55 Ben H. Chew, Anthony Emmott, Dirk Lange, & Ryan F. Paterson Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada Ureteroscopy is commonly used to treat urolithiasis and has become a standard endoscopic technique replacing open stone surgery of the past. This chapter will discuss analgesia and other medications utilized in the postoperative period. The use of ureteral stents and new and future technologies will also be discussed. Finally, the use of postoperative imaging following ureteroscopy will be examined. The overwhelming majority of patients undergoing flexible or semirigid ureteroscopy and intracorporeal lithotripsy are treated on an outpatient basis. Common indications for unplanned admission postprocedure include flank or bladder pain not manageable with oral analgesics, fever, urinary retention, or significant hematuria. In addition, management of the uncommon procedural complications of ureteral perforation or avulsion account for a small percentage of admissions. In common with other planned outpatient procedures, late procedure start times and social circumstances precluding early discharge may result in overnight admission [1]. Box 55.1 lists techniques to increase the likelihood of maintaining ureteroscopy as an outpatient procedure. Emergency admission for renal colic with subsequent emergent ureteroscopy can increase the likelihood of ongoing hospital stay postprocedure [1]. Following any surgery, physicians typically prescribe medications for the postoperative period consisting of an antibiotic and/or analgesic. Following ureteroscopy, there are many types of analgesics that can be prescribed and there is very little evidence for antibiotics in the postoperative period. In addition, there are two other types of medication that can be prescribed to patients with urolithiasis. In the case of uric acid stones, patients may be prescribed a urinary alkalinizing agent to dissolve any remaining fragments. The second are alpha‐antagonists which have been utilized to facilitate passage of fragments by relaxing ureteral smooth muscle [2, 3] and to help alleviate postoperative ureteral stent symptoms [4–7]. Patients are often prescribed antibiotics following surgical cases to prevent infection. The decision on whether to prescribe antibiotics should balance the risk of infection with the risk of adverse effects of antibiotics and the induction of antibiotic‐resistant bacterial strains. In cases where the risk of infection is high, the risk of complications such as Clostridium difficile colitis and inducing bacterial resistance is justified. In cases where there is a low risk of infection, then the utility of postoperative antibiotic prophylaxis becomes less clear. There is good evidence to give antibiotics at the time of surgery. A randomized trial of 113 patients were administered either levofloxacin 250 mg by mouth 60 minutes prior to ureteroscopy or no antibiotics [8]. The rate of bacteriuria in the control group was 12.5% compared to 1.8% in those receiving levofloxacin. They did not examine the use of antibiotics in the postoperative period. The current American Urological Association guidelines (2016) recommend preoperative antibiotic prophylaxis in all patients undergoing ureteroscopy administered within 60 minutes of the start of surgery. It can be a single oral or intravenous dose of antibiotic that covers both Gram‐positive and Gram‐negative uropathogens. Local antibiograms should be consulted for selecting an appropriate antibiotic to prevent antimicrobial resistance and ensure the best patient outcomes. There is no good evidence in the literature for using antibiotic prophylaxis in the postoperative period. The options for treating postoperative pain range from the commonly used analgesics which target pain at the central nervous system to medications that target specific receptors in the urothelium. The literature is lacking in suggestions for analgesics specifically after ureteroscopy, but the passage of fragments after intracorporeal lithotripsy can be accompanied with pain very similar to that found in renal colic. Alpha‐antagonists inhibit smooth muscle contraction and have been used extensively in the treatment of benign prostatic hyperplasia. In the endourological world, they have found two further purposes: as medical therapy to facilitate stone expulsion and to relieve ureteral stent symptoms. The theory underlying these observations is relaxation of ureteral smooth muscle to allow ureteral stones to pass and, in the case of stents, to prevent ureteral spasm. This is done by inhibiting selective alpha1‐adrenergic receptors and reducing ureteral contractility [9, 10]. Medical expulsive therapy has been found to increase the stone passage rate as well as hasten the time to stone passage and reduce pain, narcotic requirement, and hospitalizations for renal colic [11, 12]. A Cochrane systematic review of 32 studies (5864 participants) found significantly higher stone‐free rates in the alpha‐blocker group compared to standard therapy (risk ratio 1.48, 95% confidence interval [CI] 1.33–1.64). Reductions were found in stone‐expulsion time, number of pain episodes, need for analgesic medication, and hospitalization with alpha‐blockers. However, patients experienced more adverse effects with alpha‐blocker therapy than standard therapy or placebo [13]. Another meta‐analysis evaluating 693 pooled patients found a greater likelihood of stone passage than those given placebo when given an alpha‐blocker or calcium channel blocker with steroids [3]. The number needed to treat in this analysis was only four, indicating that this