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Indwelling ureteric stents: Patterns of use and nomenclature Indwelling ureteric stents: Patterns of use and nomenclature
Leong, Joon Yau; Steward, James E.; Healy, Kelly A.; Hubosky, Scott G.; Bagley, Demetrius H.
2020-10-01 00:00:00
ARAB JOURNAL OF UROLOGY 2020, VOL. 18, NO. 4, 241–246 https://doi.org/10.1080/2090598X.2020.1761675 STONES/ENDOUROLOGY: ORIGINAL ARTICLE a a b a a Joon Yau Leong , James E. Steward , Kelly A. Healy , Scott G. Hubosky and Demetrius H. Bagley a b Department of Urology, Thomas Jefferson University, Philadelphia, PA, USA; Department of Urology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA ABSTRACT ARTICLE HISTORY Received 16 March 2020 Objectives: To evaluate ureteric stenting practice patterns amongst a range of academic and Accepted 6 April 2020 community urologists, and to examine the nomenclature used to identify an indwelling ureteric stent from both our questionnaire and from a review of the literature. KEYWORDS Subjects and methods: A 16-question, peer-reviewed online survey was distributed to mem- Ureteric; stent; indwelling; bers of the Mid-Atlantic American Urological Association. Responses were collected over nomenclature; double a 1-month period. Questions included demographics, ureteric stenting practice patterns, and pigtail; Double J utilization of stenting nomenclature. Inappropriate use of nomenclature was defined as a mismatch between the visually depicted stents and the written description amongst urolo- gists. Trends in ureteric stenting and nomenclature usage were tabulated and analyzed. Results: Of 863 members, 105 (12.2%) responded to the survey. There was a wide variety of practice settings, with the single-specialty group (44.2%) and academic/university (27.9%) being the two most common. Most providers used both cystoscopy and fluoroscopy to place stents (87.5%) as compared to fluoroscopy alone (12.5%). Most urologists (63.5%) removed stents with cystoscopy as compared to using a stent string (36.5%). While about half (51.0%) of the respondents left stents in situ for ≤3 months, many respondents (43.3%) felt comfortable with maximum dwell times of up to 6 months. The most commonly placed stent was the double pigtail stent (80.8%). However, most respondents inappropriately described this stent design as a Double J stent (72.1%). In the recent literature, 80% of articles clearly defined as using double pigtail stents, incorrectly identified their stent as a ‘Double J’. Conclusions: Variations in ureteric stenting practice patterns exist amongst community and academic urologists. Although most urologists utilize double pigtail ureteric stents, the major- ity inaccurately identified this stent design as a Double J. We propose use of the term ‘indwelling ureteric stent’ (IUS) unless describing any specific stent design. Introduction practice setting, frequency of stent placement, stent type, method of stent placement, and postoperative manage- Ureteric stent placement is a common urological proce- ment. The survey was peer-reviewed and approved by dure. Indications for stent placement include relief of the Mid-Atlantic AUA (MA-AUA) and sent to all members obstruction, post-ureteroscopy placement for obstruc- via e-mail. The study period was 1 month. The e-mail was tion prevention, ureteric identification/designation, and distributed in one ‘blast’ with no follow-up reminders per as a splint after ureteric repair or operation. Associated the organization’s guidelines. Inappropriate use of risks and complications of ureteric stenting include stent nomenclature was defined as a mismatch between the migration, encrustation, injury to the ureter, loss of visually depicted stent and the written description used in patency, infection, and retained stent. The objectives of urological practice. Results were then tabulated to assess the present study were to explore trends of ureteric trends in ureteric stenting and nomenclature usage. stenting amongst a diverse group of urologists. We also Additionally, a PubMed database search was per- aimed to investigate the specificterminologyused to formed using the phrase ‘ureteral stent’. A total of 50 describe ureteric stents amongst urologists, as well as studies were identified and evaluated in March 2020. within the current literature. Finally, we propose the use The terminology used to describe the stent was noted, of the generic term ‘indwelling ureteric stent’ (IUS) unless as was any visual depiction or description of the phy- describing the specificstent