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Brain E. et al., 2023: Does pre-stenting influence outcomes of shockwave lithotripsy? A systematic review and meta-analysis.

Brain E, Geraghty RM, Tzelves L, Mourmouris P, Chatzikrachtis N, Karavitakis M, Skolarikos A, Somani BK.
Newcastle Medical School, Newcastle University, Newcastle-upon-Tyne, UK.
Department of Urology, Freeman Hospital, Newcastle-upon-Tyne, UK.
Institute of Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK.
Department of Urology, Sismanogleio Hospital, National and Kapodistrian University of Athens, Athens, Greece.
Department of Urology, University Hospital Southampton, Southampton, UK.

Abstract

Objective: To determine whether preoperative use of JJ stents in patients undergoing shockwave lithotripsy (SWL) impacts on stone clearance and the rate of postoperative complications.

Patients and methods: We screened multiple databases from inception to January 2021, using the relevant search terms for SWL in patients with a preoperative stent. Inclusion criteria were randomised controlled trials of ≥20 patients aged >18 years who had had SWL with a JJ stent. This review has been registered in the International Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42023443195). Statistical analysis was performed using 'meta' in R.

Results: There were seven eligible studies (403 patients receiving JJ stents and 394 controls). There was no significant difference in the stone-free rate (SFR) following SWL with a JJ stent compared to SWL alone. When considering the complication rates, there was a significantly reduced risk of steinstrasse in patients with a JJ stent. However, there was no significant difference in the risk of other complications including pain, fever, and haematuria, and no significant difference in the likelihood of requiring auxiliary procedures or re-treatment.

Conclusions: There was a reduced risk of steinstrasse in patients undergoing SWL with a JJ stent compared to SWL alone. However, there was no significant difference in the risk of other postoperative complications. Use of a JJ stent had no effect on the efficacy of SWL, with no significant difference in the SFR.

BJU Int. 2023 Nov 7. doi: 10.1111/bju.16219. Online ahead of print. PMID: 37935590 Review

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Comments 1

Hans-Göran Tiselius on Wednesday, 24 April 2024 11:00

In the early days of SWL the question was whether stenting would be beneficial for the outcome of the treatment and to avoid complications caused by stone fragments that accumulated in the ureter and caused obstruction (steinstrasse).
Extensive clinical experience clearly showed that pre-stenting did not improve the outcome in terms of facilitated fragment elimination. It was concluded, however that when large stones were disintegrated, the stent favorably affected the clinical course by allowing urine to pass even though fragments had accumulated in the ureter. The clinical experience showed that that for small stones stenting did not make sense. Over the years my own routine has been to insert a stent when the patients had stones corresponding to spheres with a diameter of 20 mm or more (or stones with a different shape but with a corresponding volume). In addition, it was considered helpful to have stent in place in medically weak patients, also with stone smaller than 20 mm, if any situation with obstruction would imply a risk.

Subsequently the guidelines have been adapted to what urologists in general can accomplish with modern lithotripters. Accordingly, very few patients are today treated with SWL for stones with diameters above 20 and the need of stenting is very low.

This systematic review carried out approximately 35-40 years later confirmed previous experience that the only advantage of pre-stenting was to reduce the risk associated with steinstrasse. It can be assumed that with the current report there will be no more need for literature reviews, because it is well recognized and clearly shown that stenting does not increase stone-free rates.

Important to state is, however, that this report obviously included only stones located in the kidney. The stenting of stones in the ureter is associated with other problems and might be more complicated.

Hans-Göran Tiselius

In the early days of SWL the question was whether stenting would be beneficial for the outcome of the treatment and to avoid complications caused by stone fragments that accumulated in the ureter and caused obstruction (steinstrasse). Extensive clinical experience clearly showed that pre-stenting did not improve the outcome in terms of facilitated fragment elimination. It was concluded, however that when large stones were disintegrated, the stent favorably affected the clinical course by allowing urine to pass even though fragments had accumulated in the ureter. The clinical experience showed that that for small stones stenting did not make sense. Over the years my own routine has been to insert a stent when the patients had stones corresponding to spheres with a diameter of 20 mm or more (or stones with a different shape but with a corresponding volume). In addition, it was considered helpful to have stent in place in medically weak patients, also with stone smaller than 20 mm, if any situation with obstruction would imply a risk. Subsequently the guidelines have been adapted to what urologists in general can accomplish with modern lithotripters. Accordingly, very few patients are today treated with SWL for stones with diameters above 20 and the need of stenting is very low. This systematic review carried out approximately 35-40 years later confirmed previous experience that the only advantage of pre-stenting was to reduce the risk associated with steinstrasse. It can be assumed that with the current report there will be no more need for literature reviews, because it is well recognized and clearly shown that stenting does not increase stone-free rates. Important to state is, however, that this report obviously included only stones located in the kidney. The stenting of stones in the ureter is associated with other problems and might be more complicated. Hans-Göran Tiselius
Monday, 20 May 2024