Clinical Effectiveness of Single Pigtail Suture Stent on Patient Comfort: A Double-Blind Prospective Randomized Trial

Patients undergoing double J substitution with a pigtail suture stent report a significant decrease of stent-related symptoms. Results from a prospective multicenter longitudinal trial

PURPOSE

To compare stent-related symptoms (SRS) in patients with double J (DJ) undergoing substitution with a pigtail suture stent (PSS) after ureteroscopy (URS), through the Ureteral Stent Symptom Questionnaire (USSQ).

MATERIALS AND METHODS

Patients with DJ undergoing URS for stone treatment were enrolled in this prospective multicenter longitudinal study. The USSQ was submitted thrice: 2 weeks after DJ, 2 weeks after PSS and 4 weeks after PSS removal (baseline).

PRIMARY ENDPOINT

to compare Urinary Symptom Index Score and the rate of patients with pain 2 weeks after DJ and PSS. Secondary endpoints: to compare other USSQ scores and single answers 2 weeks after DJ and PSS, and DJ and PSS USSQ scores with baseline.

RESULTS

93 patients were enrolled. 2 weeks Urinary Symptom Index Score (p < 0.001) and the percentage of patients complaining of pain (60.2% vs 88.2%, p < 0.001) were significantly in favour of PSS compared to DJ. 2 weeks scores were significantly improved with PSS compared to DJ: Pain Index (p < 0.001), VAS (p < 0.001), General Health Index (p < 0.001) and Work Performance Index (p < 0.001). All urinary symptoms were significantly decreased with PSS, including renal pain during micturition and pain interfering with life. Pain Index Score (p = 0.622) and VAS (p = 0.169) were comparable to baseline with PSS, while differed with DJ.

CONCLUSIONS

Patients undergoing DJ substitution with PSS after URS report a significant decrease of SRS. Urologists may consider positioning PSS after URS in pre-stented patients to reduce the impact of SRS.

Suture Stenting After Sialendoscopy: A Novel Technique That Reduces Risk of Recurrent Parotitis

OBJECTIVE

Chronic sialadenitis is associated with decreased quality of life and recurrent infections. While sialendoscopy with stenting is effective in relieving symptoms of sialadenitis, currently available stents are rigid and poorly tolerated by patients, leading to early removal and potential for adverse scarring. This study examines whether sutures can be used as a stenting material to improve patient comfort and reduce recurrence risk.

METHODS

This is a retrospective cohort study of a consecutive series of adult patients with chronic sialadenitis undergoing sialendoscopy with or without suture stenting. Data were collected between 2014 and 2018 with a 3-year follow-up period ending in 2021. The primary outcome measure was recurrence of sialadenitis within 3 years of surgery. Secondary outcomes were stent dislodgement and patient-reported discomfort.

RESULTS

We included 63 patients with parotid sialadenitis of whom 28 underwent suture stenting and 35 did not receive stenting after sialendoscopy. Stents were well tolerated, with a mean duration of 34.5 days, and only 2 of 28 stents (7.1%) accidentally dislodged within the first week. Suture stenting significantly reduced symptom recurrence after sialendoscopy (OR = 0.09, 95% CI 0.02-0.45, p = 0.003; 3-year sialadenitis recurrence rate: 7.1% vs. 45.7%, p = 0.005). Cox multivariate regression for clinicodemographic variables showed an HR of 0.04 (95% CI 0.01-0.19, p < 0.001) for the risk of symptom recurrence.

CONCLUSIONS AND RELEVANCE

Suture stenting after sialendoscopy is low cost, available across all institutions, well-tolerated by patients, and highly efficacious in reducing risk of recurrent sialadenitis after sialendoscopy.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:614-621, 2024.

