Indications and Outcomes of Local Anesthetic Retrograde Ureteral Stent Insertion: A Systematic Review from EAU Endourology

Abstract

Introduction and Objectives:

To evaluate the indications and clinical outcomes of local anesthetic stenting in urological procedures, assessing its effectiveness, adverse effects, and patient tolerance.

Materials and Methods:

The systematic review was conducted in line with Cochrane and Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. MEDLINE, CINAHL, EMBASE, and the Cochrane Central Register were searched up to September 2024 (PROSPERO—CRD42024596866). Studies with at least five patients, focusing on Double-J stent placement or exchange under local anesthesia, published in English, were included. Case reports, reviews, pediatric studies, and redundant older data were excluded. Data on study characteristics, patient demographics, procedural details, and outcomes, including success and complication rates, were extracted.

Results:

A total of 1725 patients and 1873 ureteral units were included, with studies that varied in sample size (6–463 patients) and included both stent placements (77.6%) and exchanges (22.4%). The overall success rate for local anesthetic stenting was 89%, with failure rates averaging 11%. Of reported studies, complications were reported in 8.68% (n = 76), predominantly Clavien–Dindo Grades I–II (5.94%) and III–IV (2.74%). Lidocaine jelly was the primary local anesthetic, with adjunct pharmacological interventions in some studies. Fluoroscopic guidance was used in 86.3% of cases, and both flexible and rigid cystoscopes were employed. Cost analysis consistently demonstrated significant cost savings with local anesthesia compared to general anesthesia. Patient satisfaction and pain scores showed variability, with many studies highlighting minimal discomfort and a strong willingness among patients to undergo the procedure again.

Conclusions:

Local anesthetic stenting is an effective alternative to general anesthesia, achieving a good success rate with a low risk of major complications. Although it offers significant cost savings and patient satisfaction is usually high, it does highlight the need for careful patient selection and counseling.

Introduction

Placement of a ureteral stent is a common urological procedure to manage ureteral compression or ureteral drainage secondary to stone disease or malignancy.^1,2 The procedure could be done in elective or emergency conditions and is usually performed under general anesthesia (GA). However, placement of a stent under local anesthesia (LA) is feasible and a suitable option, thereby avoiding the risks of a GA.^3,4

Performing ureteral stenting under LA has the added advantage of being done in an outpatient or ambulatory setup without needing the traditional operating room (OR) setup. It can also potentially avoid the delays associated with waiting lists related to the latter.⁵ Previous studies have shown success with shockwave lithotripsy, prostate biopsy, and similar urological procedures using mood lighting or music to alleviate patient anxiety and pain.⁶ Some have also used nitrous oxide (N₂O) for short interventions to reduce pain.⁷ Stent placement, which typically is a short procedure, is therefore ideal for use with this too.

Ureteral drainage can also be established by performing a percutaneous nephrostomy (PCN), which is often done under LA.⁸ Debate still exists on the best management of ureteral obstruction and whether PCN is preferable over ureteral stenting in certain situations. One of the arguments is often the use of LA for PCN and GA for ureteral stent insertion. The use of LA for stent insertion would therefore give clinicians and patients more choice with regard to the urinary drainage, especially in emergency situations.⁹

The role of ureteral stent placement as a new procedure or as a replacement and change for an existing stent can both be done under LA. In this article, we conduct a systematic review to look at the role of local anesthetic stent placement, including the underlying disease condition, stent placement or change, outcomes, and lessons learnt from the studies.

Methods

Patient/population, intervention, comparison, and outcomes statement

The PICO statement for this systematic review is as follows: In patients with any disease condition who underwent local anesthetic stent insertion or change, how did patients with LA (intervention) compare with those with GA (comparator).

Evidence acquisition

The inclusion criteria for the study: •

Studies must include a minimum of five patients

•

Articles must focus on the placement or exchange of double-J ureteral stents performed under LA

•

Articles published exclusively in English language

The exclusion criteria: •

Case reports, review articles, historical cohort studies, and laboratory studies

•

Pediatric population

•

Older studies that present the same data as more recent publications

Search strategy and study selection

The systematic review of the literature was performed in accordance with the Cochrane review and Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines.¹⁰ The databases searched were MEDLINE, CINAHL, EMBASE, and Cochrane Central Register of Controlled Trials. All studies up to September 2024 were included.

