U.S. flag

An official website of the United States government

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Cover of Stents before surgery

Stents before surgery

Renal and ureteric stones: assessment and management

Intervention evidence review (H)

NICE Guideline, No. 118

.

London: National Institute for Health and Care Excellence (NICE); .
ISBN-13: 978-1-4731-3190-3

1. Stents before surgery

1.1. Review question: Is inserting a stent clinically and cost-effective before surgical treatment in people with renal or ureteric stones?

1.2. Introduction

Ureteric JJ stents are used in stone management to relieve obstruction and uncontrollable pain in the emergency setting. In the elective setting the rationale for their use before surgery is that they will improve stone fragment passage, reduce complications, and reduce readmissions. There is particular concern that shock wave lithotripsy (SWL) for larger stones will result in stone fragments failing to pass resulting in the need for ancillary procedures and that pre-stenting will reduce this risk. However JJ stents are known to have adverse effects, and significant “stent symptoms” (for example, frequency, haematuria and pain) affecting patients quality of life are seen in 80% of cases.

There are no national agreed guidelines to the use of stents before SWL and practice varies. This questions aims to address this variation in practice.

1.3. PICO table

For full details see the review protocol in appendix A.

Table 1. PICO characteristics of review question.

Table 1

PICO characteristics of review question.

1.4. Clinical evidence

1.4.1. Included studies

Five randomised studies and two non-randomised studies were included in the review;2, 4, 35, 38, 50, 53, 70 these are summarised in Table 4 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 4). All included studies compared stent placement followed by SWL to SWL alone. All RCTs were in the adult population. No RCT evidence was identified for children and young people, so the search was extended to non-randomised studies. Two non-randomised studies were identified for inclusion; 4, 38. See also the study selection flow chart in appendix C, study evidence tables in appendix D, forest plots in appendix E and GRADE tables in appendix H.

1.4.1.1. Heterogeneity

For the comparison of stent before SWL versus SWL alone in the adult, renal, 10-20mm strata, there was substantial heterogeneity between the studies when they were meta-analysed for the outcomes of stent symptoms (haematuria). Pre-specified subgroup analyses did not explain the heterogeneity. A random effects meta-analysis was therefore applied to these outcomes, and the evidence was downgraded for inconsistency in GRADE.

1.4.2. Excluded studies

See the excluded studies list in appendix I

1.4.3. Summary of clinical studies included in the evidence review

Table 2. Summary of studies included in the evidence review.

Table 2

Summary of studies included in the evidence review.

See appendix D for full evidence tables.

1.4.4. Quality assessment of clinical studies included in the evidence review

1.4.4.1. Adults, ureteric, 10-20mm
Table 3. Clinical evidence summary: Stent followed by SWL versus SWL alone.

Table 3

Clinical evidence summary: Stent followed by SWL versus SWL alone.

1.4.4.2. Adults, renal, 10-20mm
Table 4. Clinical evidence summary: Stent followed by SWL versus SWL alone.

Table 4

Clinical evidence summary: Stent followed by SWL versus SWL alone.

1.4.4.3. Adults, renal, >20 mm
Table 5. Clinical evidence summary: Stent followed by SWL versus SWL alone.

Table 5

Clinical evidence summary: Stent followed by SWL versus SWL alone.

1.4.4.4. Children, renal, <10mm
Table 6. Clinical evidence summary: Stent followed by SWL versus SWL alone.

Table 6

Clinical evidence summary: Stent followed by SWL versus SWL alone.

1.4.4.5. Children, renal, staghorn
Table 7. Clinical evidence summary: Stent followed by SWL versus SWL alone.

Table 7

Clinical evidence summary: Stent followed by SWL versus SWL alone.

See appendix F for full GRADE tables.

1.5. Economic evidence

1.5.1. Included studies

No relevant health economic studies were identified.

1.5.2. Excluded studies

One economic study relating to this review question was identified but was excluded due to methodological limitations. 29 These are listed in appendix I, with reasons for exclusion given.

See also the health economic study selection flow chart in appendix G.

1.5.3. Unit costs

Table 8. UK costs of stent (per surgery i.e. removal and insertion = cost x 2).

Table 8

UK costs of stent (per surgery i.e. removal and insertion = cost x 2).

The clinical review data identified compares inserting a stent prior to SWL, and then leaving the stent in until a few weeks after the SWL then removing. This is compared to SWL with no stent inserted.

This essentially means that there are three procedures in the stent arm; stent insertion, SWL, and stent removal, and only the SWL in the no stent arm. This will create a large cost difference between the two interventions of over £2,000.

1.6. Resource costs

The recommendations made in this review are not expected to have a substantial impact on resources.

1.7. Evidence statements

1.7.1. Clinical evidence statements

Adults, ureteric, 10-20mm

One study compared stent use before SWL to SWL alone in a population of adults with 10-20mm ureteric stones. There was no clinical difference between the groups in terms of stone-free state and fever (1 study; n=60). There was a clinical benefit of SWL alone in terms of retreatment, and in terms of all stent symptoms outcomes (dysuria, microscopic haematuria, gross haematuria) (1 study, n=60). The quality of the evidence ranged from Low to Very Low. The main reasons for downgrading evidence included risk of bias and imprecision.

