Appropriateness Criteria for Ureteral Stent Omission following Ureteroscopy for Urinary Stone Disease

Abstract

Objective: To bridge the gap between evidence and clinical judgement, we defined scenarios appropriate for ureteral stent omission after uncomplicated ureteroscopy (URS) using the RAND/UCLA Appropriateness Method (RAM). We retrospectively assessed rates of appropriate stent omission, with the goal to implement these criteria in clinical practice.

Methods: A panel of 15 urologists from the Michigan Urological Surgery Improvement Collaborative (MUSIC) met to define uncomplicated URS and the variables that influence stent omission decision-making. Over two rounds, they scored clinical scenarios for Appropriateness Criteria (AC) for stent omission based on a combination of variables. AC were defined by median scores: 1 to 3 (inappropriate), 4 to 6 (uncertain), and 7 to 9 (appropriate). Multivariable analysis determined the association of each variable with AC scores. Uncomplicated URS cases in the MUSIC registry were assigned AC scores and stenting rates assessed.

Results: Seven variables affecting stent decision-making were identified. Of the 144 scenarios, 26 (18%) were appropriate, 88 (61%) inappropriate, and 30 (21%) uncertain for stent omission. Most scenarios appropriate for omission were pre-stented (81%). Scenarios with ureteral access sheath or stones >10mm were only appropriate if pre-stented. Stenting rates of 5,181 URS cases correlated with AC scores. Stents were placed in 61% of cases appropriate for omission (practice range, 25% to 98%).

Conclusion: We defined objective variables and AC for stent omission following uncomplicated URS. AC scores correlated with stenting rates but there was substantial practice variation. Our findings demonstrate that the appropriate use of stent omission is underutilized.

Keywords: Quality Improvement; Ureteral Stents; Ureteroscopy; Urinary Stone Disease.

Figure 1.

MUSIC Appropriateness Criteria panelists consensus definition of uncomplicated ureteroscopy.

Figure 2.

Panel consensus definitions of the seven variables that determine appropriateness for ureteral stent omission following uncomplicated ureteroscopy.

Figure 3.

Heatmap of Appropriateness Criteria for ureteral stent omission after URS: 1 - highly inappropriate, to 9 - highly appropriate. Displayed are median scores for all 144 clinical scenarios. UAS +, ureteral access sheath used. UAS -, no ureteral access sheath used. Frag +, yes fragments left behind. Frag -, no fragments left behind.

Figure 4.

Forrest plot of odds ratios of panelist scoring clinical scenario appropriate for stent omission by variable.

Figure 5.

Heatmap of standard deviation of round 2 scores among panelists for all clinical scenarios. Darker blue represents less agreement (higher standard deviation). Shaded squares meet RAM manual criteria for disagreement. UAS +, ureteral access sheath used. UAS -, no ureteral access sheath used. Frag +, yes fragments left behind. Frag -, no fragments left behind.

Figure 6.

A). Ureteral stent placement rates following uncomplicated ureteroscopy in the MUSIC registry by assigned stent omission appropriateness criteria score. Number of stented cases for each score and Spearman’s correlation coefficient (rs) are displayed. B). Rates of ureteral stent placement among MUSIC practices for cases determined to be appropriate. C). Rates of ureteral stent placement among MUSIC practices for cases determined to be inappropriate. Data shown for practices with 10 or more cases in each category.