is a worthwhile and effective treatment for ureteral stones. Some studies have produced an even higher rate of stone expulsion in patients administered tamsulosin [14]. A more recent large, multicenter clinical trial randomized 1167 patients with a single ureteral stone 10 mm or less to tamsulosin, a calcium channel blocker (nifedipine), or placebo [15]. The primary end point was need for intervention by 4 weeks after randomization. Participants, clinicians, and trial personnel were blinded to treatment assignment. There was no difference in stone passage rates between tamsulosin, nifedipine, or placebo groups, as 80–81% of patients did not need further intervention in all three groups. No differences were found between the trial groups for visual analogue pain scores at 4 weeks, number of days of analgesic use, or time to stone passage. Criticisms of this study include the fact that the need for surgery was used as a surrogate end point rather than radiologic testing. Additionally, since more than 75% of the stones were 5 mm or less, one could argue that these stones were likely going to spontaneously pass anyway and that the alpha‐blockers were unable to show a difference. Phenazopyridine and oxybutynin have been administered orally in an attempt to relieve stent‐related symptoms. A randomized trial involving 60 patients randomized to phenazopyridine, oxybutynin, or placebo was performed and the following measures were recorded: narcotic use, flank pain, suprapubic pain, urinary frequency, urgency, dysuria, and hematuria [16]. There was a trend, although statistically insignificant due to the small group numbers, for a reduction in narcotic usage in the oxybutynin group. Phenazopyridine significantly reduced the amount of hematuria patients had on postoperative day 1 compared to placebo. Perhaps a larger study would discern if either of these medications would be helpful in relieving stent symptoms. A meta‐analysis of 1408 patients showed reduction in stent‐related symptoms, as measured by the International Prostate Symptom Score, visual analogue pain scale, and quality of life instruments, for alpha‐blockers (alfuzosin or tamsulosin) alone and antimuscarinics (tolterodine or solifenacin) alone compared to control. The combination of alpha‐blockers and antimuscarinics provided even greater reduction in stent‐related symptoms [17]. Patients randomized to alfuzosin following ureteroscopy and stent insertion had significantly less narcotic use, less overall pain in the back and groin area, less flank pain during urination, and less urinary frequency compared to patients given placebo [18]. Tamsulosin also produced similar significant results in other placebo‐controlled prospective trials of patients undergoing ureteral stent placement following ureteroscopy [4, 7, 19]. In a network meta‐analysis, tamsulosin and alfuzosin were shown to have significant reduction in the urinary symptom scores and body pain scores of the Ureteric Stent Symptoms Questionnaire when compared to placebo. However, no significant difference was found between tamsulosin and alfuzosin with respect to these measures [20]. It would appear that alpha‐blockers administered postureteral stent insertion is an excellent way to prevent and relieve symptoms. The decision must be made at the end of each ureteroscopy on whether or not a ureteral stent should be placed. The absolute indications to leave a ureteral stent are listed in Box 55.2 [21]. The evidence on whether to stent a patient following ureteroscopy is controversial. There is good evidence from randomized clinical trials suggesting that patients without ureteral stents experience fewer symptoms than those who receive a ureteral stent [1, 22–25]. In unstented patients postureteroscopy, few patients require surgical intervention for ureteral obstruction with the majority managed by improved pain control. In addition, the vast majority of patients treated on a “stent‐less” basis have no obvious preprocedure predictor of subsequent flank pain or obstruction. Although the avoidance of a postprocedure ureteral stricture is commonly encountered in the literature as a justification for ureteral stenting, the meta‐analysis of randomized controlled trials by Nabi et al. indicates no difference in stricture rate between those stented and nonstented [26]. Supporting the role of postprocedure ureteral stenting is the study by Borboroglu et al. in which the authors reported a risk for admission for flank pain postureteroscopy of 7.4% in the unstented group versus a 0% re‐admission rate in the stented group [27]. However, the overall cohort of unstented patients had substantially less flank pain. While some studies have shown fewer symptoms and less pain in those patients without a stent, a metaanalysis found a trend towards fewer urologic complications in patients who received a stent following ureteroscopy [28]. Some of the trials included in this analysis did not find a difference in complication rates between stented and unstented patients, but there was an overall 4.5% reduction in rate of complications in those patients who underwent placement of a stent following ureteroscopy (P = 0.001, 95% CI 1.8–7.3%). When a more stringent random effects model was applied, however, this difference was not statistically significant (4.1% risk difference, 95% CI 1.8%–10.1%, P = 0.175). At present in the literature, there is no significant difference in outcomes between patients who receive a ureteral stent compared to those who do not receive a ureteral stent following ureteroscopy. When a ureteral access sheath is used during ureteroscopy, there