The study selection process, systematically performed in September 2024, has been described using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.¹¹ The search strategy was conducted to find relevant studies from the Medline database, setting as Medical Subject Headings (MeSH): (ureteral Stent OR JJ-Stent OR Double J) AND (placement OR insertion OR change) AND (local anesthetic OR LA OR bedside OR outpatient). Only articles available in English were eligible for inclusion, and no time limit was set in the research strategy. Boolean operators ‘‘AND’’ and ‘‘OR’’ were used to refine the results. Two reviewers (A.P. and V.J.) independently screened the studies to identify relevant studies for inclusion, and any discrepancies or queries were reviewed by the senior reviewer (B.K.S.). Inclusion criteria were all original studies assessing ureteral stents placed under local anesthetic and written in the English language.

The review was registered in PROSPERO with registration number: CRD42024596866. Where cost analysis was done, all costs were converted to US dollars ($) with a conversion rate of 10/04/2024.

The outcomes of interest encompassed author(s), year of publication, journal, study design, sample size, mean age, gender distribution, underlying disease conditions warranting stent placement, and procedural details including the type of anesthesia, cystoscope utilized, size of the JJ stent, fluoroscopic guidance, and mean operating time. The primary outcome measures evaluated were the success rate, complication rates, and documented reasons for failure. The success of local anesthetic ureteral stent placement was defined as the accurate positioning of the stent, confirmed either intraoperatively through fluoroscopic guidance or postoperatively via imaging (fluoroscopy or X-ray). Secondary outcome measures included cost, pain scores, and patient preferences when available.

Given the heterogeneous nature of the studies, a narrative review was conducted, as a formal meta-analysis could not be performed.

Results

Study selection and data extraction

The systematic review was performed in accordance with the PRISMA flow diagram, with a total of 234 articles that were identified. Subsequently, screening of the titles followed by the abstracts allowed us to identify a total of 18 articles, which were then retrieved in full-text format. Of the latter, 12 were included in the final analysis for meeting both the inclusion criteria and pertinence of the topic analyzed.^{3,12

–22}

This review encompasses articles published up to September 2024, which evaluated a diverse range of indications and outcomes associated with the placement and exchange of ureteral stents performed under LA. The analysis included a total sample size of 1725 patients and 1873 ureteral units, which encompassed both stent placements and exchanges.^{3,12

–22} The studies examined varied in sample size, with individual studies comprising between 6 and 463 patients (Table 1).

Table 1.

Demographics of the Included Studies

Study	Data acquisition	Timeframe	Inclusion criteria	Exclusion criteria	Number of units/procedures	Total no. of patients	Male:female ratio	Mean age (y)
Andriole GL, et al. Indwelling double-J ureteral stents for temporary and permanent urinary drainage: experience with 87 patients . J Urol 1984	Retrospective	July 1980–December 1982	N/A	N/A	47	47	N/A	N/A
Adeyoju AB, et al. Outpatient flexible cystoscope-assisted insertion of ureteral catheters and ureteral stents . BJU Int 1999	Prospective	July 1997–May 1998	Patients with appropriate clinical indication; no patient selection bias	No patient selection bias	6	6	N/A	N/A
McFarlane JP, et al. Outpatient ureteral procedures: a new method for retrograde ureteropyelography and ureteral stent placement . BJU Int 2001	Prospective	February–December 1999	N/A	N/A	430	N/A	N/A	N/A