design. sical characteristics of the stents. Subjects and methods Results A 16-question, online survey was developed using Of 863 members, 105 (12.2%) responded to the survey. SurveyMonkey®. It included questions pertaining to pro- Of these, one respondent did not routinely place stents vider demographic data, background in training, current CONTACT Joon Yau Leong joonyau.leong@jefferson.edu Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street, College Building, Suite 1110, Philadelphia, PA 19107, USA © 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 242 J. Y. LEONG ET AL. within their practice and was excluded from the study. Table 1. Demographic data and practice patterns. Survey responses, Table 1 provides the demographic data and practice Survey questions n (%) patterns based on survey responses. The largest group Age range, years of respondents were aged 45–54 years (28.8%), followed 25–34 14 (13.5) 35–44 21 (20.2) by 55–64 years (24.0%), and 35–44 years (20.2%). The 45–54 30 (28.8) majority were male (88.5%) and over two-thirds (72.2%) 55–64 25 (24.0) had been in practice for >10 years. Practitioners in sin- 65–74 13 (12.5) ≥75 1 (1.0) gle-specialty groups comprised the largest number of Gender respondents at 44.2%, followed by full-time academic Male 92 (88.5) Female 12 (11.5) staff (27.9%), multi-specialty group practice (11.5%), and Years in practice solo practice (11.5%). Ureteric stenting was a common <5 10 (9.6) 5–10 19 (18.3) practice amongst respondents with nearly all respon- 10–20 27 (26.0) ders (97.1%) reporting placing stents at least several >20 48 (46.2) Practice type times per month and nearly two-thirds (64.4%) placing Academic 29 (27.9) stents at least several times per week. Single-specialty group 46 (44.2) More than one-third (36.5%) reported leaving Multi-specialty group 12 (11.5) Solo practice 12 (11.5) a string on the stent for later removal. The majority Other 5 (4.8) used a combination of cystoscopy and fluoroscopy Endourology fellowship completed Yes 10 (9.6) (87.5%) when placing the stent, while the remainder No 94 (90.4) used fluoroscopy alone. The most commonly used Member of Endourological Society Yes 23 (22.1) stent diameter was 6 F (83.7%); while the most com- No 81 (77.9) monly placed stent length was 24 cm (50.0%). Frequency of stent placement Almost daily 7 (6.7) Participants were also asked ‘what was the maximum Several times per week 60 (57.7) duration that they would feel comfortable leaving an Several times per month 34 (32.7) indwelling stent, whenever indicated or necessary’. Several times per year 3 (2.9) Description of stent in operative note Nearly half (48.1%) felt comfortable leaving it for Double J 75 (72.1) a maximum of 3 months, while 43.3% felt comfortable Double pigtail 23 (22.1) Others 6 (5.8) leaving the stent in for up to 6 months, depending on String left on stent the type of stent or whenever indicated, e.g. manage- Yes 38 (36.5) No 66 (63.5) ment of ureteric strictures. Most urologists (58.7%) knew Use of fluoroscopy or cystoscopy during stent the cost of the stent they usually place. Almost all placement Fluoroscopy alone 13 (12.5) providers (95.2%) prescribed an α-blocker (18.3%), anti- Cystoscopy and fluoroscopy 91 (87.5) cholinergic (14.4%), phenazopyridine (7.7%), or Stent diameter, F a combination (54.8%) of these medications for stent- 4.7 14 (13.5) 6 87 (83.7) related symptoms. 7 0 (0.0) Participants were also asked to identify, from a picture 8 0 (0.0) Other 3 (2.9) of four different stents, the stent they most commonly Stent length, cm placed (Figure 1). The majority (80.8%) chose the double 20 1 (1.0) 22 3 (2.9) pigtail stent. The multi-length stent was the next most 24 52 (50.0) commonly placed stent (17.3%). Double J stents were 26 26 (25.0) 28 1 (1.0) used by 1.9% of participants. Interestingly, the majority Multi-length 16 (15.4) (72.1%) described stents as a Double J stent during dicta- Other 5 (4.8) tion, while only 22.1% described it as a double pigtail Maximum indwelling stent time, months 1 3 (2.9) stent. 