Optimal Time of Ureteral Catheter Removal after Retrograde Intrarenal Surgery

Document Type : Original Article

Authors

1 Urology Research Center, Tehran University of Medical Sciences, Tehran, Iran

2 Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

Abstract

Introduction: Stenting in the ureter following RIRS (Retrograde Intrarenal Surgery) and stone removal is recommended to prevent edema and colic pain. This study aims to find the optimal time for ureteral stent removal after RIRS with less complications.
Methods:This study was run under Tehran University of Medical Sciences Ethical Committee (IR.TUMS.VCR.REC.1398.750). In this retrospective study, demographic and clinical information of patients from 2013 to 2019 were investigated.  The patients were classified based on duration of ureteral catheter placement: group A less than 24h, group B 24-72h and group C Removed after 72h.
Results:  From our 80 patients who met inclusion criteria in A and B groups, urologists had to insert DJ stent for 16 of 19 (84%) (Due to pain and hydronephrosis) and 9 of 27 patients (33%), respectively. In group C, however; only 5 (15%) in 33 patients required DJ stent following the removal of simple ureteral catheter. Hence, 84% of the patients with simple ureteral catheter for over 72h in their ureter did not need re-stenting (P-value < 0.001).
Conclusions: We concluded that the optimal time of stenting for simple ureteral catheter is 72 hours. Catheter removal after this time would lead to the least complications.

Graphical Abstract

Optimal Time of Ureteral Catheter Removal after Retrograde Intrarenal Surgery

Highlights

  • The optimal time of stenting for simple ureteral catheter is 72 hours.
  • Catheter removal after 72 hours would lead to the least complications.
  • Determining the best time of simple ureteral catheter preservation in the ureter requires further studies.

Keywords

Main Subjects


 

Introduction

The prevalence of kidney stone is estimated at approximately 7%-10% in the world’s population (1-3). Almost 50% of symptomatic stones need surgical intervention. There are different methods of surgery, including extracorporeal shock wave lithotripsy (ESWL), retrograde intrarenal surgery (RIRS) for treating kidney stone and Percutaneous nephrolithotomy (PCNL) (4). Holmium laser device ureteroscopy is usually used in this method. Stones are broken down into smaller pieces to pass the urinary tract.

RIRS is an advanced lithotripsy technique with flexible ureteroscope. Recent advances in holmium laser technology, application of new generations of flexible ureteroscopes and promotion in urologists’ skills have caused RIRS to replace alternative methods (5, 6). In order to minimize RIRS-associated morbidities and according to EAU (European Association of Urology) guideline(10), RIRS and ESWL are introduced as frontline methods of choice for kidney stones less than 2cm. RIRS was raised as the first treatment method of choice when ESWL fails, especially in cases of renal and urinary structure abnormalities, obese patients and bleeding diathesis (7-9).

Most urologists insert a stent in the ureter during RIRS following stone removal to prevent edema and colic pain in the ureter (10). Stenting also helps smaller stone pieces to travel through the urinary tract and pass from the body more easily (11).The purpose of postoperative stenting is to prevent hydronephrosis, pain and ureteral stricture and to facilitate the healing process and the passage of the stone fragments. Postoperative stenting is necessary in cases of mucosal edema and hemorrhage, epithelium injury, ureter perforation and solitary kidney (10, 12, 13).

However, some studies showed that if ureter is not damaged during the procedure, stenting will not be necessary and only increase costs and bladder irritant symptoms. These Studies indicate that in case of ureter damage, DJ (double-J) stent should be remained in the urinary tract for 3-6 weeks; otherwise, the stent can be removed 3-10 days postoperatively.

In order to reduce complications associated with DJ stenting and avoiding further operation room costs for removing DJ stent (12), simple ureteral catheter can be used for most patients. There is disagreement over the exact duration required for keeping simple ureteral catheter in the ureter following RIRS. The aim of this study is to find the optimal time for ureteral stent removal after RIRS with less complications.