Adult, renal, 10-20mm

Three studies compared stent use before SWL and SWL alone in a population of adults with 10-20mm renal stones. All the studies reported stone-free state, and the evidence showed no clinical difference between the two groups (3 studies; n=258). Evidence from single studies showed no clinical difference for the outcomes clinically insignificant fragments, clinically significant fragments, ancillary procedures and retreatment (1 study; n=58-120). Evidence from two studies also showed no clinical difference in terms of readmission (2 studies; n=200). In terms of adverse events, evidence demonstrated no clinical difference in terms of UTI and in terms of fever (1-2 studies; n=58-138). In terms of stent symptoms, there was no clinical difference between groups for the outcome haematuria (3 studies; n=258). There was a clinical benefit of SWL alone in terms of all other stent symptom outcomes (urgency, frequency, dysuria, nocturia) (1 study; n=80). The quality of the evidence ranged from Moderate to Very Low. The main reasons for downgrading evidence included risk of bias, imprecision and in some cases, inconsistency.

Adults, renal, >20mm

One study compared stent use before SWL to SWL alone in a population of adults with renal stones >20mm. There was no clinical difference between the groups in terms of stone-free state, fever and failed technology (1 study; n=38-400). There was a clinical benefit of stent before SWL in terms of retreatment (1 study, n=38). The quality of the evidence ranged from Moderate to Very Low. The main reasons for downgrading evidence included risk of bias, imprecision and in some cases, indirectness.

Children, renal, 10-20mm

One non-randomised study compared stent use before SWL to SWL alone in a population of children with 10-20mm renal stones. The evidence demonstrated a clinical benefit of stent before SWL in terms of stone-free state, retreatment, ancillary procedures, and dysuria (1 study, n=20). For the outcome haematuria, there was a clinical benefit of SWL alone (1 study; n=20). The quality of the evidence was Very Low. The main reasons for downgrading evidence included risk of bias and imprecision.

Children, renal, 10-20mm

One non-randomised study compared stent use before SWL to SWL alone in a population of children with staghorn renal stones. The evidence demonstrated a no clinical difference between the groups in terms of stone-free state (1 study; n=42). There was a clinical benefit of stent before SWL in terms of readmission, ancillary procedures, length of stay and major adverse events (sepsis) (1 study, n=42). The quality of the evidence was Very Low. The main reasons for downgrading evidence included risk of bias and imprecision.

1.7.2. Health economic evidence statements

  • No relevant economic evaluations were identified.

1.8. The committee’s discussion of the evidence

1.8.1. Interpreting the evidence

1.8.1.1. The outcomes that matter most

The committee agreed that stone-free state, recurrence rate, use of healthcare services, kidney function, quality of life, failed technology, major adverse events, minor adverse events and stent symptoms were the outcomes that were critical for decision making. Pain was also considered as an important outcome.

Evidence was reported for stone-free state, recurrence rate, use of healthcare services, failed technology, major adverse events, minor adverse events and stent symptoms. There was no evidence for the critical outcomes of quality of life or kidney function, or for the important outcome pain.

No evidence was found that compared stent use to no stent for the surgery modalities of URS or PCNL. The only evidence found for inclusion used SWL as the treatment modality.

1.8.1.2. The quality of the evidence

For the majority of evidence in this review, the quality ranged from a GRADE rating of moderate to very low. This was due to a lack of blinding, presence of selection bias in terms of a lack of adequate randomisation and allocation concealment, resulting in a high risk of bias rating. Evidence was further downgraded due to the presence of imprecision for many of the outcomes, and inconsistency for one outcome. No outcomes were given a high quality rating.

1.8.1.3. Benefits and harms

Evidence for people with both symptomatic and asymptomatic stones was searched for; however no evidence was identified for the asymptomatic population. The committee therefore agreed that the recommendations should only apply to those with symptomatic stones.

Adults, ureteric, 10 to 20 mm

The committee considered very low to low quality evidence from one study with 60 participants and noted that there was no difference between the two groups, or a clinical benefit of no stent. There was no evidence of a clinical benefit of stent for any outcomes. The committee agreed that this demonstrated that there was no evidence that stents improve outcomes for participants, and may actually impede beneficial outcomes, demonstrated by more retreatments, and more stent related adverse events and symptoms. Having a stent in place during SWL may prevent the shocks reaching the stone and consequently more retreatments may be required. The committee therefore agreed that stenting should not be recommended for ureteric stones of 10-20mm. The committee’s opinion was that ureteric stones need to be treated more urgently compared to renal stones as large ureteric stones can block the kidney and can lead to obstructive uropathy within 2-6 weeks, therefore treatment needs to be completed within this time frame. The committee considered that in cases where SWL could not be done in a timely fashion, the use of a stent may be considered appropriate in individual circumstances.

Adults, renal, 10 to 20 mm

The committee considered very low to moderate quality evidence from three studies and noted that there was no clinical difference between those who had had a stent before SWL and those who had not for any outcomes apart from the stent symptoms outcomes. The committee agreed that this demonstrated that there was no benefit of stenting before SWL over not stenting, and discussed that given that stenting is associated with a number of stent related adverse events and symptoms, stenting should not be offered for this group of people.

Adults, renal, greater than 20 mm

The committee considered the evidence from one study of very low to moderate quality and noted that there was no difference between the groups for the stone-free state, minor adverse events and failed technology outcomes. There was a clinical benefit for the stent group in terms of retreatment rate, however the committee noted that this evidence was from a single study and was very imprecise. The committee further noted several concerns regarding the validity and applicability of this study. For instance, it was noted that it is unusual practice to perform SWL for renal stones of this size, and that this would not be done in the UK. The committee also noted that the number of shocks given per session was above the recommended limit, which also does not reflect UK practice. It was further noted that in order to tolerate this level of shocks, it is likely that this would have been performed under general anaesthesia, which is also a deviation from standard practice in the UK. Therefore, the committee agreed that this study does not reflect UK current practice and therefore may not be applicable to a UK population. It was also noted that following the surgical interventions review, there is no recommendation for SWL for this group of people.