Masood J, et al. ‘An interventional urology list’-a novel concept for UK urological services . Ann R Coll Surg Engl 2011	Prospective	May 2005–May 2009	Patients on the waiting list for local anesthetic JJ stent insertion and stent exchanges; postoperative stone patients who required timely stent removal	N/A	266	N/A	N/A	N/A
Sivalingam S, et al. Office-based ureteral stent placement under local anesthesia for obstructing stones is safe and efficacious . Urology 2013	Retrospective	January 2007–July 2011	Primary stent placement for symptomatic obstructive ureteral calculi	Patients who underwent stenting for other indications; stent placed as an adjunct to another procedure; stent placed nonspecific obstruction	46	46	20:26	52.2
Hussein NS, Norazan MR . Impact of self-watching double-j stent insertion on pain experience of male patients: a randomized control study using visual analog scale . ISRN Urol 2013	Prospective	January–July 2012	Males; age over 18 years old; must have attended urinary stone disease clinic and have indications for DJ insertion	History of previous cystoscopy; clinical evidence of urethral stricture; psychiatric illness; inability to understand the procedure or the questionnaires; bladder outlet obstruction; stent exchanges; patient requesting general anesthesia	80	80	80:0	38.8
Carrouget J, et al. Double-J ureteral stent under local anesthesia for women . Can J Urol 2014	Prospective	January 2010–January 2013	Female; patients aged over 18 years	Patients who required another surgical procedure during the same intervention, ureteral catheter stenting, or stent exchange	18	18	0:18	N/A
Wang JY, et al. Predicting the failure of retrograde ureteral stent insertion for managing malignant ureteral obstruction in outpatients . Oncol Lett 2016	Retrospective	January 2008–April 2013	Patients affected by malignant ureteral obstruction; absence of signs of fever or sepsis	Ureteral obstruction induced by bladder cancer, iatrogenic damage to the ureter, previous cystectomy and urinary diversion procedures, or renal transplants; patients with urological abnormalities; patients who had received previous urological operation	202	164	20:144	49.6
Nourparvar P, et al. Safety and Efficacy of ureteral stent placement at the bedside using local anesthesia . J Urol 2016	Retrospective	July 2012–August 2014	None specific	Signs of fever or evidence of systematic infection	42	42	20:22	51.3
Doersch KM, et al. Feasibility and clinical outcomes of ureteral stenting in the office procedural suite . Can J Urol 2018	Retrospective	February 2014–February 2016	Mental capability of consenting to stent placement in the clinic; patients who expressed interest in having their stents placed in a clinic; age over 18 years	Stent placement in any setting other than the clinic procedure suite; age under 18 years; mentally incapable patients; unstable vital signs; respiratory failure; signs of sepsis	565	463	190:273	56.4 ± 17.9
Carrion A, et al. Office stent placement under local anesthesia is a safe and efficient procedure for the management of multiple ureteral disorders . Actas Urol Esp (Engl Ed) 2018	Retrospective	January 2015–July 2016	Hemodynamically stable patients; must be able to cooperate during the procedure; patients affected by upper urinary tract obstruction, urinary leakage from the ureter, or that require ureteral localization during abdominopelvic operation	N/A	45	37	10 :27	58.6 ± 17.5
Connelly ZM, et al. Ureteral stenting in the clinic: a safe and cost-effective alternative to the operating room . Am J Clin Exp Urol 2023	Retrospective	May 2019–October 2021	All patients placed either in the clinic and operating room; hemodynamically stable; no signs of infection; normal urine tests; no in severe pain; patients who have chronic indwelling ureteral stent, came to the clinic with mild to moderate amount of pain, had agreed on the offer of stent in the clinic	Patients age under 18 years; patients not able to give consent; pregnant women; incarcerated persons	126	126	36:90	50

