meta - analysis ureteroscopy : systematic review and Outcomes of stenting after uncomplicated

Objective To investigate the potential beneficial and adverse effects of routine ureteric stent placement after ureteroscopy. Design Systematic review and meta-analysis of randomised controlled trials. Data sources Cochrane controlled trials register (2006 issue 2), Embase, and Medline (1966 to 31 March 2006), without language restrictions. Review methodsWe included all randomised controlled trials that reported various outcomes with or without stenting after ureteroscopy. Two reviewers independently extracted data and assessed quality. Meta-analyses used both fixed and random effects models with dichotomous data reported as relative risk and continuous data as a weightedmean difference with 95% confidence intervals. Results Nine randomised controlled trials (reporting 831 participants) were identified. The incidence of lower urinary tract symptoms was significantly higher in participants who had a stent inserted (relative risk 2.25, 95% confidence interval 1.14 to 4.43, for dysuria; 2.00, 1.11 to 3.62, for frequency or urgency) after ureteroscopy. There was no significant difference in postoperative requirement for analgesia, urinary tract infections, stone free rate, and ureteric strictures in the two groups. Because of marked heterogeneity, formal pooling of data was not possible for some outcomes such as flank pain. A pooled analysis showed a reduced likelihood of unplanned medical visits or admission to hospital in the group with stents (0.53, 0.17 to 1.60), although this difference was not significant. None of the trials reported on health related quality of life. Cost reported in three randomised controlled trials favoured the group without stents. The overall quality of trials was poor and reporting of outcomes inconsistent. Conclusions Patients with stents after ureteroscopy have significantly highermorbidity in the form of irritative lower urinary symptoms with no influence on stone free rate, rate of urinary tract infection, requirement for analgesia, or long term ureteric stricture formation. Because of the marked heterogeneity and poor quality of reporting of the included trials, the place of stenting in the management of patients after uncomplicated ureteroscopy remains unclear. INTRODUCTION The surgical management of ureteric stones has changed over the past few decades because of advances in instruments and techniques. Extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy are currently the most common treatment options in clinical practice. The routine placement of ureteric stents after fragmentation and retrieval of ureteroscopic stones is questionable. w2 The main advantages of stenting are the prevention of ureteric obstruction and renal pain that may develop as a result of ureteric oedema from balloon dilation or stonemanipulation during ureteroscopy.Ureteric stentsmay aid in thepassageof residual stone fragments secondary to the passive ureteric dilation that occurs with an indwelling ureteric stent and may prevent delayed formation of ureteric stricture. Routine placement of ureteric stents, however, is accompanied by recognised potentially troublesome urinary symptoms or morbidity, or both. 4 Related complications such as migration, infection, pyelonephritis, breakage, encrustation, and stone formation are not uncommon. Placement of ureteric stents results in additional costs. Furthermore, unless a pull string is routinely used at the distal end of the stent, secondary cystoscopy is required to remove the stent, which has cost implications and the potential to add to the disruption of patients’ lives. Ureteroscopy is now performed with small calibre endoscopes and better intracorporeal lithotripsy devices such as holmium laser so that most patients can be treated without ureteric dilation. As a result, the need for a postprocedural stent remains questionable. We determined the evidence that outcomewith routine ureteric stent placement after uncomplicated ureteroscopy is inferior to that without stent placement. METHODS Search strategy We obtained relevant trials from the Cochrane renal group’s specialised register of randomised controlled trials; the Cochrane central register of controlled trials 2006; Medline and PreMedline (1966 to 31 January 2006); Embase (1980 to 31 January 2006); reference lists of urology textbooks, review articles, and relevant trials; and abstracts of conference proceedings. Academic Urology Unit, Institute of Applied Health Sciences, College of Life Sciences and Medicine, University of Aberdeen, Health Sciences Building, Aberdeen AB25 2ZD Health Services Research Unit, Institute of Applied Health Sciences, College of Life Sciences and Medicine, University of Aberdeen Correspondence to: G Nabi g. [email protected] doi: 10.1136/bmj.39119.595081.55 BMJ | ONLINE FIRST | bmj.com page 1 of 7 Cite this article as: BMJ, doi:10.1136/bmj.39119.595081.55 (published 20 February 2007) Copyright 2007 BMJ Publishing Group Ltd on 5 April 2007 bmj.com Downloaded from