up visits
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