The Patient Voice - Stent Experiences after Ureteroscopy: Insights from In-Depth Interviews with Participants in the USDRN STENTS Nested Qualitative Cohort Study.

2023

04/2023

1557-900X

PURPOSE: Ureteral stents are commonly used after ureteroscopy and cause significant discomfort, yet qualitative perspectives on patients' stent experiences remain unknown. We describe psychological, functional, and interpersonal effects of post-ureteroscopy stents and whether additional patient-reported assessments may be needed.

MATERIALS AND METHODS: Using a qualitative descriptive study design, we conducted in-depth interviews with a nested cohort of participants in the STudy to Enhance uNderstanding of sTent-associated Symptoms. Participants shared their symptoms with a post-ureteroscopy stent and described symptom bother and impact on daily activities. All interviews were audio-recorded, transcribed, and analyzed using applied thematic analysis. During analysis, participants' experiences with interference in daily activities were categorized into three groups based on their impact: minimal, moderate, and substantial.

RESULTS: All 39 participants experienced pain, although descriptions varied and differentiated between feelings of pain versus discomfort. Almost all experienced urinary symptoms. Only a few reported other physical symptoms, although several psychological aspects were identified. In the areas of sleep, mood, life enjoyment, work, exercise, activities of daily living, driving, childcare, and leisure/social activities, the stent had little impact on daily living among participants placed in the minimal group (n=12) and far greater impact for participants in the substantial group (n=8). For patients in the moderate group (n=19), some daily activities were moderately or substantially affected, while other activities were minimally affected.

CONCLUSIONS: Counseling to better prepare patients for the impact of stent-associated symptoms may help mitigate symptom burden. While existing instruments adequately cover most symptoms, additional assessments for other domains, particularly psychological factors, may be needed.

10.1089/end.2022.0810

J Endourol

37021358

Risk Factors for Increased Stent-Associated Symptoms Following Ureteroscopy for Urinary Stones: Results from STENTS.

2023

101097JU0000000000003183

01/2023

1527-3792

PURPOSE: The STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS) sought to identify risk factors for pain and urinary symptoms, as well as how these symptoms interfere with daily activities after ureteroscopy for stone treatment.

MATERIALS AND METHODS: This prospective observational cohort study enrolled patients aged ≥12 years undergoing ureteroscopy with ureteral stent for stone treatment at 4 clinical centers. Participants reported symptoms at baseline; on postoperative days (POD) 1, 3, 5; at stent removal; and day 30 post-stent removal. Outcomes of pain intensity, pain interference, urinary symptoms, and bother were captured with multiple instruments. Multivariable analyses using mixed-effects linear regression models were identified characteristics associated with increased stent-associated symptoms (SAS).

RESULTS: A total of 424 participants were enrolled. Mean age was 49 years (SD 17); 47% were female. Participants experienced a marked increase in SAS on POD 1. While pain intensity decreased ∼50% from POD 1 to POD 5, interference due to pain remained persistently elevated. In multivariable analysis, older age was associated with lower pain intensity(p=0.004). Having chronic pain conditions(p<0.001), prior severe stent pain(p=0.021), and depressive symptoms at baseline(p<0.001) were each associated with higher pain intensity. Neither sex, stone location, ureteral access sheath use, nor stent characteristics were drivers of SAS.

CONCLUSIONS: In this multicenter cohort, interference persisted even as pain intensity decreased. Patient factors (e.g., age, depression) rather than surgical factors were associated with symptom intensity. These findings provide a foundation for patient-centered care and highlight potential targets for efforts to mitigate the burden of SAS.

10.1097/JU.0000000000003183

J Urol

36648152

Quality of life impact and recovery after ureteroscopy and stent insertion: insights from daily surveys in STENTS.

2022

53

2022 Apr 06

1471-2490

<p><strong>BACKGROUND: </strong>Our objective was to describe day-to-day evolution and variations in patient-reported stent-associated symptoms (SAS) in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS), a prospective multicenter observational cohort study, using multiple instruments with conceptual overlap in various domains.</p>

<p><strong>METHODS: </strong>In a nested cohort of the STENTS study, the initial 40 participants having unilateral ureteroscopy (URS) and stent placement underwent daily assessment of self-reported measures using the Brief Pain Inventory short form, Patient-Reported Outcome Measurement Information System measures for pain severity and pain interference, the Urinary Score of the Ureteral Stent Symptom Questionnaire, and Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index. Pain intensity, pain interference, urinary symptoms, and bother were obtained preoperatively, daily until stent removal, and at postoperative day (POD) 30.</p>

