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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 11  |  Issue : 3  |  Page : 282-286  

Preoperative ureteral stenting prior to ureteroscopy for management of urolithiasis does not impact the postoperative return for unplanned care


Department of Surgery, Division of Urology, Scott and White Medical Center, Temple, TX, USA

Date of Submission08-Jul-2018
Date of Acceptance01-Jun-2019
Date of Web Publication15-Jul-2019

Correspondence Address:
Dr. Andrew F Navetta
Department of Surgery, Division of Urology, Scott and White Medical Center, Temple, Desk 2D, 2401 S. 31st Street, Temple, TX 76508
USA
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DOI: 10.4103/UA.UA_78_18

PMID: 31413507

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   Abstract 

Introduction: Return for unplanned postoperative care is an important quality metric in the United States. Most of our postoperative return visits occur after ureteroscopy. Routine preoperative ureteral stenting is not recommended by the American Urological Association due to its impact on the quality of life, despite its proposed operative advantages. We evaluated the association between preoperative ureteral stenting and the resulting perioperative outcomes in the context of quality measures such as return to the emergency department (ED) and readmission rates.
Materials and Methods: After the Institutional Review Board approval, a retrospective review of patients undergoing ureteroscopy from February 2014 to present was conducted. Patient's demographics and perioperative outcomes were compared based on the presence or absence of a ureteral stent before ureteroscopy. Details and rates of nurse calls, returns to the ED, and readmissions within 90 days were also compared.
Results: A total of 421 instances of ureteroscopy, 278 prestented ureteroscopy (psURS), and 143 direct ureteroscopy (dURS) were included for analysis. Preoperative demographics were similar. The psURS cohort was more likely to undergo flexible ureteroscopy, utilized an access sheath more often (P < 0.0001), and had less ureteral dilation (P < 0.0001). Prestenting did not influence operative time (P = 0.8534) or stone-free rates (P = 0.2241). dURS patients were more likely to call the nurse; however, psURS versus dURS yielded no difference in return to the ED or readmission within 90 days.
Conclusions: In this study, preoperative stenting offered few operative advantages and did not meaningfully influence returns to the ED and readmissions within 90 days after ureteroscopy.

Keywords: Readmission, stent, ureteroscopy, urolithiasis


How to cite this article:
Navetta AF, Elmekresh A, Doersch K, Durdin TD, Machen G L, Cohen A, Lowry PS, El Tayeb MM. Preoperative ureteral stenting prior to ureteroscopy for management of urolithiasis does not impact the postoperative return for unplanned care. Urol Ann 2019;11:282-6

How to cite this URL:
Navetta AF, Elmekresh A, Doersch K, Durdin TD, Machen G L, Cohen A, Lowry PS, El Tayeb MM. Preoperative ureteral stenting prior to ureteroscopy for management of urolithiasis does not impact the postoperative return for unplanned care. Urol Ann [serial online] 2019 [cited 2019 Oct 16];11:282-6. Available from: http://www.urologyannals.com/text.asp?2019/11/3/282/262674




   Introduction Top


Quality measures are of increasing importance in today's health-care climate in the United States. Centers for Medicare and Medicaid Services are reducing payments to hospitals for readmissions within 30 days for certain diagnoses and procedures; likewise, quality measures impact physician reimbursement in many health systems. The association between preoperative double J (DJ) stenting and the resulting perioperative outcomes has not been well studied in the context of quality measures such as returns to the emergency department (ED) and readmission rates.

The American Urological Association (AUA) and Endourological Society recommend against the routine preoperative placement of an indwelling DJ ureteral stent before ureteroscopy for renal or ureteral calculi.[1] DJ stenting is associated with pain, irritative urinary symptoms, and hematuria, which can significantly impact a patient's quality of life.[2],[3] Despite this, the presence of a ureteral stent before definitive stone management by ureteroscopy has been reported to increase stone-free rates and decrease operative times perpetuating ongoing controversy on the topic.[4],[5],[6]

In this study, patient demographics, perioperative outcomes, and postoperative outcomes were compared based on the presence or absence of a DJ ureteral stent before ureteroscopy at our institution. The details and rates of nurse calls, returns to the ED, and readmissions within 90 days were also compared between the two groups.


