Stent Dwell Time Research Articles

Lumen-apposing metal stents provide early and late clinical benefits for the management of benign gastrointestinal strictures: Is there a role for definitive therapy?

This study aimed to characterize the clinical outcomes, safety, and efficacy of lumen-apposing metal stents (LAMS) in treating benign gastrointestinal strictures. A single-center retrospective review of all patients who underwent LAMS placement for benign strictures from June 2017 to July 2023. Primary outcomes were technical success, early clinical success, late clinical success (LCS), and sustained post-LAMS clinical success (SPLCS). Secondary outcomes included stent dwell time, stenosis changes, adverse events, reintervention rates, and symptomatology evaluation. Thirty-five patients underwent placement of 42 LAMS (74% female, mean age: 54.2 ± 11.7 years). Anastomotic strictures accounted for 64% of cases (N=27, 45% at the gastrojejunal anastomosis). The median STD was 91.0 days (interquartile range [IQR]: 55.0-132.0). Technical success was obtained in all cases. Early clinical successand LCS were achieved in 80% of cases overall. SPLCS was achieved in 45% (n=15) of cases. The overall reintervention rate was 63%, with a median time to reintervention being 50.5 days (IQR: 24-105). adverse eventsoccurred in 28% (n=12) overall, with a 24% migration rate (n=10). Follow-up was completed in 83% of cases with a median duration of 629 days (range: 192.0-1297.0). Overall symptom improvement occurred in 79% (n=27) during indwelling LAMS versus 58% and 56% at 30- and 60-days post-removal, respectively. LAMS for benign gastrointestinal strictures are associated with high technical and early clinical success/LCS rates, positive quality-of-life metrics, and a tolerable adverse event rate. Overall, recurrence of symptoms and high reintervention rates post-LAMS removal reinforce the difficulty in managing benign gastrointestinal strictures but also argue for LAMS as a definitive therapy in select cases.

Safety of long-term esophageal stent use for multiple indications.

Long-term (>30 days) esophageal stenting is controversial. Previous studies have documented complications associated with long-term esophageal stent use. This study's objective was to investigate complications associated with long-term esophageal stent use. A retrospective review of stenting done by thoracic surgery for any reason between 2010-2020 was completed. Patients were included if they had at least 30 days of follow-up after their initial stent placement. Outcomes included stent dwell time, patient outcomes, procedural and stent-related complications. Fifty-six patients, with 25 having ≥2 stents placed were included; overall, 90 stents were placed. The median length of initial esophageal stent dwell time was 59 [interquartile range (IQR), 21-119] days. Stent migration was the most common complication and occurred more with benign indications (P=0.12). As the length of dwell time increased, prevalence of any complication decreased. Complication rates between short-term (<30 days) and long-term stents were not significantly different (P=0.39). No instances of esophageal perforation or aortoesophageal fistulas related to stents were identified. There was one instance of post-esophagectomy tracheoesophageal fistula which was managed successfully with prolonged stenting. Over a 10-year period, there were no instances of stent erosion into the aorta or esophageal perforation, and the most frequent stent-related complication was stent migration. Long-term esophageal stenting did not result in increased rates of stent related complications in our cohort. This case series demonstrates that long-term stents may be safely used for many different indications. Randomized controlled studies may be needed to validate these findings.

Daily Ecological Momentary Assessments of Pain and Ability to Work After Ureteroscopy and Stenting.

Introduction: Ureteral stents can cause significant patient discomfort, yet the temporal dynamics and impact on activities remain poorly characterized. We employed an automated tool to collect daily ecological momentary assessments (EMAs) regarding pain and the ability to work following ureteroscopy with stenting. Our aims were to assess feasibility and better characterize the postoperative patient experience. Materials and Methods: As an exploratory endpoint within an ongoing clinical trial, patients undergoing ureteroscopy with stenting were asked to complete daily EMAs for 10 days postoperatively or until the stent was removed. Questionnaires were distributed through text messages and included a pain scale (0-10) and a single item from the validated Patient-Reported Outcomes Measurement Information System Ability to Participate in Social Roles and Activities instrument, as well as days missed from work or school. Results: Among the first 65 trial participants, 59 completed at least 1 EMA (overall response rate 91%). Response rates were >85% for each time point through postoperative day (POD)10. Median respondent age was 58 years (interquartile range [IQR] 50-67), and 56% were female. Stones were 54% renal and 46% ureteral, with a median diameter of 9 mm (IQR 7-10). Median stent dwell time was 7 days (IQR 6-8). Pain scores were highest on POD1 (median score 4) and declined on each subsequent day, reaching a median score of 2 on POD5. Sixty-three percent of patients on POD1 reported that they had trouble performing their usual work at least sometimes, but by POD5, this was <50% of patients. Patients who work or attend school reported a median of 1 day missed (IQR 0-2). Conclusions: An automated daily EMA system for capturing patient-reported outcomes was demonstrated to be feasible with sustained excellent engagement. Patients with stents reported the worst pain and interference with work on POD1, with steady improvements thereafter, and by POD5, the majority of patients had minimal pain or trouble performing their usual work. This work is associated with a registered clinical trial [NCT05026710].

