Ureteral Stent Placement following Ureteroscopy Increases Emergency Department Visits in a Statewide Surgical Collaborative

Abstract

Introduction: Ureteral stents are commonly placed after ureteroscopy (URS). Though studies indicate that stents are associated with patient discomfort, their impact on downstream health services use is unclear. We examined patterns of stent utilization in Michigan and their association with unplanned healthcare encounters.Methods: We used the Michigan Urologic Surgery Improvement Collaborative's Reducing Operative Complications from Kidney Stones (MUSIC ROCKS) clinical registry to identify URS cases between 2016 and 2019. Factors associated with stent placement were examined using bivariate and multivariable statistics. Using multivariable logistic regression, we evaluated whether stent placement was associated with emergency department (ED) visits and hospitalizations within 30 days. Results:We identified 9662 URS and a stent was placed in 7025 (73%) of these. Frequency of stent use across the 137 urologists varied (11-100%, p<0.001), and was not associated with total case volume. Factors associated with stent use included age and stone size. Pre-stented cases and renal stones had a decreased odds of stent placement. On multivariable analysis after adjusting for risk factors, stent placement was associated with a 1.25 higher odds of ED visit (OR 1.25; 95%CI 1.01-1.54 p=0.043) but not hospitalization (OR 1.28; 95%CI 0.94-1.76 p=0.12). In a single high-volume practice, 0.5% of cases that omit a stent required urgent stenting postoperatively. Conclusion:There is substantial variation in the use of stents in Michigan, irrespective of case volume. Stent placement significantly increased the odds of an ED visit after surgery. Importantly, stent omission rarely required subsequent urgent stent placement.

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

“…Several studies have shown comparable outcomes between unstented and stented groups in terms of early postoperative problems, including low-grade fever, hematuria, urinary tract infection, and flank pain [ 13 , 16 ]. A recent paper reported that stent placement during URS was independently associated with a 25% increase in emergency room visits within 30 days, with flank pain being the most common reason for both groups, but there was no increased risk of hospitalization [ 17 ].…”

Appropriateness Criteria for Ureteral Stent Omission following Ureteroscopy for Urinary Stone Disease

“…Details on the ROCKS (Reducing Operative Complications from Kidney Stones) initiative and clinical registry have been previously described. 4,17,18 Each MUSIC practice has obtained an exemption or approval by the local Institutional Review Board for participation in the collaborative. This study was conducted by the MUSIC coordinating center and, thus, participants were limited to those within the state of Michigan.…”

“…1,2 However, stenting remains a common practice, occurring in over two-thirds URS for urinary stone disease. 3,4 Stents are associated with pain and urinary symptoms, 5 as well as increased risk of an emergency department visit after URS. 4,6,7 These unplanned encounters substantially increase the cost of URS.…”

Which Is the Best Laser for Lithotripsy? Holmium Laser

“…These findings are consistent with reports of thermal injury and stricture after ureteroscopy with TFL in the ureter [8] . In clinical practice, 60–70% of upper urinary tract stones treated with ureteroscopy are located in the ureter [9] . For this location, holmium laser offers predictability and safety.…”