How Does RIRS Impact on Stent-Related Symptoms? Insights from a Prospective Observational Study by EAU-YAU Endourology and Urolithiasis Working Group

How Does RIRS Impact on Stent-Related Symptoms? 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Insights from a Prospective Observational Study by EAU-YAU Endourology and Urolithiasis Working Group Arman Tsaturyan, Etienne Xavier Keller, Stefano Mancon, Hayk Grigoryan, and 17 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7152265/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Nov, 2025 Read the published version in World Journal of Urology → Version 1 posted 12 You are reading this latest preprint version Abstract Purpose To assess the perception and severity of stent-related symptoms (SRS) in patients undergoing retrograde intrarenal surgery (RIRS). Material and methods A prospective observational study was performed including patients with single or multiple renal stones undergoing ureteral stenting and scheduled for a definitive RIRS. SRS were evaluated at 3 timepoints: pre-operatively on the day of RIRS, as well as on the 1st and 7th postoperative day following RIRS. Bladder pain, back pain, hematuria, urgency, frequency, nocturia, and urge incontinence were evaluated using a visual analog scoring (VAS) system. Results A total of 57 patients were included. The patients reported a significant rise in back pain at day 1 after RIRS (mean rank 2.25 on a scale of 0 to 5) compared to preoperative scores (2.06), with a significant decrease at day 7 following RIRS (1.68) (p = 0.003). A similar pattern was observed for bladder pain, frequency and urge incontinence (all p < 0.001). As for urgency and nocturia, these SRS steadily decreased from baseline to day 1, and in turn from day 1 to day 7 after RIRS (p = 0.004 and p = 0.003, respectively). Hematuria was the only SRS which did not show any significant differences over the 3 evaluated timepoints. Conclusion RIRS temporarily increases certain SRS, particularly pain and urinary discomfort within the first 24 hours postoperatively. These symptoms tend to improve by the 7th postoperative day, suggesting that surgery itself may contribute to the early symptom burden but ultimately facilitates recovery. Stent-related symptoms ureteral stenting RIRS ureteroscopy lithotripsy Figures Figure 1 Introduction Ureteral stent placement is one of the most common procedures performed in urological practice, with the double-J stent being the most frequently used type ( 1 , 2 ). Given that it is a thin, mobile tube positioned within the urinary tract, its presence often leads to discomfort that can significantly affect a patient’s quality of life to varying degrees. Over the years, several advancements have been made to improve both the placement techniques and the design of these medical devices ( 3 – 5 ). Despite these advancements stent-related symptoms (SRS) continue to be one of the main drawbacks of this procedure. Bosio et al. reported that pain interfered with daily life in 92.2% of patients, and that general health, work performance, and sexual function were also negatively affected in younger patients ( 6 ). In another study, the ureteral stent discomfort ranged from 1.1% − 88% of cases ( 5 ) Despite these findings, there remains an unmet need for studies focusing on the evaluation of SRS before and after endoscopic stone treatment, particularly in cases where is stent is placed prior to the surgical intervention. Therefore, the aim of the present study was to assess the perception and severity of SRS in patients undergoing retrograde intrarenal surgery (RIRS). Material and methods A prospective observational study was performed in the Department of Urology, Yerevan State Medical University, Armenia. The study was approved by the local Ethics Committee. Written consent was obtained from all patients. Patients who present with single or multiple renal stones undergoing ureteral stenting and scheduled for a RIRS were considered eligible. Patients’ demographic and preoperative stone-related data collection at single institution from January 2023 till November 2024 was performed. All procedures were performed by 2 senior urologists with a working experience of more than 7 years. As a department’s standard of care, ureteral pre-stenting was performed 7–10 days prior to RIRS using a 6Fr x 26cm double J ureteral stent (DJ). Similarly, a postoperative ureteral stenting of 7 days was usually recommended to patients undergoing RIRS, with a longer dwelling time depending on the surgeon’s decision and clinical reasons. All patients received an informational leaflet about possible SRS. Inclusion criteria were all patients > 18 years of age planned for RIRS because of renal stones (single or multiple) having undergone pre-stenting with 6Fr x 26cm double J ureteral stent. Exclusion criteria were concomitant ipsilateral ureteral stone at pre-operative imaging, incomplete coiling of the proximal and distal ends of the DJ stents at the time of pre-stenting, preoperative or postoperative use of stents of other diameter and