Implementing routine use of self-removed ureteric stents on extraction strings: prospective patient-reported outcome measures and complications

PurposeUreteric stents placed after ureteroscopy typically require cystoscopy for removal. Stent extraction strings allow the option of patient self-removal. This facilitates shorter stent dwell time, and cost-savings. Concerns regarding safety and limited evidence regarding patient acceptability are speculated reasons for infrequent clinical use of extraction strings. This study investigates our recent experience using routine self-removal of stents on extraction strings to provide evidence to address these concerns.MethodsIn February 2020, our hospital adopted a policy for self-removal of stents on extraction strings to be routine following ureteroscopy. This was influenced by motivation to improve service capacity for diagnostic flexible cystoscopy, hospital avoidance during the pandemic, perceived improvement for the patient experience, and cost-saving. Prospective clinical and patient-reported outcome data were collected and evaluated.ResultsThere were 168 patients who had stents on extraction strings. Mean stent dwell time was 5.2 ± 1.8 days. Primary ureteroscopy was performed in 40.5%, and 59.5% had procedures using an access sheath. Self-removal at home was successful for 79% of patients. Stent dislodgement rate was 3.0% (5/168) and retained stents due to string detachment occurred in 1.8% (3/168). Almost all indicated they “would remove the stent on string again” (90%, 128/142) and the majority reported stent removal as “very easy” (61%, 87/142). Cost modelling estimates a total saving of AUD $148,869 per annum for routine use of extraction strings at our hospital.ConclusionOur experience reflects that stent extraction strings may be used routinely with acceptable low complication rates, favourable patient experiences and associated cost savings.

What Is the Optimal Stenting Duration After Ureteroscopy and Stone Intervention? Impact of Dwell Time on Postoperative Emergency Department Visits.

AUA stone management guidelines recommend stenting duration following ureteroscopy be minimized to reduce morbidity; stents with extraction strings may be used for this purpose. However, an animal study demonstrated that short dwell time results in suboptimal ureteral dilation, and a pilot clinical study showed this increases postprocedure events. Using real-world practice data we examined stent dwell time after ureteroscopy and its association with postoperative emergency department visits. We used the Michigan Urological Surgery Improvement Collaborative registry to identify ureteroscopy and stenting procedures (2016-2019). Pre-stented cases were excluded. Stenting cohorts with and without strings were analyzed. Using multivariable logistic regression we evaluated the risk of an emergency department visit occurring on the day of, or day after, stent removal based on dwell time and string status. We identified 4,437 procedures; 1,690 (38%) had a string. Median dwell time was lower in patients with a string (5 vs 9 days). Ureteroscopy in younger patients, smaller stones, or renal stone location had a higher frequency of string use. The predicted probability of an emergency department visit was significantly greater in procedures with string, compared to without string, when dwell times were less than 5 days (P < .01) but were not statistically significant after. Patients who had ureteroscopy and stenting with a string have short dwell times. Patients are at increased risk of a postoperative emergency department visit around the time of stent removal if dwell time is ≤4 days. We recommended stenting duration of at least 5 days in nonpre-stented patients.

Management of biliary complications in liver transplant recipients using a fully covered self-expandable metal stent with antimigration features.

Following liver transplant (LT) with duct-to-duct anastomosis, biliary strictures and leaks are typically managed with endoscopic retrograde cholangiopancreatography (ERCP) and stenting. While multiple side-by-side plastic stents are typically used for management of anastomotic strictures, fully covered self-expandable metal stents (FCSEMS) can be used to decrease the number of ERCPs with longer periods of stent patency. The risk of migration can limit their use. FCSEMS with antimigration fins to manage benign biliary complications following LT may provide stricture resolution with limited adverse events (AEs). Single center retrospective study of LT patients who required FCSEMS from 1/2014 to 4/2022. Primary outcomes included stricture resolution and recurrence. Secondary outcomes were stent migration, occlusion, removability, and number of ERCPs. Forty-three patients (mean age 55.5 years) with anastomotic strictures (N.=37), bile leaks (N.=4) or both (N.=2) were included. The median time from LT to FCSEMS placement was 125 days. Within one year of LT, 31 patients required intervention; early intervention at less than 30 and 90 days was needed in 7 and 19 patients, respectively. The median length of follow-up was 816.5 days. Stricture resolution was seen in 35 patients (81%) after a median stent dwell time of 130.5 days; recurrence occurred in 8 patients. There were three instances of partial stent migration that did not require reintervention or interfere with removability. The mean number of ERCPs required was 2.5. The use of a FCSEMS with antimigration features yields effective stricture resolution with longer stent dwell times and fewer ERCPs.

