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Does omission of ureteral stents after ureteroscopy increase risk of unplanned return visit? A systematic review and meta-analysis.
Vernon M. Pais, Jr., MD1, Cody Rissman, BS2, Rebecca Smith, BS3, Elizabeth Stedina, MBA3.
1Dartmouth Hitchcock Medical Center, Lebanon, NH, USA, 2Geisel School of Medicine, Hanover, NH, USA, 3The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.
Ureteral stenting following ureteroscopy for nephrolithiasis is routinely performed despite increasing evidence that stent placement may be omitted after “uncomplicated” ureteroscopy. It has been hypothesized that many may place stents to obviate concerns of unplanned return visits, balancing risks of costly revisits due to postoperative obstruction, with increased procedural costs and concern regarding increased revisits in stented patients for pain and infection. Our objective was to systematically review and meta-analyze the body of literature comparing the risk of unplanned medical visits and other health outcomes following ureteroscopy for nephrolithiasis, according to whether a stent is placed.
We searched MEDLINE (1946-2015), CENTRAL (1898-2015), EMBASE (1947-2015), ClinicalTrials.gov (1997-2015), American Urological Association Annual Meeting abstracts (2011-2015), and reference lists using no limits or language restrictions. All searches were last updated in October 2015.
We included randomized trials (RCT), non-randomized trials, before-after studies and cohorts comparing stent omission versus stent placement following ureteroscopy for nephrolithiasis in adults, and reporting unplanned visits at 30 days.
Two reviewers, including a clinical expert, independently extracted data and assessed methodological quality using a standardized tool. We calculated pooled relative risks (RR), weighted mean differences (WMD), and standardized mean differences (SMD) using random effects models. We calculated Peto odds for our primary outcome using fixed effects; considered I2>50% to indicate substantial heterogeneity; and evaluated reporting bias using funnel plots
Our initial search yielded 1,992 studies, of which 17 studies involving 1,943 participants met inclusion criteria. Symmetry of the funnel plot of included studies reflects low risk of publication bias. Overall, unstented patients were significantly more likely to have an unplanned medical visit compared to those who received a post-ureteroscopy stent (OR 1.63, 95% CI 1.15-2.30). A priori planned subgroup analysis of the 13 RCTs confirmed this increased risk of unplanned visit among unstented patients (OR 2.12, 95% CI 1.38-3.25). Within this subgroup, the absolute risk of unplanned visit was 8.4% among unstented patients compared with 4.1% among the stented.
Conversely, unstented patients had shorter operative time (weighted mean difference -3.19 minutes, 95% CI -5.64 to -0.74) and were less likely to have dysuria (RR 0.39, 95% CI 0.25-0.62). Unstented patients were also less likely to have postoperative pain (RR 0.64, 95% CI 0.39-1.05) or infection (RR 0.89, 95% CI 0.59-1.33), and more likely to have postoperative obstruction (RR 2.24, 95% CI 0.66-7.66), although these were not statistically significant.
Stent omission following ureteroscopy is associated with an increased risk of unplanned medical visits, despite lower rates of dysuria compared to stented patients. These tradeoffs should be weighed by patients and physicians when considering post-ureteroscopy stent placement.
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