Demographics

The overall male-to-female ratio indicated a female prevalence of 0.89:1, derived from data provided by eight studies that exhibited no gender bias,^{3,14

–18,21,22} whereas excluding those with gender-specific inclusion criteria.^15,18 The mean age of participants were 52.8 years.^{3,14,16
–18,21,22} Notably, only four studies incorporated a GA control group^3,13,15,16 (Table 1).

Underlying indications for stent

This review specifically focused on primary stent placement and stent exchange, with the former comprising 77.6% (n = 1236) of cases and the latter 22.4% (n = 383).^{3,12

–22} Indications for stenting varied significantly across the studies, with the most common being adjuncts to genitourinary surgeries 1.5% (n = 25), management of pelviureteric junction (PUJ) obstruction 3% (n = 49), benign ureteral obstructions (both intra- and extraluminal) 13.6% (n = 221), malignant ureteral obstruction 27.4% (n = 443), urolithiasis 44.7% (n = 724), urinary tract fistulas 0.7% (n = 12), anuria 0.7% (n = 13), hydronephrosis 10% (n = 163), pain management 3.6% (n = 59), and others 3.6% (n = 57).^{3,12

–22} (Table 2).

Table 2.

Indications and Outcomes with Causes of Failure

Study	Type of procedure		Indication for JJ stent	Rate of procedure		Causes of insertion failure
Study	JJ insertion	JJ change	Indication for JJ stent	Success	Failure	Causes of insertion failure
Andriole GL, et al.	47	0	Ureteral obstruction 65.5% (n = 57); adjunct to genitourinary operation 17.2%(n = 15); upper urinary tract fistulas 11.5% (n = 10); hydronephrosis of uncertain etiology 5.7% (n = 5)	N/A	N/A	N/A
Adeyoju AB, et al.	6	0	Before ESWL in patients with large intrarenal calculi 33.3% (n = 2); before ESW. in patients with small symptomatic upper ureteral calculi 33.3% (n = 2); symptomatic PUJ obstruction 16.7% (n = 1); patient had underwent ureteral stenting 2 weeks before hospital admission for balloon dilatation of a stenosed previously repaired PUJ obstruction 16.7% (n = 1)	85%	15%	Inability to locate ureteral orifice, previous resection of the ureteral orifice, inadequate visualization of the ureteral orifice
McFarlane JP, et al.	230	140	Stone disease 23% (n = 165); malignant ureteral obstruction 22% (n = 157); unexplained hydronephrosis 21% (n = 150); hematuria 13% (n = 94) benign ureteral strictures 10% (n = 72); autosomal dominant polycystic kidney disease 3% (n = 20); filling defect on IVU 2% (n = 15); hydronephrosis of pregnancy 1% (n = 8); risk of contrast allergy 1% (n = 7); ureteral trauma 1% (n = 6); unexplained loin pain 1% (n = 6); other 3% (n = 23)	89%	11%	Failure to cannulate the ureteral orifice, inability to advance wire past stone, Inability to relocate ureteral orifice after stent removal, Failure to pass scope because of urethral stricture/urethritis, inability to pass stent pass stone/through a stricture, inability to locate stent because of bleeding, inability to change stent, panic attack
Masood J, et al.	24	48	Before ESWL; patients with pelviureteric junction (PUJ) 30.5% (n = 22); obstruction awaiting pyeloplasty who were in pain 2.6% (n = 2)	98.5%	1.5%	Patient discomfort, ureteral stricture
Sivalingam S, et al.	46	0	Pain 57% (n = 26); fever/pyuria 28% (n = 19)	91.3%	8.7%	Tight UVJ, impacted UVJ stone, J hooking, Inability to see the ureteral orifice, inability to negotiate wire past stone, patient discomfort
Hussein NS, Norazan MR	80	0	Ureteral stone 57.5% (n = 46); renal stone 26.3% (n = 21); anuria 16.3% (n = 13). All JJ stents were inserted as temporary measurement while waiting for definitive treatment 4–6 weeks later according to operation room availability	N/A	N/A	N/A
Carrouget J, et al.	18	0	Intraluminal obstacles 67% (n = 24); extraluminal obstacles 33% (n = 12)	N/A	N/A	N/A
Wang JY, et al.	202	0	Patients with MUO (cervical 62.8%, ovarian 11.6%, gastric 6.1%, rectal 6.7%, other 12.8%) who required ureteral decompression	65.35%	34.65%	N/A
Nourparvar P, et al.	42	0	Patients presenting to the ED with symptomatic, obstructing ureteral calculi: Infection 14% (n = 6); intractable pain 59% (n = 25); nausea and emesis 2% (n = 1)	71%	29%	Impaired advancement of the wire, premature stent deployment, inability to place stent
Doersch KM, et al.	429	136	Management of urinary obstruction: kidney or ureteral stones causing obstruction or infectious complications 67.2% (n = 380), extrinsic or intrinsic malignant condition 14.9% (n = 84), ureteral strictures 6.5% (n = 37), ureteropelvic junction obstruction (UPJO) 4.4% (n = 25), retroperitoneal fibrosis 2.5% (n = 14), or other indications 5.3% (n = 30), which included pregnancy, hematuria, flank pain without identified origin, endometriosis, UTI, Rosai. Dorfman disease, surgical ureteral injuries, recurrent retroperitoneal abscess, renal trauma, pyelitis, and unknown obstructive etiology	98.8%	1.1%	Inability to access ureteral orifice, ureteral stricture, urethral stricture, pain, unknown reason
Carrion A, et al.	33	12	Stones 37.8% (n = 17), extrinsic compression of the ureter 28.9% (n = 13), intraoperative ureteral localization 22.2% (n = 10); PUJ syndrome 2.2% (n = 1); urinary tract fistula 4.4% (n = 2); ureteral stenosis 4.4% (n = 2)	89%	11%	Inability to advance guidewire/catheter, inability to identify the ureteral orifice
Connelly ZM, et al.	79	47	Stones 72.2% (n = 78); strictures 24.1% (n = 26); other 3.7% (n = 4)	N/A	N/A	N/A

UTI = urinary tract infection.

Success and failure rate for stent placement and stent change

The procedure’s success and failure rates highlighted a mean success rate of 89% (range: 65.35%–98.9%) and a mean failure rate of 11% (range: 1.1%–29%), which was reported in eight of the studies.^{3,12,14,17,19

–22} Wang et al. presented a significantly lower success rate of 65.35%, which may be attributed to the malignant nature of the conditions assessed in their article.²² A detailed breakdown of these causes is provided (Table 2).