MP19-05 DAILY ECOLOGICAL MOMENTARY ASSESSMENTS OF PAIN AND ABILITY TO WORK AFTER URETEROSCOPY AND STENTING

You have accessJournal of UrologyCME1 Apr 2023MP19-05 DAILY ECOLOGICAL MOMENTARY ASSESSMENTS OF PAIN AND ABILITY TO WORK AFTER URETEROSCOPY AND STENTING Russell E. N. Becker, John Michael Dibianco, Andrew M. Higgins, Eduardo Kleer, David Leavitt, Andre King, Naveen Kachroo, Sami E. Majdalany, David Gandham, Golena Fernandez Moncaleano, Bronson Conrado, Stephanie Daignault-Newton, Casey A. Dauw, Khurshid R. Ghani, and for the Michigan Urological Surgery Improvement Collaborative Russell E. N. BeckerRussell E. N. Becker More articles by this author , John Michael DibiancoJohn Michael Dibianco More articles by this author , Andrew M. HigginsAndrew M. Higgins More articles by this author , Eduardo KleerEduardo Kleer More articles by this author , David LeavittDavid Leavitt More articles by this author , Andre KingAndre King More articles by this author , Naveen KachrooNaveen Kachroo More articles by this author , Sami E. MajdalanySami E. Majdalany More articles by this author , David GandhamDavid Gandham More articles by this author , Golena Fernandez MoncaleanoGolena Fernandez Moncaleano More articles by this author , Bronson ConradoBronson Conrado More articles by this author , Stephanie Daignault-NewtonStephanie Daignault-Newton More articles by this author , Casey A. DauwCasey A. Dauw More articles by this author , Khurshid R. GhaniKhurshid R. Ghani More articles by this author , and for the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003244.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteral stents can cause significant patient discomfort, yet the temporal dynamics of symptoms and impact on social activities remain poorly characterized. We employed an automated text message tool to collect daily ecological momentary assessments (EMA) following ureteroscopy with stenting regarding pain and ability to work. Our aim was to assess the feasibility of capturing EMA data, and better characterize the postoperative patient experience. METHODS: As an exploratory endpoint within an ongoing pragmatic clinical trial (NCT05026710), patients undergoing ureteroscopy and stone intervention with stenting (without a tether) were asked to complete daily EMAs for 10 days postoperatively, or until the stent was removed, whichever was longer. Stents were removed in the office. Questionnaires were distributed via text message and included a numeric pain scale (0-10) and a single item from the validated PROMIS Ability to Participate in Social Roles and Activities instrument, as well as days missed from work or school. Responses from postoperative day (POD) 1 through the day of stent removal (up to POD10) were analyzed for the first 35 participants in EMAs. RESULTS: Median patient age was 56.1 years (IQR 46.6-62.8), 51% were female. Stones were 66% renal and 34% ureteric, with median stone diameter 8.5mm (IQR 6-10). Daily EMA response rates were >90% for all days through POD10. Median stent dwell time was 7 days (IQR 6-9). Pain scores were highest on POD1 (median score 4) and declined with each day, reaching median score 2 on POD5 (Figure 1, panel A). 65% of patients on POD1 reported they had trouble performing their usual work at least sometimes, but by POD5 this was <50% of patients (Figure 1, panel B). Patients who work or attend school reported a median of 1 day missed (IQR 0-3). CONCLUSIONS: An automated daily text message EMA system for capturing patient reported outcomes was demonstrated to be feasible with sustained excellent response rates. Patients with stents reported the worst pain and interference with work on POD1 with steady improvements thereafter, and by POD5 the majority of patients had minimal pain or trouble performing their usual work. Source of Funding: Coloplast & Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e266 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Russell E. N. Becker More articles by this author John Michael Dibianco More articles by this author Andrew M. Higgins More articles by this author Eduardo Kleer More articles by this author David Leavitt More articles by this author Andre King More articles by this author Naveen Kachroo More articles by this author Sami E. Majdalany More articles by this author David Gandham More articles by this author Golena Fernandez Moncaleano More articles by this author Bronson Conrado More articles by this author Stephanie Daignault-Newton More articles by this author Casey A. Dauw More articles by this author Khurshid R. Ghani More articles by this author for the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

Implementation and Usability of an Electronic Medical Record-based Ureteral Stent Tracker

ObjectiveTo design and implement a simple electronic medical record-based ureteral stent tracker. To assess its impact on stent dwell time and stent-related complications. MethodsPatients with stents placed 12 months before and 6 months after stent tracker implementation were identified at 3 urban hospitals. Those with stents-on-strings and intentional chronic indwelling stents (greater than 90 days) were excluded. Patient demographics, stent characteristics (eg, indication, string, dwell time), and clinical outcomes (eg, positive urine cultures, complications) were reviewed and compared between pre- and posttracker cohorts. A 12-question usability survey was administered to surgical nurses to assess usability. ResultsA total of 323 stents (173 pre- and 150 posttracker) were placed in 217 patients. The prestent tracker cohort had a longer mean dwell time (pre: 40.9 ± 59.1 days vs post: 28.8 ± 22.0 days, P = .02) and a higher retention rate >90 days (pre: 8.1% [14/173] vs post: 1.3% [2/150], P = .005). The 2 cohorts had no significant differences in positive urine culture rates, patient phone calls to providers, stent-related emergency department visits, or hospitalizations. The usability survey showed that 86.4% of surgical nurses found the tracker to be user-friendly and 95.5% reported that it added less than 1 minute of work per procedure. ConclusionImplementation of an electronic medical record-based ureteral stent tracker decreased average stent dwell time and frequency of retained stents. Surgical nurses reported the tracker to be user-friendly and convenient. Stent trackers can improve the efficiency of postoperative removal of indwelling ureteral stents.

Lumen-apposing metal stents for the treatment of benign gastrointestinal tract strictures: a single-center experience and proposed treatment algorithm.

