Is ureteral stent placement considered major surgery

What is a ureteral stent?
A ureteral stent is a soft, hollow tube placed temporarily into the ureter to help drain urine from the kidney into your bladder. A double-J stent is a ureteral stent with curving ends that prevent the stent slipping into the bladder or the kidney.
How is a ureteral stent placed?
Ureteral stent placement is a surgical procedure. A tube with a tiny optic camera is inserted through the urethra into your bladder. The bladder is inspected, and the ureteric opening is located. The stent is placed by sliding it over a flexible wire inserted into the ureter. The procedure is usually performed with the patient asleep (under general anaesthesia). Sometimes a local anaesthetic, with or without sedation, is administered.
How long will I have the stent?
From several days to a few weeks, depending on why it was placed. Your doctor will tell you when the double-J stent needs to be removed.
Should I take an antibiotic?
Your doctor may prescribe an antibiotic to treat or prevent an infection or to relieve your pain. Report any signs of infection – including severe pain, chills, or fever – to your doctor right away.
I’ve had pain with the urge to urinate since the stent was placed. Is that normal?
You may feel mild to moderate pain in your lower abdomen, and you may have a strong urge to urinate. These symptoms are usually caused by the inserted stent. Ask your doctor about medication to treat these symptoms. Call the hospital or your doctor if you experience a serious burning sensation (not mild) when urinating or if you continue to have severe pain despite use of pain medication.
I’ve had blood in my urine since the stent was placed. Is that normal?
Small amounts of blood may be present in the urine after stent placement and usually disappear in a few weeks. Call the hospital or your doctor if you see large amounts of blood in your urine and it does not go away with rest and hydration.
Will the stent move inside me?
Yes, the stent is flexible and will move with your body.
Can the stent fall out?
The curved ends of a double-J stent usually keep it in place. In rare cases, however, the stent may slip into the bladder or the kidney.
If the stent falls out, what should I do?
It is very rare for a stent to fall out of the body. If this happens, wash the stent and place it in a plastic bag. Contact your doctor and bring the stent with you to your appointment.
How is a stent removed?
Stents can be removed two different ways. Sometimes a string has been left attached to the end of the stent. This string is allowed to come out of the patient’s urethra. The string can be used to pull on the stent and remove it. If a string is not attached, numbing medication is usually administered, and a small camera called a cystoscope is inserted through a flexible tube into the urethra. The cystoscope is advanced into the bladder along with a grasping instrument, which grasps and removes the stent.
Will I be asleep when the stent is removed?
Removal is very quick. A local anaesthetic is usually administered to numb the area.
Will I be in pain after I have the stent pulled?
You may experience some mild discomfort immediately afterwards. Some patients have severe pain that is temporary and resolves within a few hours.
Should I take pain medication before the stent pull?
Taking an NSAID (for example, ibuprofen) prior to stent removal can help minimise pain afterward. Always ask your doctor about treatment steps and any special instructions before a procedure.
Why is there pain after the stent is removed?
A medical device was present in your urinary tract, so some mild discomfort is expected when it is removed. More severe pain may result if the ureter spasms or swells. These symptoms disappear in a few hours. Taking an NSAID (for example, ibuprofen) before stent removal can help minimise pain.

Research Letter

Association of VA Surgeons

January 2018

JAMA Surg. 2018;153(1):87-90. doi:10.1001/jamasurg.2017.3477

The prophylactic placement of ureteral stents during colorectal surgery may facilitate ureteral identification and/or recognition of injury.1,2 However, reports have cautioned against routine use of ureteral stents owing to the potential of iatrogenic injury during insertion and postoperative complications, including stenosis and infection.3,4 At present, no evidence-based guidelines exist regarding indications for ureteral stenting during colorectal surgery. This cohort study compares the outcomes of open colectomy with ureteral stenting with the outcomes of open colectomy without ureteral stenting.