Complete Intraureteral Stents Decrease Urinary Symptoms Compared with Conventional Ureteral Stents: A Systematic Review and Meta-Analysis

Introduction: Up to 80% of stent patients report urinary discomfort, negatively impacting their daily activities and quality of life. Conventional Double-J ureteral stents (DJSs) can cause adverse kidney and bladder-related symptoms. Complete intraureteral stents (CISs) may reduce bothersome bladder symptoms by reducing foreign material in the bladder. We sought to aggregate and analyze ureteral stent symptom questionnaire (USSQ) data from the available randomized controlled trials comparing CISs with conventional ureteral stents. Methods: In February 2023, a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review was performed to identify studies that evaluated the use of CISs and reported outcomes using the USSQ score. Two authors (D.E.H.-G. and G.S.) independently extracted and analyzed data using Review Manager 5.41. Heterogeneity was assessed using Higgins I2%, with values >50% considered heterogeneous and analyzed with a random effects model; otherwise, a fixed effects model was used. The results are presented as the mean difference (MD) with 95% confidence intervals (CIs). We set our significance level at p = 0.05. Results: Six randomized controlled clinical trials compared CISs with DJSs, but only five trials reported the USSQ score. Among these patients, 235 had CISs, whereas the remaining 259 had DJSs or loop-tail stents and served as controls for 494 patients. Urinary symptoms scores were lower in the CIS group (MD -5.19, 95% CI: [-5.89 to -4.50], p < 0.0001). Pain scores were also lower in the CIS group (MD -1.90 [-2.63 to -1.16] p < 0.00001). General health and work performance domains were similar between the groups. A 2.5% stent failure or migration rate requiring endoscopic intervention was reported in the CIS group compared with 0.3% in the DJS group (odds ratio 4.01 [0.96-16.76] p = 0.06). Conclusions: CISs significantly decrease urinary symptoms and pain associated with conventional indwelling ureteral stents. However, further trials are needed to determine the optimal patient selection for this type of stent.

Comparation of intraureteral stent and conventional stent at different stages: a systematic review with meta-analysis

INTRODUCTION

Stent related symptom (SRS) is the most common adverse effect of ureteral stenting. In recent years, many efforts have been made to develope modified ureteral stents to ameliorate SRS. It has been reported that intraureteral stents have the potential to improve the tail end adverse effect of the bladder and alleviate SRS. However, there still lack of evidence for the efficacy and the safety of clinically applying intraureteral stents. The aim of this work is to investigate the efficacy and safety of intraureteral stents.

EVIDENCE ACQUISITION

A systematic review was performed by using the PubMed, Web of Science, Medline, Embase, and Cochrane library. The studies published before February 2023 were included. The study selection was following the guideline from Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). The searching strategy was: "Pigtail suture stent" OR "Intra-ureteric stent" OR "Suture Stent" OR "Intraureteral stent" AND "Ureteroscopy" OR "Urinary calculi" OR "Stent-related symptoms" OR "Lower urinary tract symptoms". The data from randomized clinical trials which meet the selection criteria were extracted. Revman 5.4 was employed to proceed the meta-analysis.

EVIDENCE SYNTHESIS

A total of six randomized clinical trials of intraureteral stents were included in this systematic review and meta-analysis. According to the different investigation time, the results could be divided into four stages: early-stage, middle-stage, late-stage, and long-term evaluation. Urinary symptoms, pain score, and general health were significantly improved in intraureteral stents group at middle stage. For late-stage, intraureteral stent achieved better outcomes in urinary symptoms index, VAS score, quality of life, general health, and pain score. However, for early-stage and long-term evaluation, there was no significant difference between two groups.

CONCLUSIONS

This systematic review and meta-analysis reveal that regardless of the stage of treatment, the efficacy and safety of intraureteral stent are no worse than that of conventional stent. During 7-14 days postoperation, which is the most commonly time for clinically using ureteral stent, most of the outcomes of intraureteral stent are better than those of conventional stent. Hence, it is confirmed that intraureteral stent is worth for more clinical study and application.