There was no evidence for ureteric or renal stones less than 10 mm, and no evidence for ureteric stones greater than 20 mm. The committee agreed that stone size should not be specified in the recommendation for a number of reasons;

  • For small renal stones, current standard practice is not to stent pre-treatment.
  • For small ureteric stones, stenting is sometimes used in current practice for a variety of reasons (ongoing pain, obstruction, lack of access to emergency definite treatment), however as shown in the timing of surgery review, there is clinical benefit to primary intervention within 48 hours, therefore avoiding the use of stents. The committee wanted to further encourage best practice of treating with primary treatment rather than temporising with a stent.
  • Ureteric stones greater than 20 mm are unlikely to be treated with SWL and therefore the recommendation would not apply to this group.

Overall, the committee agreed that although the evidence had been reviewed and presented by strata, the results demonstrated that the same recommendation should be made for all adults with either ureteric or renal stones of all sizes. This is because the recommendation would only apply to where SWL is being used anyway (which generally precludes large stones; >20mm), and would reinforce current or best practice in other groups (stents before surgery are not generally used in small renal stones, and treatment within 48 hours would preclude the use of stents before SWL). Therefore adding a size into the recommendation was not felt to be necessary. The committee agreed no evidence had been presented that would warrant recommending the use of stents prior to SWL for any of the strata.

Children and young people, renal, less than 10 mm

One small non-randomised comparative study of very low quality was identified. Although this evidence demonstrated potential clinical benefit of stenting before SWL in terms of stone-free state, retreatment rate, ancillary procedures the committee noted that there was very high risk of bias and serious and very serious imprecision in the outcomes. The committee noted that this was likely due to the unequal distribution of lower pole stones in each arm (3/10 lower pole stones in stent group versus 7/10 lower pole stones non-stented group). These stones are more difficult to treat, and therefore the committee agreed that the differences between groups in stone-free state, retreatment rate and ancillary procedures are likely to be due to this difference in stone location. The committee were also aware that although the mean stone size of the participants was less than 10mm, the maximum stone size was 16mm and so some of this evidence included participants in the 10-20mm population. The committee further noted that this evidence was not consistent with clinical experience as stents would not normally inserted before SWL in this population. Therefore, the committee did not have confidence in the evidence and decided not to make a recommendation for this stratum.

Children and young people, renal, staghorn

Evidence from one non-randomised comparative study demonstrated a clinical benefit of stenting before SWL in terms of readmission, ancillary procedures, length of stay and sepsis, and no clinical difference between groups in terms of stone-free state. The committee considered that the maximum number of shockwaves per session used in this study was high compared to standard practice in the UK, but noted that it was unclear how many participants received the maximum number of shocks. The committee noted that the evidence came from a single study of very low quality. However, it was noted that the reduction in readmission and ancillary procedures were of particular benefit for the paediatric population. Based on this evidence, clinical experience and expertise of the committee, the consensus of the committee was that children with staghorn stones would generally derive benefit from having a stent and this would reflect usual practice, therefore it was agreed that stenting before SWL should be considered for children with a staghorn stone. The committee also noted that although SWL monotherapy is an option for paediatric staghorn calculi, many centres utilise PCNL as first line treatment for children with this type of stone.

No evidence was found for ureteric stones or for renal stones greater than 10 mm for children. The committee agreed that standard practice for children and young people is varied and so agreed that a consensus recommendation could not be made.

1.8.2. Cost effectiveness and resource use

One economic evaluation was identified but excluded because it was based on retrospective data and therefore considered to have very serious limitations, as this is not in keeping with the clinical review (for adults).

All the clinical review data identified compares inserting a stent prior to SWL, and then leaving the stent in until a few weeks after the SWL, then removing. This is compared to SWL with no stent inserted. This essentially means there are 3 procedures in the stent arm; stent insertion, SWL, and stent removal, and only the SWL in the no stent arm. This will create a large cost difference between the two interventions of over £2,000, as inserting or removing a stent comes under the same procedure code which has a cost of £1,018.

There were more stent symptoms with a stent which is to be expected. This will involve resource use such as patients possibly seeking healthcare advice such as GP time or hospital attendances, and being given pain relief and/or other drug treatments. For most outcomes there was no difference. Most outcomes are informed by only one study so it is difficult to have confidence in the results. However in general, if stents are a more expensive strategy and it is uncertain if there is any benefit but they do have more adverse events, then no stents are likely to be a dominant option if cheaper and equally effective.

The committee felt that there are two aspects to using stents; 1) if having an SWL, then does a stent stop the fragments getting stuck?, and 2) if there is an obstruction, should a stent be used to delay surgery?. It’s possible that this review can answer the first nuance, but not necessarily the second.

In the data identified for an adult ureteric population, there was a clinical benefit for no stent for retreatment, and also for stent symptoms. The committee thought that the stent may be impeding stone passage, which can sometimes happen, and might explain why more people needed retreatment in the stent group. This would lead to additional resource use of more interventions in the stent group, as well as more stent symptoms. The committee concluded that there was no convincing benefit to using stents and is also likely to be more costly.

