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| Outcomes of a non-randomised audit of single pigtail suture stents in urolithiasis management of Asian patients in Singapore |
Ee Jean Lima,*( ),Zhen Wei Choob,Reshma Mangatc,Pradeep Duraic,Sarvajit Biligerec,Yiquan Tanc,Loh Hin Yeung Marcusc,Nicole Andrea Seet Li Tingc,Chin Tiong Hengc,Stefania Ferretid,Vineet Gauharc
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aUrology Department, Singapore General Hospital, Singapore
bUrology Department, Tan Tock Seng Hospital, Singapore
cUrology Department, Ng Teng Fong Hospital, Singapore
dUrology Department, Azienda Ospedaliera-Uiversitaria (Hospital and University of Parma), Parma, Italy |
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Abstract Objective: Double-J (DJ) ureteric stents are commonly placed perioperatively for semirigid or flexible ureteroscopic renal surgery. It is believed that lesser stent material within the bladder mitigates stent-related symptoms. This study aimed to evaluate the J-Fil ureteral stent, a single pigtail suture stent compared with conventional DJ stent in relation to stent symptoms in an Asian population undergoing ureterorenal intervention. Methods: Based on internal audit committee recommendation approval, the records of 50 patients retrieved, available data of 41 patients who were prospectively enrolled into two groups (Group 1 [J-Fil stent group], n=21 and Group 2 [DJ stent group], n=20) between August 2020 to January 2021, were analysed. Parameters compared were nature of procedure, stone location and size, ease of deployment or removal, and complications. A modified universal stent symptom questionnaire was used to assess morbidity of stent symptoms within 48 h of insertion and at removal. Results: Both groups had similar median age, distribution in male to female ratio, and stone size. The overall median universal stent symptom questionnaire score at insertion was similar for bladder pain, flank or loin pain, and quality of life between Group 1 and 2; however, at removal Group 1 fared significantly better than Group 2, especially for flank or loin pain and pain at voiding. Both groups had similar ease in insertion with no hospital readmissions. Conclusion: Our audit favoured the single pigtail suture stent in Asian ureters in mitigating stent-related issues. It showed a good safety profile with easy deployment and removal. It promises a new standard in stenting.
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Received: 22 August 2021
Available online: 20 April 2024
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Corresponding Authors:
* E-mail address: eejeanlim@gmail.com (E.J. Lim).
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Distal end of stent, string, and introducer.
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J-Fil suture stent with Prolene suture at distal end.
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| Characteristic | Group 1 (PSS group, n=21) | Group 2 (DJS group, n=20) | | Median age, median (range), year | 43 (30-56) | 49 (28-73) | | Sex, n (%) | | | | Male | 18 (86) | 18 (90) | | Female | 3 (14) | 2 (10) | | Stone size, median (range), mm | 8 (6-25) | 7 (3-20) | | Stone site, n (%) | | | | Kidney | 8 (38) | 1 (5) | | Ureter | 16 (76) | 19 (95) | | Proximal | 7 (33) | 6 (30) | | Middle | 1 (5) | 3 (15) | | Distal | 8 (38) | 12 (60) | | Number of stones, n (%) | | | | Single | 13 (62) | 18 (90) | | Multiple | 8 (38) | 2 (10) | | Indication for stent insertion, n | | | | Impacted stone | 6 | 15 | | Ureteral oedema | 3 | 12 | | Residual fragments | 2 | 2 | | Holdup of contrast | 2 | 1 | | Elevated creatinine, mmol/L | 3 | 9 | | Planned for reintervention | 3 | 3 | | Pre-RIRS stenting | 3 | 2 | | Procedure for insertion, n (%) | | | | URS | 13 (62) | 17 (85) | | fURS | 6 (29) | 2 (10) | | Cystoscopy (stenting only) | 2 (10) | 1 (5) | Size of DJS
(fixed length 24 cm), n (%) | | | | 6 Fr | | 13 (65) | | 5 Fr | | 7 (35) | | Size of JF stent (7 Fr), n (%) | | | | 16 cm | 11 (52) | | | 8 cm | 10 (48) | |
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Patient demographics, stone and stent characteristics.