Outcomes and Complications from a Randomized Controlled Study Comparing Conventional Stent Placement Versus No Stent Placement after Ureteroscopy for Distal Ureteric Calculus < 1 cm

Ureteric stent insertion following ureteroscopic lithotripsy (URSL) is a common and widely accepted procedure. However, there is no agreement on whether a ureteric stent should be placed following an uncomplicated URSL. Furthermore, the definition of uncomplicated URSL remains debatable. To compare the efficacy, safety, and morbidity of no stent placement with the conventional stent placement after uncomplicated retrograde semirigid URS for a distal ureteric calculus of size ≤1 cm, we compared the corresponding complication rates, emergency visits, secondary interventions, and pain at follow-up. Following an uncomplicated ureteroscopic lithotripsy, 104 patients were randomized into the conventional stented group (CSG) and nonstented group (NSG). Lower urinary tract symptoms and sexual function were evaluated using validated questionnaires (IPSS + IIEF-5 + MSHQ-EjD/FSFI) preoperatively and at 4 weeks during follow-up. Pain scores at follow-up were recorded using a visual analogue scale (VAS). Patients who visited the emergency room or needed secondary interventions before the recommended follow-up time were noted. The Generalized Estimating Equations method was used to explore the difference in change in the domains of IPSS, IIEF-5, MSHQ-EjD, and FSFI between the two groups over time. A significant difference was noted in the following IPSS domains: Frequency, Urgency, Nocturia, Storage Symptoms, Total IPSS Score (p ≤ 0.001), and QoL (p = 0.002); IIEF-5 domains: Overall Score (p = 0.004); MSHQ-EjD domains: Ejaculation Bother/Satisfaction (p ≤ 0.001); and FSFI domains: Lubrication (p ≤ 0.001), Satisfaction (p = 0.006), and Overall Score (p = 0.004). There was no significant difference between the various groups in terms of distribution of emergency visits, readmission and secondary interventions, pain at follow-up (VAS), and need for long-term analgesia. Nonplacement of stents after uncomplicated URS decreases stent-related symptoms and preserves QoL without placing the patient under increased postoperative risk.

Complete intraureteral stent placement reduces stent-related symptoms: Systemic review and meta-analysis

PURPOSE

The distal coil of a double-J ureteral stent is considered the major cause of stent-related symptoms. We noticed that some recent studies investigated whether complete intraureteral stent placement (CIU-SP) reduced these symptoms. The current systemic review and meta-analysis aimed to evaluate the safety and the effectiveness of CIU-SP, as compared to conventional stent placement (C-SP).

METHODS

We retrieved relevant trials published before December 2021 from three databases, including PubMED, Embase, and Web of Science. The following medical subject heading were used ((complete intraureteral stent) OR (suture stent)) AND (symptom OR pain) AND (randomized OR randomised). The above search was limited to English language publication.

RESULTS

We identified six prospective randomized trials, all of which investigated a short-term (1-2 weeks) stent placement following uncomplicated ureteroscopic lithotripsy. The meta-analysis revealed that CIU-SP significantly reduced stent-related symptoms: CIU-SP had lower USSQ (Ureteral Stent Symptom Questionnaire) Urinary Symptom Index score (MD -5.13; 95%CI [-5.82,-4.44]; P < 0.00001), lower USSQ Pain Index score (MD -4.21; 95%CI [-5.25,-3.17]; P < 0.00001), and lower VAS pain scale (MD -1.93; 95%CI [-2.17,-1.69]; p < 0.00001). Besides, patients with CIU-SP were less likely to have pain (RR 0.78; 95%CI [0.67,0.91]; p = 0.001). There was no significant difference regarding the USSQ General Health and Work Performance. Both CIU-SP and C-SP had similarly few complications of Clavien-Dindo grade ≥2.

CONCLUSION

This meta-analysis reveals that CIU-SP significantly decreases stent-related urinary symptoms and pain. Based on the current evidence, CIU-SP is ready to be applied in clinical practice, at least in those requiring short-term stent placement following uncomplicated ureteroscopic lithotripsy.