Analgesia and pharmacological interventions

The primary local anesthetic employed was lidocaine jelly, administered directly into the urethra prior to the insertion of the cystoscope.^{3,12,14

–18,20
–22} Only two studies reported the use of an additional lidocaine-based anesthetic within the bladder.^14,15 Only four studies specified the time interval for lidocaine administration, a with reported dwell time of 2–5 minutes in the urethra prior to cystoscopy, whereas Carrouget et al. specified at least 5 minutes and Nourparvar et al reported a minimum of 1 before administration.^3,15,21 Additionally, Carrion et al described a 5-min dwell time for lidocaine-infused saline in the bladder.¹⁴ Adjunct pharmacological interventions were documented across eight studies, including preoperative intravenous antibiotic prophylaxis (44.7%, n = 771), nonopioid analgesics and antipyretics (1%, n = 18), opioid analgesics (34.7%, n = 598), benzodiazepines (28.6%, n = 494), nonsteroidal anti-inflammatory drugs (1%, n = 18), and antihistamines/antiemetics (7.3%, n = 126), administered either as part of standard care or as needed.^{3,12,14

–18,20,21} Adeyoju et al. presented the only study that incorporated postoperative antibiotics as a standard component of care.¹³ In addition to LA and medical therapy, Doersch et al. also employed the use of nitrous oxide in 23.5% (n = 440) of cases¹⁷ (Table 3).

Table 3.

Local Anesthesia Stent Procedure Details of the Included Studies

Study	Local anesthetic	Nitrous oxide	Medical therapy	Cystoscope	Size of ureteral JJ stent	Fluoroscope guidance	Confirmation postop	Mean operating time (minutes)
Andriole GL, Bettmann MA, Garnick MB, et al.	N/A	N/A	N/A	N/A	N/A	Yes*	N/A	N/A
Adeyoju AB, Collins GN, Brooman P, et al.	Lidocaine jelly	No	Diclofenac and ciprofloxacin (preop) + ciprofloxacin (postop)	Flexible	5–6 F, 26 cm	No	Plain radiograph	>11
McFarlane JP, Cowan C, Holt SJ, et al.	Lidocaine jelly	No	IV antibiotic prophylaxis (ciprofloxacin) + diazepam and meperidine (as required)	Flexible	6–8 F, 20–26 cm	Yes	Fluoroscopy	N/A
Masood J, Ismail M, El-Husseiny T, et al.	N/A	N/A	N/A	Flexible	N/A	Yes	N/A	N/A
Sivalingam S, Tamm-Daniels I, Nakada SY.	Lidocaine jelly	N/A	Midazolam (as required)	15 F flexible in males; 21 F rigid or 15 F flexible in females	6 F	Yes	X-ray	N/A
Hussein NS, Norazan MR	Lidocaine jelly	No	IV antibiotic prophylaxis	20 F rigid	N/A	Yes	KUB-X-ray	5.35 ± 0.87
Carrouget J, Ammi M, Lasocki S, et al.	Lidocaine jelly + lidocaine and bicarbonate mixture in the bladder	N/A	Alprazolam and paracetamol (preop) + midazolam (as required)	20 F rigid	7 F	Yes^*	N/A	24.4 ± 12.9
Wang JY, Zhang HL, Zhu Y, et al.	Lidocaine jelly	No	N/A	Flexible	6 F, 22–26 cm	No	Fluoroscopy and X-ray	N/A
Nourparvar P, Leung A, Shrewsberry AB, et al.	Lidocaine jelly	No	IV antibiotic prophylaxis (mostly ceftriaxone, otherwise fluoroquinolone)	Flexible	6 F or 5 F	No	KUB-X-ray	N/A
Doersch KM, Machen GL, Thai KH, et al.	Lidocaine jelly	Yes (77.9%)	N/A	16 F flexible in males; 22 F rigid in females	N/A	Yes	Fluoroscopy	12.7 ± 8
Carrion A, D’Anna M, Costa-Grau M, et al.	Lidocaine jelly + Lidocaine-infused saline in the bladder	No	IV antibiotic prophylaxis	Flexible	4.8 F	Yes^*	N/A	N/A
Connelly ZM, Stolzle A, Vanlangendonck RA, et al.	Lidocaine jelly	No	IM meperidine, IM promethazine and IM antibiotic prophylaxis	Flexible in males; Rigid in females	6.7 F, 25.7 cm (average)	Yes	N/A	N/A

Not all patients underwent, but otherwise not specified.

Procedural details

When specified, flexible cystoscopes were predominantly employed in 69% (n = 1190), whereas rigid cystoscopes were utilized in 28.3% (n = 488) of patients.^{3,12,14

–22} It is noteworthy that only two studies exclusively used rigid cystoscopes^15,18 other studies differentiated the choice of cystoscope based on gender, favoring flexible cystoscopes for males and rigid cystoscopes for females, in alignment with anatomical variations in urethral length^3,16,17 (Table 3).