Lumen-apposing metal stents (LAMS) are an alternative therapeutic option for benign gastrointestinal (GI) tract strictures. Our study aimed to evaluate the safety and efficacy of LAMS for the management of benign GI strictures. Consecutive patients who underwent a LAMS placement for benign luminal GI strictures at a tertiary care center between January 2014 and July 2021 were reviewed. Primary outcomes included technical success, early clinical success, and adverse events (AEs). Other outcomes included rates of stent migration and re-intervention after LAMS removal. One hundred and nine patients who underwent 128 LAMS placements (67.9% female, mean age of 54.3 ± 14.2years) were included, and 70.6% of the patients had failed prior endoscopic treatments. The majority of strictures (83.5%) were anastomotic, and the most common stricture site was the gastrojejunal anastomosis (65.9%). Technical success was achieved in 100% of procedures, while early clinical success was achieved in 98.4%. The overall stent-related AE rate was 25%. The migration rate was 27.3% (35/128). Of these, five stents were successfully repositioned endoscopically. The median stent dwell time was 119days [interquartile range (IQR) 68-189days], and the median follow-up duration was 668.5days [IQR: 285.5-1441.5days]. The re-intervention rate after LAMS removal was 58.3%. LAMS is an effective therapeutic option for benign GI strictures, offering high technical and early clinical success. However, the re-intervention rate after LAMS removal was high. In select cases, using LAMS placement as destination therapy with close surveillance is a reasonable option.

S91 Management of Biliary Complications in Liver Transplant Recipients Using a Fully Covered Self-expandable Metal Stent With Antimigration Features

Introduction: Following liver transplant (LT) with duct-to-duct anastomosis, biliary strictures and leaks are typically managed with endoscopic retrograde cholangiopancreatography (ERCP) and stenting. While multiple plastic stents are typically used for strictures, self-expandable metal stents (SEMS) can be used to decrease the number of ERCPS with longer periods of stent patency. However, their use is limited by stent migration. The use of fully covered SEMS (FCSEMS), with antimigration fins to manage benign biliary complications following LT may provide stricture resolution with limited adverse events. As such we aimed to describe clinical outcomes of FCSEMS in LT recipients using one type of FCSEMS. Methods: This was a single center retrospective study of consecutive adult LT patients undergoing FCSEMS from January 2014 to April 2022. Primary outcomes were stricture resolution and recurrence. Secondary outcomes included rates of stent migration, stent occlusion, and number of ERCPs required. Results: 46 LT patients with anastomotic strictures (n=40), bile leaks (n=4) or both (n=2) (average age 55.8 years, 33% women) were treated with a FCSEMS with antimigration features (Viabil, W.L. Gore, Flagstaff, AZ) approved for malignant strictures. The median time from LT to FCSEMS placement was 132.5 days. Within one year of LT, 32 patients (69.5%) required intervention; early intervention at less than 30 and 90 days was needed in 7 and 20 patients, respectively. At the time of study conclusion there were 3 patients with stents in situ. Stricture resolution was seen in 34 patients (74%) after an average stent dwell time of 134.5 ± 71 days; recurrence was observed in 8 patients (17%). There were three instances of partial proximal stent migration that did not require reintervention or interfere with removability. Procedural details are listed in Table: The total mean number of ERCPS required was 2.48 (range 1-5). Conclusion: The use of a FCSEMS with antimigration features offers an opportunity to enhance stricture resolution with longer stent dwell times and fewer ERCPs. In our cohort there were no instances of clinically significant stent migration, dysfunction, or procedure related adverse events. Furthermore, these stents provide an opportunity reduce procedure related costs. Additional studies are needed to identify suitable patients for FCSEMS placement. Table 1. - Procedure related details and stent outcomes Stent Dwell Time +/- Standard Deviation (days) 134.5 +/- 71.8 Stent Placement transpapillary vs intraductally, n (%) 36 (78.3%) vs 10 (21.7%) Prior Sphincterotomy, n (%) 17 (40%) Stricture Recurrence, n (%) 8 (17%) Average Number ERCPs, n (range) 2.48 (1-5) Stent Migration, n (%) 3 (6.5 %) Stent Occlusion, n (%) 8 (17%)

S1088 Comparison of Safety of Lumen Apposing Metal Stents With or Without Coaxial Plastic Stent Placement for the Management of Pancreatic Fluid Collections

