September-December 2021 Vol.
40- No.
UNIVERSA MEDICINA
ORIGINAL ARTICLE
pISSN: 1907-3062 / eISSN: 2407-2230 Outcomes of ureteral stent placement for hydronephrosis in patients with ureteral stone Dyah Ratih Widyokirono1,2.
Yudhistira Pradnyan Kloping1,2.
Zakaria Aulia Rahman1,2, and Lukman Hakim1,3* ABSTRACT
BACKGROUND
Routine ureteral stent placement after ureteroscopy (URS) for ureteral stone treatment is arguable due to the possible stent-related symptoms.
Several studies claimed that its use is necessary, while others reported that its use is excessive.
Hydronephrosis occurs when urine cannot drain out from the kidney to the bladder due to blockage or obstruction.
We aimed to evaluate the role of ureteral stents in hydronephrosis resolution in ureteral stone patients following URS lithotripsy.
METHODS
This was a prospective observational study using secondary data involving 130 ureteral stone patients undergoing URS lithotripsy .
with stent placement and 31 patients .
8%) without sten.
Data consisting of baseline characteristics, pre-operative status, intraoperative characteristics, and postoperative complications were collected from the medical record database and presented descriptively.
The patients were divided into two groups based on stent placement.
Comparison of hydronephrosis resolution between the groups was analyzed with Chisquare.
Department of Urology.
Faculty of Medicine.
Universitas Airlangga.
Surabaya.
East Java.
Indonesia Dr.
Soetomo General-Academic Hospital.
Surabaya.
East Java.
Indonesia Universitas Airlangga Teaching Hospital.
Surabaya.
East Java.
Indonesia Correspondence:
*Lukman Hakim Department of Urology.
Faculty of Medicine.
Universitas Airlangga.
Universitas Airlangga Teaching Hospital.
Surabaya.
East Java.
Indonesia Email: lukman-h@fk.
ORCID ID : 0000-0003-1518-8010
RESULTS
Ureteral lesions were the most common indication of ureteral stent placement following URS lithotripsy .
3%).
The most bothersome symptoms were dysuria in 18 patients .
2%).
followed by frequency in eight patients .
1%) and low back pain in six patients .
1%).
All symptoms were successfully treated with oral medications.
There were 41 patients .
with pre-operative hydronephrosis significantly resolved after stent placement compared to 5 .
5%) patients without stent placement .
=0.
Date of first submission.
August 14.
Date of final revised submission.
November 2, 2021 Date of acceptance.
November 4, 2021
CONCLUSION
Ureteral stenting significantly resolves pre-operative hydronephrosis after URS lithotripsy in patients with ureteral stone.
Ureteral stent placement is the preferred method for the treatment of pre-operative hydronephrosis.
Cite this article as: Widyokirono DR.
Kloping YP.
Rahman ZA.
Hakim L.
Outcomes of ureteral stent placement for hydronephrosis in patients with ureteral stone.
Univ Med 2021.
40:226-33.
doi: 10.
18051/UnivMed.
Keywords: Ureteral stent, ureteral stenting, ureteroscopic lithotripsy, ureteral stone This open access article is distributed under a Creative Commons AttributionNon Commercial-Share Alike 4.
International License DOI: http://dx.
org/10.
18051/UnivMed.
Copyright@Author.
- https://univmed.
org/ejurnal/index.
php/medicina/article/view/1214 Univ Med
INTRODUCTION
Urinary tract stones are the third most common disease of the urinary tract, apart from urinary tract infections and pathological conditions of the prostate.
The prevalence of urinary tract stones is estimated to be between 1% and 15% depending on age, gender, race, and geography.
Ureteral stones may cause several complications such as renal colic, ureteric obstruction, hydronephrosis and The management of ureteral stones varies from extracorporeal shock wave lithotripsy (ESWL), ureteroscopy (URS), medical expulsive therapy (MET), and laparoscopic surgery.
URS has been used to treat lower urinary tract stones as well as those in the upper tract.
It is a method of treating ureteric stones besides ESWL.
Compared to ESWL.
URS has a greater stone free rate in four weeks and is a safe option for obese .
The technological advancements of URS lithotripters, such as the development of smaller and more flexible URS and the use of laser lithotripsy have made this procedure more effective and safer for urinary stone treatment.
