A Stent for Every Stone? Pre-stenting Habits and Outcomes from a German Multicentric Prospective Study on the Benchmarks of Ureteroroscopic Stone Treatment (BUSTER) - Beyond the Abstract

Pre-stenting, i.e. the use of ureteric stents prior to ureterolithotripsy (URS) has several advantages in the treatment of urolithiasis. It provides immediate relief from renal colic and requires relatively little skill. It can avert life-threatening urosepsis which results from obstructive pyelonephritis. Additionally, it enables patients to be scheduled for a definitive treatment without urgency. For the treating surgeon, the most obvious advantage of pre-stenting is the ureteric dilatation that facilitates stone removal while reducing the risk of ureteric injuries.

However, the disadvantages of stenting need to be taken into consideration as well. Pain, urinary urgency, hematuria, and infection are well-known side effects that deteriorate the patient’s quality of life in more than 50%. The recommendations of the European Association of Urology (EAU) and the American Urological Association (AUA) are quite divergent: The EAU guidelines state “pre-stenting facilitates URS and improves outcomes of URS (in particular for renal stones) – Strong Recommendation” while the AUA guidelines state “placement of a ureteric stent prior to URS should not be performed routinely – Strong Recommendation”. We examined the current practice of pre-stenting in German clinics and its impact on stone-free rates and complications, using the data from the multicenter, prospective BUSTER (Benchmarks of ureteroscopic stone treatment – results with regard to complications, quality of life and the stone-free rate) study.

Previous studies have already shown a frequent use of pre-stenting in German clinics, so the high overall pre-stenting rate of 70% came not as a surprise: Some clinics in our study pre-stented 100% of their stone patients prior to URS. We did not ask the treating urologists about their motivations to pre-stent; it is unlikely that reimbursement is an important driver since the German g-DRG system does not pay any extra revenue for the pre-stenting procedure unless it takes place more than 30 days before URS. We suspect the main reasons for pre-stenting are long-established structures and safety concerns.

Furthermore, our results indicate that pre-stenting improves URS outcomes for renal stones but not for ureteric stones regarding the stone-free rate, ureteric injury, and the need for post-stenting. These findings are in line with the results from other large studies;^1,2 they lead us to the conclusion that the optimal approach might be a middle path between the AUA and the EAU recommendations: for renal stones, pre-stenting should be considered as an important step to ensure a complete and safe stone removal. For ureteric stones, we believe that prestenting can be omitted in most cases without compromising the success of the treatment or the safety of the patient.

1. Assimos, Dean, Alfonso Crisci, Daniel Culkin, Wei Xue, Anita Roelofs, Mordechai Duvdevani, Mahesh Desai, Jean de la Rosette, and CROES URS Global Study Group. "Preoperative JJ stent placement in ureteric and renal stone treatment: results from the Clinical Research Office of Endourological Society (CROES) ureteroscopy (URS) Global Study." BJU international 117, no. 4 (2016): 648-654.
2. Jessen, Jan Peter, Alberto Breda, Marianne Brehmer, Evangelos N. Liatsikos, Felix Millan Rodriguez, Palle Jørn Sloth Osther, Cesare Marco Scoffone, and Thomas Knoll. "International collaboration in endourology: multicenter evaluation of prestenting for ureterorenoscopy." Journal of endourology 30, no. 3 (2016): 268-273.