length, pregnancy, urinary tract infection following DJ placement before definitive RIRS, significant post-voiding residual volume (defined 100ml), concomitant diagnosis of benign prostate obstruction with severe -to-moderate symptoms based on the international prostate symptom score, patients on chronic long term prescription of opiates or NSAIDs (rheumatological, oncological patient and etc ), and prolonged prestenting > 10 days and patients who developed complications following prestenting or after RIRS Surgical procedure Pre-stenting Rigid cystoscopy under intravenous anesthesia with propofol was performed. The ureteral orifice of the affected kidney was cannulated and a hydrophilic guidewire (Bioteq Blackwire, Bioteque corporation, Taipei, Taiwan). A ureteral catheter was advanced, the guidewire was removed and a selective urine culture was obtained. The guidewire was then reinserted and ureteral catheter was removed. A 6Fr 26cm ureteral stent made of Tecoflex® material (Marflow AG, Zurich, Switzerland) was inserted and advanced under endoscopic vision and Xray guidance. The guidewire was then removed, and coiling of the distal end of the DJ stent was confirmed fluoroscopically. In some cases, gentle manipulation of the DJ stent via an endoscopic grasper was performed to achieve coiling of the proximal end of the DJ stent fluoroscopic images. At the end of the procedure the bladder was emptied and left with no urethral catheter. RIRS RIRS was performed 7–10 days following stent placement under general anesthesia. In supine lithotomy position, rigid cystoscopy was performed and the distal end of the preplaced stent was withdrawn. A hydrophylic guidewire (Bioteq Blackwire, Bioteque corporation, Taipei, Taiwan) was introduced and advanced to the kidney through the lumen of the ureteral stent when possible. After removing the stent, a dual lumen catheter was inserted and second safety guidewire introduced into the kidney. Then the dual lumen catheter was removed and rigid ureteroscopy was performed. Thereafter a 12/14Fr ureteral access sheath (UAS) (Flexor, Cook Medical, Indiana, USA) was introduced. In case of resistance 11/13Fr UAS (Flexor, Cook Medical, Indiana, USA) was preferred. Disposable 7.5Fr (Guangzhou Red Pine Medical Instrument, Guangzhou, China) or reusable 8.5Fr digital flexible ureteroscopes (Storz Flex XC, Karl Storz Se & Co. Tuttlingen, Germany) were used. The choice of the type of ureteroscope was left up to surgeon’s choice, and depending on availability. The irrigation was achieved via manual pumping (Irriflow, Cook Medical, Indiana, USA). Lithotripsy was performed using Quanta 150W Holmium laser using either 200 or 272 fibers (Quanta Systems, Samarate, Italy). The preferred laser settings were 0.5-1.0J x 10-20Hz with Virtual basket pulse modulation depending on the stone type, size and location. To extract big fragments, flexible baskets (NGage or NCircle, Cook Medical, Indiana, USA) were used. At the end of the procedure a 6Fr 26cm ureteral stent was placed. A bladder catheter was routinely placed in all patients and removed after few hours postoperatively on the day of surgery. Two i/v infusion of antibiotic regimens (Moxifloxacin 400mg or Ceftriaxone 1g) were routinely prescribed on the day of the RIRS prior to the procedure and the following morning. A single intramuscular (IM) injection of diclofenac 75 mg on the night after the surgery was the standard use NSAID. The patients were discharged on the next day if no adverse effects were reported. A 500ml 0.9% NaCl was administered in the morning before the discharge were asked to drink at least 1500-2000ml water daily if no cardiac comorbidities were present. Evaluated parameters and outcome variables For each patient, SRS were evaluated at 3 timepoints: pre-operatively on the day of RIRS, as well as on the 1st and 7th postoperative day (with stent still in place) following the RIRS. SRS including bladder pain, back pain, hematuria, urgency, frequency, nocturia, and urge incontinence using a visual analog scoring (VAS) system were evaluated. Based on the received score, symptoms were graded as no (0), mild ( 1 – 2 ) or strong to severe ( 3 – 5 ) ( 7 ). Additionally, the patients were asked to report improvement of SRS, if applicable. The evaluated variables and patients’ characteristics included gender, age, body mass index (BMI), location of the stone, stone size (maximal diameter on CT with crossection) position of the proximal loop of the DJ stent in the kidney, position of the distal loop of the DJ stent in the bladder ( 8 ), use of analgesia, encrustation on the stent, operative time, size of the used UAS, type of the flexible scope. Statistical analysis was performed using SPSS v29 software (IBM Statistics, NY, USA). Continuous and categorical variables were reported using medians and interquartile ranges and percentages, respectively. Friedman’s test was used to compare SRS at the 3 evaluated timepoints (matched groups comparisons). Two-tailed p ≤ 0.05 was considered statistically significant. Results A total of 57 patients with a median age of 