 

Methods

In this retrospective study, demographic and clinical information of patients were referred to Sina, Kasra and Yas hospitals from 2013 to 2019 and 80 of the total 350 files were collected and entered the study. The study was confirmed byTehran University of Medical Sciences Ethical Committee (IR.TUMS.VCR.REC.1398.750).  Demographic information including age, sex, right/left operated kidney, stone size and duration of ureteral catheter placement in the ureter were extracted from the documents. Exclusion criteria included single kidney, stone larger than 20 mm, damage to ureter among surgery (RIRS), urinary tract infection or patients with routine double-J stent placement after ureterorenoscopy which included 270 patient records. All procedures were performed by a single urologist.  Written informed consent was obtained from all the patients.

Regarding procedure, Prophylactic antibiotics were administrated to all patients. Patients were placed in the lithotomy position under spinal anesthesia. After retrograde pyelography under fluoroscopic guidance, a 0.035 inch guide wire was placed in the upper tract. Ureter stones were treated by 8.0/9.8 French Ureteroscope (Karl Storz). Large stones were fragmented with holmium laser and the fragments were removed by the stone basket or grasper. After the ureteral stone was completely removed, a 12/14 F ureteral access sheath was placed. The flexible Ureteroscope (7.5Fr Karl Storz Flex-X) was inserted to the renal pelvis. All stones were fragmented with holmium laser and large fragments removed by the stone basket. At the end of the procedure, the entire pelvis and calices was inspected for the residual stones under the fluoroscopic guidance and a ureteral catheter (5-Fr, 70 cm) was remained instead of DJ stent.

Then, the patients were classified into the following three groups considering the duration of simple ureteral catheter placement in their ureter:

A.       < 24h in ureter

B.        24-72h in ureter

C.        Removed after 72h

Note that leaving ureteral catheter less than 72 hours in group A and B was not programmed action and their ureteral catheter was removed spontaneously and accidentally. And the data were investigated retrospectively. 

Statistical analysis was done using SPSS 18.0® for Windows®. Variables were shown by mean ±SD and compared with t-test.  P-value < 0.05 was considered significant.

 

Results

From our 80 patients who met inclusion criteria, there were 54 (68%) men and 26 (32%) women. After the procedure, 20 patients (67%) were classified in group A, 27 patients (34%) in group B and 33 patients (41%) in group C. In A and B groups, urologists had to insert DJ stent into 16 (84%) in 19 (due to pain and hydronephrosis) and 9 (33%) in 27 patients, respectively. In group C, however; only 5 (15%) in 33 patients required DJ stent following the removal of simple ureteral catheter. Hence, 84% of the patients with simple ureteral catheter for over 72h in their ureter did not need re-stenting (P-value < 0.001). The mean age of patients in group A, B and C was 43, 52 and 43 years, respectively. The difference between the mean age and duration of keeping simple ureteral catheter was not significantly different (P-value=0.085) (Table 1).

 

Table 1. Demographic and Clinical information

 

Variables

A

< 24h in ureter

 

B

24-72h in ureter

C

Removed after 72h

P-value

Number (No.) 

20

27

33

 

Gender (No.)

Male

13

18

21

0.065

Female

7                                     

8

11

Age (years) (Mean)

52.5

43

43.5

0.085

Stone size (mm)(Mean) 

16.3

15.8

16.5

0.689

Need to DJ insertion

16 (84%)

9 (33%)                     

5 (15%)                        

<0.001

Stone location

Left 

10

16

20

0.732

Right

10

11

13

 

Among 20 patients of the group A, 10 patients had stones in their right kidney and 10 in their left. In group B, stones were found in the right and left kidney of 11 and 16 patients, respectively. In group C, 20 patients had left kidney stones and 13 had stones in the other kidney. With reference to the data analysis, there was no significant association between kidney side and length of simple ureteral catheter maintenance in the ureter (P-value=0.732).

