Vol.

39 (2): 203-208, March - April, 2013

ORIGINAL Article
doi: 10.1590/S1677-5538.IBJU.2013.02.08

Emergency double-J stent insertion following

uncomplicated Ureteroscopy: risk-factor analysis and
recommendations
_______________________________________________
Yousef S. Matani, Mohammed A. Al-ghazo, Rami S. Al-azab, Osamah Bani-hani, Daher K. Rabadi

Department of General Surgery and Urology (YSM, MAA, RSA, OB) and Department of Anaesthesia
(DKR) Jordan University of Science and Technology, Faculty of Medicine, King Abdullah University
Hospital, Irbid-Jordan

ABSTRACT ARTICLE INFO

_________________________________________________________ ___________________
Purpose: Emergency double-J (DJ) stenting following “uncomplicated” ureteroscopic Key words:
(UURS) stone treatment is both morbid and costly. Our study aims at identifying those Ureteroscopy; Calculi; Stents;
patients who are more likely to require such an extra procedure. Handling of this com- Emergencies
plication will also be highlighted.
Materials and Methods: 319 cases of UURS cases were selected out of 903 patients, who Int Braz J Urol. 2013; 39: 203-8
were admitted for URS stone treatment at King Abdullah University Hospital during the
period from May, 2003 to December, 2010. Thirty-eight of them (11.9%) had emergency
__________________
post-URS DJ stenting within 24 hours of discharge. The medical records of all UURS cases Submitted for publication:
were retrospectively reviewed. Comparison in demographic and stone-related variables June 06, 2012
was made using 2-paired t-test with P < 0.05. Operative findings of 38 stented patients
__________________
were outlined.
Results: Significant risk factors for emergency stenting were noted in males with larger (> Accepted after revision:
1.5 cm) and proximal stones (38 stented vs. 281 unstented). Operative risk factors among January 15, 2013
the 38 patients were: initial procedure time > 45 minutes (42.1%), ureteral wall edema
(21.1%), repeated access for stones > 1.5 cm (21.1%), impacted stone (10.5%) and ignored
or missed stones/fragments (4.6%).
Conclusions: The need for emergency DJ stenting following UURS stone treatment is not
uncommon. The routine insertion is impractical and weakly-supported. With risk-factor
stratification, selective and individualized DJ stenting policy is recommended.

INTRODUCTION

Fragmentation and clearance of ureteric The insertion of double-J (DJ) stent du-
stones can either be achieved by extracorporeal ring URS stone extraction is controversial. Since
shock wave lithotripsy (ESWL) or ureteroscopy the pioneering report by Hosking et al. (2) and the
stone treatment (URS). URS stone removal has radical characterization by Moon (3), urologists
been found to carry a better overall stone-free rate started to adopt a more selective policy.
compared to ESWL. The Current European guide- Complications of DJ stent insertion inclu-
lines recommend primary use of URS in treatment de disturbing storage lower urinary tract symp-
of most ureteric stones (1). toms, pain, hematuria, infection and poorer qua-

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 ibju | Emergency double-J stent: risk-factor analysis and recommendations