47 years and a median stone size of 18 mm were included. Stones were located in renal pelvis in 25 patients (44%), whereas multiple stones were present in 7 patients (12%). The tip of the DJ stent was found to be located either in the renal pelvis (67%) or the upper calyx (33%). In almost half of the cases (49%) the crossing of the bladder midline of the distal end of DJ stent was reported (Supplementary Table 1). In the evaluation of SRS, the patients reported a significant rise in back pain at day 1 after RIRS (mean rank 2.25 on a scale of 0 to 5) compared to preoperatively before RIRS (2.06), with a significant decrease of back pain at day 7 after RIRS (1.68) (p = 0.003) (Fig. 1 ; Table 2 ). This translates to 25% of patients with strong-to-severe back pain preoperatively, 39% at day 1 and 7% at day 7 after RIRS. A similar pattern with increase of symptoms on day 1 after RIRS and gradual reduction by day 7, was observed for bladder pain, frequency and urge incontinence (all p < 0.001). Strong to severe bladder pain, frequency and urge incontinence were reported in 30, 60 and 25% respectively before surgery., 61, 81, and 39%, and 19, 35, and 5% of patients reported respectively each the SRS on the 1st and 7th day following RIRS. As for urgency and nocturia, these SRS steadily decreased from baseline to day 1, and in turn from day 1 to day 7 after RIRS (p = 0.004 and p = 0.003, respectively). Hematuria was the only SRS which did not show any significant differences over the 3 evaluated timepoints. Table 2 Patient reported outcomes Preoperative before RIRS Day 1 after RIRS Day 7 after RIRS p-value Back pain mean rank* median (IQR) 2.06 2.0 (0.5–2.5) 2.25 2.0 (1.0–3.0) 1.68 1.0 (0.0–2.5) 0.003* Back pain, n (%) None to mild (0,1,2) Strong to severe ( 3 , 4 , 5 ) 43 (75%) 14 (25%) 35 (61%) 22 (39%) 53 (93%) 4 (7%) Bladder pain mean rank* median (IQR) 1.88 2.0 (0.5–3.0) 2.49 3.0 (2.0–3.0) 1.63 1.0 (0.0–2.5) < 0.001* Bladder pain, n (%) None to mild (0,1,2) Strong to severe ( 3 , 4 , 5 ) 40 (70%) 17 (30%) 23 (40%) 34 (60%) 43 (75%) 14 (25%) Frequency mean rank* median (IQR) 2.11 3.0 (2.0–3.0) 2.34 3.0 (3.0–3.0) 1.54 2.0 (1.0–3.0) < 0.001* Frequency, n (%) None to mild (0,1,2) Strong to severe ( 3 , 4 , 5 ) 22 (39%) 35 (61%) 11 (19%) 46 (81%) 35 (61%) 22 (39%) Urgency mean rank* median (IQR) 2.32 2.0 (1.0–3.0) 1.86 1.0 (0.0–2.0) 1.82 1.0 (0.0–2.0) 0.004* Urgency, n (%) None to mild (0,1,2) Strong to severe ( 3 , 4 , 5 ) 33 (58%) 24 (42%) 45 (79%) 12 (21%) 45 (79%) 12 (21%) Nocturia mean rank* median (IQR) 2.26 2.0 (2.0–3.0) 2.09 2.0 (2.0–3.0) 1.65 1.0 (0.0–2.0) 0.001* Nocturia, n (%) None to mild (0,1,2) Strong to severe ( 3 , 4 , 5 ) 29 (51%) 28 (49%) 40 (70%) 17 (30%) 46 (81%) 11 (19%) Urge incontinence mean rank* median (IQR) 1.97 1.0 (0.0–2.0) 2.46 2.0 (1.0–3.0) 1.57 1.0 (0.0–2.0) < 0.001* Urge incontinence, n (%) None to mild (0,1,2) Strong to severe ( 3 , 4 , 5 ) 46 (81%) 11 (19%) 37 (65%) 20 (35%) 54 (95%) 3 (5%) Hematuria mean rank* median (IQR) 1.90 1.0 (0.0–2.0) 2.14 2.0 (1.0–2.0) 1.96 1.0 (0.0–2.0) 0.315* Hematuria, n (%) None to mild (0,1,2) Strong to severe ( 3 , 4 , 5 ) 50 (88%) 7 (12%) 46 (81%) 11 (19%) 47 (83%) 10 (18%) * Friedman’s test Discussion This prospective observational study aimed to evaluate how patients with urolithiasis perceive and experience SRS preceding and following RIRS in cohort of patients with planned preoperative ureteral stenting. Our results showed a noticeable increase in back pain, bladder discomfort, urinary frequency, and urge incontinence on the first postoperative day compared to preoperative levels. However, by the seventh day, these symptoms had significantly decreased. In addition, urgency and nocturia improved already by day one after the procedure. Interestingly, there was a big discrepancy between the urgency and urge incontinence in the reported outcomes, partially attributable to false interpretation of the questions by the patients. Double-J stents are known to influence patients’ overall well-being and quality of life. To better assess these symptoms, Joshi and colleagues developed the Ureteral Stent Symptom Questionnaire (USSQ), a standardized instrument that has helped streamline research on stent-related complications ( 9 ). They reported that 80% of patients with a DJ stent experienced at least one stent related symptom. Pain, voiding issues, and sexual dysfunction are among the most frequently reported. Despite its utility, the USSQ has not been fully validated in all languages, leading some centers to rely on more general or outdated scales, as it has been used in the present study. While it is often used in studies comparing stent types or evaluating medications, its use in large clinical trials is still limited. Although SRS have been widely studied, their exact causes remain uncertain. One proposed mechanism involves urinary reflux during detrusor contractions, which increases intravesical pressure and may contribute to back pain ( 10 , 11 ). Additionally, these contractions can cause the stent to move within the urinary tract, irritating the mucosa and