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JU INSIGHT: Ureteral Strictures Following Ureteroscopy for Kidney Stone Disease: A Population-based Assessment
By: Peter L. Sunaryo, MD; Philip C. May, MD; Sarah K. Holt, PhD; Matthew D. Sorensen, MD, MS; Robert M. Sweet, MD; Jonathan D. Harper, MD | Posted on: 01 Dec 2022
Sunaryo PL, May PC, Holt SK, Sorensen MD, Sweet RM, Harper JD. Ureteral strictures following ureteroscopy for kidney stone disease: a population-based assessment. J Urol. 2022;208(6):1268-1275.
Study Need and Importance
While stone-related ureteral strictures are thought to be rare, they can be morbid. Multiplied by the overall frequency of stones and ureteroscopy (URS), the potential absolute number who suffer ureteral stricture attributed to URS warrants investigation. To our knowledge, there are no published epidemiological data on the rate of ureteral strictures after stone treatment on a large population level. The goal of this study is to characterize the rate of ureteral strictures after URS for stones and identify associated risk factors.
What We Found
A total of 329,776 patients undergoing URS, shock wave lithotripsy (SWL), or SWL+URS between 2008 and 2019 were included. The utilization of URS over SWL has steadily increased from 38% in 2008 to 58% in 2019. Stricture developed in 2.9% of patients after URS, 1.5% after SWL, and 2.6% after SWL+URS. In the multivariable model, rates of stricture were 1.7-fold higher after URS vs SWL (see Table). Preoperative hydronephrosis, age, prior stones/intervention, and concurrent kidney and ureteral stones were associated with increased risk. Of those with strictures after URS, 35% were managed with drainage alone, 21% had endoscopic intervention, 4.8% required reconstructive surgery, and 1.7% underwent nephrectomy.
Limitations
Greater granularity related to patient- or surgery-specific characteristics could provide additional insight related to risk factors. Data on secondary procedures for treatment of strictures may be limited. Though SWL patients were used to represent those with kidney stone disease alone, there could be injury imparted from treatment in some of these cases.
Table. Multivariable Model of Risk Factors for Ureteral Stricture
| Adjusted odds ratio (95% CI) | P value | |
|---|---|---|
| Treatment type | ||
| SWL | Reference | |
| URS | 1.71 (1.62-1.82) | < .0001 |
| SWL+URS | 1.21 (1.11-1.32) | < .0001 |
| Location | ||
| Kidney | Reference | |
| Ureteral | 0.78 (0.73-0.84) | < .0001 |
| Both | 1.77 (1.67-1.88) | < .0001 |
| Unknown | 1.45 (1.17-1.80) | < .001 |
| Preoperative hydronephrosis | 1.44 (1.37-1.51) | < .0001 |
| Prior stone history | 1.13 (1.07-1.20) | < .0001 |
| Prior treatment | ||
| None | Reference | |
| URS and SWL | 1.96 (1.69-2.28) | < .0001 |
| SWL only | 1.07 (0.95-1.19) | .2 |
| URS only | 1.45 (1.29-1.63) | < .0001 |
| Age by decade | 1.10 (1.08-1.13) | < .0001 |
| Year by decade | 1.00 (0.93-1.07) | .9 |
| Abbreviations: CI, confidence interval; SWL, shock wave lithotripsy; URS, ureteroscopy. | ||
Interpretation for Patient Care
Ureteral stricture rate following URS was significantly higher than the rate attributable to stone disease alone. Our findings may help with counseling patients for management of kidney stone disease. Further research is required to determine ways to minimize this risk associated with URS, especially as we see new technology incorporated into practice.
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