Blackwell Publishing AsiaMelbourne, AustraliaIJUInternational Journal of Urology0919-81722006 Blackwell Publishing Asia Pty LtdJuly 2006137886890Original Article Stenting in bilharzial

ureter A Hussein et al.

International Journal of Urology (2006) 13, 886890

Original Article

Stenting versus non-stenting after non-complicated ureteroscopic manipulation of stones in bilharzial ureters
ALAYMAN HUSSEIN, EHAB RIFAAT, AHMED ZAKI AND MAMDOUH ABOL-NASR Urology Department, Minia University Hospital, El-Minia, Egypt
Background: Stents were used routinely after ureteroscopy to prevent postoperative ureteral obstruction. However, because of the recognized complications of stents, non-stenting is the new trend after uncomplicated ureteroscopy. The wall of the bilharzial ureter is characteristically thick and may be calcied. The aim of this study is to see if the non-stenting trend could be applied to ureteroscopic manipulation of stones in bilharzial ureters. Patients and Methods: In this prospective study, 56 patients, with evidence of bilharzial lesions in the urinary tract, undergoing ureteroscopy for distal ureteral stones were included. After successful uncomplicated stone fragmentation and extraction, patients were randomized into two groups. Group A includes 28 patients in whom double J 6-Fr polyurethane stents were placed for 3 weeks. Group B includes 28 non-stented patients. Postoperative fever, loin pain, lower urinary tract symptoms and change in the degree of hydronephrosis were reported. Results: There was no signicant difference in the mean age of patients and stone size in both groups. The mean operative time was 43 14 min in group A and 38 11 in group B. There was no signicant difference in the mean loin pain score, in the rst postoperative 48 h, in both groups (4.4 0.8 in group A and 4.9 0.5 in group B). Patients in group A had, signicantly, more ank pain with voiding (P < 0.01), voiding pain (P = 0.04), frequency (P = 0.01) and urgency (P = 0.04). Radiologic follow-up was available for 24 patients in group A and 23 patients in group B at the 3-month visit. Hydronephrosis had improved in all patients, in both groups, with no evidence of ureteral stricture. Conclusion: Routine placement of stents after uncomplicated ureteroscopy for distal ureteral stones is unnecessary in bilharzial ureters. Moreover, it might be unadvisable because lower urinary tract symptoms and voiding loin pain are more in patients with ureteral stents and hydronephrosis is equally improved in stented and non-stented patients. Key words bilharziasis, lower urinary tract symptom, stenting, stone, ureteroscopy.

Introduction Ureteroscopic stone fragmentation and removal is currently the treatment of choice for distal ureteral stones.1 At the completion of ureteroscopy, internal ureteral stents are usually placed to ensure drainage, prevent postoperative obstruction and probable stricture formation, particularly if vigorous manipulation of the ureteral stone was performed. In addition, stenting is thought to assist in the passage of residual stone fragments after intracorporeal lithotripsy through passive ureteral dilatation.2 However, ureteral stents have their own recognized complications: trauma, migration, bladder irritation, vesicoureteral reux, infection, breakage, encrustation and stone formation.35 Moreover, ureteral stents add some expense to the overall ureteroscopic procedure, and unless a pull string is used at the distal end of the stent, secondary cystoscopy is required for stent removal.6 Therefore, some authors started to question the need for routine stenting after ureteroscopy and to recommend a policy of selective
Correspondence: Alayman Hussein MBBCH MSc MD, Urology Department, Minia University Hospital, El-Minia 61111, Egypt. Email: alaymanh@hotmail.com Received 21 October 2005; accepted 18 January 2006.

ureteral stenting.7 Since the pioneering report by Hosking et al. 8 few prospective randomized studies have been published on ureteroscopy with or without stenting; these have concluded that patients without a stent have signicantly fewer symptoms in the early postoperative period, while there were no differences in terms of complications and stone free status.912 Non obstructive dilatation of bilharzial ureters is a common nding and is often due to vesicoureteric reux or decient peristalsis in an edematous ureteral wall.13 The wall of bilharzial ureters are characteristically thick and may be calcied and may be turned into an inelastic brous tube.14 The aim of this study is to see if the non-stenting trend could be applied to ureteroscopic manipulation of stones in bilharzial ureters. Methods The study was conducted between June 2003 and December 2004 at the Urology Department, Minia University Hospital, El-Minia, Egypt. Among patients undergoing ureteroscopy for distal ureteric stones, patients with clear evidence of bilharzial ureters were included in the study. The 56 included patients had either one or more of the

