Ureteric stenting after uncomplicated ureteroscopy: a systematic review of surgeons’ motivations and patient experiences

Despite clear guidance from the European Association of Urology (EAU) and the National Institute for Health and Care Excellence (NICE) advising against routine ureteric stenting after uncomplicated ureteroscopy (URS), stents are still widely used [1, 2]. Surveys report that up to 92% of urologists continue to insert stents in these circumstances, indicating a significant discrepancy between guidelines and real-world practice [3]. Stents are considered necessary in situations involving ureteric injury, obstruction, severe oedema, or sepsis risk. However, their use following an otherwise uncomplicated URS remains a matter of debate. Defining ‘uncomplicated URS’ is therefore crucial. Hiller et al. [4] proposed consensus criteria: unilateral, retrograde URS in patients with American Society of Anesthesiologists (ASA) Physical Status Classification System score <3, no anatomical abnormality, no active infection, no trauma or perforation, and no need for second-look procedures. Despite this, practice variation persists. A Cochrane review found evidence on stenting vs omission was of very low to low-moderate certainty, with conflicting results regarding analgesic use, unplanned hospital visits, and quality of life [5]. Some studies suggest omitting stents reduces emergency visits and improves recovery. Yet, Bhatt et al. [3] showed that most urologists still use stents in the majority of uncomplicated cases, highlighting a gap between evidence and behaviour. We systematically review surgeons’ motivations for stenting after uncomplicated URS and examine patient experiences of living with and removing stents. The review protocol was registered prospectively on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023456075). The ‘Enhancing transparency in reporting the synthesis of qualitative research’ (ENTREQ) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed [6, 7]. A structured PubMed/MEDLINE search was performed to August 2023, supplemented by hand-searching reference lists. Titles and abstracts were screened independently by three reviewers, with disagreements resolved by consensus. Data were extracted and synthesised narratively. Risk of bias in qualitative studies was assessed using the Critical Appraisal Skills Programme (CASP) checklist. Included studies examined surgeon motivations for stenting after uncomplicated URS using qualitative or survey methods or reported patient experiences with indwelling ureteric stents. Eligible designs included randomised trials, surveys, interviews, and observational studies. Reviews, non-human studies, children aged <12 years, and purely quantitative papers on stenting rates without explanatory data were excluded. In our results, four studies met the inclusion criteria: one international surgeon survey and three qualitative studies examining patient experiences. Through which two themes emerged. Theme 1: surgeons’ motivations for stenting outlined in one study: Bhatt et al. [3] conducted a global survey of 468 urologists, with 303 full responses, on post-URS drainage practices. Although guidelines discourage routine stenting, 67% of respondents placed stents in at least half of uncomplicated cases, and a subset always used stents in these cases. Key motivations included: concern for ureteric oedema (77%), fear of residual fragments (43%), case complexity (90%) and procedure duration (46%), and past experience with complications and adherence to traditional teaching (21–24%). Interestingly, >70% reported they would prefer a stent for themselves or a family member after URS, reflecting risk aversion and prioritisation of perceived safety. Despite acknowledging weak evidence, 81% expressed willingness to join a randomised controlled trial (RCT) comparing outcomes in stented vs non-stented patients. Theme 2: patient experiences with stents outlined by three studies: these are the three studies from the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS) cohort evaluated patient perspectives [8-10]. Symptom trajectory: Harper et al. [8] documented daily postoperative diaries from 40 patients with stents after URS. Pain intensity and urinary bother were highest in the early days, although pain persisted longer than urinary symptoms. Variability was substantial: some described tolerable discomfort, while others reported severe, disabling pain. Functional and psychological impact: Corneli et al. [9] and Dombeck et al. [10] used interviews to describe the broad impact of stents. Moderate cases reported disturbed mood, difficulty at work, and lifestyle restrictions, while the substantial group described insomnia, depression, inability to perform daily activities, and withdrawal from social/sexual activities. Removal anxiety was common, with some patients describing it as worse than stone colic, while others reported reassurance when supported by staff. Together, these studies reveal the significant psychological and functional burden of stents, contrasting with surgeons’ preference for routine use. This review highlights a striking disconnect: surgeons frequently stent uncomplicated URS to mitigate perceived risks, while patients bear the symptomatic and psychological burden. Current EAU and NICE guidelines recommend against routine stenting in uncomplicated cases [1, 2]. Yet, surveys reveal that most urologists continue the practice, often out of concern for rare complications rather than evidence-based necessity. This suggests that surgeon decision-making is guided by risk aversion and anecdotal experience, rather than published data. The patient burden is considerable, with up to 80% of patients reporting reduced quality of life with indwelling stents, including pain, urinary frequency, haematuria, and sexual dysfunction. Psychological consequences include anxiety, depression, and reduced social participation. Removal adds another layer of distress [9]. From health economic impact, urolithiasis management in the UK costs up to £324 million annually, with routine stenting adding further expense. A cost-analysis confirmed that selective omission is more economical than routine stenting [11]. The persistence of stenting despite evidence and guidelines reflects broader challenges in adhering to clinical practice guidelines. Surgeons’ willingness to participate in trials indicates recognition that high-quality evidence could drive change. At the same time, better communication with patients about risks, symptoms, and removal could improve experiences and potentially reduce unnecessary stenting. Regarding limitations, our review included only four eligible studies, which limited its generalisability. Patient experiences were all drawn from one study cohort. Nevertheless, the synthesis reveals consistent themes: surgeons prioritise safety, while patients face disproportionate morbidity. In conclusion, routine stenting after uncomplicated URS persists despite guideline recommendations against it. Concerns for oedema and obstruction drive surgeon decision making, while patients experience significant pain, urinary bother, psychological distress, and impaired quality of life. Bridging this gap requires more substantial evidence from RCTs, enhanced patient education, and updated guidelines with more explicit definitions. Aligning surgical decision-making with patient-centred outcomes could reduce unnecessary morbidity and healthcare costs. None declared. No ethical approval was required as no patient and/or public were involved in the development of the research aims, methodology and the distribution of this review. Nikita Bhatt and Kevin Gerard Byrnes conceptualised the study. Protocol drafted by Israa Hussein, search strategy developed and drafted by Lyn Mair and Israa Hussein. Israa Hussein, Alexander BCD Ng and Ranil Johann Boaz conducted the abstract and full text review. Israa Hussein, Alexander BCD Ng and Ranil Johann Boaz contributed to data extraction and synthesis. Israa Hussein and Simona Ippoliti contributed to writing and editing the final manuscript. With thanks to Lyn Mair, Clinical Liaison Librarian, for assistance in conducting the literature searches and Medical Subject Headings (MeSH) terms.