Introduction: Lumen opposing metal stents (LAMS) allow for safe and effective endoscopic drainage of pancreatic fluid collections (PFCs). LAMS, however, have been associated with bleeding within the cavity and pseudoaneurysm formation. Placement of a coaxial double pigtail plastic stent (DPPS) may theoretically reduce this risk and that of symptomatic stent occlusion. The aim of this study is to compare the safety of LAMS alone versus LAMS with coaxial DPPS placement (LAMS/DPPS) for the management of PFCs. Methods: Patients who underwent LAMS placement for management of a PFC between Sep 2019 and Feb 2022 were retrospectively identified from a tertiary care center procedural data base. Cases were categorized as LAMS or LAMS/DPPS. Demographics, clinical characteristics, and outcomes were compared between the two cohorts. The primary outcome was the rate and type of adverse events between the groups. Secondary outcomes included clinical success rates and time to clinical success. Results: 185 unique patients were identified; 83 (44.9%) with LAMS drainage alone and 102 (55.1%) LAMS/DPPS. There were no significant differences in age, sex, PFC etiology, PFC type, size, or paracolic extension (Table). DPPS with 7Fr or 10Fr diameters were utilized with a median length of 4.0 cm (IQR 4.0-7.0). There were no significant differences in rates of clinical success, need for early necrosectomy, number of endoscopies, or number of necrosectomies. However, stent dwell time was significantly longer in the LAMS only group (69 vs. 35 days, p=0.017). Overall, AE rates were the same in the two cohorts (15.7%, vs. 15.7%, p=0.825). Bleeding occurred in 2 (2.4%) and 9 (8.8%) cases in the LAMS and LAMS/DPPS groups, respectively (p=0.067), with 4 confirmed cases of pseudoaneurysm bleeding (1 LAMS and 3 LAMS/DPPS, p=0.220). There were no differences in the rate of clinically significant stent occlusion (2.4% LAMS vs. 2.9% LAMS/DPPS, p=0.825) or migration (3.6% LAMS vs. 1.0% LAMS/DPPS, p=0.220). Incidental DPPS migration was noted in 12 (11.8%) cases, but all patients were asymptomatic. Conclusion: The safety profile of LAMS was similar to LAMS/DPPS in this cohort. The incidence of bleeding and occlusion was low overall and not significantly impacted by the presence of a DPPS. Randomized studies are needed to further elucidate the role of coaxial DPPS in drainage of PFCs. Table 1. - Baseline clinical characteristics and outcomes of patients who underwent placement of either lumen opposing metal stent (LAMS) alone or LAMS with coaxial double pigtail plastic stent (LAMS/DPPS) placement BASELINE CHARACTERISTICS LAMSN = 83 LAMS/DPPSN=102 P Value Age, y, median (IQR) 55.0 (45.5 – 65.0) 56.5 (42.8 – 65.0) 0.760 Female 22 (26.5) 41 (40.2) 0.051 Collection Type Walled-off necrosis Pseudocyst 64 (77.1)21 (25.3) 80 (78.4)22 (21.6) 0.550 Maximum diameter of dominant collection, cm, median (IQR) 12.0 (7.9 – 18.4) 11.0 (7.8 – 15.0) 0.098 Multiple collections 30 (36.6) 51 (50.0) 0.068 Paracolic extension 32 (38.6) 34 (33.3) 0.461 OUTCOMES LAMS dwell time, d, median (IQR) 69.0 (31.0 – 131.0) 35.0 (21.0 – 65.5) 0.017 Clinical success 63 (75.9) 71 (69.6) 0.341 Total therapeutic endoscopies, no., median (IQR) 2 (1 – 3) 3 (2 – 4) 0.216 Total necrosectomies, no., median (IQR) 1 (0 – 2) 1 (0 – 2) 0.976 Unplanned early necrosectomy 12 (14.6) 16 (15.7) 0.843 Incidental stent migration LAMS DPPS 1 (1.2)N/A 1 (0.9)12 (11.8) 0.883 Adverse Events LAMS Occlusion LAMS Migration Bleeding Infection 13 (15.7)2 3 26 16 (15.7)3194 0.9960.8250.2200.0670.322 Data reported as no. (%) unless indicated.

Factors Associated with Ureteral Stent Failure in Patients with Malignant Ureteral Obstruction.

Introduction: Management of malignant ureteral obstruction (MUO) with ureteral stents remains a clinical challenge, often involving frequent stent exchanges attributable to stent failure or other urological complications. We report our institutional experience with ureteral stents for management of MUO, including analysis of clinical factors associated with stent failure. Methods: We performed a retrospective review of patients treated with indwelling ureteral stents for MUO in nonurothelial malignancies at our tertiary-care institution between 2008 and 2019. Univariate Cox proportional hazards analysis was performed to identify clinical variables associated with stent failure and stent-related complications. Stent failure was defined as need for unplanned stent exchange, placement of percutaneous nephrostomy (PCN), or tandem stents. Results: In our cohort of 78 patients, the median (range) number of stent exchanges was 2 (0-17) during a total stent dwell time of 4.3 (0.1-40.3) months. Thirty-four patients (43.6%) developed a culture-proven urinary tract infection (UTI) during stent dwell time. Thirty-five patients (44.8%) had stent failure. Twenty-two patients (28.2%) underwent unplanned stent exchanges, 23 (29.5%) required PCN after initial stent placement, and 6 (7.7%) required tandem stents. Ten (28.6%) patients with stent failure were treated with upsized stents, which led to resolution in seven patients. Stent failure occurred with 20/44 (45.4%) Percuflex™, 15/27 (55.6%) polyurethane, and 2/3 (66.7%) metal stents. In patients with ≥2 exchanges (N = 45), median time between exchanges was 4.1 (2.0-14.8) months. Bilateral stenting and history of radiation predicted UTI development. Median overall patient survival after initial stent placement was 19.9 months (95% CI 16.5-37.9 months). Conclusions: Ureteral stent failure poses a significant medical burden to patients with MUO. Better methods to minimize stent-related issues and improve patient quality of life are needed. Using a shared decision-making approach, clinicians and patients should consider PCN or tandem stents early in the management of MUO.

Post-Ureteroscopy Infections Are Linked to Pre-Operative Stent Dwell Time over Two Months: Outcomes of Three European Endourology Centres.