is good evidence to place a stent afterwards. A retrospective comparison of 51 patients stented and 51 patients not stented after flexible ureteroscopy with a ureteral access sheath found that stented patients had significantly lower postoperative pain scores and were less likely to seek medical attention for pain compared to unstented patients [29]. In another retrospective review, the rate of return to the emergency department of nonstented patients after ureteroscopy was significantly higher in those who had a ureteral access sheath (37%) compared to those treated without a ureteral access sheath (14%) (P = 0.04) [30]. Once a decision to place a stent is made, the question becomes which stent to use. There are no conclusive data as to which commercially available stent is the most comfortable for patients. There are a variety of factors that are taken into consideration including the softness (durometer) of the stent, its design, and its size both in length and diameter. Intuitively, one would think that softer stents would be more comfortable than harder stents; however, randomized trials have shown no difference between soft and hard stents in terms of urinary symptoms, pain, time away from work, or sexual dysfunction utilizing the Ureteral Stent Symptom Questionnaire (USSQ) [31], the only validated tool for evaluating ureteral stent symptoms [32, 33]. In one trial, patients randomized to a “stiffer” stent that was greater than 64A durometer in stiffness (Percuflex® stent; Boston Scientific, Natick, MA, USA) were compared to patients who received a softer stent of less than 64A (Contour™ stent, Boston Scientific) [32]. No differences between groups were seen at 1 and 4 weeks in terms of urinary symptoms, overall body pain, work performance, or general health index. Lennon et al. randomized patients to firm polyurethane stents or a softer Sof‐Flex™ stent [33]. Patients with firmer stents had a higher rate of dysuria, and renal and suprapubic pain; however, there was no significant difference in the degree of bladder inflammation, stent encrustation, urgency, frequency, nocturia, or hematuria. The only shortcoming of this study is that patients were not evaluated with a validated stent symptom questionnaire, the USSQ. More recently, Lingeman et al. and the Comfort Study Team utilized the USSQ to assess whether patient comfort was best in a short loop tail stent, a long loop tail stent, or a Percuflex Plus stent (Boston Scientific) or Polaris stent (Boston Scientific) [34]. All kidney curls were identically composed of a 6 Fr pigtail curl and the Percuflex Plus stent consists of the same material and coil in the bladder end. The distal ends differed in the other three stents: the short loop tail stent (5 cm long, 3 Fr diameter) and long loop tail stent (8 cm long, 3 Fr diameter) consisted of two loops and the Polaris stent was a dual durometer stent with a stiffer renal curl to prevent migration but a softer curl in the bladder in an attempt to decrease bladder irritation and symptoms. The 236 patients were randomized to receiving one of the stents following uncomplicated ureteroscopy and were administered the USSQ at baseline, 4 days after stent placement, and 5 days after stent removal. There were no statistically significant differences in pain scores between any of the stent groups. There was decreased use of narcotics in the first 1–3 days after stent placement in the short loop tail stents, but this was insignificant at 4 days. Most notably, the USSQ may not have been administered at the correct time as all patients had the most severe discomfort symptoms on postoperative day 1. By day 4, all symptoms had subsided when the USSQ was administered, thus there may have been a significant difference if it was measured at day 1. It also goes to support the theory that stent symptoms occur from irritation of the trigone of the bladder. Having softer material that also has less mass in the bladder may help alleviate ureteral stent‐related symptoms. Even though there are no clear data to support the use of one type of stent over another, there are good data that longer stents that protrude into the bladder produce more symptoms. Choosing the correct length of stent will significantly reduce patient stent symptoms. Stents that cross the midline of the bladder result in significantly more dysuria, urgency, and irritative voiding symptoms and more impaired quality of life than stents that do not cross the midline [35, 36]. Giannarini et al. found significant association between the distal stent loop crossing the midline of the bladder and the urinary symptoms, body pain, general health, work performance, and sexual matters domains of the USSQ [37]. Long stents are associated with excess material in the bladder – and, therefore, presumably with more bladder irritation – but do not result in excess stent length in the kidney [35]. Fluoroscopic studies of stented patients show that, with motion, the stent tends to bow in the mid and proximal ureter and the excess length slides in and out of the bladder at the ureterovesical junction, with relatively little motion seen in the kidney [38]
Ureterorenoscopy: Ureteral Stents and Postoperative Care
Ureteroscopy: outpatient versus inpatient management
Prescriptions
Antibiotics
Analgesics
Analgesics for renal colic and passage of fragments
Alpha‐antagonists for stone expulsion
Analgesics for stent‐related pain
Alpha‐blockers and stent‐related pain
To stent or not to stent? That is the question
Which stent is most comfortable?
Stent length relating to discomfort
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