Stenting in bilharzial ureter following: ureteric calcication in the plain X-ray lm (Fig. 1; 11 patients), segmental dilatation of the ureter in intravenous urography (Fig. 2; 33 patients) or bilharzial lesions in the urinary bladder and the ureter seen in cystoscopy and ureteroscopy (29 patients). Patients with active bilharzial lesions or any suspicion of ureteric stricture were excluded from the study. Also, patients were excluded when stone size was greater than 2 cm, on nding polyps suggestive of urothelial cancer, in mucosal perforation during operation and in cases of extensive manipulation. Under either general or spinal anaesthesia, all patients underwent initial formal cystoscopy. The ureteric orices were identied and retrograde pyelography was done. The intramural parts of the ureter were dilated using 18-Fr balloon dilators. A ureteroscope (8.2 Fr) was introduced to identify the stone, and intracorporeal pneumatic lithotripsy was used for fragmentation of the stone. Fragments were extracted using dormia baskets and stone graspers. After successful uncomplicated stone fragmentation and extraction, patients were randomized into two groups. Group A included 28 patients in whom double J 6-Fr polyurethane stents were placed for 3 weeks. Group B included 28 non-stented patients. The mean age of patients in group A was 39.4 11.2 years and in group B was 37.8 9.6 years; the mean stone size was 12.6 0.9 mm and 13.1 0.9 mm in groups A and B, respectively. A urethral catheter was xed for 24 h and patients were discharged after removal of the urethral catheter. Patients were administrated an intraoperative prophylactic intravenous antibiotic which was continued orally for 1 week postoperatively.

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All patients were closely evaluated on the follow-up examinations. We used a questionnaire to measure postoperative patient pain, either loin pain at rest or voiding loin pain, using a 010 scale, on which 0 represented no pain and 10 represented extreme pain. Also, we used the questionnaire to measure postoperative fever and lower urinary tract symptoms (frequency, urgency, and hematuria). The outcome and complications were assessed by urine analysis, plain X-ray and abdominal ultrasonography in the rst postoperative week and repeated 1 month after ureteroscopy. Intravenous urography was done 3 and 6 months after ureteroscopy to measure the change in the degree of hydronephrosis. All continuous variables were expressed as mean standard deviation. Independent sample t-test, Fishers exact and MannWhitney U-tests were used for comparison of continuous variables when appropriate, while the 2-test was used to compare categorical variables, with a P-value <0.05 considered signicant. A statistics software package (SPSS 10; SPSS, Chicago, IL, USA) was used for statistical analysis. Results The two patient groups were comparable with respect to the baseline variables of patient age and gender and mean stone size (Table 1). Mean operative time standard deviation in group A was 43.9 11.2 min and 38.1 13.3 min

Fig. 1 Plain X-ray showing bilharzial calcication of the bladder and ureter, Ureteric stone is seen in the lower third of the right ureter.

Fig. 2 Intravenous urography of the same patient in Figure 1 showing bilharzial segmental non-obstructive dilatation of the ureter in the left side. The dilated ureter in the right side is due to the ureteric stone and bilharziasis.

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A Hussein et al. days was slightly higher in group B, but the difference was not signicant (P = 0.09; Table 2). Figure 5 shows that lower urinary tract symptoms, painful voiding, frequency, urgency, hematuria and urinary tract infection were more prevalent in the stented group with a statistically signicant difference (P < 0.05). Concerning postoperative follow up, INTRAVENOUS UROGRAPHY of all patients, 34 months after urertroscopy, were normal with no evidence of hydronephrosis or anatomical ureteral narrowing in both stented and unstented patients. Discussion The routine placement of a ureteral stent following ureteroscopic stone removal has been widely recommended to

in group B. Thus, operative time was not signicantly longer when stents were placed (P = 0.07; Table 2). All the patients were discharged after overnight hospitalization; no patient was readmitted for severe pain, persistent fever or any other complication. Plain X-ray lm on postoperative day 15 revealed a 100% stone-free rate in both groups (Table 2). Figure 3 shows the mean pain scores at 1, 3, 7 and 15 days in the two groups. At days 1 and 3 the mean visual analog pain score in group A was lower than in group B, but the difference was statistically not signicant (P > 0.1). At days 7 and 15 pain score decreased in both groups, but becomes higher in group A than in group B, and the difference was still statistically not signicant (P > 0.1). Comparatively, the mean postoperative voiding loin pain score, as shown in Figure 4 , is signicantly higher in group A than in group B. It obviously decreased in group B in postoperative days 7 and 15 in comparison to day 3, but it was almost stationary in days 3, 7 and 15 in group A. The incidence of fever in the rst three postoperative

Fig. 4 Postoperative voiding loin pain.

Fig. 3 Postoperative loin pain. Table 1 Clinical characteristics and stone size Group A (28 patients) Mean age (years) No. males/females Mean stone size (mm) 39.4 11.2 24/4 12.6 0.9 Group B (28 patients) 37.8 9.6 25/3 13.1 0.9 P-value 0.52 0.71 0.69 Fig. 5 Postoperative lower urinary tract symptoms.

