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.
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.
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%).
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.
Urology practice. 2022 Mar 03 [Epub]
Spencer C Hiller, Stephanie Daignault-Newton, Ivan Rakic, Susan Linsell, Bronson Conrado, S Mohammad Jafri, Ronald Rubenstein, Mazen Abdelhady, C Peter Fischer, Elena Gimenez, Richard Sarle, William W Roberts, Conrad Maitland, Rafid Yousif, Robert Elgin, Laris Galejs, Jeremy Konheim, David Leavitt, Eric Stockall, J Rene Fontera, J Stuart Wolf, John M Hollingsworth, Casey A Dauw, Khurshid R Ghani, Michigan Urological Surgery Improvement Collaborative
University of Michigan Department of Urology, Ann Arbor MI., Wayne State University School of Medicine, Detroit MI., William Beaumont Hospital Department of Urology, Royal Oak MI., Detroit Medical Center, Department of Urology, Detroit MI., Associates in Urology, Chelsea MI., IHA-Urology, Ypsilanti MI., Sparrow Medical Group, Lansing MI., Sherwood Medical Center, Detroit MI., Lansing Institute of Urology, Lansing MI., Michigan Institute of Urology, St Claire Shores MI., Michigan Institute of Urology, Howell MI., Vattikuti Urology Institute, Henry Ford Health System, Detroit MI., Capital Urological Associates, Okemos MI., Michigan Institute of Urology, Troy MI., Dell Medical School University of Texas, Austin TX.