Background: The aim of this study is to investigate outcomes of pre-operative stent dwell time on infectious complications following ureteroscopy and stone treatment to identify a time cut-off. Material and Methods: Three tertiary referral centres in Europe retrospectively collected outcomes of ureteroscopy and laser fragmentation (URSL) for all patients with pre-operative indwelling ureteric stents over a period of up to 5 years. Data was collected on patient details, stone demographics, stent dwell time, complications and stone free rate (SFR). Matching for age, sex, operative time, stone size and post-operative stent insertion. To examine for a threshold effect, monthly cut-offs were used to compare post-ureteroscopic febrile UTIs. Binomial logistic regression was used (SPSS v.24) with a significance level set at 0.0036. The risk ratio (RR) with a 95% confidence interval (CI) and the number needed to harm (NNH) are reported. Results: There were 467 patients with a pre-operative stent for analysis. These patients (n = 315) were matched to non-stented controls after excluding 152 patients to achieve adequate matching. There was a significant difference in rates of post-ureteroscopic febrile UTI between stented vs non-stented patients (RR = 2.67, 95% CI: 1.10–6.48, p = 0.03). On adjustment, a dwell time of more than two months was associated with an increased risk of post-ureteroscopic febrile UTI (RR = 3.94, 95% CI: 1.30–12.01, p = 0.02), this increased risk rose with longer dwell time. At stent time longer than four months was associated with a significantly increased risk of post-ureteroscopic febrile UTI (5% vs. 15%, RR = 3.09, 95% CI: 1.56–6.10, p = 0.001), with the number needed to harm at 10. Conclusions: Overall infectious complication rates from URSL are low. The risk of post-operative UTI after four months of dwell time is nearly tripled compared to less than four months.

PD14-05 THE PATIENT VOICE: LIVING WITH A URETERAL STENT AFTER URETEROSCOPY - A URINARY STONE DISEASE RESEARCH NETWORK (USDRN) STUDY

You have accessJournal of UrologyStone Disease: Epidemiology & Evaluation I (PD14)1 Sep 2021PD14-05 THE PATIENT VOICE: LIVING WITH A URETERAL STENT AFTER URETEROSCOPY - A URINARY STONE DISEASE RESEARCH NETWORK (USDRN) STUDY Amy Corneli, Carrie Dombeck, Kevin McKenna, Jonathan Harper, Jodi Antonelli, Alana Desai, Henry Lai, Greg Tasian, Justin Ziemba, Rebecca McCune, Brooke Piskator, Hussein Al-Khalidi, Naim Maalouf, Peter Reese, Hunter Wessells, Ziya Kirkali, and Charles Scales Amy CorneliAmy Corneli More articles by this author , Carrie DombeckCarrie Dombeck More articles by this author , Kevin McKennaKevin McKenna More articles by this author , Jonathan HarperJonathan Harper More articles by this author , Jodi AntonelliJodi Antonelli More articles by this author , Alana DesaiAlana Desai More articles by this author , Henry LaiHenry Lai More articles by this author , Greg TasianGreg Tasian More articles by this author , Justin ZiembaJustin Ziemba More articles by this author , Rebecca McCuneRebecca McCune More articles by this author , Brooke PiskatorBrooke Piskator More articles by this author , Hussein Al-KhalidiHussein Al-Khalidi More articles by this author , Naim MaaloufNaim Maalouf More articles by this author , Peter ReesePeter Reese More articles by this author , Hunter WessellsHunter Wessells More articles by this author , Ziya KirkaliZiya Kirkali More articles by this author , and Charles ScalesCharles Scales More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001990.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteral stents are often employed after ureteroscopy, and thought to impair patient quality of life. Despite this well-known impact, there has been little rigorous qualitative research on patients’ experiences with stent placement after ureteroscopy. The objective of this study was to describe the qualitative impact of stents on psychological, functional, and interpersonal aspects of patients’ lives. METHODS: The USDRN Study to Enhance Understanding of Stent-Associated Symptoms (STENTS) is a prospective observational cohort study that included a nested cohort of participants who completed qualitative in-depth interviews (IDIs, n=39) within 30 days after stent removal. Participants shared their experiences focusing on symptoms and symptom impact on daily activities. All interviews were audio-recorded, transcribed, and analyzed using a rigorous qualitative approach (applied thematic analysis). Participants were categorized into three groups during analysis based on their experiences with interference in daily activities: minimal, moderate, and substantial interference. RESULTS: Of the 39 participants, 21 (54%) were female, and the median age was 44 (IQR 29,58; range 13–77); median stent dwell time was 8 days (IQR 6.5, 11). Interviews were conducted 7–30 days (median=16 days) after stent removal. All participants experienced pain and almost all experienced urinary symptoms. Participants often linked their pain with apprehension or anxiety caused by knowing that urination would be painful, as well as resentment for needing to drink water as it would ultimately lead to painful urination. A subset of participants (n=12) experienced only minimal interference with activities, 19 experienced moderate interference, and importantly, the remainder of participants (n=8, Table) reported substantial and pervasive interference with activities. CONCLUSIONS: These qualitative findings provide important insights into the lived experience of patients with stents. Counseling to better prepare patients for the impact of stent-associated symptoms, and efforts to identify patients at risk for pervasive symptom interference, may help mitigate the burden of stent-associated symptoms. Source of Funding: NIH/NIDDK © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e217-e217 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amy Corneli More articles by this author Carrie Dombeck More articles by this author Kevin McKenna More articles by this author Jonathan Harper More articles by this author Jodi Antonelli More articles by this author Alana Desai More articles by this author Henry Lai More articles by this author Greg Tasian More articles by this author Justin Ziemba More articles by this author Rebecca McCune More articles by this author Brooke Piskator More articles by this author Hussein Al-Khalidi More articles by this author Naim Maalouf More articles by this author Peter Reese More articles by this author Hunter Wessells More articles by this author Ziya Kirkali More articles by this author Charles Scales More articles by this author Expand All Advertisement Loading ...