Fluoroscopic guidance, in conjunction with cystoscopic visualization, was reported in 86.3% (n = 1616) of the procedures.^{3,14

–20} This imaging modality not only facilitated intraoperative navigation but also confirmed the correct positioning of the Double-J stent, with only five studies utilizing KUB (kidney, ureter, bladder) X-rays for additional verification^{3,12,18,21,22} (Table 3).

Complications

The complication rate, based on a total of 876 procedures in which it was reported, specifically in regard to LA,^{14

–18,21} was calculated at 8.68% (n = 76) and classified according to the Clavien–Dindo Classification of Surgical Complications.²³ Specifically, Grade I–II complications occurred in 5.94% (n = 52) of cases, including fever, hematuria, stone formation, nausea and vomiting, hypoxia, partial epileptic attacks, orthostatic hypotension, stent encrustation, and urinary tract infections (UTIs). Grade III–IV complications were observed in 2.74% (n = 24), comprising stent migration, stent dislodgement, severe pain, pyonephrosis, urosepsis, and acute kidney injury (Table 4).

Table 4.

Outcomes of the Included Studies

Study	Patient pain perception			Complication details
Study	Tools	Results	Rate (%)	Complication rate (%)	Clavien–Dindo
Andriole GL, Bettmann MA, Garnick MB, et al.	N/A	N/A	N/A	17.6%* *Does not distinguish between LA and GA	Grade II 4.41% (n = 6): severe irritative symptoms; Grade III 13.23% (n = 18): obstruction, downward migration of stents, inadequate kidney drainage, stent placed intraoperatively not in bladder.
Adeyoju AB, Collins GN, Brooman P, et al.	N/A	N/A	15%	15%* *Does not distinguish between the different procedures	Clavien–Dindo II (15%): pain
McFarlane JP, Cowan C, Holt SJ, et al.	The first 300 patients were asked to rate the procedure as acceptable, uncomfortable, or painful.	6%	6%*	2.9%* *Does not distinguish between the different procedure	Grade I 0.14% (n = 1): nausea and vomiting; Grade II 0.28% (n = 2): pain necessitating admission; Grade III 1.8% (n = 13): inability to replace the stent, severe pain, torn collecting system, perforated ureter, misplacement of the stent, severe hemorrhage; Grade IV 0.55% (n = 4): sepsis Grade V 0.14% (n = 1): death* (it was unlikely that the procedure contributed)
Masood J, Ismail M, El-Husseiny T, et al.	N/A	N/A	N/A	N/A	N/A
Sivalingam S, Tamm-Daniels I, Nakada SY.	Subjective description of pain or discomfort, or objective signs thereof	N/A	N/A	N/A	N/A
Hussein NS, Norazan MR	VAS score and evaluation of vital signs variations (pulse rate, systolic and diastolic bp) before and after the procedure	Statistically and significantly different between pre- and postop	N/A	0% (n = 0)	0% (n = 0)
Carrouget J, Ammi M, Lasocki S, et al.	Survey after the operation + mean perioperative VAS scale	VAS scores: 5.89 ± 2.95	88.8%	27.8% (n = 5)	Grade II 22.3% (n = 4): hypoxia, partial epilepsy attack, orthostatic hypotension, Grade III 5.6% (n = 1): urinary sepsis
Wang JY, Zhang HL, Zhu Y, et al.	N/A	N/A	N/A	N/A	N/A
Nourparvar P, Leung A, Shrewsberry AB, et al.	Not evaluated	Not evaluated	Not evaluated	0% (n = 0)	0% (n = 0)
Doersch KM, Machen GL, Thai KH, et al.	Not evaluated	Not evaluated	Not evaluated	6.55% (n = 37)	Grade I 0.18% (n = 1): nausea and vomiting; Grade II 2.48% (n = 14): UTI; Grade III 2.65% (n = 16): stent migration, stent dislodgement, severe pain with stent removal and restenting, failure of stents to resolve obstruction, pyonephrosis, intractable stent pain; Grade IV 1.06% (n = 6): urosepsis, AKI
Carrion A, D’Anna M, Costa-Grau M, et al.	Not evaluated	Not evaluated	Not evaluated	17.8% (n = 8)	Grade I 15.6% (n = 7): fever or hematuria Grade III 2.2% (n = 1): stent migration.
Connelly ZM, Stolzle A, Vanlangendonck RA, et al.	Not evaluated	Not evaluated	Not evaluated	18.3% (n = 26)	Grade I 1.8% (n = 5): stone formation; Grade II 7.5% (n = 21): stent encrustation

AKI = acute kidney injury; GA = general anesthesia; LA = local anesthesia; VAS = visual analog scale.