In the adult renal stones population, data was identified for two strata; 10-20cm and >20cm. in the smaller stone group, the only outcome where there was a clinical benefit was of stent symptoms, again signalling that there is no benefit to stents but possible increased costs and quality of life impact. In the larger renal stone group, the committee had concerns about the quality of the paper with regards to the high frequency of shockwaves, and also that using SWL for this size stones was not in keeping with UK practice. There was only a clinical benefit of retreatment favouring the stent arm. This is in contrast to the result of the ureteric study where no stent led to lower retreatments. Perhaps with a larger stone the stent is helping the fragments to pass, or the increase in shockwave frequency compared to other studies has resulted in smaller fragments which can pass despite the stent. The study did not define the time frame it was reporting which may impact on outcomes such as retreatments. The committee did not feel confident making a recommendation based on this study.

The committee decided to make recommendations against using stents prior to SWL for both the ureteric and renal groups. As only data prior to SWL was identified, nothing can be said about stenting prior to other types of intervention. Kidney function can deteriorate irreversibly if left for up to 6 weeks with an obstruction, and so it is only safe to stent if treatment with SWL is available in a timely manner. In some areas, where a fixed site lithotripter is not available and patients have to wait for a mobile lithotripter, then it is a clinical decision whether the patient can safely wait for that period of time. If they cannot, then SWL is unlikely to be the appropriate intervention and surgery should be planned as soon as possible. Hence the population that cannot safely wait for SWL is a separate population that is not the intended population for these recommendations.

Stenting before SWL is not particularly common in UK practice at the moment (around 5% based on a recent UK audit (Doherty et al, 2017), however in areas where it might be, these recommendations are likely to be cost saving.

In children, only non-randomised evidence was identified. One study in children with renal stones had differing baseline characteristics which were thought to explain the results. One study relating to staghorn stones demonstrated that stenting pre SWL had a benefit with respect to readmission, ancillary procedures, and major adverse events. Readmission and ancillary procedures lead to higher resource use. The shockwave dose was thought to be high in this study. SWL monotherapy is an option for children with this type of stone. The committee reached a consensus that a consider recommendation should be made for stents in this group. A consider recommendation allows an element of clinician judgement. This population is small and therefore is unlikely to reach the resource impact threshold, even with full uptake.

1.8.3. Other factors the committee took into account

The only evidence available was for stenting pre SWL. The committee considered the availability of SWL and noted that most urology departments in the UK have access to SWL, but the majority use a mobile machine on a sessional basis. Therefore, the use of SWL for treatment of patients presenting acutely and within a timely fashion of that admission is mainly limited to units with a fixed site facility. For this reason, SWL is more routinely used for renal stones, where time to treatment is less critical.

