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UPJ INSIGHT: Appropriateness Criteria for Ureteral Stent Omission following Ureteroscopy for Urinary Stone Disease
By: Spencer C. Hiller, MD; Stephanie Daignault-Newton, MS; Ivan Rakic, BS; Susan Linsell, MHSA; Bronson Conrado, MHSA; S. Mohammad Jafri, MD; Ronald Rubenstein, MD; Mazen Abdelhady, MD; C. Peter Fischer, MD; Elena Gimenez, MD; Richard Sarle, MD; William W. Roberts, MD; Conrad Maitland, MD; Rafid Yousif, MD; Robert Elgin, MD; Laris Galejs, MD; Jeremy Konheim, MD; David Leavitt, MD; Eric Stockall, MD; J. Rene Fontera, MD; J. Stuart Wolf, Jr., MD; John M. Hollingsworth, MD, MS; Casey A. Dauw, MD; Khurshid R. Ghani, MD, MS | Posted on: 01 Jun 2022
Hiller SC, Daignault-Newton S, Rakic I et al: Appropriateness criteria for ureteral stent omission following ureteroscopy for urinary stone disease. Urol Pract 2022; 9: 253.
Study Need and Importance
Ureteral stent placement following uncomplicated ureteroscopy for urinary stone disease occurs in over two-thirds of cases and is associated with pain, urinary symptoms and increased risk of emergency department visits. Routine stenting occurs despite American Urological Association guidelines that recommend stents be omitted following uncomplicated ureteroscopy. Underutilization of ureteral stent omission may be an indication of uncertainty regarding scenarios suitable for stent vs no stent. In this study, we defined the scenarios appropriate for ureteral stent omission by use of RAM (RAND/UCLA Appropriateness Method).
What We Found
We convened a panel of 15 urologists from the Michigan Urological Surgery Improvement Collaborative (MUSIC), representing diverse practices across the State of Michigan, to implement RAM. We created a consensus definition of uncomplicated ureteroscopy and scored clinical scenarios for appropriateness criteria for stent omission (1–3: inappropriate; 4–6: uncertain; 7–9: appropriate). The majority of scenarios appropriate for stent omission were pre-stented (81%). Findings were matched to ureteroscopy cases within the MUSIC registry. Stents were placed in 61% of cases meeting appropriateness criteria for stent omission.
Limitations
It was not possible to capture every variable under consideration during stent omission decision making, and several factors were not included because they could not be objectively quantified. Our panel and retrospective analysis included only practices in Michigan, so our results may not translate to other national or global trends in practice.
Interpretation for Patient Care
We comprehensively defined uncomplicated ureteroscopy as well as those situations appropriate and inappropriate for stent omission. Stent omission following uncomplicated ureteroscopy is currently underutilized in practice, and there is substantial variation. We have now implemented stent omission criteria in Michigan (see Figure) with the goal to reduce the overuse of stenting after uncomplicated ureteroscopy.