Presented by: Francesco Del Giudice MD
"Sapienza" University of Rome

Introduction

Ureteropelvic junction obstruction (UPJO) is the most common congenital anomaly of the ureter in the US. UPJO presenting in adults could be congenital or acquired and an increasing number of subclinical and asymptomatic UPJO are diagnosed incidentally on cross-sectional imaging studies. While double-J (DJ) indwelling stent placement during the end phase of pyeloplasty uretero-pelvic junction anastomosis is a well-established standard of care, there is no consensus regarding time to DJ stent removal among endourological international guidelines. Accordingly, we sought to investigate trends and patterns influencing the choice for early rather than later DJ stent removal across a large insurance claim dataset from US.

Materials

Men ≥ 18 y/o undergone primary or salvage, open or minimally invasive (MIS) pyeloplasty followed by DJ stent placement for UPJO were identified in the IBM Marketscan® Research De-identified Database between 2007 and 2015. Time from pyeloplasty and subsequent DJ stent removal was assessed. Descriptive statistics as well as multivariable regression modeling were implemented to examine trends and patters of DJ indwelling duration with demographics and perioperative factors affecting time to stent removal.

Results

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In total, n=4,925 subjects (49.6% male, 50.4% female) with mean age of 31.5 (SD: 21.6) years were reviewed. Median time for DJ stent was steady across the range of study time from 5.9 (0.9 – 51.0) days in 2007 up to 5.7 (0.4 – 29.9) days in 2015. This was also mainly unchanged when examining on sub-group by age, gender, Charlson comorbidity index (CCI), US region and surgical pyeloplasty indication (primary vs. salvage) or approach (open vs. MIS). Of note, at Cox regression modeling, older median age, female gender, as well as primary indication with MIS approach were all independently associated with lower DJ stenting interval (adjusted Hazard Ratio [HR], 1.13 95% confidence interval [CI], 1.05 - 1.2, aHR, 1.08, 95%CI, 1.02 - 1.15, aHR, 1.24, 95%CI,1.12 - 1.37, aHR, 1.24 95%CI,1.16 - 1.31, respectively). On the opposite, ≥ CCI 2 and longer length for hospital stay at the time of the procedure were found to increase the risk for longer time to DJ stent removal (aHR, 0.89, 95%CI, 0.82 - 0.96, and aHR, 0.74, 95%CI, 0.65 - 0.84). 

Conclusion

The decision whether how long DJ ureteral stents after pyeloplasty should be maintained in place is an open topic with absence of standardized protocols in the US. To the best of our knowledge this is the first study on a large US population-based cohort addressing trends and predictors for decision-making in timing for DJ stent removal. Our findings could help for tailoring the shape of more patient-oriented risk stratification for adverse events including UPJO relapse or perioperative complications in future research.

Funding

None

Lead Authors

Deok Hyun Han, MD
Stanford University School of Medicine

Co-Authors

Satvir Basran,
Department of Urology, Stanford University School of Medicine

Shufeng Li,
Department of Urology, Stanford University School of Medicine

Simon Conti, MD
Department of Urology, Stanford University School of Medicine

Federico Belladelli, MD
Department of Urology, Stanford University School of Medicine

Benjamin I. Chung, MD
Department of Urology, Stanford University School of Medicine