resulting in pain or irritative symptoms ( 12 , 13 ). Accuracy of stent placement also thought to influence symptom severity. Studies have indicated that a proximal coil lodged in a renal calyx or a distal coil extending across the bladder midline may be associated with worse pain and urinary symptoms ( 7 , 14 , 15 ). Some findings suggest that proper stent sizing, avoiding midline crossing, reduces symptom burden. For instance, Taguchi et al. found that patients with midline-crossing stents experienced significantly worse SRS, including urgency, frequency, nocturia, and urge incontinence ( 16 ). In our study, 49% of patients had a stent crossing the bladder midline. However, other research, like that by Abt et al., found no association between stent position and morbidity ( 17 ). Overall, the evidence remains inconclusive. There is also limited data on how the physical properties of the stent might influence symptom severity ( 18 – 20 ). While several studies have investigated stent materials, no consistent link has been established between the material type and symptom severity ( 21 , 22 ). Bosio et al. compared loop-tail and standard DJ stents after flexible ureteroscopy and found no significant differences in symptoms two days or four weeks post-insertion ( 23 ). Urgency and frequency are generally thought to result from mechanical irritation of the bladder wall by the distal stent loop. These symptoms often ease at night, likely due to reduced physical activity and stent movement ( 24 , 25 ). Although the precise pathophysiology behind SRS remains partially unclear, it is likely of multifactorial etiology resulting from both direct mechanical contact and increased pressure within the urinary tract due to reflux. Pharmacological strategies for managing SRS have gained attention in recent years, but little has been done to evaluate the effects of surgery alone. Bosio and colleagues examined DJ-related symptoms after semirigid and flexible RIRS using the USSQ, confirming that DJ stents significantly impair quality of life. They emphasized the importance of patient counseling and minimizing stent dwell time ( 6 ). Our findings suggest that while RIRS initially intensifies certain symptoms, such as back and bladder pain, frequency, and urge incontinence, these effects are temporary. The procedure itself likely contributes to short-term irritation through mechanical manipulation, use of access sheaths, and laser lithotripsy, potentially causing edema, transient uroepithelial irritation, and elevated intrarenal pressure ( 26 ). However, symptom improvement by day seven suggests that these effects are reversible. The primary drivers of discomfort may stem more from the stone disease itself than the presence of the stent alone. The removal of stones likely helps reduce symptom burden over time. This trend was especially clear for urgency and nocturia, which improved immediately post-RIRS. Few studies have explored how surgery alone, separate from stenting, affects symptom progression. Our findings provide evidence that while RIRS may temporarily worsen SRS, it ultimately contributes to their resolution within a short time frame. This study has several limitations that should be acknowledged. First, the sample size was relatively small and limited to a single center, which may restrict the broader applicability of the results. Second, the absence of a control group without surgery or stenting makes it difficult to isolate the specific role of RIRS in symptom variation. Third, we used a visual analog scale instead of a fully validated instrument like the USSQ due to unavailability of this instrument in the native language of patients, potentially limiting comparison with other research. Symptom reports were subjective and could have been influenced by individual pain thresholds or emotional states, which we did not formally assess. Moreover, we did not perform detailed subgroup analyses based on variables such as stent type, positioning, or sheath size. Lastly, data on the precise day of symptom improvement were missing in many patients, reducing the specificity of our findings regarding recovery timelines. Conclusion In this prospective study, we observed that RIRS temporarily contributes in increasing certain SRS, particularly pain and urinary discomfort, within the first 24 hours postoperatively. However, these symptoms tend to significantly improve by the seventh postoperative day, suggesting that surgery itself may contribute to the early symptom burden but ultimately facilitates recovery. Our findings highlight the dynamic nature of stent-related symptoms in the perioperative period and suggest that counseling patients about this expected symptom could help manage postoperative expectations and improve satisfaction. Further larger, multicenter studies using validated assessment tools are needed to confirm these results and better understand the factors influencing symptom trajectories after RIRS. Declarations Funding: Not applicable Conflicts of interest: The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. Ethical standards: The study has been carried out in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The study was approved by the local Ethical Committee. Consent to participate: A written consent was obtained from each patient. Acknowledgment: Not applicable Authors’ contribution Study conception - A.T., E.X.K., E.S., V.D.C., F.E., B.B.M., P.J.J., L.T., G.M., A.P. Study design - A.T., E.V., A.P. Data Collection - A.T., H.G., Manuscript drafting - A.P., E.V., S.M Manuscript editing and critical revision - E.S., V.D.C., F.E., B.B.M., P.J.J., L.T., G.M., A.S.D.R., A.O., M.C., V.J., A.T., M.B., R.E., L.N., A.P. References Marmar JL. The management of ureteral obstruction with silicone rubber splint catheters. 