<p><strong>RESULTS: </strong>The median age was 44&nbsp;years (IQR 29,58), and 53% were female. The size of the dominant stone was 7.5&nbsp;mm (IQR 5,11), and 50% were located in the kidney. There was consistency among instruments assessing similar concepts. Pain intensity and urinary symptoms increased from baseline to POD 1 with apparent peaks in the first 2&nbsp;days, remained elevated with stent in situ, and varied widely among individuals. Interference due to pain, and bother due to urinary symptoms, likewise demonstrated high individual variability.</p>

<p><strong>CONCLUSIONS: </strong>This first study investigating daily SAS allows for a more in-depth look at the lived experience after URS and the impact on quality of life. Different instruments measuring pain intensity, pain interference, and urinary symptoms produced consistent assessments of patients' experiences. The overall daily stability of pain and urinary symptoms after URS was also marked by high patient-level variation, suggesting an opportunity to identify characteristics associated with severe SAS after URS.</p>

10.1186/s12894-022-01004-9

BMC Urol

35387623

Prevention of Urinary Stones With Hydration (PUSH): Design and Rationale of a Clinical Trial.

2020

2020 Nov 16

1523-6838

<p><strong>RATIONALE &amp; OBJECTIVE: </strong>Although maintaining high fluid intake is an effective, low-risk intervention for the secondary prevention of urinary stone disease (USD), many stone patients do not increase their fluid intake.</p>

<p><strong>STUDY DESIGN: </strong>We describe the rationale and design of the Prevention of Urinary Stones with Hydration (PUSH) study, a randomized trial of a multi-component behavioral intervention program to increase and maintain high fluid intake. Participants are randomized (1:1 ratio) to intervention or control arm. The target sample size is 1642 participants.</p>

<p><strong>SETTING &amp; PARTICIPANTS: </strong>Adults and adolescents ≥12 years of age with a symptomatic stone history and low urine volume are eligible. Exclusion criteria include infectious or monogenic causes of USD and comorbid conditions precluding increased fluid intake.</p>

<p><strong>INTERVENTIONS: </strong>All participants receive usual care and a smart water bottle and smartphone application. Participants in the intervention arm receive a fluid intake prescription and an adaptive program of behavioral interventions, including financial incentives, structured problem solving, and other automated adherence interventions. Control arm participants receive guideline-based fluid instructions.</p>

<p><strong>OUTCOMES: </strong>The primary endpoint is recurrence of a symptomatic stone over 24-months of follow-up. Secondary endpoints include changes in radiographic stone burden, 24-hour urine output, and urinary symptoms.</p>

<p><strong>LIMITATIONS: </strong>Periodic 24-hour urine volumes may not fully reflect daily behavior.</p>

<p><strong>CONCLUSIONS: </strong>With its highly novel features, the PUSH study will address an important healthcare problem.</p>

10.1053/j.ajkd.2020.09.016

Am J Kidney Dis

33212205

Study to Enhance Understanding of Stent-Associated Symptoms: Rationale and Study Design.

2020

2020 Nov 16

1557-900X

<p>Ureteral stents are commonly employed after ureteroscopy to treat urinary stone disease, but the devices impose a substantial burden of stent-associated symptoms (SAS), including pain and urinary side effects. The NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases) Urinary Stone Disease Research Network sought to develop greater understanding of SAS causes and severity among individuals treated ureteroscopically for ureteral or renal stones. We designed a prospective, observational cohort study comprising adolescents and adults undergoing ureteroscopic intervention for ureteral or renal stones. Participants will undergo detailed symptom assessment using validated questionnaires, a psychosocial assessment, and detailed collection of clinical and operative data. Quantitative sensory testing will be utilized to assess pain sensitization. In addition, a small cohort (∼40 individuals) will participate in semi-structured interviews to develop more granular information regarding their stent symptoms and experience. Biospecimens (blood and urine) will be collected for future research. The Study to Enhance Understanding of sTent-associated Symptoms (STENTS) enrolled its first participant in March 2019 and completed nested qualitative cohort follow-up in August 2019. After a planned pause, enrollment for the main study cohort resumed in September 2019 and is expected to be completed in 2021. STENTS is expected to provide important insights into the mechanisms and risk factors for severe ureteral SAS after ureteroscopy. These insights will generate future investigations to mitigate the burden of SAS among individuals with urinary stone disease.</p>

10.1089/end.2020.0776

J Endourol

33081503

Retreatment after Ureteroscopy and Shockwave Lithotripsy: A Population-Based Comparative Effectiveness Study.

