Bosnali E. et al., 2025: Effects of Double J Stent (DJS) Placement Before Pediatric ESWL on Complications and Stone-free Rates.

Efe Bosnali, Nazim Mutlu, Kutlucan Cakmak, Enes Malik Akdas, Engin Telli, Abdullah Enes Baynal, Muhlis Unal, Hakkıcan Yuvak, Kerem Teke, Onder Kara 
J Pediatr Surg. 2025 May;60(5):162274. doi: 10.1016/j.jpedsurg.2025.162274

Abstract

Background: Pediatric urolithiasis remains a significant health problem in certain regions worldwide. Extracorporeal shock wave lithotripsy (ESWL) is the preferred treatment for upper urinary tract stones smaller than 20 mm in children due to its ease of application and efficacy. However, the utility of double J stenting (DJS) before ESWL in pediatric patients is still debatable. This study aims to evaluate the impact of DJS placement prior to ESWL on children's complication and stone-free rates (SFRs).

Objectives: To determine the effect of pre-ESWL double J stent (DJS) application on stone-freeness and complications in the pediatric age group.

Study design: This retrospective study included 277 renal units from 268 pediatric patients (≤18 years) treated with ESWL at Kocaeli University between 2006 and 2024. Patients were divided into two groups: those with (DJS+) and without (DJS-) pre-ESWL stenting. Demographic and clinical data, including outcomes and complications, were compared between the groups using univariate analyses. The Clavien-Dindo grading system was used to evaluate complications after ESWL. Multiple logistic regression analysis was performed to determine the factors affecting the risk of steinstrasse (SS) formation.

Results: A total of 277 renal units were included in the study: 33 (13.1 %) with pre-ESWL DJ stents and 244 (86.9 %) without stents. 150 (54.1 %) of the patients were male, and the mean age was 7.32 ± 4.8. The mean stone size was 9.7 ± 3.3 mm. The DJS + group (33 RUs) and DJS- group (244 RUs) showed no significant difference in SFR (60.6 % vs. 68.4 %, p = 0.36) and complication rates (15.2 % vs. 14.3 %, p = 0.79). A total of 40 (14.4 %) cases had complications following ESWL. Of these complications, 24 (8.7 %) were major (Clavien Grade 3) and 16 (5.8 %) were minor (Clavien Grade 1-2). In addition, DJS placement did not reduce the risk of steinstrasse (SS) formation (p = 0.97). Multiple logistic regression identified stone size as the only independent predictor of SS formation (OR: 1.13, 95 % CI: 1.01-1.26, p = 0.02).

Discussion: Unlike adult studies, studies reporting the effects of pre-ESWL ureteral stent placement in children are limited. To our knowledge, the present study has the highest number of patients in the literature evaluating the effects of pre-ESWL ureteral stent use on success and complications in treating urolithiasis with ESWL in the pediatric population. In addition, the findings of our study may contribute to the literature due to the limited number of studies investigating the effect of ureteral stents before ESWL in the pediatric age group and their small sample size.

Conclusions: This study showed that pre-ESWL DJS application in the pediatric age group did not increase ESWL success, had no effect on post-ESWL complications and did not prevent the development of steinstrasse.

Comment Peter Alken

This is a retrospective study on a rarely discussed problem. Double-J stents before ESWL have been abandoned in adults and were rarely used in children. The introduction explains the reason for conducting this study: “Ureteral stent placement before ESWL is not recommended in children, the effect of pre-ESWL ureteral stent application on stone-freeness and complications has not yet been elucidated [11,12].” However, it is strange that these references are from 1989 and 1995. Later on, there are more recent references.
33 cases may be the “highest number of patients in the literature” bit it is still small. A handful of cases added could change the statistical results. Otherwise it is a well written paper. All clinically available data were gathered, however what is missing are details on quality of life, long term follow up and costs. Children suffer from double-J stents just as adults and they need two additional procedures: stent in and stent out. Hopefully, no one will implement the suggestion in the last sentence of this paper.: “Prospective randomized designed studies are needed to support our findings”

Peter Alken