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Supplementary Files Suppl.Table1.docx Cite Share Download PDF Status: Published Journal Publication published 10 Nov, 2025 Read the published version in World Journal of Urology → Version 1 posted Editorial decision: Revision requested 15 Sep, 2025 Reviews received at journal 13 Sep, 2025 Reviewers agreed at journal 03 Sep, 2025 Reviewers agreed at journal 23 Aug, 2025 Reviews received at journal 12 Aug, 2025 Reviews received at journal 09 Aug, 2025 Reviewers agreed at journal 31 Jul, 2025 Reviewers agreed at journal 29 Jul, 2025 Reviewers invited by journal 29 Jul, 2025 Editor assigned by journal 28 Jul, 2025 Submission checks completed at journal 28 Jul, 2025 First submitted to journal 17 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Medicine","correspondingAuthor":false,"prefix":"","firstName":"Tarik","middleName":"Emre","lastName":"Sener","suffix":""},{"id":492353508,"identity":"24a18a71-4c13-4919-b1e6-3f60f2a11059","order_by":5,"name":"Eugenio Ventimiglia","email":"","orcid":"","institution":"Uppsala University","correspondingAuthor":false,"prefix":"","firstName":"Eugenio","middleName":"","lastName":"Ventimiglia","suffix":""},{"id":492353509,"identity":"bccbf198-7929-46cc-bdbe-46ea84189c79","order_by":6,"name":"Francesco Esperto","email":"","orcid":"","institution":"Campus Biomedico University of Rome","correspondingAuthor":false,"prefix":"","firstName":"Francesco","middleName":"","lastName":"Esperto","suffix":""},{"id":492353510,"identity":"a3d564e7-5d8d-435b-9943-7e65be53959d","order_by":7,"name":"Vincent De Coninck","email":"","orcid":"","institution":"AZ Klina","correspondingAuthor":false,"prefix":"","firstName":"Vincent","middleName":"","lastName":"De 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Thessaloniki","correspondingAuthor":false,"prefix":"","firstName":"Ioannis","middleName":"","lastName":"Mykoniatis","suffix":""},{"id":492353517,"identity":"0aef3bf3-3442-40cf-987c-b7d99438f966","order_by":11,"name":"Alba Sierra Del Rio","email":"","orcid":"","institution":"Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Alba","middleName":"Sierra Del","lastName":"Rio","suffix":""},{"id":492353520,"identity":"690d85d2-6468-48c3-920d-fb80526065c6","order_by":12,"name":"Lazaros Tzelves","email":"","orcid":"","institution":"National and Kapodistrian University of Athens","correspondingAuthor":false,"prefix":"","firstName":"Lazaros","middleName":"","lastName":"Tzelves","suffix":""},{"id":492353523,"identity":"1a8b1baa-abdf-4f7f-9084-33740958b277","order_by":13,"name":"Alberto Olivero","email":"","orcid":"","institution":"ASST Grande Ospedale Metropolitano Niguarda","correspondingAuthor":false,"prefix":"","firstName":"Alberto","middleName":"","lastName":"Olivero","suffix":""},{"id":492353524,"identity":"d6f4b2e6-c7e8-43a2-9eae-4c494e5b5a21","order_by":14,"name":"Mariela Corrales","email":"","orcid":"","institution":"Sorbonne University GRC Urolithiasis No. 20 Tenon Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mariela","middleName":"","lastName":"Corrales","suffix":""},{"id":492353527,"identity":"78fa990b-685b-4ae9-9387-09431fca7a39","order_by":15,"name":"Victoria Jahrreiss","email":"","orcid":"","institution":"Medical University of Vienna","correspondingAuthor":false,"prefix":"","firstName":"Victoria","middleName":"","lastName":"Jahrreiss","suffix":""},{"id":492353530,"identity":"b8752280-5609-48a7-b00a-539546f07433","order_by":16,"name":"Ali Talyshinskii","email":"","orcid":"","institution":"Astana Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Talyshinskii","suffix":""},{"id":492353532,"identity":"0f0bc543-4f46-4df0-b367-ef68fabc6c4c","order_by":17,"name":"Matthias Boeykens","email":"","orcid":"","institution":"University Hospital Ghent","correspondingAuthor":false,"prefix":"","firstName":"Matthias","middleName":"","lastName":"Boeykens","suffix":""},{"id":492353534,"identity":"d2e40635-b805-4a01-8388-ee9c55a3eb8c","order_by":18,"name":"Rifat Ergul","email":"","orcid":"","institution":"Istanbul University","correspondingAuthor":false,"prefix":"","firstName":"Rifat","middleName":"","lastName":"Ergul","suffix":""},{"id":492353535,"identity":"ab529149-d3f9-401e-88c8-6b05328d83f1","order_by":19,"name":"Lukasz Nowak","email":"","orcid":"","institution":"University Centre of Excellence in Urology, Wroclaw Medical