lity of life (4,5). It is, however, thought to reduce negative. Prophylactic antibiotic was given at induc-
post URS obstruction, facilitate clearance of stone tion as a single 1 g IV ceftriaxone. Subsequently,
fragments and decrease stricture rate (6,7). 500mg oral ciprofloxacin tablets were given twice
The definition of uncomplicated URS daily for 24 hours.
(UURS) is both lacking and weakly standardized. The stone size and location were determined
Denstedt et al. defined UURS as a procedure with by KUB and NECT films. They were divided into pro-
“no evidence of perforation or lack of clinically ximal, middle and distal third ureteral stones. URS
important edema”. Free flow of contrast into the stone extraction was achieved by Dormia basket
bladder on retrograde pyelography is exclusive of and/or forceps.
edema (8). Other studies used an endoscopic, non- Thirty-eight out of 319 UURS had emer-
-validated grading of ureteric edema on a scale of gency stent insertion within 24 hours of initial URS
0 (mild) to 2 (severe) (6,9). due to intolerable colic and significant discomfort.
Our study will look at risk-group stratifi- Diagnostic URS was performed, prior to stenting, for
cation of patients who might require stenting du- defining a possible etiology or injury. A height-ma-
ring their initial “UURS” and address the concept tched length 6F DJ stent was used. Discharge was
of “prophylactic” DJ stent use. made within 24 hours and the stent was removed
after 1-2 weeks.
MATERIALS AND METHODS The demographic features, stone-related
factors and operative URS findings were analyzed
From May 2003 to December 2010, 903 pa- and tabulated. Comparison between those stented
tients had undergone semirigid URS with Holmium and un-stented (38 vs. 281) groups was made using
laser (365 micron; 0.5-1.4J/5-10 Hz) lithotripsy. All 2-tailed t-test statistics. A P < 0.05 was taken as
patients were admitted to the urology department at the level of significance. The analysis was performed
King Abdullah University Hospital and their medical with computer software (Statistical Package for the
records retrospectively analyzed. All patients had a Social Sciences, version 16.0).
preoperative consent. Imaging studies included kid-
ney-ureter-bladder (KUB) X-ray and non-enhanced RESULTS
computed tomography (NECT).
Among a total of 903 patients, 319 un- Thirty eight of the 319 UURS (11.9 %) pa-
derwent primary “straightforward” UURS which was tients had emergency stent insertion. The proce-
defined based on the following selection criteria: dure was complication-free. The mean operative
1. All had single and unilateral ureteric time was 25 minutes. The demographic and sto-
stone; ne-related variables of the study group are listed
2. Intra-operative perforation was not in Table-1. Twenty seven patients were men and
documented; 11 women (2.5:1), with a mean age of 38.2 ye-
3. DJ stent and/or ureteric catheter were ars (range 28-62). The stones included 9 proxi-
not inserted; mal (23.7%), 11 mid-ureter (28.9%), and 18 distal
4. Ureteric dilatation and/or usage of stones (47.4%). Average stone diameter was 10.2
access catheter were not used; cm (range 7-23 mm).
5. Children and pregnant ladies were Significant preoperative risk variables in-
excluded; cluded male sex (P = 0.037) and proximal stones
6. Stone free after the procedure was (P = 0.018). Average ages were comparable (38.2
documented (defined as complete vs. 39.1 years, P = 0.30). Average stone diameter
removal and/or residual stone frag- was 1.2 cm and 0.94 cm in the stented and un-
ments < 3 mm in diameter). -stented groups, respectively (P = 0.06).
URS was performed, using 8/9.8 semirigid The URS findings are listed in Table-2.
ureteroscope (Richard Wolf, Germany), under ge- Relevant risk factors included: operative time su-
neral anesthesia in all patients. Urine cultures were perior to 45 minutes in 16 patients (42.1%), repe-

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Table 1 - Demographics and stone features. Table 2 - URS findings prior to DJ stenting (Risk factors).

No. of patients 38 No. of patients 38

sex(M:F) 2.5:1(27/11) Mean operative time(minutes) 25

Mean age in years(Range) 38.2 (28-62) Risk factors

Stone Operative time > 45 minutes 16(42.1%)

Mean size in mm (range) 10.2(7-23) localized wall edema 8(21.1%)

Location Repeated access for stones >1.5 cm 8(21.1%)

Upper 9(23.7%) Impacted stone 4(10.5%)

Middle 11(28.9%) Ignored small calyceal stone 1(2.3%)

Lower 18(47.4%) Residual stone fragment < 3 mm 1(2.3%)

