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Sfoungaristos S et al, 2015: History of Ureteral Stenting Negatively Affects the Outcomes of Extracorporeal Shockwave Lithotripsy. Results of a Matched-pair Analysis.

Sfoungaristos S, Gofrit ON, Pode D, Landau EH, Yutkin V, Latke A, Duvdevani M.
Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel.

Abstract:

To evaluate the impact of ureteral stenting history to the outcomes of extracorporeal shockwave lithotripsy, we retrospectively analysed patients who underwent shockwave lithotripsy with Dornier Gemini lithotripter between September 2010 and August 2012. Forty seven patients (group A) who had a double J stent which was removed just before the procedure were matched-paired with another 47 patients (group B) who underwent shockwave lithotripsy having no stent history. The correlation between ureteral stenting history and stone-free rates was assessed. Stone-free rates were 68.1% and 87.2% for patients of group A and B, respectively (p=0.026). Postoperative complications were not different between groups. Multivariate analysis revealed that stone size (p=0.007), stone location (p=0.044) and history of ureteral stenting (p=0.046) were independent predictors for stone clearance after shockwave lithotripsy. Ureteral stents adversely affect shockwave lithotripsy outcome, even if they are removed before the procedure. Stenting history should divert treatment plan towards intracorporeal lithotripsy.

Prague Med Rep. 2015;116(3):225-32. doi: 10.14712/23362936.2015.62.

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Comments 1

Hans-Göran Tiselius on Thursday, 07 April 2016 11:10

The authors demonstrated in matched groups of patients that SWL results were better in those patients who had NOT been stented compared with the results in patients with a history of stenting. This was the outcome despite stent removal on the day of SWL.

It is well recognized that ureteral oedema, inflammatory changes and disturbed peristaltic activity have negative effects on fragment clearance. For stones in the ureter the stent itself, as well as the pathology remaining after stent removal, are probably also associated with less efficient disintegration.

In several clinical situations, stenting is necessary and sometimes a life saving procedure. Moreover, in patients with large renal stones treated with SWL, the negative effects of ureteral obstruction caused by steinstrasse can be avoided.

The lesson learnt from this report is that for the best SWL-result, stenting should be avoided as far as possible. This is a well recognized observation. The new message is, however, that also when stents were removed before SWL, the results were not as good as those in patients entirely treated with a “non-touch” technique.

In each of the two groups 29 patients had stones in the kidney and 18 in the ureter. Whether the overall lower stone-free rates were related to stones located in the ureters or kidneys cannot be decided, because the treatment results were not stratified in a way to answer that question. But apparently the overall stone-free rate was lower for stones located in the ureter.

That the presence of ureteral stents results in less effective SWL of ureteral stones was reported previously [1,2]. Moreover, it was shown in another report that stone-free rates were lower in patients with stents. [3].

My personal interpretation is: Do not stent patients unless absolutely necessary and whenever possible proceed to SWL as early as possible. Whether the result will be improved by stent removal some days before SWL remains to be demonstrated.

References
1. Pettenati C, El Fegoun AB, Hupertan V, Dominique S, Ravery V.
Double J stent reduces the efficacy of extracorporeal shock wave lithotripsy in the treatment of lumbar ureteral stones.
Cent European J Urol. 2013;66(3):309-13. doi: 10.5173/ceju.2013.03.art14. Epub 2013 Nov 18
2. Sfoungaristos S, Polimeros N, Kavouras A, Perimenis P Stenting or not prior to extracorporeal shockwave lithotripsy for ureteral stones? Results of a prospective randomized study.
Int Urol Nephrol. 2012 Jun;44(3):731-7. doi: 10.1007/s11255-011-0062-3. Epub 2011 Sep 30.
3. Ozkan B, Dogan C, Can GE, Tansu N, Erozencı A, Onal B
Does ureteral stenting matter for stone size? A retrospectıve analyses of 1361 extracorporeal shock wave lithotripsy patients. Cent European J Urol. 2015;68(3):358-64. doi: 10.5173/ceju.2015.611. Epub 2015 Oct 15.

The authors demonstrated in matched groups of patients that SWL results were better in those patients who had NOT been stented compared with the results in patients with a history of stenting. This was the outcome despite stent removal on the day of SWL. It is well recognized that ureteral oedema, inflammatory changes and disturbed peristaltic activity have negative effects on fragment clearance. For stones in the ureter the stent itself, as well as the pathology remaining after stent removal, are probably also associated with less efficient disintegration. In several clinical situations, stenting is necessary and sometimes a life saving procedure. Moreover, in patients with large renal stones treated with SWL, the negative effects of ureteral obstruction caused by steinstrasse can be avoided. The lesson learnt from this report is that for the best SWL-result, stenting should be avoided as far as possible. This is a well recognized observation. The new message is, however, that also when stents were removed before SWL, the results were not as good as those in patients entirely treated with a “non-touch” technique. In each of the two groups 29 patients had stones in the kidney and 18 in the ureter. Whether the overall lower stone-free rates were related to stones located in the ureters or kidneys cannot be decided, because the treatment results were not stratified in a way to answer that question. But apparently the overall stone-free rate was lower for stones located in the ureter. That the presence of ureteral stents results in less effective SWL of ureteral stones was reported previously [1,2]. Moreover, it was shown in another report that stone-free rates were lower in patients with stents. [3]. My personal interpretation is: Do not stent patients unless absolutely necessary and whenever possible proceed to SWL as early as possible. Whether the result will be improved by stent removal some days before SWL remains to be demonstrated. References 1. Pettenati C, El Fegoun AB, Hupertan V, Dominique S, Ravery V. Double J stent reduces the efficacy of extracorporeal shock wave lithotripsy in the treatment of lumbar ureteral stones. Cent European J Urol. 2013;66(3):309-13. doi: 10.5173/ceju.2013.03.art14. Epub 2013 Nov 18 2. Sfoungaristos S, Polimeros N, Kavouras A, Perimenis P Stenting or not prior to extracorporeal shockwave lithotripsy for ureteral stones? Results of a prospective randomized study. Int Urol Nephrol. 2012 Jun;44(3):731-7. doi: 10.1007/s11255-011-0062-3. Epub 2011 Sep 30. 3. Ozkan B, Dogan C, Can GE, Tansu N, Erozencı A, Onal B Does ureteral stenting matter for stone size? A retrospectıve analyses of 1361 extracorporeal shock wave lithotripsy patients. Cent European J Urol. 2015;68(3):358-64. doi: 10.5173/ceju.2015.611. Epub 2015 Oct 15.
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