References

1.
Aghamir SM, Mohammadi A, Farahmand H, Meysamie AP. Effects of prophylactic insertion of double-j stents to decrease episodes of renal colic in patients with recurrent ureteral stones. Journal of Endourology. 2008; 22(3):435–7 [PubMed: 18355138]
2.
Al-Awadi KA, Abdul Halim H, Kehinde EO, Al-Tawheed A. Steinstrasse: a comparison of incidence with and without J stenting and the effect of J stenting on subsequent management. BJU International. 1999; 84(6):618–21 [PubMed: 10510104]
3.
Al-Ba’adani T, Ghilan A, El-Nono I, Alwan M, Bingadhi A. Whether post-ureteroscopy stenting is necessary or not? Saudi Medical Journal. 2006; 27(6):845–8 [PubMed: 16758048]
4.
Al-Busaidy SS, Prem AR, Medhat M. Pediatric staghorn calculi: the role of extracorporeal shock wave lithotripsy monotherapy with special reference to ureteral stenting. Journal of Urology. 2003; 169(2):629–33 [PubMed: 12544330]
5.
Ali W, Al-Bareeq R, Samiei MR, Al-Muttawa S. The evaluation of not stenting after uncomplicated ureteroscopy: a randomized prospective study. Bahrain Medical Bulletin. 2001; 23(1):34–36
6.
Ali W, Al-Durazi M, Al-Bareeq R, Samiei MR, Al-Mutawa S. The evaluation of not stenting after uncomplicated ureteroscopy: a randomized prospective study. Bahrain Medical Bulletin. 2004; 26(1):3–5
7.
Barnes KT, Bing MT, Tracy CR. Do ureteric stent extraction strings affect stent-related quality of life or complications after ureteroscopy for urolithiasis: a prospective randomised control trial. BJU International. 2014; 113(4):605–9 [PubMed: 24765679]
8.
Baseskioglu B, Sofikerim M, Demirtas A, Yenilmez A, Kaya C, Can C. Is ureteral stenting really necessary after ureteroscopic lithotripsy with balloon dilatation of ureteral orifice? A multi-institutional randomized controlled study. World Journal of Urology. 2011; 29(6):731–6 [PubMed: 21590466]
9.
Bierkens AF, Hendrikx AJ, Lemmens WA, Debruyne FM. Extracorporeal shock wave lithotripsy for large renal calculi: the role of ureteral stents. A randomized trial. Journal of Urology. 1991; 145(4):699–702 [PubMed: 2005681]
10.
Borboroglu PG, Amling CL, Schenkman NS, Monga M, Ward JF, Piper NY et al. Ureteral stenting after ureteroscopy for distal ureteral calculi: a multi-institutional prospective randomized controlled study assessing pain, outcomes and complications. Journal of Urology. 2001; 166(5):1651–7 [PubMed: 11586195]
11.
Byrne RR, Auge BK, Kourambas J, Munver R, Delvecchio F, Preminger GM. Routine ureteral stenting is not necessary after ureteroscopy and ureteropyeloscopy: a randomized trial. Journal of Endourology. 2002; 16(1):9–13 [PubMed: 11890453]
12.
Castagnetti M, Rigamonti W. Extracorporeal shock wave lithotripsy for the treatment of urinary stones in children. Archivio Italiano di Urologia, Andrologia. 2010; 82(1):49–50 [PubMed: 20593721]
13.
Cevik I, Dillioglugil O, Akdas A, Siegel Y. Is stent placement necessary after uncomplicated ureteroscopy for removal of impacted ureteral stones? Journal of Endourology. 2010; 24(8):1263–7 [PubMed: 20615145]
14.
Chander J, Dangi AD, Gupta N, Vindal A, Lal P, Ramteke VK. Evaluation of the role of preoperative double-j ureteral stenting in retroperitoneal laparoscopic pyelolithotomy. Surgical Endoscopy. 2010; 24(7):1722–6 [PubMed: 20044764]
15.
Chandhoke PS, Barqawi AZ, Wernecke C, Chee-Awai RA. A randomized outcomes trial of ureteral stents for extracorporeal shock wave lithotripsy of solitary kidney or proximal ureteral stones. Journal of Urology. 2002; 167(5):1981–3 [PubMed: 11956422]
16.
Chang SC, Kuo HC, Hsu T. Extracorporeal shock wave lithotripsy for obstructed proximal ureteral stones. A prospective randomized study comparing in situ, stent bypass and below stone catheter with irrigation strategies. European Urology. 1993; 24(2):177–84 [PubMed: 8375437]
17.
Chauhan VS, Ahuja M. Comparison of efficacy and tolerance of short-duration open-ended ureteral catheter drainage and tamsulosin administration to indwelling double J stents following ureteroscopic removal of stones. Hong Kong Medical Journal. 2015; 21(2):124–30 [PubMed: 25756274]
18.
Chen AS, Saltzman B. Stent use with extracorporeal shock wave lithotripsy. Journal of Endourology. 1993; 7(2):155–62 [PubMed: 8518830]
19.
Chen YT, Chen J, Wong WY, Yang SS, Hsieh CH, Wang CC. Is ureteral stenting necessary after uncomplicated ureteroscopic lithotripsy? A prospective, randomized controlled trial. Journal of Urology. 2002; 167(5):1977–80 [PubMed: 11956421]
20.
Cheung MC, Lee F, Leung YL, Wong BB, Tam PC. A prospective randomized controlled trial on ureteral stenting after ureteroscopic holmium laser lithotripsy. Journal of Urology. 2003; 169(4):1257–60 [PubMed: 12629338]
21.
Cheung MC, Yip SK, Lee FC, Tam PC. Outpatient ureteroscopic lithotripsy: selective internal stenting and factors enhancing success. Journal of Endourology. 2000; 14(7):559–64 [PubMed: 11030536]
22.
Chew BH, Knudsen BE, Denstedt JD. The use of stents in contemporary urology. Current Opinion in Urology. 2004; 14(2):111–5 [PubMed: 15075840]
23.
Clayman RV. Ureteric stenting after ureteroscopy for ureteric stones: a prospective randomized study assessing symptoms and complications. Journal of Urology. 2005; 173(6):2022 [PubMed: 15879810]
24.
Corcoran AT, Smaldone MC, Mally D, Ost MC, Bellinger MF, Schneck FX et al. When is prior ureteral stent placement necessary to access the upper urinary tract in prepubertal children? Journal of Urology. 2008; 180:(Suppl 4):1861–4 [PubMed: 18721946]
25.
Crook TJ, Lockyer CR, Keoghane SR, Walmsley BH. A randomized controlled trial of nephrostomy placement versus tubeless percutaneous nephrolithotomy. Journal of Urology. 2008; 180(2):612–4 [PubMed: 18554657]
26.
Damiano R, Autorino R, Esposito C, Cantiello F, de Sio M, D’Armiento M. Stent positioning after ureteroscopy for stone removal. American Journal of Urology Review. 2005; 3(4):204–8
27.
Damiano R, Autorino R, Esposito C, Cantiello F, Sacco R, de Sio M et al. Stent positioning after ureteroscopy for urinary calculi: the question is still open. European Urology. 2004; 46(3):381–8 [PubMed: 15306112]
28.
Danuser H, Germann C, Pelzer N, Ruhle A, Stucki P, Mattei A. One- vs 4-week stent placement after laparoscopic and robot-assisted pyeloplasty: results of a prospective randomised single-centre study. BJU International. 2014; 113(6):931–5 [PubMed: 24472002]
29.
Darrad M, Sibartie T, Inglis J, Rukin N. Is acute ureteroscopy for painful ureteric colic cost effective and beneficial for patients? A cost-analysis. Journal of Clinical Urology. 2017; 10(1):17–21
30.
