Abstract:Many patients receive only one or none of these options, and the barriers to receiving optimal, combined, systemic therapy and surgery remain to be defined. Our bladder cancer population is increasing in size, age, and comorbidity supporting the acute need for multidisciplinary approach integrating physical therapy, geriatricians, oncologists and nutritionists.Taken together, surgery and perioperative chemotherapy are integral parts of the multimodal therapeutic concept of patients with LN-positive bladder can… Show more
“…1 ). Of these, four articles that were excluded involved one case report [ 19 ], one comment [ 20 ], one study that looked at extraction string use in children [ 21 ], and one paper where an updated article was available from the same authors [ 14 ]. Fig.…”
Section: Resultsmentioning
confidence: 99%
“…There is also a need for equipment, including a cystoscope, fluid irrigation, camera stack, and stent graspers. Cystoscopy itself is associated with a small risk of morbidity [ 20 ]. For patients, travelling to and from the hospital for multiple appointments can be cumbersome and costly [ 5 , 13 ].…”
Section: Discussionmentioning
confidence: 99%
“…Although the rate of premature inadvertent stent removal in the combined group was relatively low, the use of extraction strings are not advisable in patients whom early stent removal would risk major morbidity. Such cases include those with ureteric perforation, solitary kidney, pyelonephritis, or extrinsic ureteric compression [ 12 , 14 , 20 ].…”
Section: Discussionmentioning
confidence: 99%
“…Although extraction strings avoid the need for repeat cystoscopy for stent removal, more than two-thirds of urologists remove stent extraction strings prior to their insertion [ 2 , 14 ]. The rationale behind this is thought to be due to concerns over perceived risks, including increased LUTS from string irritation, stent dislodgement, infection, stent retention due to patients forgetting to remove stents, broken strings, and lack of strong evidence relating to its safety and tolerability [ 5 , 12 – 20 ].…”
Short-term ureteric stents are commonly placed after ureteroscopy. The removal usually entails having a cystoscopy, but recently, endourologists have been using stents with extraction strings attached to them for ease of removal. We wanted to conduct a systematic review of literature looking at the outcomes of ureteric stents with extraction strings attached to them. Our objective was to investigate the use, morbidity, tolerability, complications, associated cost, and patient preference of stents with extraction strings attached to them. All studies in English language (between 1990 and 2015) where stents on extraction strings were either self-removed by patients or removed by physician were included. A total of eight studies (1279 patients) were included, of which 483 (38 %) patients had extraction strings for removal. There seemed to be no overall difference in pain scores or urinary symptoms between patients with and without extraction strings, but nearly 10 % of patients suffered stent dislodgement in the group with extraction strings attached. Overall stent dwell time was lower in patients who had their stents removed via extraction strings, and majority of them were able to remove their stents at home. Our study suggests that stents with extraction strings are easy for patient self-removal and can reduce the stent dwell time for patients, thus reducing the duration of morbidity and physical and financial burden to patients. However, this must be balanced against a risk of stent dislodgement and, hence, may not be a good option in all patients.
“…1 ). Of these, four articles that were excluded involved one case report [ 19 ], one comment [ 20 ], one study that looked at extraction string use in children [ 21 ], and one paper where an updated article was available from the same authors [ 14 ]. Fig.…”
Section: Resultsmentioning
confidence: 99%
“…There is also a need for equipment, including a cystoscope, fluid irrigation, camera stack, and stent graspers. Cystoscopy itself is associated with a small risk of morbidity [ 20 ]. For patients, travelling to and from the hospital for multiple appointments can be cumbersome and costly [ 5 , 13 ].…”
Section: Discussionmentioning
confidence: 99%
“…Although the rate of premature inadvertent stent removal in the combined group was relatively low, the use of extraction strings are not advisable in patients whom early stent removal would risk major morbidity. Such cases include those with ureteric perforation, solitary kidney, pyelonephritis, or extrinsic ureteric compression [ 12 , 14 , 20 ].…”
Section: Discussionmentioning
confidence: 99%
“…Although extraction strings avoid the need for repeat cystoscopy for stent removal, more than two-thirds of urologists remove stent extraction strings prior to their insertion [ 2 , 14 ]. The rationale behind this is thought to be due to concerns over perceived risks, including increased LUTS from string irritation, stent dislodgement, infection, stent retention due to patients forgetting to remove stents, broken strings, and lack of strong evidence relating to its safety and tolerability [ 5 , 12 – 20 ].…”
Short-term ureteric stents are commonly placed after ureteroscopy. The removal usually entails having a cystoscopy, but recently, endourologists have been using stents with extraction strings attached to them for ease of removal. We wanted to conduct a systematic review of literature looking at the outcomes of ureteric stents with extraction strings attached to them. Our objective was to investigate the use, morbidity, tolerability, complications, associated cost, and patient preference of stents with extraction strings attached to them. All studies in English language (between 1990 and 2015) where stents on extraction strings were either self-removed by patients or removed by physician were included. A total of eight studies (1279 patients) were included, of which 483 (38 %) patients had extraction strings for removal. There seemed to be no overall difference in pain scores or urinary symptoms between patients with and without extraction strings, but nearly 10 % of patients suffered stent dislodgement in the group with extraction strings attached. Overall stent dwell time was lower in patients who had their stents removed via extraction strings, and majority of them were able to remove their stents at home. Our study suggests that stents with extraction strings are easy for patient self-removal and can reduce the stent dwell time for patients, thus reducing the duration of morbidity and physical and financial burden to patients. However, this must be balanced against a risk of stent dislodgement and, hence, may not be a good option in all patients.
“…Shorter stent dwell times may help reduce the overall burden of stent related symptoms, and it is worth emphasising that none of the patients whose stent was removed at 7 days post operatively had any adverse consequences; neither did the 15% of this group whose stents fell out even earlier. As Fernando and Bultitude comment in the associated editorial, the next question is: “If you are going to place a stent, how long does the stent need to stay for?” Perhaps, in order to emphasise that, where stent bother is concerned, shorter is better, this should be re‐phrased as “how little time is enough time for a stent to stay in”……”
Purpose
Ureteric stents placed after ureteroscopy typically require cystoscopy for removal. Stent extraction strings allow the option of patient self-removal. This facilitates shorter stent dwell time, and cost-savings. Concerns regarding safety and limited evidence regarding patient acceptability are speculated reasons for infrequent clinical use of extraction strings. This study investigates our recent experience using routine self-removal of stents on extraction strings to provide evidence to address these concerns.
Methods
In February 2020, our hospital adopted a policy for self-removal of stents on extraction strings to be routine following ureteroscopy. This was influenced by motivation to improve service capacity for diagnostic flexible cystoscopy, hospital avoidance during the pandemic, perceived improvement for the patient experience, and cost-saving. Prospective clinical and patient-reported outcome data were collected and evaluated.
Results
There were 168 patients who had stents on extraction strings. Mean stent dwell time was 5.2 ± 1.8 days. Primary ureteroscopy was performed in 40.5%, and 59.5% had procedures using an access sheath. Self-removal at home was successful for 79% of patients. Stent dislodgement rate was 3.0% (5/168) and retained stents due to string detachment occurred in 1.8% (3/168). Almost all indicated they “would remove the stent on string again” (90%, 128/142) and the majority reported stent removal as “very easy” (61%, 87/142). Cost modelling estimates a total saving of AUD $148,869 per annum for routine use of extraction strings at our hospital.
Conclusion
Our experience reflects that stent extraction strings may be used routinely with acceptable low complication rates, favourable patient experiences and associated cost savings.
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