Surgery Rotation Article review

Meta-Analysis of Stenting versus Non-Stenting for the Treatment of Ureteral Stones

Citation: Wang H, Man L, Li G, Huang G, Liu N, Wang J. Meta-Analysis of Stenting versus Non-Stenting for the Treatment of Ureteral Stones. PLoS One. 2017;12(1):e0167670. Published 2017 Jan 9. doi:10.1371/journal.pone.0167670

Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5221881/

Introduction:

• Urolithiasis is the most common urological disease with a prevalence rate of 10–15% and a recurrence rate of 50%. In countries with a high standard of life, the rates are even higher.
• Dangers: ureteric obstruction, infection, hydronephrosis.
• Treatment options: medical therapy if no obstruction or: ureteroscopic lithotripsy (URL), ESWL, percutaneous nephrolithotomy and laparoscopic surgery.
• The goal of ureteral stone insertion is to decompress the kidney, reduce the risk of ureteral obstruction and alleviate the renal colic pain
• After a surgical intervention the stent is placed in order to aid the healing of mucosal injury caused by the procedure and prevent the formation of ureteral strictures.
• Risks of stenting: stent migration, vesico-ureteral reflux and stent encrustation
• Risks vs benefits: stent related complications vs improvement of the stone-free rates
• Current American Urological Association (AUA) guidelines suggest that the placement of ureter stents is not required in the surgical treatment of ureteral stones. Other studies suggest that routine stenting is desirable for prophylaxis.
• This analysis aims to evaluate the benefits and disadvantages of ureteral stents for the treatment of ureteral stones

Methods:

• 221 records were identified, 22 RCTs were selected comparing stenting and non-stenting
  • N = 1257 pts w ureteral stents; 1295 pts w/o stent placement
  • Inclusion criteria: pts w ureteral stones treated with URL or SWAL and reports of at least one outcome of interest such as operation time, stone-free rate, complications, and related data
  • Exclusion criteria: pts with stones in locations other than ureters (kidney, bladder, urethra), studies not reporting outcomes of interest
  • Baseline demographic variables included: age, proportion of male/female, stone size and degree of distal location. Perioperative and postoperative variables included operating time, length of hospital stay, stone-free rate and readmission, complications including pain, dysuria, urinary infection, hematuria, fever, irritative symptoms and ureteral strictures.

Conclusions:

• Stented group: longer operation time. Complications: significantly higher rates of hematuria, irritative urinary symptoms, urinary infection, and dysuria as opposed to non-stented group.
• No difference was detected in hospital stay/hours, stricture formation or fever.

Overall conclusion:

Additional RCTs are needed to corroborate these findings with more thorough patient selection criteria as it is possible that the patients originally chosen for the stent placement had a higher severity of disease to begin with (type of stone extracted, degree of hydronephrosis, etc)  and, therefore, it is difficult to reliably draw the conclusion that stent complications were triggered specifically by stenting.