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Are Ureteral Stents More Trouble Than They're Worth?
Abstract & Commentary
By Joseph E. Scherger, MD, MPH, Professor, University of California, San Diego. Dr. Scherger reports no financial relationship to this field of study.
Synopsis: In a systematic review and meta-analysis of worldwide data on the placement of ureteral stents after ureteroscopy in patients with kidney stones, the authors found higher morbidity with lower urinary tract problems and no benefit on stone-free rate, rate of urinary tract infection, requirement for analgesia or long term ureteral stricture formation.
Source: Nabi G, et al. BMJ. 2007;334:572.
Ureteral stents are commonly placed by urologists after ureteroscopy in patients with kidney stones. Using the Cochrane controlled trials registry, these authors from Scotland did a systematic review and meta-analysis of 9 identified randomized controlled trials looking at clinical outcomes with and without stenting after ureteroscopy. Eight hundred thirty-one patients were identified. The incidence of lower urinary tract symptoms was significantly higher in patients who had a stent inserted (relative risk 2.25). For dysuria, the relative risk was 2.00, and for frequency or urgency, 1.11.
Among patients with ureteral stents, there were no significant benefits, nor difference in postoperative requirement for analgesia, urinary tract infections, stone free rate, or ureteral strictures. Costs were higher in the group with stents. None of the trials reported on health-related quality of life.
The authors point out that the quality of the trials was poor, with marked heterogeneity of study methods which limited the power of the systematic review. While these findings suggest that the complications of ureteral stents exceed any benefits in patients with uncomplicated ureteroscopy, the authors state that this area remains unclear and that better randomized controlled trials should be done.
This study caught my eye since my experience with ureteral stents has been consistently negative. First of all, the great majority of patients with kidney stones may be treated conservatively with analgesia, hydration, and observation. Time heals. A referral to a urologist in the acute phase may result in the patient undergoing ureteroscopy. As stents became common practice, I often asked why, especially when the patients came back with pain and dysuria. Did my patient really need to have this foreign body and when can we get it out?
Uncomplicated kidney stones should by managed by primary care physicians, emergency room physicians or hospitalists. Imaging can identify patients who are developing serious obstruction. A few more days of analgesia is usually better than a procedure with a high complication rate. Even if ureteroscopy is indicated, ask whether the patient really needs a stent before it is placed. By avoiding stents, we will not have to deal with their complications.