Denstedt JD, Wollin TA, Sofer M, Nott L, Weir M, RJ DAH. A prospective randomized controlled trial comparing nonstented versus stented ureteroscopic lithotripsy. Journal of Urology. 2001; 165(5):1419–22 [PubMed: 11342889]
31.
Dudek P, Gołabek T, Jaskulski J, Orłowski P, Bukowczan J, Szopiński T et al. [Prospective evaluation of pain associated with indwelling JJ stents following ureterorenoscopic lithotripsy]. Przeglad Lekarski. 2013; 70(11):936–8 [PubMed: 24697033]
32.
El Harrech Y, Abakka N, El Anzaoui J, Ghoundale O, Touiti D. Ureteral stenting after uncomplicated ureteroscopy for distal ureteral stones: a randomized, controlled trial. Minimally Invasive Surgery. 2014; 2014:892890 [PMC free article: PMC4241699] [PubMed: 25431663]
33.
Elgammal MA, Safwat AS, Elderwy A, El-Azab AS, Abdelkader MS, Hammouda HM. Primary versus secondary ureteroscopy for pediatric ureteral stones. Journal of Pediatric Urology. 2014; 10(6):1193–8 [PubMed: 25138475]
34.
ElSheemy MS, Shouman AM, Shoukry AI, ElShenoufy A, Aboulela W, Daw K et al. Ureteric stents vs percutaneous nephrostomy for initial urinary drainage in children with obstructive anuria and acute renal failure due to ureteric calculi: a prospective, randomised study. BJU International. 2015; 115(3):473–9 [PubMed: 24698195]
35.
Ghoneim IA, El-Ghoneimy MN, El-Naggar AE, Hammoud KM, El-Gammal MY, Morsi AA. Extracorporeal shock wave lithotripsy in impacted upper ureteral stones: a prospective randomized comparison between stented and non-stented techniques. Urology. 2010; 75(1):45–50 [PubMed: 19811806]
36.
Gou J, Dong Q, Seng S, Xu Y. Necessity and safety of ureteral stenting after ureteroscopic lithotripsy in treatment of ureteral calculi: a systematic review. Chinese Journal of Evidence-Based Medicine. 2010; 10(9):1096–101
37.
Grossi FS, Ferretti S, Di Lena S, Crispino M. A prospective randomized multicentric study comparing stented vs non-stented ureteroscopic lithotripsy. Archivio Italiano di Urologia, Andrologia. 2006; 78(2):53–6 [PubMed: 16929603]
38.
Gunduz M, Sekmenli T, Ciftci I, Elmacl AM. Do JJ stents increase the effectiveness of extracorporeal shock wave lithotripsy for pediatric renal stones? Urologia Internationalis. 2017; 98(4):425–8 [PubMed: 27780167]
39.
Gunlusoy B, Degirmenci T, Arslan M, Kozacyoglu Z, Minareci S, Ayder AR. Is ureteral catheterization necessary after ureteroscopic lithotripsy for uncomplicated upper ureteral stones? Journal of Endourology. 2008; 22(8):1645–8 [PubMed: 18721044]
40.
Haleblian G, Kijvikai K, de la Rosette J, Preminger G. Ureteral stenting and urinary stone management: a systematic review. Journal of Urology. 2008; 179(2):424–30 [PubMed: 18076928]
41.
Hammady A, Gamal WM, Zaki M, Hussein M, Abuzeid A. Evaluation of ureteral stent placement after retroperitoneal laparoscopic ureterolithotomy for upper ureteral stone: randomized controlled study. Journal of Endourology. 2011; 25(5):825–30 [PubMed: 21457084]
42.
Hussein A, Rifaat E, Zaki A, Abol-Nasr M. Stenting versus non-stenting after non-complicated ureteroscopic manipulation of stones in bilharzial ureters. International Journal of Urology. 2006; 13(7):886–90 [PubMed: 16882049]
43.
Ibrahim HM, Al-Kandari AM, Shaaban HS, Elshebini YH, Shokeir AA. Role of ureteral stenting after uncomplicated ureteroscopy for distal ureteral stones: a randomized, controlled trial. Journal of Urology. 2008; 180(3):961–5 [PubMed: 18639269]
44.
Jeong H, Kwak C, Lee SE, Pearle MS. Ureteric stenting after ureteroscopy for ureteric stones: a prospective randomized study assessing symptoms and complications. BJU International. 2004; 93(7):1032–5 [PubMed: 15142158]
45.
Ji C, Gan W, Guo H, Lian H, Zhang S, Yang R et al. A prospective trial on ureteral stenting combined with secondary ureteroscopy after an initial failed procedure. Urological Research. 2012; 40(5):593–8 [PubMed: 22491753]
46.
Kenan I, Salih B, Suat E, Huseyin E, Vehbi K. Is routine ureteral stenting necessary after uncomplicated ureteroscopic lithotripsy for lower ureteral stones larger than 1 cm? Urological Research. 2008; 36(2):115–9 [PubMed: 18385992]
47.
Marcovich R, Jacobson AI, Singh J, Shah D, El-Hakim A, Lee BR et al. No panacea for drainage after percutaneous nephrolithotomy. Journal of Endourology. 2004; 18(8):743–7 [PubMed: 15659895]
48.
Mercado A, Fernandez MI, Recabal P, Fleck D, Ledezma R, Moya F et al. Immediate postoperative morbidity in patients with indwelling double-J stent versus overnight-externalized ureteral catheter after tubeless percutaneous nephrolithotomy: a prospective, randomized study. Urolithiasis. 2013; 41(3):253–6 [PubMed: 23525631]
49.
Minevich E, Defoor W, Reddy P, Nishinaka K, Wacksman J, Sheldon C et al. Ureteroscopy is safe and effective in prepubertal children. Journal of Urology. 2005; 174(1):276–9 [PubMed: 15947666]
50.
Mohayuddin N, Malik HA, Hussain M, Tipu SA, Shehzad A, Hashmi A et al. The outcome of extracorporeal shockwave lithotripsy for renal pelvic stone with and without JJ stent-a comparative study. Journal of the Pakistan Medical Association. 2009; 59(3):143–6 [PubMed: 19288938]
51.
Mokhmalji H, Braun PM, Martinez Portillo FJ, Siegsmund M, Alken P, Kohrmann KU. Percutaneous nephrostomy versus ureteral stents for diversion of hydronephrosis caused by stones: a prospective, randomized clinical trial. Journal of Urology. 2001; 165(4):1088–92 [PubMed: 11257644]
52.
Moon KT, Cho HJ, Cho JM, Kang JY, Yoo TK, Moon HS et al. Comparison of an indwelling period following ureteroscopic removal of stones between double-J stents and open-ended catheters: a prospective, pilot, randomized, multicenter study. Korean Journal of Urology. 2011; 52(10):698–702 [PMC free article: PMC3212665] [PubMed: 22087365]
53.
Musa AA. Use of double-J stents prior to extracorporeal shock wave lithotripsy is not beneficial: results of a prospective randomized study. International Urology and Nephrology. 2008; 40(1):19–22 [PubMed: 17394095]
54.
Mustafa M. The role of stenting in relieving loin pain following ureteroscopic stone therapy for persisting renal colic with hydronephrosis. International Urology and Nephrology. 2007; 39(1):91–4 [PubMed: 17268908]
55.
Mustafa M, Ali-El-Dein B. Stenting in extracorporeal shockwave lithotripsy; may enhance the passage of the fragments! Journal of the Pakistan Medical Association. 2009; 59(3):141–3 [PubMed: 19288937]
56.
Nabi G, Cook J, N’Dow J, McClinton S. Outcomes of stenting after uncomplicated ureteroscopy: systematic review and meta-analysis. BMJ. 2007; 334(572):1–7 [PMC free article: PMC1828345] [PubMed: 17311851]
57.
