Prevention and treatment of symptoms associated with indwelling ureteral stents: A systematic review

Temporary drainage of the upper urinary tract by internal ureteral stents is a routine procedure in endourology. However, it is associated with a clear side‐effect profile. Our aim was to evaluate prevention and treatment options of stent‐related symptoms. We carried out a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis guidelines using MEDLINE and SCOPUS, and identified 107 appropriate records. A high number of these studies showed clear methodological limitations. Available data clearly support the use of α₁‐blockers in patients suffering from stent‐related symptoms. It seems that antimuscarinic monotherapy or combination with α₁‐blockers might also play an important role, whereas the use of classical analgesics in the treatment of stent‐related symptoms has not been assessed systematically within clinical trials so far. Improvements in stent design and material seem to have the potential to reduce stent‐related symptoms. However, so far there is no type of stent with outstanding characteristics and clear evidence suggesting fundamental advantages compared with a standard double pigtail stent. Although stent diameter does not seem to influence patients’ comfort, it seems to be beneficial to choose a proper stent‐length. Coated and drug‐eluting stents, as well as intravesical drug application, seem to be promising concepts to prevent stent‐related symptoms, but still have to be considered as experimental approaches. Furthermore, thorough patient education has the potential to reduce the morbidity associated with ureteral stenting. Further research in the field seems to be mandatory.     

输尿管支架管移位的原因分析及对策

目的探讨输尿管支架管(双J管)移位的原因、处理防范及预防措施。方法对16例双J管移位患者的临床资料进行回顾分析。结果 3例下移的双J管取出后重新放置,2例开放手术取出上移的双J管,6例用输尿管镜取出上移的双J管,5例上移者用预留的丝线拖出双J管。结论术前应测量肾盂至膀胱的长度选择合适的双J管;放置双J管时应先充分放置膀胱端,尾端预留丝线是取管的简易方法。术后第1周观察双J管是否移位相当重要。     

Comparison of clinical outcomes between intravascular ultrasound‐guided and angiography‐guided drug‐eluting stent implantation: A meta‐analysis of randomised control trials and systematic review

This systematic review was designed to evaluate the overall efficacy of angiography‐guided drug‐eluting stent (DES) implantation vs intravascular ultrasound‐guided (IVUS) implantation for percutaneous coronary intervention. The electronic databases CENTRAL, PubMed, Cochrane, and EMBASE were searched for systematic reviews to investigate angiography‐guided and IVUS‐guided DES implantation. We measured the following six parameters in each patient: cardiovascular death, stent thrombosis, target lesion revascularisation (TLR), myocardial infarction (MI), major adverse cardiac events (MACEs), and all‐cause death. Twelve studies involving 6268 subjects were included, with 2984 receiving IVUS‐guided DES implantation and 3284 using angiography‐guided DES implantation. With regard to MACEs, TLR, MI, cardiovascular death, and all‐cause death, the IVUS‐guided DES implantation group had remarkably improved clinical outcomes. However, there was no significant statistical difference in stent thrombosis between the two groups. Dramatic decrease in MACEs through IVUS guidance was presented by trial sequential analysis. Remarkably improved clinical outcomes, including MACEs, cardiovascular death, all‐cause death, and TLR, were identified through IVUS‐guided DES implantation in comparison with angiography‐guided DES implantation. Nonetheless, the effect on stent thrombosis and MI required further confirmation. In this meta‐analysis, eligible randomised clinical trials were warranted to verify the findings and to determine the beneficial effect of IVUS guidance for patients.     

Urethral in situ biocompatibility of new drug‐eluting biodegradable stents: an experimental study in the rabbit

OBJECTIVE

To assess the effect of drug‐eluting properties on the degradation process and the biocompatibility of biodegradable drug‐eluting urethral stents.

