With a steady rise in the incidence of stone disease globally, there has been a continuing trend toward ureteroscopy as the intervention of choice. This is largely due to improvements in ureteroscope size and flexibility, as well as advances in laser efficiency, power and availability. These factors have contributed to improvements in stone-free rates and reduced morbidity in a single ureteroscopic procedure.¹

Historically, post-ureteroscopy stenting has been the standard of care. This has largely been due to the assumed benefits in stone fragment passage, as well as mitigation of postsurgical infection, edema and obstruction with anecdotal experience to support these claims. This long-standing dogma has been challenged over the past 15 years with multiple randomized controlled trials and 2 large meta-analyses demonstrating stentless uncomplicated ureteroscopy is feasible and safe. However, these studies also pre-date the advances in ureteroscopes (with larger caliber digital and single-use ureteroscopes), higher power laser technology, treatment of larger stone burdens, and widespread use of ureteral access sheaths. There has been no demonstrated improvement in stone-free rates, strictures, infection or unplanned emergency room visits with ureteral stenting after “uncomplicated” ureteroscopy.^2,3 Not surprisingly, stented patients experience significantly higher rates of irritative lower urinary tract symptoms (LUTS) and pain. Based on these data, the AUA Guidelines provide a strong recommendation (Grade A) that stenting may be omitted in uncomplicated ureteroscopy when no ureteric injury is suspected, no stricture or other anatomical impediment is identified and in those without renal insufficiency and a normal contralateral unit.⁴ However, what constitutes “uncomplicated” ureteroscopy and which stones are ideal for a stentless procedure remain open questions.

Historically, a 2007 study looking at practice patterns of 173 American urologists shows that about two-thirds of urologists placed a stent after “routine” ureteroscopy more than half the time, and 13% placed them all the time.⁵ More recently (after the AUA Guidelines), a 2021 prospective study of 2,544 patients from 50 centers worldwide demonstrated a 91.8% stenting rate after ureteroscopy.⁶ Similar results were found in a feasibility study of uncomplicated ureteroscopy with stents placed 92% of the time.⁷

Every urologist has anecdotally experienced the postoperative patient with severe stent colic often resulting in multiple phone calls, prescriptions, and emergency room visits. At the same time, urologists who do not routinely place stents following uncomplicated ureteroscopy have also experienced the occasional patient where postoperative pain is so significant that it may require more analgesics, further imaging, hospital observation overnight and/or return to the operating room for stent placement. Significant investigation and resources have been dedicated to stent design, stent material, as well as optimal medical regimens to help combat this issue, with few definitive solutions. Considering this, the best course is likely to avoid stent placement entirely after uncomplicated ureteroscopy after a preoperative discussion with the patient. If guidelines support stentless ureteroscopy when certain criteria are met, then why are urologists placing so many stents?

The above studies cite reasons for stenting such as ureteric edema, stone fragment passage and “surgeon preference,” noting this last indication as broadly variable that is difficult to quantify.⁶ Interestingly, instances where no ureteric drainage was preferred were in the pre-stented patient, after semirigid ureteroscopy without flexible ureteroscopy, with operative times <45 minutes, and when dusting technique was used (see figure, part A).⁷

Figure. A, dusting of larger stone fragments with a high-powered laser. B, pulverized stones after completion of dusting technique.

Meta-analyses draw broad and convincing conclusions that stents increase pain and LUTS, while demonstrating no benefit with regard to outcomes after uncomplicated ureteroscopy. However, the exact indications as to who is the best candidate are more difficult to determine. Are there specific patient and/or stone characteristics ideal for a stentless ureteroscopy? A Cochrane review looked at this exact question and was unable to conduct a subgroup analysis with regard to age, gender, stone size, location, flexible vs semirigid ureteroscope use and sheath placement.⁸ Looking at 23 studies, their analysis highlights performance and detection bias as well as study imprecision. Due to marked heterogeneity, the authors concluded that while these variables may be important effect modifiers with regard to stent placement, definitive conclusions cannot be drawn. Considering this, it is likely surgeon judgment and experience that determines which ureteroscopies are “uncomplicated” and warrant no stent placement afterward.

The aforementioned and relatively new technique of “dusting,” in which stones are pulverized into extremely small fragments without extraction and often without use of a ureteral access sheath, has been popularized due to newer available high-powered holmium and thulium lasers (see figure, part B). This “dusting” technique has been shown to have shorter operative times and is an emerging potential area of study for stentless ureteroscopy.⁹

The high rate of stenting after uncomplicated ureteroscopy may reflect skepticism of the available data or may be more for surgeon comfort rather than patient. Regardless, stentless ureteroscopy is feasible using a selective approach (see table for our typical scenarios when we perform stentless ureteroscopy); however, more rigorous investigation is necessary to determine the ideal candidate.