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Eleanor Brain et al., 2024: Does pre-stenting influence outcomes of shockwave lithotripsy? A systematic review and meta-analysis

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Eleanor Brain 1 , Robert M Geraghty 2 3 , Lazaros Tzelves 4 , Panagiotis Mourmouris 4 , Nikolaos Chatzikrachtis 4 , Markos Karavitakis 4 , Andreas Skolarikos 4 , Bhaskar K Somani 5
1Newcastle Medical School, Newcastle University, Newcastle-upon-Tyne, UK.
2Department of Urology, Freeman Hospital, Newcastle-upon-Tyne, UK.
3Institute of Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK.
4Department of Urology, Sismanogleio Hospital, National and Kapodistrian University of Athens, Athens, Greece.
5Department 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. 2024 Jul;134(1):22-30. doi: 10.1111/bju.16219. Epub 2023 Nov 20. PMID: 37935590

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Comments 1

Hans-Göran Tiselius
Hans-Göran Tiselius on Wednesday, 20 November 2024 10:00

This report is another one in the obviously endless series of systematic reviews and meta-analyses. The specific question asked was if a stent inserted before SWL was beneficial for stone clearance. That this is not the case is rather well-recognized based on considerable clinical experience over the years.
The use of an internal stent to avoid problems caused by steinstrasse has been recommended for large stones and the preventive effect on formation of steinstrasse is demonstrated in this report. However, modern lithotripters are not suitable for treating large stones and the guidelines support that statement.
In this series 15 mm was the size limit, but my own rule has been to insert a stent in case of stones ≥20 mm. The accumulation of ureteral fragments is not prevented, but in the reviewer’s opinion the management of a steinstrasse is much facilitated, particularly in patients in whom the treatment modality is SWL.
One problem not discussed in the report is the negative effect of a stent in place at the time of SWL for ureteral stones.
The lack of overall positive effects of stenting is supported and in line with previous experience. It had been of interest, however, if the two senior authors of the article had added some personal aspects on their experience of stenting. The reason is that although randomized, the studies include only a small number of SWL-treated patients with stent.
Another aspect that needs attention is the beneficial prevention by a stent for patients sensitive to and at risk of infection complications.

Hans-Göran Tiselius

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This report is another one in the obviously endless series of systematic reviews and meta-analyses. The specific question asked was if a stent inserted before SWL was beneficial for stone clearance. That this is not the case is rather well-recognized based on considerable clinical experience over the years. The use of an internal stent to avoid problems caused by steinstrasse has been recommended for large stones and the preventive effect on formation of steinstrasse is demonstrated in this report. However, modern lithotripters are not suitable for treating large stones and the guidelines support that statement. In this series 15 mm was the size limit, but my own rule has been to insert a stent in case of stones ≥20 mm. The accumulation of ureteral fragments is not prevented, but in the reviewer’s opinion the management of a steinstrasse is much facilitated, particularly in patients in whom the treatment modality is SWL. One problem not discussed in the report is the negative effect of a stent in place at the time of SWL for ureteral stones. The lack of overall positive effects of stenting is supported and in line with previous experience. It had been of interest, however, if the two senior authors of the article had added some personal aspects on their experience of stenting. The reason is that although randomized, the studies include only a small number of SWL-treated patients with stent. Another aspect that needs attention is the beneficial prevention by a stent for patients sensitive to and at risk of infection complications. Hans-Göran Tiselius
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