3 50 (48.1) An online PubMed search was performed using the 6 45 (43.3) 12 2 (1.9) keywords ‘ureteral stent’ and 50 articles were identified Other 4 (3.8) in March 2020. In all, 16 articles describe stent use, either Aware of the cost of most commonly placed stent Yes 61 (58.7) as a picture or a description of the physical character- No 43 (41.3) istics. Of these 16 articles, 15 (94%) used double pigtail Medications used for stent-related symptoms α-blocker 19 (18.3) stents. Of the articles using double pigtail stents, 80% Anticholinergic 15 (14.4) described the stent as a ‘Double J’ (Figure 2). Phenazopyridine 8 (7.7) Combination of ≥2 57 (54.8) None 5 (4.8) Discussion psychologically. As such, ever since its inception in the Ureteric stents are utilized frequently by urologists. However, deployment of these stents often gives rise to late 1960s, the applications, indications, designs, features side-effects that may affect a patient physically and and models of ureteric stent have evolved over the ARAB JOURNAL OF UROLOGY 243 described the Double J ureteric stent, which included a 180 ° J curve at each end to prevent distal and proximal migration. The double pigtail ureteric stent was subse- quently described in 1979, which resembles today’s most commonly placed stent [4]. The Double J stent is a specificdesign with a 180° bend at each end and a closed proximal tip. It was first patented in the USA in 1980 (#4212304), and the name ‘Double J’ was trademarked in the same year by the Medical Engineering Corporation (Serial No. 73265596). The materials used to manufacture these stents initially included silicone for the Double J and polyethylene for the double pigtail. This has largely been replaced by polyurethane and other copolymers for increased flex- ibility and biocompatibility. Over 70% of respondents identified the Double J stent (180°curl) use in their operative note. However, Figure 1. Images of four different stents and their respective the majority (81%) chose the picture of the double pig- survey response rate. Survey participants were blinded to tail stent (360°curl) when asked which stent most resem- stent nomenclature. (a) Double J stent, (b) Multi-length stent, (c) Loop stent, (d) Double pigtail stent. bles their stent choice. This suggests that most urologists mislabel or misidentify the double pigtail stentfor theDoubleJ. This finding was consistent with decades, all with a common goal aimed at improving its a review of recent literature in which 80% of publica- durability, effectiveness and tolerability [1]. In 1978, tions that used a double pigtail stent described their Hepperlen et al. [2] first described the use of a ‘pigtail’ stents as a Double J. It is important to note that Double at one end of a ureteric stent, which describes a full 360° J stents may have a higher chance of proximal migration curl at the end of the stent. Later that year, Finney [3] Figure 2. Flowchart of the PubMed literature review. 244 J. Y. LEONG ET AL. in comparison to the double pigtail stent, as a distal curl symptoms. However, there was a significantly of <180 ° has been shown to be associated with increased percentage of stents that migrated distally asignificantly higher risk of proximal stent migration. in the 4.7-F stent group. They recommended place- In the discipline of endourology, specificnomencla- ment of 6-F stents based on these findings. Yet another ture promotes clear, succinct communication and ulti- recent study by Nestler et al. [6] in 2019 also showed mately, quality patient care. For example, there is an that while the success of ureteroscopy is not compro- important difference between retrograde and antegrade mised by a smaller stent diameter, thinner stents sig- endoscopic approaches. Similarly, ‘pigtail’ and ‘J’ both nificantly decreases the risk of discomfort and pain describe two structurally different stents. In our survey postoperatively. Hence, ureteric stents with small dia- and brief review of the literature, we consistently found meters should be preferred. that 80% of urologists used incorrect nomenclature Stent length, unlike stent diameter, has been shown when referring to a double pigtail ureteric stent. to correlate with degree of stent-related symptoms. The reason for this occurrence is unclear, although Choosing the correct length stent has the potential to speculations can be made. Branding may have played reduce these symptoms. In a study of 60 patients with a role. The term Double J in relation to the ureteric stent stents for 1 week after stone surgery, increased symptom can be likened to Kleenex® as it relates to facial tissues. Or severity positively correlated with stents crossing the perhaps, as the clinically superior ‘pigtails’ supplanted the midline and stents with an incomplete distal curl [7]. In ‘Double Js’, urologists and stent manufacturers preferred astudy of 120 patients,urgency,dysuria,and overall fewer syllables with ‘dou-ble-J’. Additionally, as there was decreased quality of life were associated with longer an almost universal adoption of pigtail stents