Re: Preoperative Stenting Decreases Operative Time and Reoperative Rates of Ureteroscopy (From: Chu L,Sternberg KM,Averch TD. Preoperative stenting decreases operative time and reoperative rates of ureteroscopy. J Endourol 2011;25:751–754)

Dear Editor:

W e read the article by Chu and associates with great interest. The authors made a comparison of the outcomes for the patients in whom a stent was placed before ureteroscopy (URS) and those who did not receive a stent. They concluded that preoperative stent placement was associated with decreased operative time and reoperative rates, especially in patients who had stones larger than 1 cm. In addition, although the stone clearance rates were found superior in the prestented group, the results did not reach statistical significance.

It is obvious that stent placement before URS procedures for dilation of the ureter is still a subject of debate, which is a certain conclusion that could not be reached until now. The effort of the authors to clarify this point should be appreciated. There are some points of the study that needs to be well addressed, however.

The first factor that needs to be taken into account before the decision of pre-URS stent placement is the cost-effectiveness. It has been reported that stent placement increases the economic liability, which is about 140 Canadian dollars ($144) for each patient. ¹ Although the cost of the anesthesia and URS might change slightly between the countries, this factor should be taken into account seriously. Moreover, in the given series, it has been reported that in patients with stones that are located at the proximal ureter, about one-third of the patients needed secondary procedures in the group with pre-URS stent placement. For those patients, a total of three procedures were performed: One for stent placement before URS, one for initial therapeutic URS, and the last for the auxiliary procedure. Receiving anesthesia three times will definitely have adverse effects on the patients both economically and psychologically. For this reason, patient selection and counseling should be performed meticulously before the decision of stent placement before URS is made.

In the given series, it has been reported that the stents were placed successfully without any complications and with minimal anesthetic morbidity before stone treatment. In all 45 patients with stents before URS, unsuccessful stent placement has not been reported in any of them. When stone dimensions are in a range of 0.3 to 4 cm and with 23% of them larger than 2 cm, it may be considered good luck by the authors for not having any impacted stone in any of their patients. Stone impaction to the ureteral wall, however, is a common condition that may cause complete obstruction and subsequent strictures. ² In those cases with impaction, stent placement may sometimes becomes impossible, and fragmantation of the stone is mandatory to be able to reach the proximal portions of the ureter. We believe and have experienced that stent placement before URS may not be possible in all cases because of the large size and the impaction of the stone. For this reason, although the authors have not experienced it in their study, this point should also be taken into account by the literature until a large high number of series for stent placement before URS has been published.

The authors preferred to leave a postoperative stent in all of their patients, and they removed the stent 3 days after in those with a pre-URS stent and 10 to 14 days after in the nonstented group. Subsequently, they indicated that prestented patients had a shorter postoperative stent duration. This could not be presented as some kind of advantage of the procedure, while this is only a preference of the surgeon. One might prefer to proceed vice versa or even not leave a postoperative stent and have opposite findings. The beneficial effect of postoperative stent placement is also a question in the literature, and many authors ^3,4 have previously randomized their patients either for postoperative stent placement or not to elucidate the necessity of this procedure. They have concluded that ureteral stent placement is not necessary after uncomplicated URS. In addition, they found that the ureteral stent does not prevent urinary sepsis and also may influence postoperative pain and discomfort. It is understandable that postoperative stent placement is the preference in the given series, but with having this evidence-based data from the literature and the report of the authors indicating that only one major complication has occurred in 104 patients, postoperative stent duration should not be discussed in this manner.

Finally, the duration of pre-URS stent placement sufficient for dilation of the ureter and the severity of the discomfort caused by this procedure are the other questions that need to be addressed. All in all, unless the indications and duration of stent placement before URS are well described within the enlarged series, we think that the indications for this procedure in elective cases might be limited.