2019

101097JU0000000000000712

2019 Dec 20

1527-3792

<p><strong>PURPOSE: </strong>Shockwave lithotripsy (SWL) and ureteroscopy (URS) are the most commonly performed surgeries for kidney and ureteral stones, but the comparative effectiveness of these interventions at the population level is unclear. The purpose of our study was to compare retreatment for SWL and URS.</p>

<p><strong>MATERIALS AND METHODS: </strong>A retrospective cohort study using all-payer claims data for all patients who underwent SWL or URS from 1997-2016 at 74 hospitals in South Carolina was performed. The primary outcome measure was subsequent SWL or URS within 6 months of initial surgery. Pseudorandomized trials of URS versus SWL were performed for each year, applying propensity scores to balance hospital and patient characteristics. Discrete time failure models were fit using propensity-score weighted logistic regression.</p>

<p><strong>RESULTS: </strong>Overall, 136,152 URS and SWL surgeries were performed on 95,227 unique patients with retreatment representing 9% of all surgeries. 74,251 index surgeries were SWL (59.9%) and 49,743 were URS (40.1%). SWL was associated with a 20% increased odds of retreatment (OR 1.20, 95% CI 1.13, 1.26). The probability of retreatment was 7.5% for URS and 10.4% for SWL. SWL had the greatest risk for retreatment at months 2 (OR 1.85, 95% CI 1.64, 2.10) and 3 (OR 1.76, 95% CI: 1.50, 2.06). Initial SWL patients were more likely to have SWL for retreatment (84.6%) than were patients who had initial URS to have URS (29.3%).</p>

<p><strong>CONCLUSIONS: </strong>Compared to URS, SWL was associated with increased odds of retreatment. These results have implications for shared decision-making and value-based surgical treatment of nephrolithiasis.</p>

10.1097/JU.0000000000000712

J. Urol.

31859598

Urology Consultation and Emergency Department Revisits for Children with Urinary Stone Disease.

2018

180-186

2018 Jul

1527-3792

<p><strong>PURPOSE: </strong>To determine the association between urology consultation and emergency department (ED) revisits for children with urinary stones.</p>

<p><strong>MATERIALS AND METHODS: </strong>This retrospective cohort study included patients ≤18 years-old who presented to an ED in South Carolina with a urinary stone from 1997-2015. The primary exposure was urology consultation during the index ED visit. The primary outcome was a stone-related ED revisit occurring within 180 days of discharge from an index ED visit. Secondary outcomes included CT utilization, inpatient admission, and emergent surgery.</p>

<p><strong>RESULTS: </strong>Among 5,642 index ED visits for acute urinary stones, 11% resulted in at least one stone-related ED revisit within 180 days. Fifty-nine percent of revisits occurred within 30-days of discharge and 39% were due to pain. The odds of ED revisit were highest within the first 48-hours of discharge (odds ratio [OR] 22.6, 95% confidence interval [CI] 18.0-28.5) and rapidly decreased thereafter. Urology consultation was associated with a 37% lower adjusted odds of ED revisit (OR 0.63, 95% CI 0.44-0.90) and 68% lower odds of CT utilization across all ED visits (OR 0.32, 95% CI 0.15-0.69). Among those who revisited, the frequency of pain complaints was 27% among those with urologic consultation at the index visit and 39% among those without.</p>

<p><strong>CONCLUSIONS: </strong>Urology consultation was associated with decreased ED revisits and CT imaging among pediatric patients with urinary stones. Future studies should identify the patients that benefit most from urology consultation and ascertain processes of care that decrease ED revisits among high-risk patients.</p>

10.1016/j.juro.2018.02.069

29474848

Urinary Stone Disease: Advancing Knowledge, Patient Care, and Population Health.

2016

2016 Mar 10

1555-905X

<p>Expanding epidemiologic and physiologic data suggest that urinary stone disease is best conceptualized as a chronic metabolic condition punctuated by symptomatic, preventable stone events. These acute events herald substantial future chronic morbidity, including decreased bone mineral density, cardiovascular disease, and CKD. Urinary stone disease imposes a large and growing public health burden. In the United States, 1 in 11 individuals will experience a urinary stone in their lifetime. Given this high incidence and prevalence, urinary stone disease is one of the most expensive urologic conditions, with health care charges exceeding $10 billion annually. Patient care focuses on management of symptomatic stones rather than prevention; after three decades of innovation, procedural interventions are almost exclusively minimally invasive or noninvasive, and mortality is rare. Despite these advances, the prevalence of stone disease has nearly doubled over the past 15 years, likely secondary to dietary and health trends. The NIDDK recently convened a symposium to assess knowledge and treatment gaps to inform future urinary stone disease research. Reducing the public health burden of urinary stone disease will require key advances in understanding environmental, genetic, and other individual disease determinants; improving secondary prevention; and optimal population health strategies in an increasingly cost-conscious care environment.</p>

10.2215/CJN.13251215

Clin J Am Soc Nephrol

26964844