University","correspondingAuthor":false,"prefix":"","firstName":"Lukasz","middleName":"","lastName":"Nowak","suffix":""},{"id":492353537,"identity":"a7bd8904-7fa6-4005-a0c9-0c988d57984b","order_by":20,"name":"Amelia Pietropaolo","email":"","orcid":"","institution":"University Hospital Southampton NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Amelia","middleName":"","lastName":"Pietropaolo","suffix":""}],"badges":[],"createdAt":"2025-07-17 21:23:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7152265/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7152265/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00345-025-06007-3","type":"published","date":"2025-11-10T15:57:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88003738,"identity":"49913875-06ee-4aa9-9ead-f1ade786daa3","added_by":"auto","created_at":"2025-07-31 10:33:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":188317,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDepiction of severity of stent-related symptoms\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1SRS.png","url":"https://assets-eu.researchsquare.com/files/rs-7152265/v1/1e8882996e26f9d96786207a.png"},{"id":96105863,"identity":"6f25749c-e6d5-4024-b687-2865776a7523","added_by":"auto","created_at":"2025-11-17 16:12:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":877315,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7152265/v1/4d9f1051-ab19-4d53-b08e-a7df1519b82e.pdf"},{"id":88003734,"identity":"cd2e4e43-8491-4d6e-91f0-c52eae36d8ca","added_by":"auto","created_at":"2025-07-31 10:33:44","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":14012,"visible":true,"origin":"","legend":"","description":"","filename":"Suppl.Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7152265/v1/ec7f921d05547e39de69e545.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"How Does RIRS Impact on Stent-Related Symptoms? Insights from a Prospective Observational Study by EAU-YAU Endourology and Urolithiasis Working Group","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUreteral stent placement is one of the most common procedures performed in urological practice, with the double-J stent being the most frequently used type (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Given that it is a thin, mobile tube positioned within the urinary tract, its presence often leads to discomfort that can significantly affect a patient\u0026rsquo;s quality of life to varying degrees. Over the years, several advancements have been made to improve both the placement techniques and the design of these medical devices (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite these advancements stent-related symptoms (SRS) continue to be one of the main drawbacks of this procedure. Bosio et al. reported that pain interfered with daily life in 92.2% of patients, and that general health, work performance, and sexual function were also negatively affected in younger patients (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In another study, the ureteral stent discomfort ranged from 1.1% \u0026minus;\u0026thinsp;88% of cases (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Despite these findings, there remains an unmet need for studies focusing on the evaluation of SRS before and after endoscopic stone treatment, particularly in cases where is stent is placed prior to the surgical intervention. Therefore, the aim of the present study was to assess the perception and severity of SRS in patients undergoing retrograde intrarenal surgery (RIRS).\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eA prospective observational study was performed in the Department of Urology, Yerevan State Medical University, Armenia. The study was approved by the local Ethics Committee. Written consent was obtained from all patients. Patients who present with single or multiple renal stones undergoing ureteral stenting and scheduled for a RIRS were considered eligible. Patients\u0026rsquo; demographic and preoperative stone-related data collection at single institution from January 2023 till November 2024 was performed. All procedures were performed by 2 senior urologists with a working experience of more than 7 years. As a department\u0026rsquo;s standard of care, ureteral pre-stenting was performed 7\u0026ndash;10 days prior to RIRS using a 6Fr x 26cm double J ureteral stent (DJ). Similarly, a postoperative ureteral stenting of 7 days was usually recommended to patients undergoing RIRS, with a longer dwelling time depending on the surgeon\u0026rsquo;s decision and clinical reasons. All patients received an informational leaflet about possible SRS.