Indications for ureteric stone removal include persistent pain or obstruction, renal insufficiency, and low chance of spontaneous discharge, comorbidity profile, social situation and patient .
Treatment after stone treatment varies depending on patient characteristics and comorbidities, residual stones, complications, and the decision of the surgeon.
Stent placement after URS is recommended by the latest European Association of Urology (EAU) guidelines if there is an increase in postoperative complications.
case of ureteral lesions, bleeding, residual fragments, perforation, urinary tract infection and and in patients who are at increased risk of complications.
Ureteral stent insertion after URS reduces the risk of ureteral stricture, which can lead to ureteral obstruction and obstructive nephropathy.
The stents sustain the patency of the ureter for drainage of stone Vol.
40 No 3 fragments to prevent steinstrasse formation and simultaneously resolve hydronephrosis.
However, ureteral stent insertion for the treatment of ureteral stone is still debatable, considering the stent-associated symptoms including hematuria, dysuria, and other discomforts such as stent fragmentation and .
Symptoms associated with stenting cannot be ignored and it is still controversial whether the patient should have a stent inserted after surgery.
The European Association of Urology (EAU) guidelines state that routine stenting after an uncomplicated URS procedure with clean stone removal is unnecessary.
A meta-analysis showed that stenting failed to improve the stonefree rate, and instead, it generated complications such as hematuria, irritative urinary symptoms, urinary infection, and dysuria, which were significantly higher in the stented group.
These symptoms may reduce the quality of life of affected patients.
Despite the recommendations made by the EAU and American Urological Association (AUA) guidelines, recent studies reported that there is an excessive use of ureteral stents among patients undergoing URS .
Stent placement is indicated in patients with symptomatic hydronephrosis and patients with renal dysfunction.
One study reported that 85.
2% of patients with symptomatic hydronephrosis showed symptom improvement after stent placement, .
while the failure rate of ureteral stent placement was reported to be 16Ae58%.
In view of this, we aimed to evaluate the role of ureteral stents in hydronephrosis resolution following URS lithotripsy in ureteral stone patients.
METHODS
Research design This was an analytical study with a prospective approach utilizing secondary data taken from the medical records of Dr.
Soetomo General-Academic Hospital from January 2018 to December 2019.
Widyokirono.
Kloping.
Rahman, et al Study subjects Total sampling was performed in this study.
thus, the sample size represents the whole population of all eligible patients admitted to the A total of 130 patients who had ureteral stones and underwent URS lithotripsy were included in this study.
The inclusion criteria of this study were male and female patients with ureteral stones who underwent URS lithotripsy, and were aged 18 years or above.
The exclusion criteria of this study were patients with comorbidities, history of malignancy, abnormal laboratory results, and patients with incomplete Patient assessment All patients were admitted to the hospital and assessed preoperatively by history and physical examination.
Laboratory data collected included full blood counts.
kidney function tests including serum creatinine, urea, sodium, and urine analyses.
and urine cultures.
Stone size and location were assessed preoperatively by plain abdominal radiographs of the kidneys, ureters, and bladder (KUB) and by non-enhanced computed tomography (CT).
Upper ureteric stones were defined as those located above the superior border of the sacroiliac joint.
Mid-ureteric stones were defined as those located between the superior and inferior borders of the sacroiliac joint, and distal ureteric stones as those located below the inferior border of the sacroiliac joint.
Statistical analysis All statistical values were presented as frequency and percentage.
Comparison of variables between groups with and without stent placement was analyzed using the Chi-square A p value of <0.
05 was considered statistically significant.
All statistical analyses in this study were performed using SPSS ver.
Ethical clearance This study was approved by the Health Ureteral stenting following ureteroscopic lithotripsy Research Ethical Committee.
Medical Faculty of Airlangga University .
5/KEPK/i/2.
All subjects participating in this study were informed about the aims and benefits of the study and signed informed consent during admission.
RESULTS
There were 130 patients with ureteric stones who underwent URS lithotripsy.
Table 1 displays the baseline characteristics of subjects, as well as their pre-operative status and stone Many patients who used stents after ureteroscopy (URS) were above 40 years old .
9%) with a mean age of 51.
12 years.
the patient group with a body mass index (BMI) <25 kg/m2 there were 29 patients .
3%) using stents and 16 patients .
6%) not using stents.
There was a significant difference in patientAos BMI among the stent users .
=0.
A total of 47 patients .