A cohort of 374 consecutive patients who underwent open colectomy at a tertiary care center between January 1, 2011, and September 30, 2016, was evaluated. Demographic and laboratory data and data on comorbidities, procedural indications, and operative details were collected. Patients with a planned ureteral resection to achieve a negative oncologic margin were excluded (n = 3). The Charlson comorbidity index with age adjustment, a validated measure of perioperative mortality, was calculated and used for risk stratification.5 The primary outcomes of ureteral injury were compared between patients who underwent colectomy with ureteral stent placement and patients who underwent colectomy without ureteral stent placement. Secondary outcomes of length of stay, in-hospital mortality, procedural duration, and new-onset urinary complication (hematuria, dysuria, or urinary tract infection in the postoperative period) were also compared. The Yale Human Investigation Committee approved this study with waiver of patient consent. Multivariable logistic regression models were created to analyze factors associated with each outcome by a backward elimination technique with a significance threshold for inclusion in the final model of P < .10. Use of ureteral stents was forced into all models to determine the association of prophylactic stenting with each outcome. All analyses were performed using SAS, version 9.4 (SAS Institute Inc). P < .05 was considered significant.

The demographic and clinical characteristics of the patients with stent placement (n = 322) and the patients without stent placement (n = 52) were similar, although more emergency colectomies were performed without stenting (204 [63.4%] vs 13 [25.0%]; P < .001) (Table 1). Prophylactic ureteral stents were placed in 52 patients (13.9%) undergoing colectomy for indications including anticipated dense adhesions (31 [59.6%]), known urologic pathological conditions (6 [11.5%]) or surgeon preference (15 [28.8%]). One ureteral injury occurred (0.3%) in a patient who had stents placed. This injury was noted after the procedure, and the patient required reoperation. When accounting for the age-adjusted Charlson comorbidity index, procedural indication, sex, body mass index, emergency vs elective status, and extent of resection (right, left, or total colectomy), we found that there was no difference in mean (SD) hospital length of stay (11.8 [9.5] days vs 13.1 [13.3] days; P = .49) and in-hospital mortality (1 [1.9%] vs 34 [10.6%]; P = .25) between patients with stenting and patients without stenting (Table 2). There was a trend toward longer operative times with stenting (an additional 55 minutes; P = .16), which may in part be due to the time needed to place stents. Patients who received stents had higher rates of new-onset urinary complications (odds ratio, 4.29; 95% CI, 1.83-10.06; P < .001).

In this cohort of 374 patients undergoing open colectomy, prophylactic ureteral stenting was associated with increased operative times and increased rates of postoperative urinary complications. Although the overall rate of ureteral injury was low (0.3%) compared with other studies, the only injury occurred in a patient who received prophylactic ureteral stents.

Injury to the ureter is a serious complication in colorectal surgery, with a reported incidence of 0.2% to 7.6%, and the use of prophylactic ureteric stents remains controversial.6 Although some surgeons advocate for routine use of stents, others use stents selectively in patients with large tumors, prior radiotherapy or pelvic surgery, chronic inflammatory disease, or urologic pathologic conditions.1,2,6 Although the advantage of using stents to aid in ureteral identification and facilitate early repair of ureteral injuries is theorized, this study suggests that these benefits may not be realized for patients undergoing open colectomy. In addition, the risk of postoperative infection and the resultant increase in hospital costs without significant benefit may call into question the practice of routine stent use. This study may be underpowered, given the rare occurrence of ureteral injury. Prospective multi-institutional studies should be conducted to fully assess the utility of ureteral stents in open colectomies and to aid in the establishment of practice guidelines.

Corresponding Author: Kevin Y. Pei, MD, Department of Surgery, Yale University School of Medicine, 330 Cedar St, Boardman Bldg, Ste 310, New Haven, CT 06519 ().

Published Online: September 27, 2017. doi:10.1001/jamasurg.2017.3477

Author Contributions: Drs Merola and Pei had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Merola, Resio, Davis, Pei.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Merola, Arnold, Ibarra, Pei.

Critical revision of the manuscript for important intellectual content: Merola, Arnold, Luks, Resio, Davis, Pei.

Statistical analysis: Merola, Arnold, Luks.

Administrative, technical, or material support: Resio.

Study supervision: Davis, Pei.

Conflict of Interest Disclosures: None reported.

Meeting Presentation: This paper was presented at the Annual Meeting of the Association of VA Surgeons; May 7, 2017; Houston, Texas.

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St-Louis  E, Iqbal  S, Feldman  LS,  et al.  Using the age-adjusted Charlson comorbidity index to predict outcomes in emergency general surgery.  J Trauma Acute Care Surg. 2015;78(2):318-323.PubMedGoogle ScholarCrossref

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