ated access through the ureteral orifice for larger tency and lack of standardization. They, therefore,
stones (> 1.5 cm) in 8 (21.1%), localized wall ede- kept the issue of stenting open (5). Similar con-
ma in 8 (21.1%), handling of impacted stones in 4 clusions were reached by three recent evaluations
(10.5%), ignored small calyceal stone in 1 patient (13-15). They, basically, advised against routine DJ
(2.3%) and residual stone fragments < 3mm in 1 stenting and were not satisfied by homogeneity and
patient (2.3%). Control and comparison of these pooling of materials. An excellent review of this di-
risk factors with the unstented group would have lemma was expressed by Keeley and Timoney (16)
been contributory but clearly unethical. who identified the pros and cons of stenting and
advised for more meaningful studies.
DISCUSSION The use of an alternative and temporary drai-
nage procedure has, recently, been considered. It uti-
URS was first reported in 1982 (10) by Pe- lizes short-term insertion of ureteric catheters. This
rez-Castro in cooperation with Karl Storz. The use of accessory procedure may overcome edema, reduce
stents during this period was not only strange, but pain, decrease outpatient visits, avoid secondary en-
also unfavorable. Eisenberger referred to stents as doscopy and limit costs. Djaladat et al. were able to
‘‘Steckerin’’ (Bavarian for small sticks) (11). DJ stent show that pain, storage LUTS and outpatient visits
was first described by Finney et al. in 1978 (12). were significantly reduced in the catheter group.
Criticism to its role, however, appeared in the late Urinary tract infection (UTI) was established in 7 and
90s (2,3). Nowadays, the urologists remain, sharply, 4 % in catheter and non-catheter groups respecti-
divided on the need for stenting following UURS vely. Readmission and stone clearance rates were
treatment of lithiasis. Both routine and selective comparable in a 2-week follow up (17). Reduction
use has been practiced. Selective use, in particular, in pain and international prostate symptom scores
should depend on a variety of variables related to was noted in one-day post-URS catheterization (18).
patients, stones, technology and experience. Baseless avoidance of stenting carries me-
Nabi et al. meta-analyzed 9 trials and con- asureable morbidity and cost. DJ stenting is bene-
cluded that stents have significantly higher rate of ficial when obstruction secondary to edema and/or
storage lower urinary symptoms (LUTS), infection, inflammation was anticipated (19). It is, also, effec-
analgesia use, and ureteric stricture. Stenting, on the tive in reducing pain and promoting drainage in
other hand, did not influence rates of stone clearan- hydronephrosis (20). Cheung et al. highlighted the
ce. The authors, however, criticized data inconsis- value of selection in reducing overall stenting rate

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 ibju | Emergency double-J stent: risk-factor analysis and recommendations

without altering stone-free outcome. Their stenting In this analysis, higher risk of emergency
rate was 39% and limited to impacted stones, severe stenting was noted among males with larger and
preoperative obstruction and residual poor postope- more proximal ureteric stones. The impact of stone
rative drainage (21). Stents were, additionally, found location and size might be explained by increased
useful in pregnant ladies (22), in upper urinary tract manipulation, repeated access and development of
diseases (urolithiasis) (23) and when ureteral access wall edema. Increased risk in males is, however,
sheath was used (24). Factors that contribute to DJ- difficult to justify. Comparable Intraoperative risk
-associated morbidity include stent design, size, po- factors were reported in a similar recent study by
sitioning, associated UTI, and duration (25). Recent Tanriverdi et al. (28). Summary of variables is listed
use of drug eluting stents (26) and alpha blockers in Table-3. In their analysis, about 2/3 of cases had
(27) were reported to cause less pain and discomfort. prolonged procedure, repeated access and ureteral

Table 3 - Summary of data: current and reference no. 28 studies.

Current Ref. 28

No. of patients (%) 38/319 (11.9) 23/276 (8.3)

Sex(M:F) 2.5:1(27:11) 1.5:1(14:9)

Mean age in years(Range) 38.2 (28-62) 41.5

Stone:

Mean size in mm (range) 10.2(7-23) 12(9-22)

Location (%)

Upper 9(23.7) 6(26.1)

Middle 11(28.9) 6(26.1)

Lower 18(47.4) 11(47.8)

Mean operative time(minutes) 25 14

Etiology & Risk factors: (%)

Operative time (minutes) > 45 in 16(42.1) > 60 in 9(39.1)

Localized wall edema 8(21.1) 10(43.5)

Repeated access for stones > 1.5 cm 8(21.1) 6(26.1)

Impacted stone 4(10.5) 4(17.4)

Small calyceal stone Ignored in 1(2.3) Unrecognized in 4(17.4)