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| Question | USSQ domain score at 48 h | USSQ domain score at time of removal | | Group 1 (PSS group) | Group 2 (DJS group) | Group 1 (PSS group) | Group 2 (DJS group) | | Weak stream | 5 | 5 | 0 | 2 | | Intermittency | 5 | 5 | 0 | 1 | | Incomplete voiding | 5 | 5 | 0 | 4 | | Straining to start | 4 | 6 | 1 | 0 | | Urinary spasm | 2 | 3 | 1 | 5 | | Urgency | 2 | 5 | 3 | 6 | | Nocturia | 3 | 4 | 3 | 3 | | Dysuria | 7 | 9 | 4 | 8 | | Haematuria | 9 | 9 | 10 | 11 | | Urge incontinence | 0 | 0 | 0 | 2 | | Impact on QoL | 2 | 2 | 4 | 3 | | Flank or loin pain | 6 | 6 | 7 | 10 | | Hypochondriac pain | 3 | 1 | 0 | 3 | | Groin pain | 1 | 4 | 0 | 2 | | Bladder pain | 2 | 2 | 4 | 3 | | External genitalia pain | 2 | 3 | 0 | 3 | | Pain affected by physical activity | 0 | 0 | 2 | 2 | | Pain at voiding | 5 | 7 | 2 | 8 | | Pain in kidney area at voiding | 2 | 2 | 0 | 4 | | Total USSQ score, median | 2.0 | 3.5 | 2 | 3 |
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USSQ domain scores at 48 h of insertion and at time of removal.
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| Outcome | Group 1 (PSS group, n=21) | Group 2 (DJS group, n=20) | | Ease of insertion, n (%) | 19 (90) | 19 (95) | | Difficulty encountered, n (%) | | | | Yes | 3 (14) | 2 (10) | | No | 18 (86) | 18 (90) | | Type of difficulty encountered for JF stent, n | | NA | | Visualization of string | 0 | | Grasping of string | 2 | | Pulling out of stent | 3 | | Special instrument needed | 2 | | Adverse events, n | | | | Readmission | 0 | 0 | | Encrustation | 2 | 0 | | Need for removal earlier | 1 | 0 | | Need for anticholinergics | 2 | 2 | | Complication Clavien-Dindo grade, n | | | | I (severe haematuria) | 0 | 0 | | II (fever >38 °C) | 0 | 0 | | III (stent dislodgement) | 0 | 0 | | IV (urosepsis) | 0 | 0 |
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The outcomes during insertion and removal of JF stent.
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| Outcome | At 48 h of insertion | At time of removal of stent | | J-Fil PSS 16 cm (n=12)a | J-Fil PSS 8 cm (n=8)a | J-Fil PSS 16 cm (n=12)a | J-Fil PSS 8 cm (n=8)a | | Bladder pain | 0 | 0 | 0 | 0 | | Loin pain | 0 | 0 | 0 | 0 | | Haematuria | 0 | 0 | 0 | 1 | | QoL | 0 | 0 | 0 | 0 |
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Comparison between both J-Fil suture stents based on USSQ score.
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| Characteristic | Bosio et al. [3] | Current study | | Patient population | Caucasian | Asian | | Country | Italy | Singapore | | Design | Prospective blinded RCT | Prospective audit | | Two arms or groups | Yes | Yes | | Total number of patients | 78 | 41 | | Randomised | Yes | No | | Blinding | Single blind | No | | Both length of JF stents used (8 cm and 16 cm) | Yes | Yes | | Conventional DJ stent | Multi-length (22-28 cm, 6 Fr) | Fixed length (22 cm or 24 cm, 5 Fr or 6 Fr) | | Proceduralist | 2 experienced endourologists | 1 experienced endourologist | | All stones | No (excluded distal and residual fragments) | All ureteric and renal stones and pre-fURS patients. | | USSQ domain score | 3 times (2 days or 2 weeks or 6 weeks) | 2 times (2 days or 4-6 weeks) | | Major complication in study, n | 3 for JF and 4 for DJ | Nil for both groups | | Encrustation of JF stent | Nil | 2 | | Need for medical intervention for SRS | Not reported | Nil | | Conclusion | JF superior to DJ for SRS | JF superior to DJ for SRS |
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Similarities and differences between Bosio et al. [3] RCT versus our study.
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