National Institute for Health and Care Excellence. Developing NICE guidelines: the manual. London. National Institute for Health and Care Excellence, 2014. Available from: http://www​.nice.org.uk​/article/PMG20/chapter​/1%20Introduction%20and%20overview [PubMed: 26677490]
58.
Netto NR, Jr., Ikonomidis J, Zillo C. Routine ureteral stenting after ureteroscopy for ureteral lithiasis: is it really necessary? Journal of Urology. 2001; 166(4):1252–4 [PubMed: 11547052]
59.
NHS Improvement. Reference costs 2016/17: highlights, analysis and introduction to the data. London. 2017. Available from: https://improvement​.nhs​.uk/resources/reference-costs/
60.
Noh JH, Kim DK, Jeong H. Comparison of stented and unstented patients following ureteroscopy for ureter stones. Korean Journal of Urology. 2002; 43(1):28–31
61.
Okada S. Randomized evaluation of the necessity of indwelling urethral catheter for patients with upper urinary tract calculi under retrograde intra renal surgery (RIRS) [UMIN000014474]. 2014. Available from: https://upload​.umin.ac​.jp/cgi-open-bin/ctr/ctr​.cgi?function=brows&action​=brows&type=summary&language​=E&recptno=R000016829 Last accessed: 07/03/2018.
62.
Ordonez M, Borofsky M, Bakker CJ, Dahm P. Ureteral stent versus no ureteral stent for ureteroscopy in the management of renal and ureteral calculi. Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD012703. DOI: 10.1002/14651858.CD012703. [PMC free article: PMC6365118] [PubMed: 30726554] [CrossRef]
63.
Ozkan B, Dogan C, Can GE, Tansu N, Erozenci A, Onal B. Does ureteral stenting matter for stone size? A retrospective analyses of 1361 extracorporeal shock wave lithotripsy patients. Central European Journal of Urology. 2015; 68(3):358–64 [PMC free article: PMC4643708] [PubMed: 26568882]
64.
Pais VM, Smith RE, Stedina EA, Rissman CM. Does omission of ureteral stents increase risk of unplanned return visit? A systematic review and meta-analysis. Journal of Urology. 2016; 196(5):1458–66 [PubMed: 27287523]
65.
Pengfei S, Yutao L, Jie Y, Wuran W, Yi D, Hao Z et al. The results of ureteral stenting after ureteroscopic lithotripsy for ureteral calculi: a systematic review and meta-analysis. Journal of Urology. 2011; 186(5):1904–9 [PubMed: 21944085]
66.
Prasanchaimontri P, Nualyong C, Taweemonkongsap T, Chotikawanich E. Impact of ureteral stent size on stone-free rates in ureteroscopic lithotripsy for ureteral stones: randomized controlled trial. Journal of the Medical Association of Thailand. 2017; 100(4 Suppl 3):S162–68
67.
Pryor JL, Jenkins AD. Use of double-pigtail stents in extracorporeal shock wave lithotripsy. Journal of Urology. 1990; 143(3):475–8 [PubMed: 2406462]
68.
Shao Y, Zhuo J, Sun XW, Wen W, Liu HT, Xia SJ. Nonstented versus routine stented ureteroscopic holmium laser lithotripsy: a prospective randomized trial. Urological Research. 2008; 36(5):259–63 [PubMed: 18797859]
69.
Shao YS, Huang X. The value of ureteral stent placement before extracorporeal shock wave lithotripsy: a meta-analysis. Chinese Journal of Evidence-Based Medicine. 2010; 10(11):1293–301
70.
Sharma R, Choudhary A, Das RK, Basu S, Dey RK, Gupta R et al. Can a brief period of double J stenting improve the outcome of extracorporeal shock wave lithotripsy for renal calculi sized 1 to 2 cm? Investigative And Clinical Urology. 2017; 58(2):103–8 [PMC free article: PMC5330380] [PubMed: 28261679]
71.
Shen P, Jiang M, Yang J, Li X, Li Y, Wei W et al. Use of ureteral stent in extracorporeal shock wave lithotripsy for upper urinary calculi: a systematic review and meta-analysis. Journal of Urology. 2011; 186(4):1328–35 [PubMed: 21855945]
72.
Singh I, Singh A, Mittal G. Tubeless percutaneous nephrolithotomy: is it really less morbid? Journal of Endourology. 2008; 22(3):427–34 [PubMed: 18355137]
73.
Sofimajidpour H, Rasti M, Gharibi F. The effect of a double-j stent in the treatment of kidney stones larger than 10 mm in children under 13 years, using extracorporeal shock wave lithotripsy (ESWL). Iranian Red Crescent Medical Journal. 2016; 18(1):e24684
74.
Sofimajidpour H, Rasti M, Gharibi F. The effect of double j stent in the treatment of renal pelvis stones larger than ten mm in the children under 13 years of age using extracorporeal shock wave lithotripsy. Scientific Journal of Kurdistan University of Medical Sciences. 2016; 21(1):1–9
75.
Song T, Liao B, Zheng S, Wei Q. Meta-analysis of postoperatively stenting or not in patients underwent ureteroscopic lithotripsy. Urological Research. 2012; 40(1):67–77 [PubMed: 21573923]
76.
Srivastava A, Gupta R, Kumar A, Kapoor R, Mandhani A. Routine stenting after ureteroscopy for distal ureteral calculi is unnecessary: results of a randomized controlled trial. Journal of Endourology. 2003; 17(10):871–4 [PubMed: 14744352]
77.
Telha KA, Alba’adani TH, Alkohlany KM, Al-Adimy AO, Alnono IH. Tubeless percutaneous nephrolithotomy with double-J stent compared with external ureteral catheter to decrease postoperative complications. Saudi Medical Journal. 2010; 31(10):1137–40 [PubMed: 20953530]
78.
Wang CJ, Huang SW, Chang CH. Indications of stented uncomplicated ureteroscopic lithotripsy: a prospective randomized controlled study. Urological Research. 2009; 37(2):83–8 [PubMed: 19183976]
79.
Wang H, Man L, Li G, Huang G, Liu N, Wang J. Meta-analysis of stenting versus non-stenting for the treatment of ureteral Stones. PloS One. 2017; 12(1):e0167670 [PMC free article: PMC5221881] [PubMed: 28068364]
80.
Xu Y, Wei Q, Liu LR. A prospective randomized trial comparing non-stented versus routine stented ureteroscopic holmium laser lithotripsy. Saudi Medical Journal. 2009; 30(10):1276–80 [PubMed: 19838433]
81.
Younesi Rostami M, Taghipour-Gorgikolai M, Sharifian R. Treatment of kidney stones using extracorporeal shock wave lithotripsy (ESWL) and double-j stent in infants. Advances in Urology. 2012; 2012:589038 [PMC free article: PMC3329132] [PubMed: 22550483]
82.
Zaki MR, Salman A, Chaudhary AH, Asif K, Rehman MU. Is DJ stenting still needed after uncomplicated ureteroscopic lithotripsy? A randomized controlled trial. Pakistan Journal of Medical and Health Sciences. 2011; 5(1):121–4
83.
Zhao PT, Hoenig DM, Smith AD, Okeke Z. A randomized controlled comparison of nephrostomy drainage vs ureteral stent following percutaneous nephrolithotomy using the Wisconsin StoneQOL. Journal of Endourology. 2016; 30(12):1275–84 [PubMed: 27736198]
84.
Zhou Y, Zhu J, Gurioli A, Yuan D, Luo J, Li Z et al. Randomized study of ureteral catheter vs double-j stent in tubeless minimally invasive percutaneous nephrolithotomy patients. Journal of Endourology. 2017; 31(3):278–82 [PubMed: 27967216]