Left/retained stone fragments < 3 mm in 1(2.3) < 4mm in 3(13.1)

Obstructing blood clots 0 4(17.4)

Kinking of ureter 0 2(8.7)

Relatively narrowed segment 0 2(8.7)

UTI 0 1(4.4)

Nonspecific findings - 9(39.1)

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 ibju | Emergency double-J stent: risk-factor analysis and recommendations

wall edema. Additional causes of postoperative 7. Lumma PP, Schneider P, Strauss A, Plothe KD, Thelen P, Ring-
obstruction were linked to residual or missed stones, ert RH, et al.: Impact of ureteral stenting prior to ureterore-
blood clots, kinking or narrowed segments and UTI. noscopy on stone-free rates and complications. World J Urol.
We do agree with the arguments raised 2011. Oct 29. [Epub ahead of print]
against routine DJ stenting in UURS stone treat- 8. Denstedt JD, Wollin TA, Sofer M, Nott L, Weir M, D’A Honey
RJ: A prospective randomized controlled trial comparing non-
ment (5,13-15,28,29). Insertion should better be
stented versus stented ureteroscopic lithotripsy. J Urol. 2001;
individualized. Relative indications might include
165: 1419-22.
prolonged procedure (> 45 minutes), “significant” 9. Cheung MC, Lee F, Leung YL, Wong BB, Tam PC: A prospective
wall edema, repeated access, impacted stone, lar- randomized controlled trial on ureteral stenting after uretero-
ger stones (> 1.5 cm), use of access sheath, ureteric scopic holmium laser lithotripsy. J Urol. 2003; 169: 1257-60.
dilatation and pregnancy. Complete removal and 10. Pérez-Castro Ellendt E, Martínez-Piñeiro JÁ: Ureteral and renal
clearance of stone(s)/fragments are highly recom- endoscopy. A new-approach. Eur Urol. 1982; 8: 117-20.
mended. The use of ureteric catheterization was 11. Rassweiler J: A landmark paper for endourology. Eur Urol.
not tested in our analysis. 2006; 50: 395.
12. Finney RP: Experience with new double J ureteral catheter
CONCLUSIONS stent. J Urol. 1978; 120: 678-81.
13. Pengfei S, Yutao L, Jie Y, Wuran W, Yi D, Hao Z, et al.: The
results of ureteral stenting after ureteroscopic lithotripsy for
Insertion of DJ stents during UURS treat-
ureteral calculi: a systematic review and meta-analysis. J Urol.
ment of stones is neither Angel nor Evil. Its role
2011; 186: 1904-9.
has not yet been decisively outlined. Stent inser- 14. Tang L, Gao X, Xu B, Hou J, Zhang Z, Xu C, et al.: Placement of
tion remains “optional” and a consensus is still ureteral stent after uncomplicated ureteroscopy: do we really
remote. A risk-based selection may prove to be a need it? Urology. 2011; 78: 1248-56.
better practice. In difficult and lengthy URS pro- 15. Song T, Liao B, Zheng S, Wei Q: Meta-analysis of postopera-
cedures with significant stone burden, DJ stenting tively stenting or not in patients underwent ureteroscopic litho-
should be seriously considered. tripsy. Urol Res. 2012; 40: 67-77.
16. Keeley FX Jr, Timoney AG: Routine stenting after ureteroscopy:
CONFLICT OF INTEREST think again. Eur Urol. 2007; 52: 642-4.
17. Djaladat H, Tajik P, Payandemehr P, Alehashemi S: Ureteral
None declared. catheterization in uncomplicated ureterolithotripsy: a random-
ized, controlled trial. Eur Urol. 2007; 52: 836-41.
18. Moon KT, Cho HJ, Cho JM, Kang JY, Yoo TK, Moon HS, et al.:
REFERENCES Comparison of an Indwelling Period Following Ureteroscopic
Removal of Stones between Double-J Stents and Open-End-
1. Preminger GM, Tiselius HG, Assimos DG, Alken P, Buck AC, ed Catheters: A Prospective, Pilot, Randomized, Multicenter
Gallucci M, et al.: 2007 Guideline for the management of ure- Study. Korean J Urol. 2011; 52: 698-702.
teral calculi. Eur Urol. 2007; 52: 1610-31. 19. Wang CJ, Huang SW, Chang CH: Indications of stented uncom-
2. Hosking DH, McColm SE, Smith WE: Is stenting following ure- plicated ureteroscopic lithotripsy: a prospective randomized
teroscopy for removal of distal ureteral calculi necessary? J controlled study. Urol Res. 2009; 37: 83-8.
Urol. 1999; 161: 48-50. 20. Mustafa M: The role of stenting in relieving loin pain follow-
3. Moon TD: Ureteral stenting--an obsolete procedure? J Urol. ing ureteroscopic stone therapy for persisting renal colic with
2002; 167: 1984. hydronephrosis. Int Urol Nephrol. 2007; 39: 91-4.
4. Netto NR Jr, Ikonomidis J, Zillo C: Routine ureteral stenting 21. Cheung MC, Yip SK, Lee FC, Tam PC: Outpatient ureteroscopic
after ureteroscopy for ureteral lithiasis: is it really necessary? J lithotripsy: selective internal stenting and factors enhancing
Urol. 2001; 166: 1252-4. success. J Endourol. 2000; 14: 559-64.
5. Nabi G, Cook J, N’Dow J, McClinton S: Outcomes of stent- 22. Akpinar H, Tüfek I, Alici B, Kural AR: Ureteroscopy and hol-
ing after uncomplicated ureteroscopy: systematic review and mium laser lithotripsy in pregnancy: stents must be used post-
meta-analysis. BMJ. 2007; 334: 572. operatively. J Endourol. 2006; 20: 107-10.
6. Ryan PC, Lennon GM, McLean PA, Fitzpatrick JM: The effects 23. Hao P, Li W, Song C, Yan J, Song B, Li L: Clinical evaluation
of acute and chronic JJ stent placement on upper urinary tract of double-pigtail stent in patients with upper urinary tract dis-
motility and calculus transit. Br J Urol. 1994; 74: 434-9. eases: report of 2685 cases. J Endourol. 2008; 22: 65-70.