These classifications reflect the necessary interventions required to manage the complications. Although it must be noted that some studies did not clearly distinguish complications specifically associated with JJ stent placement under LA.^12,13,20 Therefore, the data presented only includes studies where this information was explicitly delineated or where we could extrapolate these data.

Costs

Six studies reported on cost expenses and savings, all of which demonstrated cost savings when using LA compared to GA.^{3,12,14,16,19,21} Carrion et al. reported an almost fourfold higher average expense rate in the OR compared to the cystoscopy suite ($2500 vs $640), excluding emergency expenses and preoperative imaging.¹⁴ Connelly et al. calculated a cost difference for stent placement in the OR compared to clinic, finding a difference of $85,484.22 ($16,349.91 vs $7865.69).¹⁶ Similarly, Masood et al. extrapolated a cost savings of approximately $26,566 over a 4-year period.¹⁹ Nourparvar et al. observed that the cost of ureteral stent placement in the OR was more than double the cost of the same procedure performed bedside ($25,000 vs $11,000).²¹ Sivalingam et al. conducted a cost analysis, which demonstrated a greater than four times higher expense for the use of GA compared to LA ($30,060 vs $7000).³ Finally, Adeyoju et al. noted that the potential for savings in the health budget is self-evident.¹²

Pain score and patient satisfaction

Ten studies examined pain perception and patient feedback,^{3,12,14

–18,20
–22} with five reporting a lack of significant findings,^{14,16,17,21,22} primarily attributing this to limitations inherent to the retrospective design of the studies. Adeyoju et al. noted that three patients in their series of 20 patients reported the procedure as excessively painful and expressed a preference for GA, whereas the remaining participants experienced minimal to no discomfort.¹² These patients appreciated the avoidance of hospital admission and the overall efficiency of the procedure, which mitigated the typical anxiety associated with prolonged waiting.¹² Carrouget et al. employed the visual analog scale (VAS) for pain assessment, reporting a mean score of 5.89 ± 2.95, alongside a patient satisfaction survey that indicated significant satisfaction with the procedure in 61.1% of cases.¹⁵ However, it was noted that 50% of patients who underwent the procedure under LA would not opt for the procedure again, although it included a sample size of only 18 patients.¹⁵ Hussein et al. evaluated pain and physiological stress responses by measuring systolic blood pressure and VAS scores pre- and postprocedure. They compared a group of patients who were able to view the procedure with a control group who were visually restricted, noting a significant increase in both parameters in the former group, with an overall mean VAS of 3.91 ± 3.12. Additionally, both systolic and diastolic blood pressure increased in the control group, whereas patients who viewed the procedure experienced only a rise in diastolic blood pressure.¹⁸ McFarlane et al. categorized the experience of the first 300 patients undergoing the procedure into acceptable, uncomfortable, or painful, with 6% reporting significant discomfort.²⁰ Similarly, Sivalingam et al. assessed procedural discomfort through both subjective patient description and objective signs, noting that only one procedure was prematurely discontinued because of pain.³

Quality assessment

The quality assessment of literature showed that most were of moderate to high quality (Supplementary Figs. S1 and Figs. S2).

Discussion

Patients with long-term need for indwelling ureteral stents are bound to routine change of the device to prevent infection and encrustation. The replacement can take place in 6, 9, or 12 months based on the reason for stent insertion. A timely change is paramount to prevent complications that can affect the patients in cases when the stents are left longer than the scheduled time.^24,25 However, the backlog of surgical procedures after the COVID pandemic and the lack of resources and staff are universal issues among health care providers.²⁶ Dedicated time in the OR and trained anesthetic and surgical staff are often lacking.²⁷ This scenario often leads to prioritizing cancer surgeries and urgent procedures over benign routine ones, thereby often causing delays in stent change planning. Our study aims to demonstrate the safety and effectiveness of ureteral stent insertion or change under LA.

Based on the mentioned struggles faced by the health system worldwide, a new tendency of taking procedures out of the OR is therefore advancing in many fields, including diagnostic procedures and small therapeutic surgical procedures. The change of environment often entails a different approach to the anesthetic that may no longer involve a GA but can rely on alternative methods. This wave of need for change has already affected the prostate cancer diagnostic pathways. Transrectal and transperineal prostate biopsies have indeed noted a variation of direction because of the introduction of precision point biopsy under local anesthetic techniques.^28,29 Hogan et al. indeed demonstrated that transperineal biopsy can be safely performed under LA with no difference in cancer detection.³⁰ Advantages were also found in less theater and recovery use with consequent saving of resources.