MATERIALS AND METHODS

Braided biodegradable 80 L/20D‐PLGA (copolymer of polylactide and polyglycolide) stents with drug‐eluting properties were used as the test material. The drugs analysed were indomethacin, dexamethasone and ciprofloxacine. 80 L/20D‐PLGA stents without a drug coating served as controls. In all, 16 male rabbits were used and divided into four groups. The stents were inserted under general anaesthesia into the posterior urethra. After 1 month, the rabbits were killed and the urethra removed for histological and optic microscopy analyses.

RESULTS

Control stents and the dexamethasone‐eluting stents degraded totally during the follow‐up period. Conversely, in both indomethacin‐ and ciprofloxacine‐eluting stent groups, the degradation process was significantly delayed and they induced an increase in epithelial hyperplasia. Histological analysis showed that all the stents induced eosinophilia, but there were no significant differences in the intensity of acute or chronic inflammatory reactions and fibrosis.

CONCLUSIONS

A drug‐eluting capacity can be added to biodegradable stents. The addition of a drug influences the biodegradation time of PLGA urethral stents. Further studies are needed, to find the proper concentrations and releasing profiles of the drugs to achieve the desired bioactivity and biocompatibility properties.     

多沙唑嗪对于改善输尿管支架管引起的下尿路症状的作用

目的评价多沙唑嗪对置入输尿管支架管（D-J）患者下尿路症状以及生活质量的改善作用。方法从2010年3月至2010年12月,共收集了28例输尿管镜碎石后留置D-J管的患者入组本研究。患者被随机分为2组（治疗组、对照组）,对照组14例患者未接受多沙唑嗪治疗,治疗组14例患者接受了2～4周的多沙唑嗪（4mg/d）治疗。所有患者均在2～4周后D-J管去除之前接受国际前列腺症状评分和世界卫生组织生存质量测定量表简表对患者下尿路症状及生存质量进行评估。结果对照组IPSS平均分为9.79,治疗组中IPSS平均分为5.07,P〈0.05;对照组中生理领域平均分为13.80,治疗组中为15.43,P〈0.05。结论多沙唑嗪可改善一系列D-J管相关下尿路症状以及患者的生活质量。     

Impact of Tamsulosin,Tolterodine and drug-combination on the outcomes of lower urinary tract symptoms secondary to post-ureteroscopy ureteral stent: A prospective randomized controlled clinical study

Objectives

To compare the role of alpha-blocker (Tamsulosin) monotherapy, anticholinergic (Tolterodine) monotherapy or combination of both drugs versus analgesics in improving post-ureteroscopy (URS) lower urinary tract symptoms related to double-J ureteral stent.

Percutaneous nephrostomy versus ureteral stents for diversion of hydronephrosis caused by stones: a prospective, randomized clinical trial

PURPOSE: Urinary diversion with percutaneous nephrostomy or ureteral stent is indicated by symptoms, such as persistent colic, high temperature and uremia, of hydronephrosis caused by stones. We evaluate which of these 2 methods is superior concerning the course of procedure, relief of accompanying symptoms and quality of life in regard to patient age and sex. MATERIALS AND METHODS: A total of 40 patients with stone induced hydronephrosis were randomized into either percutaneous nephrostomy or stent insertion groups. These patients were then evaluated by procedure (use of analgesics, x-ray exposure, success of insertion), relief of accompanying symptoms (duration of diversion, intravenous administration of antibiotics for high temperature) and quality of life (questionnaire immediately and 2 to 4 weeks postoperatively). RESULTS: Two comparable groups of patients were formed, with an average age of 55 versus 49 years and a male-to-female ratio of 12:8 versus 9:11 for those who underwent percutaneous nephrostomy versus those who received a stent, respectively. Percutaneous nephrostomy was successfully completed in 100% of patients and stents were successful in 80%, with a 20% conversion to percutaneous nephrostomy. The x-ray exposure was shorter in the percutaneous nephrostomy group (p = 0.052). Administration of analgesics was more frequent in the stent group (p = 0.061). Percutaneous nephrostomy indwelling time was shorter (50% less than 2 weeks) than that of stents (25% less than 2 weeks, p = 0.043). Antibiotics were administered for greater than 5 days in 0% of patients who underwent percutaneous nephrostomy versus 64% in those with stents (p = 0.174). Reduction in quality of life was moderate but more pronounced in patients with stents compared to those who underwent percutaneous nephrostomy, and was more distinct in males and younger patients. The quality of life progressively improved in the course of diversion with percutaneous nephrostomy but deteriorated with stents. CONCLUSIONS: Our results demonstrated that percutaneous nephrostomy is superior to ureteral stents for diversion of hydronephrosis caused by stones, especially in patients with a high temperature, as well as in males and juveniles.     