by endour- stents, which was defined as the proximal end of the ologists, the incorrect use of clinical nomenclature did not stent terminating in an upper calyx, while the distal end carry with it an overall negative clinical outcome during crosses the midline [8]. This was consistently true in the transition. Nonetheless, continual misuse of the term astudybyInnetal. [9], which found that distal place- Double J serves to underappreciate the importance of the ment of a ureteric stent that crosses the midline to the ‘double pigtail’ and ignores the ingenuity and innovation contralateral site of the bladder significantly increases that was required to create its superior design. the risk of urinary irritative symptoms and body pain. We propose using the generic term ‘indwelling ure- Along with reduction of stent-related symptoms, proper teric stent’ with the acronym being ‘IUS’.Thiswould serve stent length is also associated with decreased proximal as a universal term to describe Double J, double pigtail, migration rate [10]. In a study of 156 patients, measure- and other self-retaining stent types, and it would help ments of the ureter made on CT (from the renal vein to differentiate between ureteric catheters that are internal the uretero-vesical junction) most accurately predicted only vs. those that extend outside the body. This concept ureteric length when measured with a ruled-5-F ureteric is supported by Current Procedural Terminology (CPT) catheter. This was in comparison to measurements made codes, which distinguish between the two drainage with body height, body surface area, and linear distance designs. The code 52332 represents ‘insertion of indwel- onintravenouspyelograms(IVP) [11]. As such, this may ling ureteric stent’, while the code 52005 represents ‘ure- be a reliable method to estimate ureteric lengths and teric catheterisation’.Ifone needstodescribe the specific prepare for the appropriate stent length preoperatively stent design, the correct terminology should be used (i.e. to minimize postoperative stent-related discomfort. double pigtail stent, Double J stent, loop stent, multi- Finally, while there have been many studies evalu- length stent, etc.). Appropriate descriptions of these ating the effects of ureteric stent diameter and stent devices would foster better communication amongst length on patient experiences and stent-related symp- providers and could lead to better outcomes, as func- toms, there have not been many head-to-head studies tional differences may exist amongst stent types. Looking comparing these outcomes to ureteric stents con- forward, as novel stents and designs are developed, it structed from different materials. Yet, in a prospective wouldbeevenmoreimportant to usecorrect terminol- study with 50 patients conducted by Gadzhiev et al. ogy when describing ureteric stents in operative notes or [12], the authors compared the tolerability of silicone medical reports to ensure accuracy and to avoid any stents to polyurethane stents. Notably, they found that confusion or miscommunication. compared to the polyurethane stents, silicone ureteric Another goal of the study was to assess current stents were associated with a much lower reported stenting practice patterns amongst urologists. The pain score and pain intensity. Other variables such as most typical diameter of stents placed by survey the overactive bladder awareness tool, difficulty of respondents was 6 F (83.7%), with the 4.7 F diameter stent placements and complications of haematuria or stent being the second most common (13.5%). Erturk stent encrustation were not significantly different et al. [5] randomized 46 patients undergoing uretero- between the two materials. As the literature compar- scopy for stone disease to have a 4.7-F or 6-F stent ing stent material to patient outcomes remain scarce, placed for 1 week postoperatively. They found no future studies are necessary to further evaluate this difference in patient-reported pain or irritative topic at hand to better improve patient’s quality of life. ARAB JOURNAL OF UROLOGY 245 Up to 80% of patients with ureteric stents will However, this rate is consistent with the typical rate experience stent-related symptoms, such as urgency, of external surveys [19,20]. The survey was limited to frequency, dysuria, suprapubic pain, and flank pain. In those with e-mail access and those who were members our survey, >95% of urologists prescribed an α-blocker, of the organization. Additionally, survey data were also anti-cholinergic, phenazopyridine, or a combination