Advances in ureteral stent technology

PURPOSE OF REVIEW

Ureteral stents are an invaluable tool for urologists but suffer from several drawbacks, including: limited durability due to stent encrustation, significant morbidity from bothersome urinary symptoms, pain and infection, risk of the forgotten stent and costly removal. This review highlights key advances in ureteral stent technology that seek to address these issues.

RECENT FINDINGS

Over the past 2 years clinical trials have brought ureteral stent technology aimed to reduce stent-associated morbidity closer to clinical application. Stent material and changes to stent design show promise in improving patient tolerability without increasing complications. Low-tech innovations such as magnetic and catheter snare removal may quickly reduce costs. Radical advances such as biodegradable stent materials remain in preclinical models but show promise for eliminating the need for stent removal.

SUMMARY

The ideal ureteral stent does not currently exist in clinical practice. This review highlights key studies that have advanced ureteral stent technology in the past 2 years.

The intraureteral placement of the stent's distal end decreases stent-related urinary symptoms: a prospective randomized clinical trial

PURPOSE

We compared intraureteral stent placement (CIU-SP) with conventional stent placement (C-SP) regarding the stent-related symptoms.

METHODS

We randomized patients who underwent ureteroscopic lithotripsy into two groups. In CIU-SP group, a 16-cm or 18-cm stent was placed with its distal end above the ureterovesical junction. In C-SP group, a 22-cm or 24-cm stent was placed in a conventional method. Stent-related symptoms were assessed with the Ureteral Stent Symptom Questionnaire (USSQ) before the stent was removed, around 7 days after the operation. The primary outcome was the urinary symptoms; the secondary outcomes included postoperative pain and quality of life.

RESULTS

We randomized 103 patients, of which 91 (45 in CIU-SP and 46 in C-SP) entered the final analysis. Regarding the primary endpoint, the CIU group had less urinary symptoms; the mean USSQ urinary symptom score was significantly lower in the CIU-SP versus C-SP group (25.5 ± 6.3 vs 31.7 ± 5.9, P < 0.001). The CIU-SP group also had more favorable profiles in the following outcomes: lower USSQ body pain score (15.5 ± 5.3 vs 20.1 ± 5.2, P < 0.001), lower overall pain score (3.2 ± 2.2 vs 5.7 ± 2.3, P < 0.001), less number of pain site (1.0 ± 0.9 vs 1.7 ± 0.9, P = 0.001, lower USSQ general health score (10.4 ± 3.7 versus 13.9 ± 3.4, P < 0.001), and lower USSQ work performance score (5.2 ± 3.3 versus 6.7 ± 2.8, P = 0.033). In either group, there was no complication of Clavien-Dindo Class 2 or greater.

CONCLUSION

The complete intraureteral placement significantly decreases stent-related urinary symptoms and pain. It is also associated with better postoperative general health condition and is less likely to limit physical activity and work ability.

Developments in Ureteral Stent Technology

Ureteral stents have been utilized for decades in maintaining ureteral patency, most commonly after ureteroscopy in the treatment of urolithiasis. Since their initial development, ureteral stents have had many technological advances that have allowed for better patient outcomes with improvements in comfort, durability, patency, encrustation resistance, biocompatibility, ease of insertion, migration, and biofilm development. Several new ureteral stents enter the market every year, each with their own touted benefits. It is essential to understand the different advantages for each ureteral stent to provide the best available care to patients when possible. The purpose of this review is to give a brief history of ureteral stent development and summarize the recent developments in ureteral stent designs. We aim to review the data supporting the clinical advantages of the latest ureteral stents available for use by urologists.