   Materials and Methods Top


Patients

After the Institutional Review Board approval, a retrospective review of patients undergoing ureteroscopy for treatment of renal and/or ureteral calculi by eight surgeons at the authors' institution from February 1, 2014, to April 30, 2016 was performed. Four hundred and fifty-eight instances of ureteroscopy were identified during the study period through a search of the operative logs at the authors' institution for CPT codes 52352, 52353, and 52356. Patients were grouped based on whether they were prestented ureteroscopy (psURS) or went for direct ureteroscopy (dURS). Twenty-four patients were excluded because they were miscoded and underwent ureteroscopy for reasons other than stone. Eleven patients had inadequate follow-up data and were also excluded from the study. Three hundred and eighty-two patients who underwent 421 instances of ureteroscopy were ultimately included for the final analysis. Forty-one patients had repeat instances of ureteroscopy during the study period. Patient demographics and perioperative outcomes were compared along with details and rates of nurse calls, returns to ED, and readmissions within the first 90 days postoperatively.

Procedure

Perioperative evaluation, technique, and follow-up varied between surgeons at the studied institution. When absolute indications for ureteral stent are absent, preoperative stenting was performed based on surgeon and/or patient preference. It was found to be standard practice to treat positive preoperative urine cultures as per the AUA guidelines.

A 7.5 F fiber optic flexible and/or 7 F semi-rigid ureteroscope was used for the majority of cases. Necessity of ureteral dilation was decided by the surgeon and was typically performed either by using a 12 F ureteral balloon dilator or by serially passing the inner obturator alone and then the entire assembled ureteral access sheath. A 10/12 F or 12/14 F ureteral access sheath was placed when felt to be clinically indicated by the surgeon. This is also the case for postoperative ureteral stent placement.

Follow-up intervals and imaging modalities varied slightly between surgeons. It typically consisted of renal ultrasound with or without plain film abdominal X-ray at 6–8 weeks postoperatively. Patients were characterized as stone-free if documented in the operative report as visually and radiographically stone-free and/or on follow-up imaging.

Statistical analysis

All statistical analysis was performed in SAS 9.4 (SAS Institute Inc, Cary, North Carolina, USA). A Chi-square test or Fisher's exact test was used for bivariate comparison of categorical variables. Continuous variables were analyzed using the Wilcoxon Rank-Sum test. Generalized estimating equations were used to account for patients who had repeat instances of ureteroscopy during the study period. Statistical significance was defined as P < 0.05.


   Results Top


A total of 382 patients, who underwent 421 instances of ureteroscopy, 278 instances of psURS, and 143 instances of dURS during the study period, were included for the final analysis. Forty-one patients had repeat ureteroscopy. Patient demographics are summarized in [Table 1]. Age and body mass index were similar between the two groups. Prestented patients had higher American Society of Anesthesiologists (ASA) scores and were statistically more likely to be female.
Table 1: Patient demographics

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Preoperative urine culture was positive in 55 prestented patients versus 13 undergoing dURS (P = 0.0015). Stone location was categorized as either ureteral (proximal, mid, and distal) or renal based on the location of the most proximal stone, as this stone would be most likely to drive operative technique [Table 2]. Stone location was renal in 36.7% of dURS and 37.6% of psURS (P = 0.8541). When only a ureteral stone was treated, the dURS group had more distal location of stones compared with more proximal ureteral stones in the psURS group (P = 0.0009). Right ureteral stone size was larger in psURS versus dURS (7.00 mm ± 2.31 vs. 5.00 mm ± 2.13, P = 0.0039). There was no statistically significant difference in left ureteral, right renal, or left renal stone size between the two groups. Those who underwent a trial of passage were more likely to undergo dURS versus psURS (36.36% vs. 25.88%, P = 0.0353).
Table 2: Stone burden

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Operative times were similar, despite the presence or absence of a preoperative stent (70.70 min ± 45.66 min vs. 73.79 ± 48.92, P = 0.8534) [Table 3]. About 75.82% of psURS utilized flexible ureteroscopy alone or in combination with semi-rigid ureteroscopy, as compared with just 59.29% of dURS (P = 0.0007). A ureteral access sheath was placed more often in cases of psURS (66.55% vs. 45.07%, P < 0.0001); such patients required less ureteral dilation than those undergoing dURS (19% vs. 48.18%, P < 0.0001). Intraoperative failure of the procedure and/or ureteral injury were more common in the absence of a preoperative ureteral stent (P = 0.0092). There was an inability to reach the stone requiring stent placement and staged ureteroscopy in four dURS versus zero psURS. Intraoperative injury to the ureter occurred on four occasions during dURS and only once during psURS.
Table 3: Operative characteristics

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Stone-free rates (as documented in the operative report as visually and radiographically stone-free and/or on follow-up imaging within 90 days) were similar between the two groups (96.04% stone-free psURS vs. 93.71% stone-free dURS, P = 0.2441) [Table 3]. psURS patients were then stented postoperatively 91.37% of the time versus 80.42% of dURS (P = 0.0012).