\u003c/p\u003e\u003cp\u003eInclusion criteria were all patients\u0026thinsp;\u0026gt;\u0026thinsp;18 years of age planned for RIRS because of renal stones (single or multiple) having undergone pre-stenting with 6Fr x 26cm double J ureteral stent. Exclusion criteria were concomitant ipsilateral ureteral stone at pre-operative imaging, incomplete coiling of the proximal and distal ends of the DJ stents at the time of pre-stenting, preoperative or postoperative use of stents of other diameter and length, pregnancy, urinary tract infection following DJ placement before definitive RIRS, significant post-voiding residual volume (defined 100ml), concomitant diagnosis of benign prostate obstruction with severe -to-moderate symptoms based on the international prostate symptom score, patients on chronic long term prescription of opiates or NSAIDs (rheumatological, oncological patient and etc ), and prolonged prestenting\u0026thinsp;\u0026gt;\u0026thinsp;10 days and patients who developed complications following prestenting or after RIRS\u003c/p\u003e\u003cp\u003e\u003cb\u003eSurgical procedure\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003ePre-stenting\u003c/span\u003e\u003c/p\u003e\u003cp\u003eRigid cystoscopy under intravenous anesthesia with propofol was performed. The ureteral orifice of the affected kidney was cannulated and a hydrophilic guidewire (Bioteq Blackwire, Bioteque corporation, Taipei, Taiwan). A ureteral catheter was advanced, the guidewire was removed and a selective urine culture was obtained. The guidewire was then reinserted and ureteral catheter was removed. A 6Fr 26cm ureteral stent made of Tecoflex\u0026reg; material (Marflow AG, Zurich, Switzerland) was inserted and advanced under endoscopic vision and Xray guidance. The guidewire was then removed, and coiling of the distal end of the DJ stent was confirmed fluoroscopically. In some cases, gentle manipulation of the DJ stent via an endoscopic grasper was performed to achieve coiling of the proximal end of the DJ stent fluoroscopic images. At the end of the procedure the bladder was emptied and left with no urethral catheter.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eRIRS\u003c/span\u003e\u003c/p\u003e\u003cp\u003eRIRS was performed 7\u0026ndash;10 days following stent placement under general anesthesia. In supine lithotomy position, rigid cystoscopy was performed and the distal end of the preplaced stent was withdrawn. A hydrophylic guidewire (Bioteq Blackwire, Bioteque corporation, Taipei, Taiwan) was introduced and advanced to the kidney through the lumen of the ureteral stent when possible. After removing the stent, a dual lumen catheter was inserted and second safety guidewire introduced into the kidney. Then the dual lumen catheter was removed and rigid ureteroscopy was performed. Thereafter a 12/14Fr ureteral access sheath (UAS) (Flexor, Cook Medical, Indiana, USA) was introduced. In case of resistance 11/13Fr UAS (Flexor, Cook Medical, Indiana, USA) was preferred. Disposable 7.5Fr (Guangzhou Red Pine Medical Instrument, Guangzhou, China) or reusable 8.5Fr digital flexible ureteroscopes (Storz Flex XC, Karl Storz Se \u0026amp; Co. Tuttlingen, Germany) were used. The choice of the type of ureteroscope was left up to surgeon\u0026rsquo;s choice, and depending on availability. The irrigation was achieved via manual pumping (Irriflow, Cook Medical, Indiana, USA). Lithotripsy was performed using Quanta 150W Holmium laser using either 200 or 272 fibers (Quanta Systems, Samarate, Italy). The preferred laser settings were 0.5-1.0J x 10-20Hz with Virtual basket pulse modulation depending on the stone type, size and location. To extract big fragments, flexible baskets (NGage or NCircle, Cook Medical, Indiana, USA) were used. At the end of the procedure a 6Fr 26cm ureteral stent was placed.\u003c/p\u003e\u003cp\u003eA bladder catheter was routinely placed in all patients and removed after few hours postoperatively on the day of surgery. Two i/v infusion of antibiotic regimens (Moxifloxacin 400mg or Ceftriaxone 1g) were routinely prescribed on the day of the RIRS prior to the procedure and the following morning. A single intramuscular (IM) injection of diclofenac 75 mg on the night after the surgery was the standard use NSAID. The patients were discharged on the next day if no adverse effects were reported. A 500ml 0.9% NaCl was administered in the morning before the discharge were asked to drink at least 1500-2000ml water daily if no cardiac comorbidities were present.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEvaluated parameters and outcome variables\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFor each patient, SRS were evaluated at 3 timepoints: pre-operatively on the day of RIRS, as well as on the 1st and 7th postoperative day (with stent still in place) following the RIRS. SRS including bladder pain, back pain, hematuria, urgency, frequency, nocturia, and urge incontinence using a visual analog scoring (VAS) system were evaluated. Based on the received score, symptoms were graded as no (0), mild (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) or strong to severe (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Additionally, the patients were asked to report improvement of SRS, if applicable.\u003c/p\u003e\u003cp\u003eThe evaluated variables and patients\u0026rsquo; characteristics included gender, age, body mass index (BMI), location of the stone, stone size (maximal diameter on CT with crossection) position of the proximal loop of the DJ stent in the kidney, position of the distal loop of the DJ stent in the bladder (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), use of analgesia, encrustation on the stent, operative time, size of the used UAS, type of the flexible scope.