Table 2 Operative time and postoperative follow up Group A (28 patients) Mean operative time (min) Mean hospital stay (days) Fever (%) Readmission for complications Stone-free rate (%) Improvement in hydronephrosis (%) Evidence of postoperative stricture (%) 43.9 11.2 1 17.9 0 100 100 0 Group B (28 patients) 38.1 13.3 1 21.4 0 100 100 0 P-value 0.07 1 0.09 1 1 1 1

Stenting in bilharzial ureter reduce postoperative pain and avoid ureteral stricture at the stone impaction site and possibly facilitate the passage of small stone fragments.2 With the relatively recent development of small caliber ureteroscopes and more effective intracorporeal lithotripsy devices, it is now possible to perform ureteroscopy in most patients without dilatation.15 As a result, ureteroscopic stone fragmentation has become a relatively atraumatic procedure. This encourages the new trend of non-stenting after uncomplicated ureteroscopy. There have been few prospective studies in the past to determine whether routine stenting after uncomplicated ureteroscopy for distal ureteral stones is necessary. These trials have several similarities to our study including a preponderance of patients with distal ureteral calculi, mean stone size, and exclusion of patients indwelling ureteral stents preoperatively and those with lesions suspicious of malignancy. But our study is different as it is limited to cases with bilharzial ureters and we did ureteral dilatation in all cases. The wall of bilharzial ureter is thick and may be dilated without obstruction.16 The ureters may show a generalized or segmental dilatation due to hypotonia or even aperistalsis of the ureter.13,16,17 So, it is expected that manipulation of stones in bilharzial ureter is, in particular, less risky due to its natural thick wall and luminal dilatation. This made stent positioning, as a routine part of uncomplicated ureteroscopy for fragmentation and extraction of stones in the distal part of bilharzial ureter, a questionable issue. Many randomized trials have demonstrated similar postoperative complication rates among stented and unstented patient populations after treatment of ureteral calculi.6,1012,1820 In ureteroscopy in bilharzial ureters, as in previous studies in non-bilharzial ureters, there is no difference in stone-free status between stented and nonstented groups.6,1012,1820 And, if the operative times are longer in case of stenting,12 the difference is not signicant in most of the studies including ours.6 Early studies suggest stenting after ureteroscopic fragmentation and removal of ureteral stones to prevent ureteric obstruction in the early postoperative days due to edema secondary to ureteroscopic manipulation.12 Accordingly, postoperative loin pain should be avoided in stented patients. But we found no signicant difference in postoperative loin pain in stented and non-stented patients correlating with previous studies,6,8,10,21 and in some studies stented patients were documented to have signicantly higher pain scores.11,17,22 Loin pain in stented patients could be explained by the increase in the intrapelvic pressure and extravasation of the irrigation uid during stone manipulation,23 as we found that loin pain decreases by time in the stented and non-stented patients, correlating with the study by Damiano et al.6 Another type of pain is the voiding loin pain, which is signicantly higher in stented patients, in previous studies in non-bilharzial ureter, as well as in our current study in bilharzial ureter.10 This type of pain could be simply explained by the reuxing nature of the stent and the increase in the intrapelvic pressure during voiding. Few non-stented patients suffer from vesicoureteric reux in the

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early postoperative days, especially if dilatation was done. In the case of bilharzial ureter, and due to the thick tough nature of the ureteric wall and the possibility of accompanied bilharzial bladder neck obstruction, the incidence of reux and voiding loin pain in non-stented patients is relatively higher than in other studies in non-bilharzial ureters and in all studies it decreases with time.10 Patients with an indwelling ureteral stent have a wide range of urinary symptoms that affect their quality of life.24 Correlating with previous studies,11,19 we found that lower urinary tract symptoms such as painful voiding, frequency of micturition, urgency, hematuria and urinary tract infection were signicantly more prevalent in stented patients than in patients without stents. Other disadvantages to stent placement following ureteroscopy include stent migration, encrustation, fragmentation and breakage, infections, secondary stone formation and obstruction of the stented tract and the substantial overall cost of the stent itself and the cost of cystoscopy to remove it.6,12,22,25 Routine placement of ureteral stent after ureteroscopic stone has been considered the standard of care in most centers but Denstedt et al. performed a prospective trial of non-stented versus stented ureteroscopic lithotripsy, and concluded that patients without a stent have signicantly fewer symptoms in the early postoperative period, while there were no differences in terms of complications and stone-free status.18 Similar data from Hosking et al. and Rane et al. presenting cases after uncomplicated ureteroscopic lithotripsy shows that routine ureteral stenting after ureteroscopy and intracorporeal lithotripsy does not appear to be necessary.8,9 Hollenbeck et al. reviewed 266 patients who did not have a ureteral stent placed after ureteroscopic treatment of calculi and considered numerous variables associated with postoperative morbidity and stressed that their data is suggestive that some patients are at greater risk for complications after stentless ureteroscopy, as there may be other factors that may affect the decision to leave a stent after ureteroscopy.26 We think that bilharziasis is one of these factors. Stenting is not preferred after uncomplicated ureteroscopic stone fragmentation and removal, if bilharziasis is associated with a dilated non-obstructed ureter. Conclusion The routine placement of a stent after uncomplicated ureteroscopy for stones in the distal third of bilharzial ureters is no longer necessary. The prevalence of loin pain is comparable in stented and non-stented patients and hydronephrosis is equally improved in stented and non-stented patients. In addition, patients with stents seem to have signicantly more voiding loin pain and irritative voiding symptoms and the routine placement of a stent signicantly adds to the overall cost of the procedure. References
1 Segura JW, Preminger GM, Assimos DG, Dretler SP, Kahn RI, Lingeman JE. Ureteral stones clinical guidelines panel

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