Urolithiasis, one of the most prevalent urological conditions worldwide, significantly affects patients’ quality of life. In the United States, its lifetime prevalence is approximately 1 in 11, while global rates vary from 1% to 13%. The management of urolithiasis offers several treatment options, with decisions guided by the characteristics of the stone and the patient’s condition. Both the American Urological Association (AUA) and the European Association of Urology (EAU) recommend ureteroscopy (URS) as a first-line treatment for symptomatic stones in the ureter or kidney that are less than 20mm in size. In cases of acute ureteral obstruction, immediate surgical decompression with a ureteral stent is indicated, particularly when severe infection or impaired kidney function is present. Once the patient stabilises, definitive treatment can be pursued. The placement of a stent before URS is believed to promote passive dilation of the ureter, easing the insertion of an access sheath and ureterorenoscope. However, the use of stents carries risks such as infection, pain, and irritative voiding symptoms, all of which can adversely affect the patient’s quality of life. Studies have suggested that pre-stenting (PS) may improve stone-free rates (SFR) and reduce complications, but the results are inconsistent. Neither the AUA nor the EAU recommends routine use of PS, though the EAU recognises its potential benefits for renal stones. The aim of this study was to evaluate whether PS improves clinical outcomes compared to non-PS (NPS). A pooled analysis of 12 studies involving 9503 patients found no significant difference in the success rates of ureteral access sheath (UAS) placement between PS and NPS groups. Similarly, operative time, assessed in 18 studies, did not differ significantly between the two groups, despite notable heterogeneity in the data. Postoperatively, the SFR was higher in the PS group, with results showing a significantly greater likelihood of achieving SFR in both kidney and ureteric stones. Subgroup analyses confirmed that PS was particularly beneficial for kidney stones treated with flexible URS (f-URS), whereas it had a less pronounced effect on ureteric stones. Overall, the SFR was notably better in the PS cohort, with a significant relative risk (RR) of 1.05. Complications were also fewer in the PS group. Analysis of five studies reporting overall complications revealed that PS reduced the risk by 17%. Additionally, PS was associated with fewer intraoperative and postoperative complications, with a risk reduction of approximately 30% and 18%, respectively. In terms of length of hospital stay, data from six studies showed no significant difference between the groups, despite some studies suggesting that PS might lead to shorter stays. These results highlight the need for more consistent reporting methods in future research, as differences in study protocols can introduce variability in outcomes. Despite its potential benefits, PS remains a controversial topic. Previous studies have shown mixed results regarding its impact on UAS insertion success and operative time. While PS seems to reduce intraoperative and postoperative complications, its effect on UAS insertion and operative time remains unclear. Furthermore, there are concerns regarding the higher healthcare costs associated with PS due to the additional interventions required. These costs, coupled with the potential for repeated procedures, may further impact a patient’s quality of life and financial burden. A US-based study demonstrated that re-treatment following URS significantly increased healthcare costs, emphasising the economic implications of treatment decisions. The present study contributes valuable insights into the ongoing debate over PS in URS. It suggests that PS may offer advantages in terms of SFR and complication rates, particularly for kidney stones. However, the variability in study methodologies and patient populations calls for further research to standardise reporting and assess the cost-effectiveness and impact on quality of life. Future randomised controlled trials are necessary to confirm these findings and provide more robust evidence for clinical practice. In conclusion, this meta-analysis of 23,668 patients undergoing URS suggests that PS is as safe as NPS and may improve the SFR and reduce complication rates. However, more rigorous studies, including those examining cost-effectiveness and quality of life, are needed to validate these results and refine treatment strategies for urolithiasis.
Preoperative stenting compared to non‑stenting in ureteroscopy for urinary stone disease
Reviewed by Asif H Ansari
Safety and effectiveness of preoperative stenting compared to non‑stenting in ureteroscopy for urinary stone disease: a meta‑analysis of comparative studies.