of limited by provider recall bias. Future directions these medications for stent symptoms. A meta-analysis include exploring temporal trends in these practice of 12 randomized controlled trials verified that α- patterns, especially if and when new stent technology, blockers are associated with improvement in ureteric including drug-eluting and biodegradable stents, stent-related symptoms [13]. Lee et al. [14] found becomes more commonplace. a lower total symptom score, as well as urgency, urge incontinence, flank pain, abdominal pain, urethral pain, Conclusion and haematuria in patients given solifenacin after uncomplicated ureteroscopy and stent placement In conclusion, stent placement is a common practice when compared to a control group. Similar results amongst urologists in a variety of settings. However, were seen with patients randomized to tolterodine vs variations in ureteric stenting practice patterns exist placebo, with tolterodine demonstrating decreased amongst community and academic urologists, as evi- postoperative symptoms [15]. denced by our present survey responses. The most Almost two-thirds of participants removed the stent common stent diameter and length placed was 6 F string prior to placement. With increasing concern for and 24 cm, respectively. Most urologists feel comfor- harm to patients, cost to the healthcare systems and table leaving a stent in situ for ≤3 months. Almost all liability risk from retained stents, it will be interesting to urologists who completed the survey prescribe an α- see if the number of providers leaving a string on the blocker, anti-cholinergic, phenazopyridine, or stent increases in the future. A forgotten ureteric stent a combination for stent-related symptoms. In terms submits the patient to otherwise unnecessary imaging, of stent nomenclature, although most urologists utilize procedures, and possible loss of renal function or even the double pigtail ureteric stent, the majority often loss of an entire kidney. In a cost-effectiveness study of 27 mislabel and misidentify the double pigtail for patients with forgotten stents, Sancaktutar et al. [16] a Double J, even though the terms describe two struc- determined the economic cost is seven times higher turally distinct stents. Our review of the current litera- than the cost of a timely removal. In a review of 493 ture also revealed a similar error rate. We propose the urological cases in the UK, in which a total of use of the generic term ‘indwelling ureteric stent’ (IUS) >20 million pounds in indemnity claims were paid, unless describing the specific stent design. retained ureteric stents were the most common post- operative-related claim [17]. The majority of urologists in our present survey felt comfortable leaving the stent in situ for ≤3months. Author contributions Prolonged dwell time is the most important risk factor in the development of encrustation. In a study of 330 ure- (1) JY Leong: data analysis, manuscript writing/editing. teric stents, the encrustation rates were 26.8% at (2) JE Steward: data collection and analysis, manu- <6 weeks, 56.9% at 6–12 weeks, and 75.9% at script writing/editing. >12 weeks [18]. Most stents need to be replaced at least (3) KA Healy: data collection and analysis, manuscript every 3 months, but some are approved for up to writing/editing. 6–12 months. Additionally, most respondents prefer the (4) SG Hubosky: protocol/project development, manu- use of both cystoscopy and fluoroscopy during stent script writing/editing. placement. While the cystoscopy procedure increases (5) DH Bagley: protocol/project development, manu- operative time, potential benefits include decreased script writing/editing. radiation exposure to patients and providers, as fewer fluoroscopy images are necessary. Potential risks of addi- tional cystoscopy include urethral trauma and displace- ment of the safety wire. Disclosure statement Limitations of our present study include the limited DemetriusH.Bagley, MD is aconsultantfor Bard Medicaland geographical distribution of the survey, which was Olympus. All other authors declare that they have no conflict of restricted to the Mid-Atlantic region of the USA. This interest. group was chosen, as opposed to the Endourological Society for example, because it provided a broader representation of urologists in practice. The survey ORCID response rate was only 12.2%, and this may have been limited by the one-blast e-mail allowance. Joon Yau Leong http://orcid.org/0000-0002-1698-8442 246 J. Y. 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