Within the first 90 days postoperatively, 16.20% of dURS patients called the clinic nurse for a urologic reason directly related to their surgery compared with 8.99% of prestented patients (P = 0.0263) [Table 4]. Despite calling the nurse more often, dURS patients returned to the ED at a similar rate compared to psURS patients within 90 days of surgery (15.49% vs. 15.47%, P = 0.9854). PsURS patients were readmitted from the ED (7.22%) of the time while dURS only 4.23% of the time. However, this did not reach statistical significance (P = 0.2797). The most common urologic reasons for a return to the ED were pain, infection, and hematuria. When stratified for a return to the ED within 90 days for urologic reasons only, psURS patients tended to return at lower rates when compared to dURS (8.66% vs. 11.97%); however, this was not statistically significant (P = 0.2942). Prestented patients returned to the ED more frequently for non-urologic reasons than dURS (19 vs. 5 patients).
Table 4: Nurse calls, return to emergency department, and readmission within 90 days

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For those who had a postoperative stent, psURS and dURS tended to return to the ED similarly after the ureteral stent was removed (68.97% vs. 61.54%, P = 0.7291). The time from surgery to return to ED or from stent removal to ED did not differ between prestented and dURS patients (7.5 days ± 24.33 vs. 8.5 days ± 21.40, P = 0.9880) (3.5 days ± 25.61 vs. 7.0 days ± 21.3, P = 0.8073). Of all patients that returned to the ED, those who returned for urologic reasons presented sooner than those who presented for other reasons (5 days ± 11.55 vs. 27.50 days ± 26.20, P < 0.0001) within the first 90 days postoperatively.


   Discussion Top


In a matched-pair analysis of 246 patients, and using a similar definition of “stone-free” to the present study, Netsch et al.[5] showed a statistically significant improvement in stone free rate (SFR) (98.2% psURS vs. 83.3% dURS) for those with large stones ≥5 mm. Using a strict definition of stone-free, Rubenstein et al.[4] demonstrated similar findings of statistically significant improvement in SFR in favor of psURS. Meanwhile, other studies have shown no statistically demonstrable impact on stone-free rates,[6],[7] and in the present study, SFR favors psURS 96.04% versus 93.71% but does not reach significance.

Operative times were also similar between the psURS and dURS groups in this study. The time that is purportedly saved by already having access to the ureter in psURS is likely mitigated by the more proximal location of ureteral stones, need for flexible ureteroscopy, and more prevalent use of ureteral access sheath and the associated time needed to place it. The majority of retrospective studies on the topic are in line with our findings.[4],[5],[8] Chu et al.[9] demonstrated shorter total operative times for prestented patients with overall stone burdens >1 cm; however, similarly, there was no difference for stone burdens <1 cm.

The conflicting perioperative results with regard to SFR and operative times highlight the relatively low level of evidence on psURS versus dURS and the need for randomized prospective studies on the topic.

The negative impact of ureteral stenting on the quality of life is a central feature of the AUA/Endourological Society Guideline. Through validation studies of the Ureteral Stent Symptom Questionnaire, Joshi et al.[2] found that of 85 patients with a unilateral indwelling ureteral stent, 76% reported bothersome urinary symptoms, 80% experienced pain directly attributed to the stent, 32% reported sexual dysfunction, and 58% noted that the stent had a negative impact on work performance.

How patients experience symptoms related to a ureteral stent may impact unscheduled postoperative care in the form of nurse calls, return to the ED, and readmission. The Affordable Care Act has addressed this problem with the Hospital Readmissions Reduction Program, which penalizes hospitals for readmissions within 30 days for certain diagnoses and surgical procedures. Though ureteroscopy is not included on the list, the creation of this program highlights a theme moving forward that may be relevant for many surgeons and subspecialists, including urologists. Similarly, some institutions, including our own, already reimburse urologists based on these quality measures.