5%) with stones in the proximal ureter, 14 patients .
1%) with stones in the middle ureter and 38 patients .
4%) with stones in the distal ureter underwent stent insertion postURS.
Stone location did not have a significant correlation with stent placement post URS .
=0.
There were 68 patients .
7%) with one stone and 31 patients .
2%) with more than one stone that had stent placement.
however, the analysis results showed that there was no significant relationship between the number of stones and stent placement post-URS .
=0.
There were 61 patients .
6%) with ureteral stones less than 1 cm in diameter, 23 patients .
2%) with ureteral stones of 1-2 cm in diameter, and 15 patients .
1%) with stones of more than 2 cm.
The analysis results showed that the size of the stone had a significant effect on stent placement after URS .
=0.
Preoperative hydronephrosis was present in 53 patients, with 45 patients undergoing stent Table 2 displays the details regarding the intraoperative characteristics of the subjects, in which there were 13 out of 130 patients .
who experienced intraoperative complications and Univ Med Vol.
40 No 3 Table 1.
Patients demographic, stone characteristics and pre-operative status Characteristics Stent .
,%) Non Stent .
,%) p value Age .
< 40 Ou 40 14 .
Gender Male Female 70 .
BMI .
g/m.
* < 25 Ou 25 Stone size < 1 cm 1-2 cm > 2 cm Stone quantity Ou Pre-operative Yes *BMI : body mass index underwent stent placement.
There was a significant difference in complications in the stent group and the non-stent group during surgery .
=0.
Patients that underwent stent insertion had longer duration of surgery and there was a statistically significant difference when compared with the group without stents .
=0.
There were four patients with remaining stones and eleven patients with retropulsion of stones during the URS procedure and all of these patients had stent insertion.
The stone-free rate in the stent and non-stent groups was 84.
8% and 100%, respectively, and there was a significant Table 2.
Intraoperative characteristics during ureteroscopy procedure Characteristics Intraoperative complications None Present Duration of surgery .
A > 60
< 60
Stone free rate Free of stones Residual stone Retropulsion A difference between the two groups .
=0.
(Table .
Table 3 shows the postoperative characteristics of the subjects.
Most of the indications for stent placement in this study were the presence of lesions in the ureter, which occurred in 28 patients .
3%), followed by impacted stones in 20 patients .
2%).
There were also 16 patients .
2%) with residual stones, 14 patients .
1%) with a duration of surgery of more than 60 minutes, and 14 patients .
1%) in whom stent placement was the surgeonAos preference.
Stent .
,%) Non-Stent .
,%) p value 86 .
min : minutes Widyokirono.
Kloping.
Rahman, et al Ureteral stenting following ureteroscopic lithotripsy Table 3.
Characteristics of stent placement post- ureteroscopy Characteristic Post-operative complications None
Hematuria
Dysuria
Urinary retention Low back pain
Frequency Indications Ureteral lesions Impacted stones Residual stones Duration >60 mins Surgeon preferences Ureteral edema
Ureteral stricture Postoperative follow up None
PNL *
ESWL **
Stent size 6 French Stent indwelling time .
<90 >90 Hydronephrosis resolution after stenting Persisted Resolved Stent .
,%) Non-Stent .
,%) p value 61 .
n=45 4 .
* PNL: percutaneous nephrostolithotomy.
ESWL: extracorporeal shock wave lithotripsy On post-operative evaluation, the most frequent symptom that occurred in patients undergoing stent insertion was dysuria with a total of 18 patients and 4 patients without stents had the major complaint of low back pain.
There was a significant difference in postoperative complications between the stent and non-stent groups .
=0.
The majority of patients did not require further follow-up after URS, but four patients were planned for percutaneous nephrostolithotomy (PNL) and three patients needed ESWL afterwards.
All patients requiring ESWL and PNL after URS had stent placement.
In this study all patients used a 6 French stent.
total of 91 patients .
9%) had a stent indwelling time of less than 90 days, whereas in 8 patients .
1%) the stent indwelling time was more than 90 days, as shown in Table 3.
After stent placement, 41 patients .
1%) had their hydronephrosis resolved significantly compared with 5 .
5%) patients with non-stent placement .
=0.
However, the analysis showed that stent placement had a significant effect on the incidence of postoperative hydronephrosis in patients who had preoperative hydronephrosis.
DISCUSSION