The mean stone burden in group A, B and C was 16, 15 and 16mm, correspondingly and analysis of the data showed no significant relationship between stone burden and duration of simple ureteral catheter use in the ureter (P-value= 0.689).

 

Discussion

Considering the evidence obtained from patient files with simple ureteral catheter insertion following RIRS, we found that the most appropriate time of preserving simple ureteral catheter is 72 hours. Following technological advances and making delicate ureteroscopes as well as promotion of urologists’ experiences, RIRS can be conducted by skillful urologists with no complications in most cases and there is no need for long-term DJ catheter placement in the ureter.

 

The presence of the stent DJ as a foreign object is the common cause of patients’ postoperative discomfort, though DJ is not associated with Bladder irritation symptoms and severe hematuria. However, it has more severe complications like catheter migration and fragmentation, urosepsis, ureteral perforation, visceral ureteral fistula and calcium deposition on catheter with different rates reported in various studies. For instance, correspondingly 15% and 75% of the patients develop above complications 3-4 weeks and 3 months postoperatively. Moreover, removing DJ catheter would impose further operation room costs (12, 14-16). In case, catheter removal is carried out on an outpatient basis, this cost would be omitted. Many studies have pointed out that over 50% of patients for whom postoperative stenting is used developed complications like irritative voiding symptoms, groin pain, hematuria, stent migration, infection and pyelonephritis (10).

 One of the important points about simple ureteral catheter requiring attention is the proper time of catheter removal and no studies have been conducted in this field. In our study, 84% and 33% of patients were in groups A and B, respectively. However, in group C, only 15% required DJ stent following the removal of simple ureteral catheter.

Peter et al., showed that patients who had external ureter catheter insertion had a better quality of life in patients undergoing URS (ureteroscopic retrograde surgery). In this clinical trial, 141 patients were divided into two groups. In one group, a short-term ureter catheter inserted for 6 h following URS and the second group had a DJ stent embedded in them, and they were removed within five days. They showed that short-term ureter catheter is a safe procedure and superior to DJ stent with regard to urinary symptoms, pain, quality of life, and stent related Symptoms (12). Although their ureteral catheter time was much less than 72 hours, they reported no complications.

Although this study was one of the first attempts to find the optimal time of ureteral catheter maintenance after RIRS, there was some limitations. The first one is retrospective nature of this study. As removing of this catheters was accidentally and spontaneously, randomization could not be performed. Secondly, the sample size of this story is not adequate for making strong recommendation.   Determining the best time of simple ureteral catheter preservation in the ureter requires further randomized double-blind clinical trials with larger sample sizes.

 

Conclusions

In conclusion, the most appropriate time of preserving simple ureteral catheter is 72 hours. Extracting the catheter after this time would have the least complications. The likelihood of sepsis, hydronephrosis and pain increases if the catheter is extracted before 72 hours. Also, if simple ureteral catheter is removed spontaneously or mistakenly by the patient, he should promptly refer to a urologist for possible necessary procedures (DJ stent placement). However, determining the best time of simple ureteral catheter preservation in the ureter requires further studies. The effect of intrarenal anatomy on stone-free rates after RIRS is unclear; however, unfavorable lower calyceal anatomy might hamper the value of the procedure. 

 

Authors' contributions

VA had main idea for this research and conceived the study. M FY and M S were involved in protocol development, gaining ethical approval, patient recruitment and data analysis. F KH wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version of the manuscript.

 

Acknowledgements

Special thanks for Sina hospital to provide the equipment and space to run project. There was not any funding or grant.

 

Competing interests

All author claim that there is no any conflicting interest in this case report.

 

Funding

There is no founding to report.

 

Ethical statement

The study was run under Tehran University of Medical Sciences Ethical Committee (IR.TUMS.VCR.REC.1398.750).

 

Data availability

All data and information will be providing on request.

