Pre Stenting or not prior to URS/RIRS

Dear All,

Of late the surgical management of urinary stones have been dramatically changed because of various technological advances. At many centres in USA, RIRS is fast becoming the standard treatment for renal stone as against PCNL. PCNL appear to be restricted to Academic Centres of late and this is probably because at many centres even today the Radiologist performs the Initial access into the collecting system. At most centres Semi Rigid Ureteroscope is being replaced by Flexible scopes.

This raises the issue as to whether a pre stenting has to be performed when RIRS for Renal stones and URS for Ureteral Stones are attempted.

 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. Both are strong Recommendations.

What is the attitude of us Indian Urologists regarding this? A discussion on this would help us to clear the cobwebs surrounding this issue.

‘Should we Pre Stent the Ureter or Not prior to accepting a patient for these procedures’.

With warm regards,

Venu

 

Comments(10)

  • Ravindra Sabnis
    Ravindra Sabnis
    25 Feb 2020 09:31:21 PM

    Most Indian Urologists follow practical approach. Pre stenting is done in 2 situations. 1) Elective - pre decided as stenting & then later RIRS 2) Stenting done because ureter is tight & hence access sheath or even FURS can't be passed. 

    First situaiton indications are hardly any from Indian Urologists point of view. one indication could be -  ectopic kidney / anamolous kidney- lower pole RIRS. 
    Most indian urologists will do pre-stenting only for second situation. 
    Most will tell patients that if Ureter is tight & RIRS is not possible, same sitting miniperc can be done. If pats not willing & pts want onlt RIRS , then stenting is done & then later RIRS. 
    So whatever AUA or EAU guidelines, or whatever strong recomendations, we follow very practical approach, which is quite rational. 

  • Nitesh Jain
    Nitesh Jain
    25 Feb 2020 10:30:57 PM

    With current fURS , stenting is hardly required in routine procedure 


    Currently most of us who do routine fURS will outright stent in 

    1. paediatric cases 
    2. It may be useful in select anomalous kidney 
    3. Rarely a tight ureter 
    4. Large LC stone where patient I
    Unwilling for mPCNL
    5. Large stone bulk as part of stage procedure 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    26 Feb 2020 08:26:36 AM

    In my initial 10 to 15 cases I was doing routine pre stenting prior to RIRS. 

    Now only in indicated cases,  indications narrated by Sabnis Sir and Nitesh. 
    I was used to dilate with balloon if required while doing RIRS to introduce access sheath or flexi scope to avoid stenting and staged procedure .  But since couple of months stopped that practice for RIRS after advice from Prof.  Oliver Texer.  He says it is traumatic in otherwise normal ureter and should not be done to complete RIRS without prior stenting .  Better put the stent and stage the procedure. 
    Over a time we all learnet various techniques to enter without prior stenting and that is why now we only  explain/ take consents of patients we may need to put stent if indicated and in that case will  stage the procedure. 
    Lastly in our operative workshops we keep almost all cases pre- stented to facilitate easy demonstration of case. 
    That means we believe prior stenting facilitate procedure and reduces failures and complications,  like EAU. 

  • Dr Parimal Gharia
    Dr Parimal Gharia
    26 Feb 2020 09:05:40 AM

    I totally agree with Dr Sabnis sir
    I don’t do pre stenting but explain each patient that in case of ureter does not accommodate Ureteral access sheath or bare scope ( only in case of low stone bulk) , I will do stent and comeback later.
    But prior check ureteroscopy with 4.5 fr ureteroscope is of help to gauge the ureter.
    New fresh Ureteral access sheath has definite advantage if someone is using resterilized access sheath.
    No force ballon or Ureteral Dilators use.
    Use of Zebra wire for access sheath introduction.
    Empty bladder at time of introduction of access sheath helps.

  • Venugopal P
    Venugopal P
    26 Feb 2020 10:41:08 AM

    Dear All,

    I am happy that this issue has ruffled few feathers. We in India are ardent followers of EAU Guidelines and AUA Guidelines and follow it as Gospel truth and violation from them are considered a sin. Of late we are informed that we are developing Indian Guidelines that we have to follow in future. The idea is good but I am afraid that we will only copy and paste what is given in few of the existing Guidelines. Sabnis has rightly mentioned ‘Practical approach’ but how many still follow the Guidelines mentioned which are at variance with each other. Many of the Guideline approaches that we are asked to follow may not to be suitable for Indian scenario. Hence the developers of Indian Guidelines should take into consideration many aspects and notably what is going to be given in the Indian Guideline should be able to be practiced by the majority of practicing Urologists in the country. If one a guideline is brought out, it is going to be quoted in the court of law if and when litigation happens and a guideline based on what could be possible only in major academic centres could put many of our Urologists in a quandary. In the development of Indian Guidelines, attention should be placed on the financial aspects of the proposed treatments as well.