A randomized trial investigating clinical outcomes and stent-related symptoms after placement of a complete intra-ureteric stent on a string versus conventional stent placement

OBJECTIVE

To compare stent-related symptoms (SRS) associated with conventional ureteric JJ stent (CUS) placement and SRS associated with placement of a modified complete intra-ureteric stent (CIUS) with extraction suture, designed to minimize SRS, using the validated Ureteral Stent Symptom Questionnaire (USSQ).

MATERIALS AND METHODS

We randomized 124 patients who had undergone uncomplicated ureteroscopic lithotripsy into a CIUS and a CUS placement group. USSQ scores were evaluated on postoperative days 1 and 7 (just before stent removal) and 4 weeks after stent removal (control values). Pain scores on a visual analogue scale (VAS) after stent removal were also recorded. Subdomain analysis of all SRS and stent-related complications were also compared.

RESULTS

No significant intergroup differences were found in the domain scores for urinary symptoms (P = 0.74), pain (P = 0.32), general health (P = 0.27), work (P = 0.24), or additional problems (P = 0.29). However, a statistically significant difference was noted in VAS scores (P = 0.015). Analysis of subdomains of USSQ item scores showed the CIUS group had significantly better scores for urge incontinence (1.21 vs 1.00; P ≤ 0.001), discomfort on voiding (2.07 vs 1.50; P ≤ 0.001), difficulties with respect to light physical activity (1.131 vs 1.00; P ≤ 0.001), fatigue (1.84 vs 1.57; P = 0.002), feeling comfortable (3.68 vs 3.16; P = 0.003), need for extra help (1.96 vs 1.00; P ≤ 0.001), and change in duration of work (4.27 vs 1.86; P ≤ 0.001). However, the patients in the CIUS group were sexually inactive for the time during which the stent was indwelling (mean: 7.34 days). There was no difference in complication rates between the two groups.

CONCLUSION

The use of a CIUS with strings after Ureteroscopy decreases SRS.

Pigtail Suture Stents Significantly Reduce Stent-related Symptoms Compared to Conventional Double J Stents: A Prospective Randomized Trial

Background

Double J (DJ) ureteral stents are commonly inserted after ureteroscopy (URS) procedures for stone treatment. However, stent-related symptoms are still a major issue.

Objective

To determine whether a commercially available pigtail suture stent (PSS) can reduce stent-related symptoms compared to a conventional DJ stent after uncomplicated URS.

Design setting and participants

We designed a randomized, single-blind, parallel-group trial from January to November 2020. The inclusion criteria were stone-free URS without intraprocedural complications. Patients with distal ureteral stones were excluded.

Intervention

Insertion of a PSS or DJ stent after URS.

Outcome measurements and statistical analysis

The primary endpoint was the Urinary Symptom Index score on the Ureteral Stent Symptoms Questionnaire (USSQ) 2 wk after URS. Secondary endpoints were USSQ domain scores and responses to individual USSQ questions at 2 d and 2 wk after surgery.

Results and limitations

A total of 78 patients were randomized and treated according to protocol. The Urinary Symptom Index score (p = 0.004), overall Visual Analogue Scale (VAS) score (p = 0.022), and the percentage of patients complaining of pain (63.9% vs 86.1%, p = 0.029) were significantly in favor of PSS at both 2 d and 2 wk after URS. At 2 d, the VAS score among patients with pain (p = 0.025) and the General Health Index score (p = 0.036) were significantly better in the PSS group. No severe complications occurred in either group. Study limitations are the exclusion of patients with distal ureteral stones and the limited sample size.

Conclusions

PSS significantly reduced stent-related symptoms after URS, in particular urinary symptoms and pain, compared to conventional DJ stents, and showed a good safety profile.

Patient summary

Stents are hollow tubes placed in the passage between the kidney and the bladder (ureter). The standard stent has two coiled ends (double J stent) to keep it in place in both the kidney and the bladder. We tested a commercial stent with two strings at the bladder end (pigtail suture stent) after procedures to remove stones from the upper urinary tract and found that it caused less stent-related symptoms compared to a double J stent.