 

Abbreviations

DJ          Double J stenting

EAU      European Association of Urology

ESWL   Extracorporeal Shock Wave Lithotripsy

PCNL    Percutaneous Nephrolithotomy

RIRS     Retrograde Intrarenal Surgery

URS      Ureteroscopic Retrograde Surgery

 
1. Bayne DB, Chi TL. Assessing cost-effectiveness of new technologies in stone management. Urologic Clinics. 2019;46(2):303-13.
2. Rode J, Bazin D, Dessombz A, Benzerara Y, Letavernier E, Tabibzadeh N, et al. Daily green tea infusions in hypercalciuric renal stone patients: no evidence for increased stone risk factors or oxalate-dependent stones. Nutrients. 2019;11(2):256.
3. Aune D, Mahamat-Saleh Y, Norat T, Riboli E. Body fatness, diabetes, physical activity and risk of kidney stones: a systematic review and meta-analysis of cohort studies. European journal of epidemiology. 2018;33(11):1033-47.
4. Ozyuvali E, Resorlu B, Oguz U, Yildiz Y, Sahin T, Senocak C, et al. Is routine ureteral stenting really necessary after retrograde intrarenal surgery? Archivio Italiano di Urologia e Andrologia. 2015;87(1):72-5.
5. Akinci M, Esen T, Tellaloğlu S. Urinary stone disease in Turkey: an updated epidemiological study. European urology. 1991;20:200-3.
6. Dickstein RJ, Kreshover JE, Babayan RK, Wang DS. Is a safety wire necessary during routine flexible ureteroscopy? Journal of endourology. 2010;24(10):1589-92.
7. Reşorlu B, Ünsal A. Böbrek Taşlarının Tedavisinde Retrograd İntrarenal Cerrahi (RIRC). Turk Urol Sem. 2011;2:64-7.
8. Jafari Shahdani MR, Fattahi B, Mohseni MG, Aghamir SMK. Comparison of Mini-perc and Retrograde Intrarenal Surgery in Residual Stone Fragments with Hounsfield Unit after Percutaneous Nephrolithotomy. Translational Research Urology. 2021;3(2):40-4.
9. Zia H, Khatami F, Rahimi MR, Aghamir SMK. Combined Direct Visual and Imaging Guided Percutaneous Nephrolithotomy: A Novel Technique. Translational Research Urology. 2021;3(1):4-9.
10. Knudsen BE, Beiko DT, Denstedt JD. Stenting after ureteroscopy: pros and cons. The Urologic clinics of North America. 2004;31(1):173-80.
11. Türk C, Petřík A, Sarica K, Seitz C, Skolarikos A, Straub M, et al. EAU guidelines on diagnosis and conservative management of urolithiasis. European urology. 2016;69(3):468-74.
12. Bach P, Reicherz A, Teichman J, Dahlkamp L, von Landenberg N, Palisaar RJ, et al. Short‐term external ureter stenting shows significant benefit in comparison to routine double‐J stent placement after ureterorenoscopic stone extraction: A prospective randomized trial–the Fast track stent study (Fa ST). International Journal of Urology. 2018;25(8):717-22.
13. Aghamir SMK, Khorrami MH, Saatchi M, Seyedesmaeili SN. A Comparison of Minimally Invasive Surgery Ureterolithotomy and Transurethral Lithotripsy in Combination with Retrograde Intrarenal Surgery: A Randomized Clinical Trial. Translational Research Urology. 2020;2(4):127-31.
14. Aghamir SMK, Hamidi M, Salavati A, Mohammadi A, Farahmand H, Meysamie AP, et al. Is antibiotic prophylaxis necessary in patients undergoing ureterolithotripsy? Acta Medica Iranica. 2011:513-6.
15. Mohseni M, Khazaeli MH, Aghamir SMK, BINIAZ A. Changes in intrarenal resistive index following electromagnetic extracorporeal shock wave lithotripsy. 2007.
16. Alishah S, Khayyamfar F, Foroutan Sk. Antegrade Urethral Approach for Urethral Stricture in Patients with Previous Failed Retrograde Intervention. Translational Research Urology. 2020;2(2):37-44.