输尿管软镜碎石术前预置双J管必要性的荟萃分析

目的 系统评价输尿管软镜碎石术前预置双J管的必要性。方法 计算机检索Pubmed、CochraneLibrary、Embase、Scopus、万方、中国知网、维普数据库。检索从建库至2018年11月关于术前预置双J管对输尿管软镜碎石术治疗效果影响的临床研究。英文检索词为Flexible ureteroscopic、preoperative、Double J stent、Calculus,中文检索词为输尿管软镜、术前、双J管、结石。纳入标准:①病例对照研究或随机对照试验,包括学位论文及会议摘要;②研究对象术前经泌尿系超声、腹部X线片、尿路造影或腹部CT等检查确诊为泌尿系结石,均行输尿管软镜碎石术;③试验组术前预置双J管,对照组术前不预置双J管;④观察指标包括术后结石清除率、通道鞘置入成功率、球囊扩张使用率、术中及术后并发症发生率、手术时间等。排除标准:①无对照组;②相同的作者、单位的重复报告;③未涉及相关指标或原始数据不完整,无法提取利用的文献。由2名研究者独立进行文献筛选、质量评价、提取资料,并使用RevMan 5.3统计软件进行Meta分析。结果 本研究共纳入46篇文献,其中病例对照试验32篇,随机对照试验14篇。共纳入17 480例患者,其中试验组6 211例,对照组11 269例。Meta分析结果显示,试验组术后结石清除率高于对照组(OR=1.69,95%CI 1.37~2.08,P<0.05)。亚组分析结果显示,肾结石亚组中,试验组结石清除率高于对照组(OR=1.67,95%CI 1.41~1.99,P<0.05);输尿管结石亚组中,两组差异无统计学意义(OR=1.71,95%CI 0.91~3.20,P=0.100)。试验组的软镜通道鞘置入成功率高于对照组(OR=5.77,95%CI 3.32~10.31,P<0.05),球囊扩张器使用率低于对照组(OR=0.23,95%CI 0.15~0.35,P<0.05),术中并发症发生率低于对照组(OR=0.56,95%CI 0.38~0.84,P=0.004),术后并发症发生率低于对照组(OR=0.64,95%CI 0.45~0.90,P=0.010),手术时间短于对照组(MD=-4.95,95%CI -8.90^-1.01,P=0.010)。结论 术前预置双J管可提高输尿管软镜碎石术治疗肾结石的术后结石清除率,提高软镜通道鞘的置入成功率,降低输尿管球囊扩张器的使用率,减少术中、术后并发症的发生率,缩短手术时间。     

An antireflux stent versus conventional stents for palliation of distal esophageal or cardia cancer: a randomized clinical study