Appendices

Appendix B. Literature search strategies

The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual 2014, updated 2017 https://www.nice.org.uk/guidance/pmg20/resources/developing-nice-guidelines-the-manual-pdf-72286708700869

For more detailed information, please see the Methodology Review. [Add cross reference]

B.1. Clinical search literature search strategy

Searches were constructed using a PICO framework where population (P) terms were combined with Intervention (I) and in some cases Comparison (C) terms. Outcomes (O) are rarely used in search strategies for interventions as these concepts may not be well described in title, abstract or indexes and therefore difficult to retrieve. Search filters were applied to the search where appropriate.

Table 11. Database date parameters and filters used

Medline (Ovid) search terms

Embase (Ovid) search terms

Cochrane Library (Wiley) search terms

B.2. Health Economics literature search strategy

Health economic evidence was identified by conducting a broad search relating to renal and ureteric stones population in NHS Economic Evaluation Database (NHS EED – this ceased to be updated after March 2015) and the Health Technology Assessment database (HTA) with no date restrictions. NHS EED and HTA databases are hosted by the Centre for Research and Dissemination (CRD). Additional searches were run on Medline and Embase for health economics studies.

Table 12. Database date parameters and filters used

Medline (Ovid) search terms

Embase (Ovid) search terms

NHS EED and HTA (CRD) search terms

Appendix D. Clinical evidence tables

Download PDF (380K)

Appendix E. Forest plots

Appendix G. Health economic evidence selection

Figure 35. Flow chart of economic study selection for the guideline

Appendix H. Health economic evidence tables

None

Appendix I. Excluded studies

Final

Intervention evidence review (H)

This evidence review was developed by the National Guideline Centre

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Copyright © NICE 2019.
Bookshelf ID: NBK577654PMID: 35133762

Views

  • PubReader
  • Print View
  • Cite this Page
  • PDF version of this title (1.9M)

In this Page

Other titles in this collection

Related NICE guidance and evidence

Supplemental NICE documents

Related information

  • PMC
    PubMed Central citations
  • PubMed
    Links to PubMed

Similar articles in PubMed

See reviews...See all...

Recent Activity

ClearTurn OffTurn On

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...