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Routine intraoperative ureteric stenting for kidney transplant recipients

  1. Colin H Wilson1,*,
  2. David A Rix2,
  3. Derek M Manas3

Editorial Group: Cochrane Kidney and Transplant Group

Published Online: 17 JUN 2013

DOI: 10.1002/14651858.CD004925.pub3


How to Cite

Wilson CH, Rix DA, Manas DM. Routine intraoperative ureteric stenting for kidney transplant recipients. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD004925. DOI: 10.1002/14651858.CD004925.pub3.

Author Information

  1. 1

    The Freeman Hospital, Transplant Surgery, Newcastle-upon-Tyne, Tyne and Wear, UK

  2. 2

    The Freeman Hospital, Urology and Transplantation, Newcastle-upon-Tyne, UK

  3. 3

    The Freeman Hospital, The Liver/Renal Unit, Newcastle upon Tyne, UK

*Colin H Wilson, Transplant Surgery, The Freeman Hospital, Freeman Road, High Heaton, Newcastle-upon-Tyne, Tyne and Wear, NE7 7DN, UK. colinwilson2206@gmail.com.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 17 JUN 2013

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Characteristics of included studies [ordered by study ID]

MethodsStudy: RCT/ quasi-RCT
Blinding: No
Intention-to-treat: No
Complete follow-up: No
Follow-up: 2-10 months


Participants84 consecutive transplants

Treatment group
Number of patients: 35

Control group
Number of patients: 37
Excluded: "previous pelvic operations and bladder problems".


InterventionsTreatment group
Stent calibre: NR
Stent length, type: 16 cm, double J
Stent duration: 6-8 weeks
Antibiotic regimen: NR
Anastomosis: L-G
Surgeon: same team


Outcomes
  1. MUCs: Haematuria: unclear (no definitions given - "frank haematuria")
  2. Graft loss
  3. Death
  4. Encrustation
  5. Expulsion


NotesDeaths and rejection excluded
Donor source: NR


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear


MethodsStudy: RCT/ quasi-RCT
Blinding: No
Intention-to-treat: Yes
Complete follow-up: Yes
Follow-up: up to 3 years


Participants194 consecutive cadaveric, live, kidney-liver-pancreas

Treatment group
Number of patients: 97

Control group
Number of patients: 97

No exclusions.


InterventionsTreatment group
Stent calibre: 7 Fr
Stent length, type: 16 cm, double J
Stent duration: 1 month
Antibiotic regimen: cotrimoxazole 480 mg od
Anastomosis: L-G and L-P
Surgeon: many surgeons

Prophylactic antibiotics for 48 hrs followed by cotrimoxazole.


Outcomes
  1. MUCs: UTI: positive culture > 105
  2. MUCs: Haematuria, no definition
  3. Death
  4. Breakage
  5. Migration/malpositioning
  6. Encrustation
  7. Expulsion


Notes2 graft losses to stents.
Donor source: cadaveric, live, multiorgan


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear


Methodsquasi-RCT
Blinding: No
Intention-to-treat: Yes
Complete follow-up: Yes
Follow-up: 3 months


Participants331 consecutive patients

Treatment group
Number of patients: 143

Control group
Number of patients: 137

Excluded: "abnormal urinary tract, small calibre ureter, multiorgan, paediatric".


InterventionsTreatment group
Stent calibre: 6 Fr
Stent length, type: 12 cm, double J
Stent duration: 7-10 days
Antibiotic regimen: Cotrimoxazole 480 mg, 3 doses/week
Anastomosis: L-G
Surgeon: Many surgeons


Outcomes
  1. MUCs: Urine culture > 105 bacteria plus fever/symptoms
  2. MUCs: Haematuria, no definition
  3. Irritative symptoms
  4. Breakage
  5. Migration/malpositioning
  6. Encrustation
  7. Expulsion


NotesDonor source: Cadaveric and live
Used an intraoperative stent for all anastomoses
Attending surgeon altered treatment designation


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)High riskC - Inadequate


MethodsStudy: RCT
Blinding: No
Intention-to-treat: Yes
Complete follow-up: One patient lost
Follow-up: 6 months


Participants108 consecutive live-related

Treatment group
Number of patients: 54

Control group
Number of patients: 54


InterventionsTreatment group
Stent calibre: NR
Stent length, type: 24 cm, double J
Stent duration: 14-21 days
Antibiotic regimen: Oral cephalexin 5 days
Anastomosis: L-G and L-P
Surgeon: Same team


Outcomes
  1. MUCs: UTI: on culture. Weekly urine culture
  2. Graft loss
  3. Death
  4. Irritative symptoms
  5. Breakage
  6. Migration/malpositioning
  7. Encrustation
  8. Expulsion


NotesDonor source: live only


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Low riskA - Adequate


MethodsStudy: RCT
Blinding: No
Intention-to-treat: Yes
Complete follow-up: Yes
Follow-up: 16 to 32 months


Participants100 consecutive transplants

Treatment group
Number of patients: 57

Control group
Number of patients: 43

No exclusions.