207
 ibju | Emergency double-J stent: risk-factor analysis and recommendations

24. Rapoport D, Perks AE, Teichman JM: Ureteral access sheath 27. Yakoubi R, Lemdani M, Monga M, Villers A, Koenig P: Is there
use and stenting in ureteroscopy: effect on unplanned emer- a role for α-blockers in ureteral stent related symptoms? A sys-
gency room visits and cost. J Endourol. 2007; 21: 993-7. tematic review and meta-analysis. J Urol. 2011; 186: 928-34.
25. El-Nahas AR, El-Assmy AM, Shoma AM, Eraky I, El-Kenawy 28. Tanriverdi O, Yencilek F, Koyuncu H, Yencilek E, Sarica K: Emer-
MR, El-Kappany HÁ: Self-retaining ureteral stents: analysis of gent stenting after uncomplicated ureteroscopy: evaluation of
factors responsible for patients’ discomfort. J Endourol. 2006; 23 patients. Urology. 2011; 77: 305-8.
20: 33-7. 29. Hollenbeck BK, Schuster TG, Seifman BD, Faerber GJ, Wolf JS
26. Krambeck AE, Walsh RS, Denstedt JD, Preminger GM, Li J, Jr: Identifying patients who are suitable for stentless ureteros-
Evans JC, et al.: A novel drug eluting ureteral stent: a prospec- copy following treatment of urolithiasis. J Urol. 2003; 170:
tive, randomized, multicenter clinical trial to evaluate the safety 103-6.
and effectiveness of a ketorolac loaded ureteral stent. J Urol.
2010; 183: 1037-42.
_____________________
Correspondence address:
Dr. Yousef S. Matani
Associate professor of Urology
Department of General Surgery and Urology,
Faculty of Medicine
Jordan University of Science and Technology
Irbid, Jordan
Um Al-sommaq Post Office, PO Box 2171
11821 Amman, Jordan
Telephone: +96 279 557-2751
E mail: ymatani@gmail.com

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