Prophylactic Ureteric Stents in Renal Transplant Recipients

A Multicenter Randomized Controlled Trial of Early Versus Late Removal

P. Patel; I. Rebollo-Mesa; E. Ryan; M. D. Sinha; S. D. Marks; N. Banga; I. C. Macdougall; M. C. Webb; G. Koffman; J. Olsburgh

Disclosures

American Journal of Transplantation. 2017;17(8):2129-2138. 

In This Article

Abstract and Introduction

Abstract

Prophylactic ureteric stenting in renal transplantation reduces major urological complications; however, morbidity is related to the indwelling duration of a stent. We aimed to determine the optimal duration for stents in this clinical setting. Patients (aged 2–75 years) from six UK hospitals who were undergoing renal transplantation were recruited and randomly assigned to either early stent removal at 5 days (without cystoscopy) or late removal at 6 weeks after transplantation (with cystoscopy). The primary outcome was a composite of stent-related complications defined as pain, visible hematuria, migration, fragmentation, and urinary tract infections (UTIs) within 3 mo of transplantation. Between May 2010 and Nov 2013, we randomly assigned 227 participants, with 205 included in the final analysis of the primary outcome. Stent-related complications were significantly higher in the late versus early stent removal groups (36 of 126 [28.6%] vs. 6 of 79 [7.6%]; p < 0.001). The majority of stent complications consisted of UTIs, with an incidence of 31 of 126 (24.6%) in the late group compared with 6 of 79 (7.6%) in the early group (p = 0.004). We found early stent removal on day 5 significantly reduced stent-related complications and improved quality of life in the first 3 mo after transplantation (ISRCTN09184595).

Introduction

Kidney transplantation is the optimal management for patients with end-stage kidney disease, improving both quality of life (QoL) and life expectancy. It is recognized that kidney transplantation is associated with complications and morbidity related to both surgery and immunosuppression. Major urological complications (MUCs) of ureteric stenosis or urinary leak that can occur in the early posttransplant period contribute to patient morbidity, graft loss, and mortality. These complications mainly arise from the vesicoureteric anastomosis and occur either as a result of technical failure or ureteric ischemia. It has been shown that placement of a ureteric stent across the vesicoureteric anastomosis at the time of transplantation can significantly reduce these complications.[1,2] A recent Cochrane review of seven randomized controlled trials (RCTs) and quasi-RCTs of medium to low quality concluded that routine prophylactic stenting for a minimum of 14 days reduces the incidence of MUCs from 0–17.3% (median 7%) to 0–4% (median 1%).[3] Nevertheless, not all centers routinely stent; some choose to stent selectively when complications may be expected. Stents themselves give rise to potential complications including urinary tract infections (UTIs), visible hematuria, migration, encrustation, and fragmentation as well as potential pain and lower urinary tract symptoms. Stent complications, in particular UTI, not only contribute to patient morbidity but also may compromise allograft function.[4] Consequently, any benefits of prophylactic stenting may be outweighed by their potential complications.

Incidence of stent symptoms and complications appears to be related to the length of time the stents remain in situ.[5–7] Timing of stent removal varies between centers, commonly between 2 and 6 weeks after transplantation. The optimal timing for stent removal is currently not known; however, one randomized trial suggested that stents should be removed within 4 weeks to reduce the incidence of infective complications.[8] At our centers, stents are placed for 6 weeks routinely. An internal audit between 2006 and 2008 found stent complications reported in 15–20% of our renal transplant population.

Placement of a ureteric stent during transplantation is a straightforward procedure and provides a scaffold over which the vesicoureteric anastomosis can heal. Removal of the stent requires an additional procedure, incurring additional health care costs and resources. Most stent removal is performed under local anesthesia with flexible cystoscopy, although a general anesthetic and rigid cystoscopy is used routinely in children and is occasionally needed for some adults.

A novel technique of tying the ureteric stent to the urethral catheter was described in 1998.[9] This allowed the removal of both the stent and the urethral catheter together without recourse to cystoscopy or anesthesia. In the original description of the technique, both the urinary catheter and the attached ureteric stent were removed at a mean of 8 days (range 6–10 days). A retrospective study of this technique in 590 renal transplant recipients, with removal at 10 days (range 8–12 days), found the incidence of urological complications was significantly reduced compared with a nonstented group.[10] This technique enables earlier stent removal without the need for cystoscopy and has the potential to reduce stent-related complications.

We report the results of the randomized Transplant Ureteric Stent Trial (TrUST), designed to determine the benefits of early stent removal in patients managed routinely with prophylactic stenting after renal transplant. We sought to establish whether early ureteric stent removal after renal transplant would decrease stent-related complications and to determine the effects on MUCs, patient acceptability, and health care costs.

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