Role of Ureteral Stenting After Uncomplicated Ureteroscopy for Distal Ureteral Stones: A Randomized, Controlled Trial Hamdy M. Ibrahim, Ahmed M. Al-Kandari, Hani S. Shaaban, Yahya H. Elshebini and Ahmed A. Shokeir* From the Al-Adan Urology Unit, Ministry of Health (HMI, AMAK, HSS, YHE) and Department of Surgery, Kuwait University (AMAK), Kuwait City, Kuwait, and Urology and Nephrology Center (AAS), Mansoura, Egypt Purpose: We determined the differences in outcome between ureteral stenting and nonstenting following uncomplicated ureteroscopy for distal ureteral stones. Materials and Methods: A total of 220 patients treated with successful ureteroscopy for distal ureteral stones were randomized to 2 equal groups according to postoperative placement of a ureteral stent (Cook Ireland, National Technological Park, Ireland), including group 1—without a stent and group 2—with a stent. Outcome measures were flank pain and dysuria at 48 hours and 1 week, early postoperative complications, analgesia need, rehospitalization, return to normal physical activity, stone-free rate, stone recurrence and late postoperative complications. Patients were followed a mean  SD of 25  9 months (range 12 to 49). Results: Early postoperative complications, including low grade fever, hematuria and urinary tract infection, were observed in 22 patients (20%) in group 1 and 19 (19%) in group 2, a difference of no significant value. Mean initial hospitalization and time to return to normal physical activity were not different between the 2 groups. At 48 hours and 1 week there was no significant difference in flank pain between the 2 groups, while dysuria was significantly less in the nonstented group. The amount of analgesics required in the recovery room was not different but after discharge from the hospital stented patients used a larger amount of analgesia while the stent was still in the ureter. The stone-free rate at 4 weeks was 100% in each group. Late postoperative sequelae, including stone recurrence and ureteral narrowing, were reported in 6 patients (5.5%) in group 1 and 4 (3.6%) in group 2, a difference of no significant value. Conclusions: Uncomplicated ureteroscopy for treatment of distal ureteral stones is safe without stent placement. Patients without stents have significantly fewer irritative bladder symptoms and are not at risk of increased complications. Key Words: ureter, ureteroscopy, stents, ureteral calculi E xtracorporeal shock wave lithotripsy and ureteros- copy are currently the most common treatment op- tions for ureteral stones. The routine placement of ureteral stents after uncomplicated ureteroscopy is contro- versial. The main advantage of stenting is the prevention of ureteral obstruction and renal colic, which may develop fol- lowing stone retrieval. Moreover, stents may aid in the pas- sage of stone fragments and prevent delayed ureteral stric- ture. 1 However, routine placement of ureteral stents is accompanied by troublesome urinary symptoms and/or mor- bidity. 2,3 Related complications are common, such as lower urinary tract symptoms, infection, migration, breakage, en- crustation and stone formation. 4 Moreover, placement of ureteral stents results in additional cost and it may require additional secondary cystoscopy to remove the stent with disturbance to patient lives. 5 Nabi et al recently evaluated the outcomes of stenting after uncomplicated ureteroscopy in a systematic review and meta-analysis 5 that included 9 randomized, con- trolled trials reporting on a total of 831 participants. 6–14 The investigators found that the overall quality of trials was poor and the reporting of outcomes was inconsistent. Because of the marked heterogeneity and poor quality of reporting of the included trials, Nabi et al concluded that the place of stenting in patients after uncomplicated ure- teroscopy remains unclear. Limitations of the previous randomized studies include a lack of standardization of outcome measures, trial duration, stenting duration, stent material, patient population, uretero- scope size and intracorporeal lithotripsy method. 5 Moreover, most trials had a small sample size with a followup of less than 6 months. We tried to overcome some of the limitations of previous trials by performing a randomized clinical trial with a good sample size (220 patients) and a reasonable followup (min- imum 1 year). Moreover, we standardized most variables, such as the ureteroscopy technique, intracorporeal stone disintegration technology, patient population, stent mate- rial and stenting duration. MATERIALS AND METHODS Patients This prospective, randomized study was done between Jan- uary 2004 and December 2006. A total of 220 patients Submitted for publication January 20, 2008. Study received local ethical committee approval. * Correspondence: Urology and Nephrology Center, Mansoura, Egypt (telephone: +2050 2262222; FAX: +2050 2263717; e-mail: ahmedshokeir@hotmail.com). For another article on a related topic see page 1161. 0022-5347/08/1803-0961/0 Vol. 180, 961-965, September 2008 THE JOURNAL OF UROLOGY ® Printed in U.S.A. Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION DOI:10.1016/j.juro.2008.05.030 961