PD14-08 THE IMPACT OF COVID-19 ON SURGICAL CARE DELIVERY FOR PATIENTS WITH URINARY STONES

You have accessJournal of UrologyStone Disease: Epidemiology & Evaluation I (PD14)1 Sep 2021PD14-08 THE IMPACT OF COVID-19 ON SURGICAL CARE DELIVERY FOR PATIENTS WITH URINARY STONES John Michael DiBianco, Stephanie Daignault-Newton, John Ludlow, Jessica Phelps, Erik Ratchford, Michael Cotant, Khurshid R. Ghani, Casey A. Dauw, and for the Michigan Urological Surgery Improvement Collaborative John Michael DiBiancoJohn Michael DiBianco More articles by this author , Stephanie Daignault-NewtonStephanie Daignault-Newton More articles by this author , John LudlowJohn Ludlow More articles by this author , Jessica PhelpsJessica Phelps More articles by this author , Erik RatchfordErik Ratchford More articles by this author , Michael CotantMichael Cotant More articles by this author , Khurshid R. GhaniKhurshid R. Ghani More articles by this author , Casey A. DauwCasey A. Dauw More articles by this author , and for the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001990.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: During the COVID-19 pandemic, limits on elective surgical care were instituted by hospitals to preserve resources. Additionally, patients’ desire to limit health care contact may impact surgical decision making. We aimed to understand how institutional pressures and patient preference affected the delivery, choice and outcome of ambulatory surgical care for urinary stone disease during the COVID-19 pandemic. METHODS: Reducing Operative Complications from Kidney Stones (ROCKS) is a quality improvement initiative from the Michigan Urological Surgery Improvement Collaborative (MUSIC) that maintains a prospective clinical registry of ureteroscopy (URS) and shockwave lithotripsy (SWL) cases. Using this registry, we categorized all cases by time frame, defining July 1st - December 31st 2019 as preCOVID (PC), March 16th - June 15th 2020 as duringCOVID (DC) and June 16th - September 15th 2020 as afterCOVID (AC). Patients in each cohort were characterized across a range of sociodemographic and clinical factors. We assessed changes in procedure choice (URS vs SWL), procedure acuity (elective vs emergent), and outcomes (ED visit and hospitalization within 30 days of surgery). RESULTS: 6375 cases were identified, 4513 URS and 1862 SWL. PC consisted of 3310 cases (2238 URS and 1072 SWL), DC consisted of 1141 cases (888 URS and 253 SWL) and AC consisted of 1924 cases (1387 URS and 537 SWL). A higher proportion of URS cases were performed DC compared to PC and AC (77.8% vs 67.6% vs 72.1%, p <0.001, respectively). A higher percentage of emergent cases in DC compared to PC and AC (21.8% vs 13.7% vs 15.3%, p <0.001, respectively). Significantly more cases in DC compared to PC and AC were prestented, had positive UA/urine culture, ureteral stones, had hydronephrosis, were stented and had longer stent dwell time. ED visits and unplanned hospitalizations were not significantly different. CONCLUSIONS: The COVID-19 pandemic resulted in a lower overall stone treatment rates and higher proportions of URS compared to SWL. Significantly more emergent cases for ureteral stones with positive UA/urine cultures and evidence of obstruction were performed duringCOVID with higher stent placement rates and longer stent dwell times. These data pointing towards preference for higher intensity or acuity cases without differences in unplanned healthcare encounters. Source of Funding: Funding from Blue Cross Blue Shield of Michigan © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e218-e219 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information John Michael DiBianco More articles by this author Stephanie Daignault-Newton More articles by this author John Ludlow More articles by this author Jessica Phelps More articles by this author Erik Ratchford More articles by this author Michael Cotant More articles by this author Khurshid R. Ghani More articles by this author Casey A. Dauw More articles by this author for the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

Endoscopic transpapillary gallbladder stenting to prevent acute cholecystitis in patients receiving FCEMS for benign biliary stricture.

Background and study aims Fully covered self-expanding metal stents (FCSEMS) are being increasingly used for benign biliary strictures (BBS); however, they are associated with risk of acute cholecystitis. Prophylactic endoscopic transpapillary gallbladder stenting (ETPGBS) can facilitate continuous gallbladder drainage and prevent acute cholecystitis from occlusion of cystic duct orifice by the FCSEMS. The aim of this study was to assess the technical feasibility, efficacy, and safety of ETPGBS to prevent acute cholecystitis in patients receiving FCSEMS for BBS. Patients and methods This was a retrospective analysis of a prospectively collected database at a single center of all patients who underwent prophylactic ETPGBS with FCSEMS for BBS between December 1, 2016 and November 30, 2020. Results A total of 71 ETPGBS were placed during the study period. Sixteen patients (mean age: 66.4 ± 19.8 years; 81 % male) underwent ETPGBS prior to biliary FCSEMS during the same endoscopic session. FCSEMS were left in place (stent dwell time) for a median of 173 days (range: 69–473; mean 196 ± 121) with resolution of BBS and successful removal of ETPGBS and FCSEMS in 12 patients. There was significant improvement in total bilirubin level (5.25 ± 5.53 vs 0.94 ± 0.85 gm/dL; P = 0.008). No episodes of acute cholecystitis or any other post-procedural complications were noted during the median follow-up of 337 days (range: 150–856; mean 394 ± 236). Conclusions ETPGBS prevented stent-related acute cholecystitis with continued efficacy of FCSEMS for BBS.