    One final Question is whether a candidate in an exit exam mentions an answer deviating from such Guidelines like AUA and/or EAU, likely to pass. I personally know some who insist the answers given should be based on either AUA or EAU Guidelines.

    With warm regards,

    Venu

  • Ravindra Sabnis
    Ravindra Sabnis
    26 Feb 2020 08:26:49 PM

    You are absolutely right sir. You have always expressed your apprehensions of blindly following EAU or AUA guidelines. Now slowly people have started realising that it may do harm if followed blindly On that background of what is mentioned, we have to follow our own protocols. I am also concerned about developing Indian guidelines. When you make guidelines, it assumes, that infrastructure, experties, economic considerations are same everywhere. This assumption is flawed in India. Scenario in India differ from place to place & in same city, from hospital to hospital. So all guidelines should allow urologist to understand what is ideal & then make protocols pertaining to local conditions. So as Venu Sir has mentioned, let's not take EAU & AUA as gospel truth. 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    26 Feb 2020 10:45:18 PM

    Sabnis Sir,

    What is your opinion on acute dilatation (balloon or sequential) to facilitate entry of access sheath or flexi in tight ureter?
    Experts members please share your opinions on my query?
    Thanks

  • Pankaj N Maheshwari
    Pankaj N Maheshwari
    27 Feb 2020 04:10:02 PM

    Pre-stenting as a protocol or rule: not needed.

    Needed if:
    1. Tight lower ureter
    2. Urine looks purulent (this can happen despite sterile culture)
    Even in anomalous kidney, paediatric patients, large stone bulk or lower calyces calculus, if the access sheath walks in, why pre-stent? 
    Disadvantage of pre-stent:
    1. Adds to cost
    2. Adds an additional procedure (Patient may need to go to theatre thrice: stent, RIRS and then Stent removal)
    3. Risk of infection increases
    About acute dilatation: Any patient who needs acute dilatation for placement of the access sheath, i would stent and stage.
    My RIRS plan:
    1. GA
    2. Assess lower ureter either by rigid ureteroscopy or by a 8Fr double lumen catheter; if this goes smooth, access sheath would go, else stent and stage.
    3. I like to use safety guide wire during my RIRS hence like to use a double lumen catheter: calibrates the ureter and i can place the safety wire.
    4. I firmly believe that in contrast to PCNL, Ureteroscopy is not a forgiving procedure. Any injury can have lasting impact on patients quality of life so when in doubt, stage, stent and come back again after few days. 
    5. New access sheath in most men for RIRS, re-sterilized access sheath (if situations demand) can be used for stented patients or women. Do not use access sheath more than 2-3 times. If the older access sheath does not deploy, a new one usually goes in.
    6. Try and not keep a gap of more than 10 days between stenting and RIRS; increasing gap increases the risk of infection. 

  • Dr.Kandarp Parikh
    Dr.Kandarp Parikh
    28 Feb 2020 08:38:33 AM

    Though India has huge population and large number of stone patients,it is pitty that we have not our own guidelines.Most of us use Eau and Aua guidelines selectively during our practice and all the time during our talks.

    Bottom line is please adjust your instruments to anatomy and don't try anatomy to adjust your instruments!
    I don't routinely pre stent my patients but as and when required as discussed by esteem colleagues (indications are few).
    Of course pre stenting usually make your life easy for access , placement of 10/12 or 12/14 UAS  , complications of UAS and may be retrieval of stone fragments and clearance.It also helps when you are learning art of Rirs so not a bad idea for first few cases.
    Again I emphasis, there can Never be Never.Remember you are doing flexible urs and so be flexible in your decision making according to case😃

  • Ajay Bhandarkar
    Ajay Bhandarkar
    02 Mar 2020 11:41:20 PM

    As nicely written by Sabnis and Pankaj, we always try to do our fURS in single stage if ureter permits. For such situations, my choice of endoscope is fibre optic scope as tip is 7.5 F. But, given a choice, I like pre-stenting as it makes flexible scopy easy and enjoyable. But, majority of our patients do not like it. They need lot of counselling to get convinced for two procedures over and above cost concerns. 

    But, my personal limited experience with disposable scopes is very encouraging. I won’t mind convincing my patients for pre stenting If I routinely use disposable 8.5 F scope as a protocol. Vision and flexibility is excellent.

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