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Dear colleagues and stent enthusiasts,

We are back with the summer edition of our newsletter. As always, I have selected three recent scientific papers,all published this past July, to bring you up to date on topics related to ureteral stents. 

First, we feature an excellent survey conducted by the EAU that evaluates real-world stent utilization and varying practice patterns globally. 

The second paper reinforces the concept that placing a stent and awaiting its removal without close oversight is associated with worse quality-of-life outcomes and higher rates of urinary tract infections (UTIs). It is clear that patient education and close follow-up mitigate stent-related adverse effects, proving that these strategies are well worth adopting.

Finally, we highlight a manuscript evaluating the reduction of stenting duration following failed primary access to the urinary tract, a study with high clinical applicability in daily practice. I hope you find them interesting!!

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This global survey across 48 countries evaluates contemporary practices, preferences, and decision-making patterns in ureteral stent use among endourologists.

What key routine practices stand out? Regarding stenting after URS, it is noteworthy that, following uncomplicated URS, routine stent placement remained common among urologists. The most frequently reported indications included intraoperative ureteral trauma, large stone burden or residual fragments, and the presence of a solitary kidney. In complicated cases, the tendency to place a ureteral stent was high, with 73.3% of stenting. Regarding, stent characteristics, 6 Fr was the most commonly used stent size, followed by 4.8 Fr and 7 Fr, and was also the preferred size for pre-stenting.

Polyurethane was the predominant stent material. Standard lengths are 26 cm (males) and 24 cm (females); 43% of respondents never adjust length based on height. Stents with extraction strings are mostly preferred for short-term stenting (<1 week), though 33% never use them. In the best-case scenario, following uncomplicated URS, 52% of respondents removed the stent within 1 week, 22% within 2–3 weeks, and 20% performed same-day removal.

After complicated URS, half of the respondents reported stent removal within 2–3 weeks. Overall, 33% did not use stents with extraction strings, while 30% used them in less than 5%. Stents with extraction strings were most commonly preferred after uncomplicated URS, particularly when short-term stenting (< 1 week) was planned.

Regarding the question of exchange intervals when chronic stenting is indicated, most respondents exchanged long-term stents at 6-month intervals (60%), while 20% preferred 3-month intervals, and another 20% extended the interval to 12 months. Notably, 45% did not use any reminder or alert system to track stent removal, whereas only 39% consistently used structured alert systems.

Regarding ureteral stenting and suction access sheaths—which might seem to be a clear indication for short-term ureteral stenting—only 62% of respondents reported postoperative stent placement always and 9% reported never placing a stent. Stent-related symptoms were common, occurring in 25–50% of cases in 38.5% of respondents and in 50–75% in 29.9%. Urgency (79.2%) and frequency (75.0%) were the most frequently reported symptoms, followed by hematuria (67.7%) and dysuria (66.7%), while flank pain (56.3%) was less common. The majority of respondents (71.8%) had never used standardized symptom assessment tools such as the USSQ, which may be considered a shortfall in evaluating patient quality of life. Regarding patient education materials—which have proven effective in reducing stent-related morbidity—written instructions were not provided by 41.6%, whereas 32.7% reported always providing them.

A major insight is the persistent over-use of ureteral stents after uncomplicated URS. Despite EAU and AUA guidelines supporting stent omission in selected cases, real-world practice remains slow to adopt stent-free URS.

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It is evident that close and comprehensive management of stented patients should yield improvements in quality of life and early diagnosis of complications; therefore, it represents an important objective to consider. The aim of this study was to prospectively compare conventional management with full process intelligent information management in patients with postoperative indwelling ureteral stents after surgery for urinary tract stones.

Basically, the study comprises two study groups. The control group received routine care plus telephone follow-up, including health education, dietary guidance, and reminders of stent removal time. A low-oxalate diet was recommended, and patients were instructed to maintain a daily fluid intake of 2,000 mL to promote urine excretion. Based on the surgical procedure, patients were clearly informed of the scheduled stent removal time. In contrast, the intervention group received additional full-process management, as follows: intelligent stent removal reminders, App-based medication reminders, urine test reminders, and perioperative infection prevention maneuvers, as well as detailed “multimodal health education,” including the development of standardized oral education templates for the preoperative, postoperative, and post-discharge stages; the production of educational materials and brochures with graphical illustrations of complication recognition; and the creation of a 5–8 min “double-J stent care practice video” showing correct hydration and activity methods. The researchers developed an anatomical model of the ureteral stent, which was used to visually demonstrate stent position, and nurses provided hands-on demonstration of perineal hygiene to reduce infection risk. One week after surgery, satisfaction with the decision-making process was assessed using a 5-point Likert scale.

Finally, the investigators developed an extraordinary “checklist-based follow-up and innovative continuity of care” system, including 10 indicators such as stent-related symptoms, daily fluid intake, and review plans, which were embedded into the cloud follow-up system for online completion by medical staff. A “post-discharge Care questionnaire for patients with indwelling double-J stents” was administered at discharge and 1 month after discharge to assess adherence to hydration (≥2,000 mL/day considered adequate), compliance with activity recommendations, and other aspects.

Compared with the control group, the intervention group showed better outcomes in all predefined comparison domains. Specifically, the intervention group had a statistically significant higher “quality of discharge teaching scale” score, a higher post-management “social support rating scale” score, a statistically significant lower rate of delayed ureteral stent removal, a lower rate of stent-related UTI, and a higher overall satisfaction rate.

In summary, full-process intelligent information management, consisting of a multidisciplinary team, HIS-based intelligent reminders, perioperative infection-prevention measures, multimodal education, and checklist-based continuity of care, was associated with lower rates of delayed stent removal and catheter-related urinary tract infection, as well as better discharge teaching quality, social support, and patient satisfaction in patients with postoperative indwelling ureteral stents after stone surgery.

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As is well known, the use of the ureteral access sheath (UAS) during RIRS decreases intrarenal pressure, improves the SFR, decreases operative time, and decreases postoperative fever and UTI. However, primary access to the stones by either UAS or direct ureteroscope may fail in 10–11% of patients, particularly in those with a narrow, kinked, or spastic ureter. The most suitable and safe decision for failed access is ureteral stent placement, which improves ureteral compliance after a time interval.

The objective of this interesting single-blind, randomized controlled trial was to compare two versus four weeks of ureteral stenting prior to secondary flexible ureteroscopy in patients with failed primary ureteral access, focusing on ureteral access sheath insertion success (10/12 Fr), stone-free rate, perioperative outcomes, complications, and stent-related symptoms. In this study, failed primary access was found in 22% of cases, which appears somewhat high compared to other series, but reflects the difficulties associated with UAS insertion, bearing in mind that the investigators did not employ pre-stenting.

The study results confirm that there were no significant differences between both groups regarding the successful insertion of UAS, intraoperative and postoperative SFR, exit strategy, reason for restenting, complications, and operative time.

Given that the goal is always to reduce the duration of ureteral stenting to minimize its associated morbidities, which are substantial, and in light of the findings of this randomized trial, which showed no statistically significant differences between 2-week and 4-week preoperative stenting regarding UAS insertion success, SFR, operative time, or complication rates, these findings suggest that prolonging stent dwell time beyond 2 weeks may not provide a substantial additional benefit in this patient population.