BAUS 2021 Abstracts

Introduction: Traditional ureteric stent practice involves patients attending the hospital for stent removal. Our aim was to empower patients to remove their stent at home, obviating the need for a hospital visit and flexible cystoscopy, thereby reducing the risk of contracting Covid-19 for both staff and patients. Patients and Methods: Between March 2020 and January 2021 all patients undergoing ureteroscopic procedures were consented for a possible stent on string (SOS) if clinically appropriate. Verbal and written instructions were provided to enable patients to remove their stent at home. Prospective records were collected including patient and stone demographics, stent dwell time, complications and patient reported outcome measures including pain scores, satisfaction and whether they would consider a SOS in future. Results: 45 patients had a SOS inserted. 40/45 (89%) had stone disease: 27% renal, 20% proximal, 9% mid- and 33% distal ureter. 17/45 (38%) were pre-stented. Mean stent dwell time was 4 days (range 1-6 days). 30/45 (66%) patients removed their own stent at home without complication. The remainder were removed by healthcare professionals for a variety of reasons: 7 patient anxiety, 3 in-patients, 3 attended A&E with stent symptoms, 2 complete migration. Median pain score was 3.5/10, with 50% reporting it was better than a cystoscopic removal and 89% rating removal as easy. Conclusions: Empowering patients to self-extract their own stent is effective and safe for the majority of patients. Clear written and verbal communication and telephone follow-up on the day of stent removal are paramount to facilitate this.

P0296 - Post-ureteroscopy febrile urinary tract infections are linked to pre-operative stent dwell time: Results from three European endourology centres

P0296 - Post-ureteroscopy febrile urinary tract infections are linked to pre-operative stent dwell time: Results from three European endourology centres

A Prospective Evaluation of a Nurse-Led Stent Removal Service Using the Single-Use Isiris®in a Tertiary Referral Stone Unit and its Impact on Patient Waiting Times

Background and Objective Double J (JJ) ureteric stenting represents one of the most significant causes of patient discomfort and dissatisfaction following endourological procedures. At our institution, a large tertiary referral centre for complex stones, standard JJ stent removal was previously undertaken with a flexible cystoscope (FC) in the endoscopy department by a doctor. The pathway was prone to delays through capacity constraints and prioritization being given to cancer investigations. The Isiris® is a single-use stent removal system consisting of a ‘camera on chip’ disposable FC with an integrated grasper. We examine the feasibility of a nurse-led stent removal service using Isiris®, performed as an office-based procedure, and its effect on waiting times. Material and Methods A specialist stone nurse undertook training in FC approved by the British Association of Urological Surgeons (BAUS) and the British Association of Urological Nurses (BAUN). Once competency was reached, a nurseled service was offered to patients in the outpatient setting. A prospective database from April 2018 to March 2020 was maintained to include patient data for stent removals in the nurse-led clinic using Isiris®. This was compared to a retrospective dataset of FC and stent removal between July 2016 and December 2016, performed by a doctor in the endoscopy department. The delays in stent removal compared to the ‘ideal’ stent removal date (planned date plus or minus 3 days tolerance allowed) were compared between the two pathways. Results The specialist nurse undertook BAUS theory training and competency was reached using an approved BAUS/BAUN competency package. 414 stent removals were booked in the nurse group, of which 395 were undertaken. 291 of 395 (74%) patients in the nurse removal Isiris® group had their stent removed on time, whereas only 16 of 54 (30%) patients had their stents removed on time in the FC stent removal group. A delay of more than 21 days was seen in 22% of FC group vs only 2% in the nurse-led Isiris® group. Both planned removal and actual stent dwell time were longer in the FC group compared to Isiris® group (p &lt; 0.0001). There were no major complications with the use of Isiris® for stent removal in the nurse-led clinic. Conclusion This study has demonstrated that it is feasible to introduce a nurse-led stent removal service. The introduction of this service using the Isiris® system has led to a reduction in delays of stent removal, which is likely to translate into significant quality of life improvement for patients and economic benefits for the healthcare system.

Association between ureteric stent dwell time and urinary tract infection.

Ureteric stone obstruction commonly presents to the emergency department, with definitive management often involving ureteroscopy and laser lithotripsy. Insertion of a ureteric stent prior to staged lithotripsy is commonly performed in the public healthcare system. Foreign bodies in the urinary tract are also known to increase urinary tract infection (UTI) risk. This study aims to evaluate the association between stent dwell time and UTI prior to lithotripsy. The medical records of all patients who were treated for ureteric stones with initial stent insertion and staged lithotripsy, from 1 January 2018 to 30 June 2019 at a single tertiary centre, by eight urologists were retrospectively reviewed. Demographic features, disease factors and urine culture data were collected and analysed. Of the 172 patients (median age 56.7 years) identified, one-third had a positive pre-stent urine culture. Twenty-three percent had a positive pre-lithotripsy urine culture with 38% of females compared with 15% of males having a positive culture (P = 0.001). Only 4.3% of patients had a pre-lithotripsy UTI when the stent dwell time was less than 1 month compared with 26.2% when ureteric stents were in situ for longer than 1 month (P = 0.021). The correlation between ureteric stent dwell time and pre-lithotripsy UTI was not linear. Patient comorbidities, stone size, burden and location were not statistically correlated to pre-lithotripsy UTI. In delayed two-staged surgical management of acute urolithiasis, optimal ureteric stent dwell time is less than 1 month to reduce pre-lithotripsy UTI. Female gender is an independent risk factor for pre-lithotripsy UTI.