Prophylactic Ureteral Stent Placement vs No Ureteral Stent Placement During Open Colectomy

The prophylactic placement of ureteral stents during colorectal surgery may facilitate ureteral identification and/or recognition of injury.^1,2 However, reports have cautioned against routine use of ureteral stents owing to the potential of iatrogenic injury during insertion and postoperative complications, including stenosis and infection.^3,4 At present, no evidence-based guidelines exist regarding indications for ureteral stenting during colorectal surgery. This cohort study compares the outcomes of open colectomy with ureteral stenting with the outcomes of open colectomy without ureteral stenting.

A cohort of 374 consecutive patients who underwent open colectomy at a tertiary care center between January 1, 2011, and September 30, 2016, was evaluated. Demographic and laboratory data and data on comorbidities, procedural indications, and operative details were collected. Patients with a planned ureteral resection to achieve a negative oncologic margin were excluded (n = 3). The Charlson comorbidity index with age adjustment, a validated measure of perioperative mortality, was calculated and used for risk stratification.⁵ The primary outcomes of ureteral injury were compared between patients who underwent colectomy with ureteral stent placement and patients who underwent colectomy without ureteral stent placement. Secondary outcomes of length of stay, in-hospital mortality, procedural duration, and new-onset urinary complication (hematuria, dysuria, or urinary tract infection in the postoperative period) were also compared. The Yale Human Investigation Committee approved this study with waiver of patient consent. Multivariable logistic regression models were created to analyze factors associated with each outcome by a backward elimination technique with a significance threshold for inclusion in the final model of P < .10. Use of ureteral stents was forced into all models to determine the association of prophylactic stenting with each outcome. All analyses were performed using SAS, version 9.4 (SAS Institute Inc). P < .05 was considered significant.

The demographic and clinical characteristics of the patients with stent placement (n = 322) and the patients without stent placement (n = 52) were similar, although more emergency colectomies were performed without stenting (204 [63.4%] vs 13 [25.0%]; P < .001) (Table 1). Prophylactic ureteral stents were placed in 52 patients (13.9%) undergoing colectomy for indications including anticipated dense adhesions (31 [59.6%]), known urologic pathological conditions (6 [11.5%]) or surgeon preference (15 [28.8%]). One ureteral injury occurred (0.3%) in a patient who had stents placed. This injury was noted after the procedure, and the patient required reoperation. When accounting for the age-adjusted Charlson comorbidity index, procedural indication, sex, body mass index, emergency vs elective status, and extent of resection (right, left, or total colectomy), we found that there was no difference in mean (SD) hospital length of stay (11.8 [9.5] days vs 13.1 [13.3] days; P = .49) and in-hospital mortality (1 [1.9%] vs 34 [10.6%]; P = .25) between patients with stenting and patients without stenting (Table 2). There was a trend toward longer operative times with stenting (an additional 55 minutes; P = .16), which may in part be due to the time needed to place stents. Patients who received stents had higher rates of new-onset urinary complications (odds ratio, 4.29; 95% CI, 1.83-10.06; P < .001).

In this cohort of 374 patients undergoing open colectomy, prophylactic ureteral stenting was associated with increased operative times and increased rates of postoperative urinary complications. Although the overall rate of ureteral injury was low (0.3%) compared with other studies, the only injury occurred in a patient who received prophylactic ureteral stents.

Injury to the ureter is a serious complication in colorectal surgery, with a reported incidence of 0.2% to 7.6%, and the use of prophylactic ureteric stents remains controversial.⁶ Although some surgeons advocate for routine use of stents, others use stents selectively in patients with large tumors, prior radiotherapy or pelvic surgery, chronic inflammatory disease, or urologic pathologic conditions.^1,2,6 Although the advantage of using stents to aid in ureteral identification and facilitate early repair of ureteral injuries is theorized, this study suggests that these benefits may not be realized for patients undergoing open colectomy. In addition, the risk of postoperative infection and the resultant increase in hospital costs without significant benefit may call into question the practice of routine stent use. This study may be underpowered, given the rare occurrence of ureteral injury. Prospective multi-institutional studies should be conducted to fully assess the utility of ureteral stents in open colectomies and to aid in the establishment of practice guidelines.

Corresponding Author: Kevin Y. Pei, MD, Department of Surgery, Yale University School of Medicine, 330 Cedar St, Boardman Bldg, Ste 310, New Haven, CT 06519 (kevin.pei@yale.edu).

Published Online: September 27, 2017. doi:10.1001/jamasurg.2017.3477

Author Contributions: Drs Merola and Pei had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Merola, Resio, Davis, Pei.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Merola, Arnold, Ibarra, Pei.

Critical revision of the manuscript for important intellectual content: Merola, Arnold, Luks, Resio, Davis, Pei.

Statistical analysis: Merola, Arnold, Luks.

Administrative, technical, or material support: Resio.

Study supervision: Davis, Pei.

Conflict of Interest Disclosures: None reported.

Meeting Presentation: This paper was presented at the Annual Meeting of the Association of VA Surgeons; May 7, 2017; Houston, Texas.