InterventionsTreatment group
Stent calibre: 6 Fr
Stent length, type: 16 cm, double J
Stent duration: 4 weeks
Antibiotic regimen: Cotrimoxazole 960 mg alternate days
Anastomosis: L-G
Surgeon: Same team


Outcomes
  1. MUCs: UTI: "positive culture". Urine culture reported separate to UTI
  2. MUCs: Haematuria, no definition
  3. Graft loss
  4. Death
  5. Irritative symptoms
  6. Breakage
  7. Migration/malpositioning
  8. Encrustation
  9. Forgotten
  10. Expulsion


NotesDonor source: live only


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Low riskA - Adequate


MethodsStudy: RCT
Blinding: No
Intention-to-treat: No
Complete follow-up: Yes
Follow-up: 7 to 16 months


ParticipantsTreatment group
Number of patients: 50

Control group
Number of patients: 50

Exclusions: "intra-operative technical difficulties", "abnormal urinary tracts", aged less than 10 years; No laparoscopic


InterventionsTreatment group
Stent calibre: 5 Fr
Stent length, type: 20 cm, multilength
Stent duration: 14 days
Antibiotic regimen: IV amoxicillin 5 days
Anastomosis: L-G
Surgeon: Same team


Outcomes
  1. MUCs: UTI: positive urine culture bacteria > 105 (every other day)
  2. MUCs: Haematuria (definition - change in heparin dose required to control)
  3. Graft loss
  4. Death
  5. Breakage
  6. Migration/malpositioning
  7. Encrustation
  8. Forgotten
  9. Expulsion


NotesDonor source: Live only


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Low riskA - Adequate


MethodsStudy: RCT
Allocation concealment: Opaque envelopes pre-randomised
Blinding: No
Intention-to-treat: Yes
Complete follow-up: Yes
Follow-up: 3 months


ParticipantsTreatment group
Number of patients: 150

Control group
Number of patients: 150

No exclusions


InterventionsTreatment group
Stent calibre: 7 Fr
Stent length, type: 12 cm, double J
Stent duration: 3 months
Antibiotic regimen: Cotrimoxazole 960 mg alternate days
Anastomosis: L-G
Surgeon: Many surgeons


Outcomes
  1. MUCs: UTI diagnosed clinically (fever/symptoms) and confirmed on microscopy
  2. MUCs: Haematuria (definition - catheter clot obstruction requiring washout)
  3. Breakage
  4. Migration/malpositioning
  5. Encrustation
  6. Expulsion


NotesDonor source: live and cadaveric, multiorgan, no paediatric


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Low riskA - Adequate

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Anil 2012Prospective RCT, both arms received stents- no control group without stents.

Asadpour 2011Prospective RCT comparing length of ureteric spatulation.

Battaglia 2005RCT, but compared patients receiving different types of stent.

Dadkhah 2010Comparison of anterior and posterolateral ureteroneocystostomy techniques.

Gunawansa 2011RCT, early versus late stent removal.

Huang 2012Early versus late stent removal.

Moray 2005"RCT" however on contacting author used a historical cohort of patients "randomly chosen" as controls for the treatment group.

Parapiboon 2012Early versus late stent removal

Simpson 2006Not RCT

Tavakoli 2007Prospective RCT. However, intention-to-treat analysis and randomisation flawed. "Clerical error" in randomisation process led to significantly different numbers from protocol in each group. 11/112 (c.10%) of patients in No Stent group removed from analysis. Contacted author team and asked for details of these patient outcomes; unfortunately data not available - therefore the study had to excluded.

TrUST Study 2011Early versus late stent removal

Valentini 2004Not RCT

Zargar 2005RCT, compared two different surgical techniques (Taguchi versus, modified Lich-Gregoir) rather than stents.