Background Self-expandable metal stents placed across the esophagogastric junction for palliative treatment of malignant strictures may lead to gastroesophageal reflux and pulmonary aspiration. This study compared the effects of a Dua antireflux stent with those of a conventional stent. Methods Patients with incurable cancer of the distal esophagus or gastric cardia were randomly assigned to receive an antireflux stent (n = 19) or a standard stent (n = 22) at nine Swedish hospitals during the period September 1, 2003 to July 31, 2005. Complications were recorded at clinical follow-up visits. Survival rates were assessed through linkage to the Population Register. Dysphagia, reflux symptoms, esophageal pain, dyspnea, and global quality of life were assessed as changes in mean scores between baseline and 1 month after stent insertion through validated questionnaires. Results No technical problems occurred during stent placement in the 41 enrolled patients. Fewer patients with complications were observed in the antireflux stent group (n = 3) than in the standard group (n = 8), but no statistically significant difference was shown (p = 0.14). The survival rates were similar in the two groups (p = 0.99; hazard ratio, 1.0; 95% confidence interval, 0.5–2.0). The groups did not differ significantly in terms of studied esophageal or respiratory symptoms or quality of life. Clinically relevant improvement in dysphagia occurred in both groups. Dyspnea decreased after antireflux stent insertion (mean score change, –11), and increased after insertion of standard stent (mean score change, +21). Conclusions Antireflux stents may be used without increased risk of complications, mortality, esophageal symptoms, or reduced global quality of life. These results should encourage large-scale randomized trials that can establish potentially beneficial effects of antireflux stents.     

Effects of proximal and distal ends of double-J ureteral stent position on postprocedural symptoms and quality of life: a randomized clinical trial

PURPOSE: To evaluate the effect of the position of the proximal and distal ends of Double-J ureteral stents on postprocedural flank pain, lower urinary-tract symptoms, and quality of life. PATIENTS AND METHODS: The study included 120 patients who required unilateral Double-J ureteral stents for various indications. They were randomized into two equal groups. Group 1 had longer stents, with the proximal end in the upper calix and the distal end crossing the midline of the bladder. Group 2 had proper stent length with the proximal end in the pelvis and the lower end just beyond the vesicoureteral junction. Patients answered a questionnaire regarding flank pain, dysuria, and urgency as well as quality of life after 1 week of stenting. RESULTS: Forty patients (67%) of group 1 and 43 (72%) of group 2 had mild flank pain, especially during urination. There was no significant difference in the degree of flank pain in the two groups. Moderate to severe dysuria was reported by 53 patients (88%) in group 1 and 11 patients (18%) in group 2 (P < 0.001). Moderate to severe urgency was reported by 48 patients (80%) in group 1 and in 14 (23%) in group 2 (P < 0.001). A worse quality of life was reported by patients in group 1, among whom moderate to severe bother was noted by 51 (85%) compared with group 2, in which moderate to severe bother was reported by only 13 patients (22%) (P < 0.001). CONCLUSION: Ureteral stents are associated with flank pain and lower urinary-tract symptoms. The flank pain was not affected by the length of stent. Urgency and dysuria as well as a worse quality of life were significantly more common in the patients who had longer stents.     

Treatment of partial-thickness burns: a prospective, randomized trial using Transcyte

BACKGROUND: The purpose of the present study was to compare the effectiveness of three burns dressings (TransCyte, a bio-engineered skin substitute; Biobrane; and Silvazine cream (silver sulphadiazine and 0.2% chlorhexidine)), in treating children with partial-thickness burns. The primary objective was to determine the days until > or =90% re-epithelialization. The secondary objectives were to evaluate the number of wounds requiring autografting and the number of dressing changes/local wound care required. METHODS: Study wounds were identified on each patient and the patients were randomized to receive TransCyte or Biobrane or Silvazine. Assessment of study wound closure began at 2 days after treatment and continued at least every other day thereafter until the wounds re-epithelialized or were autografted. A laser Doppler imaging system was used as an adjunct to assessing the depth of the burn. RESULTS: Thirty-three patients with 58 wound sites enrolled in the study (TransCyte, n = 20, Biobrane, n = 17; Silvazine, n = 21). Mean time to re-epithelialization was 7.5 days for TransCyte, 9.5 days for Biobrane, and 11.2 days for Silvazine. The number of wounds requiring autografting were 5/21 (24%) for Silvazine, 3/17 (17%) for Biobrane, and 1/20 (5%) for TransCyte. CONCLUSIONS: When used in partial-thickness burns in children, TransCyte promotes fastest re-epithelialization and required less overall dressings then Biobrane or Silvazine. Patients who received Silvazine or Biobrane require more autografting than those treated with TransCyte.