Bosnali E. et al., 2025: Effects of Double J Stent (DJS) Placement Before Pediatric ESWL on Complications and Stone-free Rates.
Efe Bosnali 1, Nazim Mutlu 2, Kutlucan Cakmak 2, Enes Malik Akdas 3, Engin Telli 2, Abdullah Enes Baynal 2, Muhlis Unal 2, Hakkıcan Yuvak 2, Kerem Teke 2, Onder Kara 2
1University of Health Sciences, Derince Training and Research Hospital, Department of Urology, Kocaeli, Turkey.
2Kocaeli University, School of Medicine, Department of Urology, Kocaeli, Turkey.
3Kocaeli City Hospital, Department of Urology, Kocaeli, Turkey.
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.
J Pediatr Surg. 2025 Mar 8;60(5):162274. doi: 10.1016/j.jpedsurg.2025.162274. Online ahead of print. PMID: 40118000
Comments 1
Ever since the introduction of SWL, pre-treatment stenting has been used in adults to prevent the problems associated with accumulation of stone fragments and gravel in the ureter (steinstrasse).
Although the benefit was obvious for adults with large stones, the advantage never was demonstrated for children. The explanation is that children’s ureters have a much better transport capacity than that seen in adults. My own experience is that for children, stenting for this purpose does not make sense.
In the present article the authors retrospectively studied the effect of stenting by comparing the effect in 33 children treated with stents and that in 233 children without stents. There was no significant difference in clinically problematic steinstrasse or other complications. The conclusion was that in children, stenting can be omitted before SWL.
This is in line with my own routines for children with stones. I always considered pre-stenting in children more traumatic and problematic than beneficial.
Hans-Göran Tiselius