Attempts have been made over the years with the aim to switch other urological procedures to LA in outpatient settings, such as urethrotomy, prostate operation, and bladder neck suspension.³¹ According to Neuman et al., spinal and GA are equivalent in terms of safety and acceptability for most patients who have no contraindications.³² Options can be chosen based on patients’ preferences for a wide variety of procedures. Different types of localized anesthesia are based on the concept of neuraxial anesthesia, locoregional or intraurethral anesthesia, which guarantee a more local control of the pain without systemic effects.^33,34

Owing to the progress in anesthesia, recently more complex procedures like ureteroscopy and Rezum vapor thermal therapy of prostatic hyperplasia with LA can be considered a valid option in selected patients.^35,36 All these aspects are even more true when we consider the post operative nausea and vomiting that can follow GA,³⁷ together with the uncertainty above the long-term toxicity of repeated GA in cases of multiple exposures or comorbid patients.³⁸ Baring this in mind, other urological noninvasive procedures are now performed under alternative types of distracting mechanisms. For example, cystoscopy, stent removal, and urodynamics are already done with a music background only in order to stimulate deep relaxation and keep the patients’ attention away from the possible pain.³⁹ Music of patients’ preference is indeed the most used tool; however, other mechanism like acupuncture, TENS, and audiovisual distraction can be used with the same aim.^40,41

Our study aimed at investigating the safety and efficacy of ureteral stent insertion or change under LA. The results show how the procedure can be well tolerated and lead to good outcomes in expert hands. The risk of failure of stent insertion should be considered, and the patients always need to be informed of the possible failure rate and/or the need for conversion to GA. In the studies analyzed, the complication rates were low and mostly related to infection or temporary discomfort.

Cost

Theater utilization is expensive and includes anesthetic time, nursing time, and drugs. As a secondary outcome, this study demonstrated how converting stent change to LA in an outpatient setting can reduce costs for healthcare providers by almost fourfold in most studies. This is likely related to less staff involvement and recovery time and drugs and anesthetic involvement that would be needed in cases done under GA. Moreover, this trend would reduce the backlog of patients waiting for other GA procedures, allowing them to backfill this space created. Finally, patients who need a routine stent change will no longer be delayed and will therefore have less risk of incurring into possible infections or encrustations or stent-related symptoms, often leading to prolonged hospitalization. Their procedure will therefore be more straightforward, reducing the risk of postoperative complications, all of which would further reduce costs.

Limitations of the study

Several limitations should be considered for this study. This study analyzed articles reporting on stent change and insertion under LA. Most studies have a retrospective or observational prospective methodology, and the volume of patients is low in many cases, thereby negatively affecting the level of evidence. Detailed patient data were not available from all studies, and there was a heterogeneity among the studies in terms of surgical technique, type of cystoscope used, type of anesthesia or analgesia used, and surgeon experience. The questionnaires used for assessment of patient satisfaction were not always reported or varied between studies; hence, the pain scale measurement was also heterogeneous. Additionally, some studies did not report on the postoperative complications.

Future randomized studies are needed to compare results and evaluate the outcomes of this procedure in high-volume settings. Overall, the literature supports the use of LA in ureteral stent insertion and change, and this could potentially become the first-line treatment for emergency and elective stent placement in most patients. However, the success rates vary depending on the technique, reason for stent insertion, and characteristics of the patients. Therefore, a standardized technique would be useful to choose the most optimal treatment approach and to compare the cost of treatment.⁴² Further research is needed to identify suitable patients and the most appropriate technique to reduce failure and complications. Perhaps patient-reported outcome measures can help with the decision-making and compare outcomes too.⁴³

Conclusion

Local anesthetic stenting is a viable alternative to GA, demonstrating high success rates and low risk of major complications. Although cost savings are significant, patient experiences with pain and satisfaction are mixed, suggesting that careful patient selection and preprocedural counseling are essential. Local anesthetic stenting offers a practical, efficient solution for stent placement and exchange, particularly in outpatient settings, though more research is needed to optimize patient comfort and improve procedural methods.

Footnotes

Authors’ Contributions

A.P.: Data collection and article writing. V.J.: Data collection and article editing. O.T., R.M.S., F.E., and A.P.: Article editing. B.K.S.: Conceptualization, overall responsibility, and article editing.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Data

Supplementary Figure S1

Supplementary Figure S2

Abbreviations Used

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