 
Comparison 1. Stent versus no stent

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Urine leak and obstruction7Risk Ratio (M-H, Random, 95% CI)Subtotals only

   1.1 Combined - urine leak and obstruction
71154Risk Ratio (M-H, Random, 95% CI)0.24 [0.07, 0.77]

   1.2 Urine leak
71154Risk Ratio (M-H, Random, 95% CI)0.29 [0.12, 0.74]

   1.3 Ureteric obstruction
71154Risk Ratio (M-H, Random, 95% CI)0.27 [0.09, 0.81]

 2 Surgeon number MUC subgroup analysis7Risk Ratio (M-H, Random, 95% CI)Subtotals only

   2.1 Same surgeon
4380Risk Ratio (M-H, Random, 95% CI)0.39 [0.08, 1.86]

   2.2 Many surgeons
3774Risk Ratio (M-H, Random, 95% CI)0.13 [0.01, 1.16]

 3 UTI71154Risk Ratio (M-H, Random, 95% CI)1.49 [1.04, 2.14]

 4 UTI incidence by diagnostic criteria6Risk Ratio (M-H, Random, 95% CI)Subtotals only

   4.1 Culture only
3402Risk Ratio (M-H, Random, 95% CI)1.44 [0.85, 2.43]

   4.2 Culture plus symptoms/ signs
3680Risk Ratio (M-H, Random, 95% CI)1.23 [0.80, 1.90]

 5 UTI incidence by antibiotic regime6Risk Ratio (M-H, Random, 95% CI)Subtotals only

   5.1 Co-trimoxazole 480mg od (960 mg alt. days)
3594Risk Ratio (M-H, Random, 95% CI)0.97 [0.71, 1.33]

   5.2 Other regime
3488Risk Ratio (M-H, Random, 95% CI)1.78 [1.44, 2.21]

 6 Haematuria61046Risk Ratio (M-H, Random, 95% CI)0.74 [0.37, 1.48]

 
Table 1. Incidence of major urological complications (MUCs)

StudyEvents (stent)Patients (stent)Incidence (stent)Events (no stent)Patients (no stent)Incidence (no stent)

Bassiri 19950350%3378.1%

Benoit 19961971.0%109710.3%

Dominguez 200051433.5%91376.6%

Guleria 19981541.9%3545.6%

Kumar 19980570%3437.0%

Osman 20042504%0500%

Pleass 199501500%2615017.3%

Total9586median 1.0 (0 - 4.0)54568median 7.0 (0 - 17.3)

 
Table 2. Influence of surgeon number on incidence of MUCs

Comparison/ StudyEvents (stent)Patients (stent)Incidence (stent)Events (no stent)Patients (no stent)Incidence (no stent)

Bassiri 19950350%3378.1%

Guleria 19981541.9%3545.6%

Kumar 19980570%3437.0%

Osman 20042504%0500%

Same surgeon (4 studies, 380 patients)3196median 0.95 (0 - 4.0)9184median 6.3 (0 - 8.1)


Benoit 19961971.0%109710.3%

Dominguez 200051433.5%91376.6%

Pleass 199501500%2615017.3%

Many surgeons (3 studies, 774 patients)6390median 1.0 (0 - 3.5)45384median 10.3 (6.6 - 17.3)

 
Table 3. Graft loss and patient mortality

StudyFollow-upStent related lossStent related deathsOverall mortalityOverall graft loss

Bassiri 19952-10 months005 patients total either lost their graft or died (6.5%)-

Benoit 1996Up to 3 years207.8%NR

Dominguez 20003 months00NRNR

Guleria 19986 months0001.9%

Kumar 199816-32 months0093% 1 year survival89% 1 year survival

Osman 20047-16 months000.8%0.8%

Pleass 19953 months00NRNR

 NR - not reported
 
Table 4. Incidence of haematuria

StudyStentNo Stent

Bassiri 19955.7%0%

Benoit 1996NR1 ureter clot retention (1.0%)

Dominguez 2000NR1 ureter clot retention (0.7%)

Guleria 1998NRNR

Kumar 19980%0%

Osman 20046.0%2.0%

Pleass 19956.0%10.0%

 NR - not reported
 
Table 5. Other stent-related complications

StudyIrritative symptomsBreakageMigration/malpositioningEncrustationForgottenExpulsion

Bassiri 1995NRNRNR5.7%NR0

Benoit 1996NR2.1%1.0%2.1%NR1.0%

Dominguez 20000%0 %0 %0 %NR0%

Guleria 19985.6%0 %7.4%0 %NR7.4%

Kumar 19985.3%0 %0 %0 %7.0 %0

Osman 2004NR0 %4.0%0 %00

Pleass 1995NR0 %"+""++"NR> 1 patient

 NR - not reported