Prior study has been directed at postoperative stent status and unplanned return to the ED after ureteroscopy. A recent meta-analysis performed by Pais et al.[10] showed a 60% increase in the risk of unplanned ED return when a postoperative stent was omitted. In the present study, psURS patients were stented postoperatively at a significantly higher rate than dURS patients. psURS patients trended toward lower 90-day return to ED rates, but this did not reach statistical significance and could be explained by confounding postoperative stent status. dURS patients also called to the nurse for urologic reasons more often than psURS, and it is unclear whether or not this deterred them from presenting to the ED as compared with psURS patients who used this resource less often.

The presence of a ureteral stent and the passive dilation it provides (as evidenced in this study by lower rates of ureteral dilation, ureteral injury, and failure to reach the stone) does not seem to offer advantages in how patients experience pain after the procedure. Pain was the most common reason for return to ED in both psURS and dURS groups. Both psURS and dURS patients who were stented postoperatively returned to the ED at similar rates with the stent still in place. This indicates that the experience of having a stent preoperatively has little impact on the pain that is experienced postoperatively compared to dURS.

Readmission within 90 days after ureteroscopy trended toward a higher rate in psURS patients but did not reach statistical significance. psURS patients tended to have higher ASA scores and presented at higher rates for non-urologic reasons, which may explain this finding. Interestingly, those who returned to ED within 90 days for urologic reasons presented sooner than those who presented for other reasons. With physician compensation becoming more and more reliant on quality measures such as these, the future study may be useful in delineating appropriate return to ED time cutoffs so that physicians are not subject to penalties that are not directly related to the surgery performed.


   Conclusions Top


In this study, preoperative ureteral stent placement offers few operative advantages and does not offer meaningful influence to quality measures such as return to ED and readmission within 90 days after ureteroscopy. Future prospective studies would be useful to further evaluate.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Assimos D, Krambeck A, Miller NL, Monga M, Murad MH, Nelson CP, et al. Surgical management of stones: American Urological Association/Endourological Society Guideline, PART I. J Urol 2016;196:1153-60.  Back to cited text no. 1
    
2.
Joshi HB, Stainthorpe A, MacDonagh RP, Keeley FX Jr., Timoney AG, Barry MJ, et al. Indwelling ureteral stents: Evaluation of symptoms, quality of life and utility. J Urol 2003;169:1065-9.  Back to cited text no. 2
    
3.
Joshi HB, Newns N, Stainthorpe A, MacDonagh RP, Keeley FX Jr., Timoney AG, et al. Ureteral stent symptom questionnaire: Development and validation of a multidimensional quality of life measure. J Urol 2003;169:1060-4.  Back to cited text no. 3
    
4.
Rubenstein RA, Zhao LC, Loeb S, Shore DM, Nadler RB. Prestenting improves ureteroscopic stone-free rates. J Endourol 2007;21:1277-80.  Back to cited text no. 4
    
5.
Netsch C, Knipper S, Bach T, Herrmann TR, Gross AJ. Impact of preoperative ureteral stenting on stone-free rates of ureteroscopy for nephroureterolithiasis: A matched-paired analysis of 286 patients. Urology 2012;80:1214-9.  Back to cited text no. 5
    
6.
Chu L, Farris CA, Corcoran AT, Averch TD. Preoperative stent placement decreases cost of ureteroscopy. Urology 2011;78:309-13.  Back to cited text no. 6
    
7.
Shields JM, Bird VG, Graves R, Gómez-Marín O. Impact of preoperative ureteral stenting on outcome of ureteroscopic treatment for urinary lithiasis. J Urol 2009;182:2768-74.  Back to cited text no. 7
    
8.
Lumma PP, Schneider P, Strauss A, Plothe KD, Thelen P, Ringert RH, et al. Impact of ureteral stenting prior to ureterorenoscopy on stone-free rates and complications. World J Urol 2013;31:855-9.  Back to cited text no. 8
    
9.
Chu L, Sternberg KM, Averch TD. Preoperative stenting decreases operative time and reoperative rates of ureteroscopy. J Endourol 2011;25:751-4.  Back to cited text no. 9
    
10.
Pais VM Jr., Smith RE, Stedina EA, Rissman CM. Does omission of ureteral stents increase risk of unplanned return visit? A systematic review and meta-analysis. J Urol 2016;196:1458-66.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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