This trial is registered at Clinicaltrials.gov as NCT03344120.

Loop-tail stents fail in reducing stent-related symptoms: results of a prospective randomised controlled trial

OBJECTIVE

To compare stent-related symptoms (SRS) of loop-tail (LT) and conventional double J (DJ) stents after uncomplicated flexible ureterorenoscopy (fURS), in a prospective randomised controlled single-blind parallel-group study.

PATIENTS AND METHODS

Patients undergoing fURS were randomised into two groups: the LT Group received LT stents (Polaris™ Loop) and the DJ Group received conventional DJ stents (Vortek^® ). The stent was removed after 4 weeks. The Ureteric Stent Symptom Questionnaire (USSQ) was administered at 2 days, 4 and 8 weeks (baseline evaluation) after stent insertion. The primary endpoint was to compare the Urinary Symptom Index Score of the LT vs DJ groups at 4 weeks after stent insertion. The secondary endpoints were to compare the USSQ domains' subscores at 2 days and 4 weeks after stent insertion, USSQ single answers at 4 weeks, and the 4-week USSQ domains' subscores adjusted for baseline.

RESULTS

A total of 68 patients were randomised (34 LT and 34 DJ). The answers given at 4 weeks were not significantly different between the two groups for the Urinary Symptom Index Score (P = 0.982), Pain Index Score (P = 0.169), visual analogue scale (P = 0.276), and all the other domains of the USSQ. At 4 weeks, the single-answer analysis did not find any differences between the groups; the urinary symptoms were all comparable, as was the requirement for pain painkillers (P = 0.684) and pain during sex (P = 0.496). There were also no significant differences for every single domain score for the responses given at 2 days. The same applied to USSQ subscores at 4 weeks adjusted for the 8-week baseline results, which were also comparable.

CONCLUSIONS

The study found no differences in terms of SRS between the LT and DJ groups, either at 2 days or 4 weeks after stent insertion, with or without baseline correction.

Reduction of stent-associated morbidity by minimizing stent material: a prospective, randomized, single-blind superiority trial assessing a customized 'suture stent'

OBJECTIVES

To compare a customized 'suture stent' with a standard ureteric stent regarding stent-related symptoms, safety and efficacy.

MATERIALS AND METHODS

Patients with urolithiasis located proximal to the iliac vessel crossing, requiring stenting in preparation for secondary ureterorenoscopy (URS) were randomized to standard ureteric stenting or a suture stent. Secondary ureterorenoscopy was performed 2-6 weeks later. The Ureteral Stent Symptoms Questionnaire (USSQ) was completed after 1 week, on the day before URS and 2-6 weeks after stent removal. Stent efficacy and safety were systematically assessed.

RESULTS

A total of 88 patients were included in the analysis. The median (range) suture stent length was 10 (5-25) cm vs 26 cm for standard stents. Operation time was longer for insertion of the suture stent (24.0 vs 14.5 min; P < 0.001). Patients with a suture stent had a significantly lower USSQ urinary symptoms score 1 week after stent insertion, adjusted for baseline symptoms by subtracting scores from the final visit without indwelling stent (mean 7.1 vs 13.7, difference -6.6, 95% confidence interval [CI] -3.4 to -9.8; P < 0.001). Prior to secondary URS (after 2-6 weeks), baseline-adjusted urinary symptoms (mean 4.7 vs 12.2, difference -7.5, 95% CI -4.5 to -10.4; P < 0.001) and pain subscores (11.5 vs 17.6, difference -6.1, 95% CI -0.7 to -11.6; P = 0.004) were significantly lower in the suture stent group. All other USSQ subscores showed no significant differences. Adverse events occurred in 15 patients and were similarly frequent in the two groups. No significant differences were found between the groups regarding ureteric access during secondary URS.

CONCLUSION

Replacement of the distal part of ureteric stents by a suture can reduce stent-associated symptoms without restrictions regarding secondary stone removal or safety.