External ureteric stent versus internal double J stent in kidney transplantation: a retrospective analysis on the incidence of urological complications and urinary tract infections

Long-term Double-J stenting is superior to short-term Single-J stenting in kidney transplantation

BACKGROUND AND OBJECTIVES

Urological complications after kidney transplantation, due to the ureteroneocystostomy, are associated with significant morbidity, prolonged hospital stay and even mortality. Ureteral stents can minimize the number of complications but are not consistently used, as previous studies were retrospective in nature. We aim to prospectively determine the most effective stenting approach.

METHODS

We performed a non-blinded single-centre randomised controlled trial in an academic hospital. Kidney transplant recipients were randomised to either a Single-J stent or a Double-J stent, removed according to respective protocols. Primary outcome was PCN placement within six months. Secondary outcomes encompassed urinary tract infections, cost-effectiveness, and hospital admission time. The study was conducted from November 2018 to August 2023, during which 300 recipients were included with complete follow-up.

RESULTS

PCN was performed in 14.5% in the Single-J group (21/145) and 4.5% in the Double-J group (7/155), p = 0.003. Multivariable logistic regression, corrected for recipient age, BMI, sex, and donor type, showed an OR of 0.26 [0.10, 0.61] (OR [95%CI]). To prevent PCN in one recipient, 10 would have to receive the Double-J. All secondary outcomes were comparable, whereas hospital admission time and cost-effectiveness analysis heavily favoured Double-J stenting. An important limitation was that Single-J participants were unable to leave, even if their recovery allowed earlier discharge.

CONCLUSION

This trial showed that Double-J stenting consistently reduced urological complications from 14.5% to 4.5%, while being highly cost-effective. Transplant surgeons should favour Double-J stenting to minimise the risk of complications.

Effect of increasing age and ureteral stent implantation on urinary tract infections after kidney transplantation - update of recent literature

PURPOSE OF REVIEW

This review aims to present the recent literature regarding effects of aging and ureteral stent implantation (UrS) on the risk of urinary tract infections (UTIs) in kidney transplant (KTX) recipients.

RECENT FINDINGS

UTIs in kidney transplant recipients remain a clinical challenge and represent a leading cause of morbidity, hospitalization rates, and mortality. Higher age was described as a significant risk factor for UTIs in several studies including a recent Brazilian analysis, indicating a 3.6%/years of age increase in UTI risk. Subsequently, a large meta-analysis, published in 2023, confirmed the correlation between older age and elevated UTI risk. The Swiss Transplant Cohort Study in 2022, largest of its kind, similarly confirmed a link between advanced age and heightened risk of recurrent UTIs in KTX. A recent prospective study highlighted UrS placement as a modifiable risk factor, emphasizing the need for careful consideration and antibiotic prophylaxis. Additionally, the type of stents played a crucial role, with external stents associated with a 1.69 times higher UTI risk. The challenge of determining optimal UrS removal timing further complicates posttransplant care, with insufficient evidence to guide practices.

SUMMARY

The aging population of KTX recipients requires a personalized approach to effectively reduce and manage UTIs as one of the most important complications following KTX. Prophylactic stent implantation is successful in lowering ureteral complications, however, is associated with an increased incidence of UTIs. To reduce the increased risk of UTIs, the length of stent insertion requires strict supervision and maintenance.