\u003c/p\u003e\u003cp\u003eStatistical analysis was performed using SPSS v29 software (IBM Statistics, NY, USA). Continuous and categorical variables were reported using medians and interquartile ranges and percentages, respectively. Friedman\u0026rsquo;s test was used to compare SRS at the 3 evaluated timepoints (matched groups comparisons). Two-tailed p\u0026thinsp;\u0026le;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 57 patients with a median age of 47 years and a median stone size of 18 mm were included. Stones were located in renal pelvis in 25 patients (44%), whereas multiple stones were present in 7 patients (12%). The tip of the DJ stent was found to be located either in the renal pelvis (67%) or the upper calyx (33%). In almost half of the cases (49%) the crossing of the bladder midline of the distal end of DJ stent was reported (Supplementary Table\u0026nbsp;1).\u003c/p\u003e\u003cp\u003eIn the evaluation of SRS, the patients reported a significant rise in back pain at day 1 after RIRS (mean rank 2.25 on a scale of 0 to 5) compared to preoperatively before RIRS (2.06), with a significant decrease of back pain at day 7 after RIRS (1.68) (p\u0026thinsp;=\u0026thinsp;0.003) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e; Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This translates to 25% of patients with strong-to-severe back pain preoperatively, 39% at day 1 and 7% at day 7 after RIRS. A similar pattern with increase of symptoms on day 1 after RIRS and gradual reduction by day 7, was observed for bladder pain, frequency and urge incontinence (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Strong to severe bladder pain, frequency and urge incontinence were reported in 30, 60 and 25% respectively before surgery., 61, 81, and 39%, and 19, 35, and 5% of patients reported respectively each the SRS on the 1st and 7th day following RIRS. As for urgency and nocturia, these SRS steadily decreased from baseline to day 1, and in turn from day 1 to day 7 after RIRS (p\u0026thinsp;=\u0026thinsp;0.004 and p\u0026thinsp;=\u0026thinsp;0.003, respectively). Hematuria was the only SRS which did not show any significant differences over the 3 evaluated timepoints.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient reported outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePreoperative before RIRS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDay 1 after RIRS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDay 7 after RIRS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBack pain\u003c/p\u003e\u003cp\u003e\u003cem\u003emean rank*\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003emedian (IQR)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.06\u003c/p\u003e\u003cp\u003e2.0 (0.5\u0026ndash;2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.25\u003c/p\u003e\u003cp\u003e2.0 (1.0\u0026ndash;3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.68\u003c/p\u003e\u003cp\u003e1.0 (0.0\u0026ndash;2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.003*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBack pain, n (%)\u003c/p\u003e\u003cp\u003e\u003cem\u003eNone to mild (0,1,2)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eStrong to severe\u003c/em\u003e (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43 (75%)\u003c/p\u003e\u003cp\u003e14 (25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (61%)\u003c/p\u003e\u003cp\u003e22 (39%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e53 (93%)\u003c/p\u003e\u003cp\u003e4 (7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBladder pain\u003c/p\u003e\u003cp\u003e\u003cem\u003emean rank*\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003emedian (IQR)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.88\u003c/p\u003e\u003cp\u003e2.0 (0.5\u0026ndash;3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.49\u003c/p\u003e\u003cp\u003e3.0 (2.0\u0026ndash;3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.63\u003c/p\u003e\u003cp\u003e1.0 (0.0\u0026ndash;2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBladder pain, n (%)\u003c/p\u003e\u003cp\u003e\u003cem\u003eNone to mild (0,1,2)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eStrong to severe\u003c/em\u003e (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40 (70%)\u003c/p\u003e\u003cp\u003e17 (30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23 (40%)\u003c/p\u003e\u003cp\u003e34 (60%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e43 (75%)\u003c/p\u003e\u003cp\u003e14 (25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003cp\u003e\u003cem\u003emean rank*\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003emedian (IQR)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.11\u003c/p\u003e\u003cp\u003e3.0 (2.0\u0026ndash;3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.34\u003c/p\u003e\u003cp\u003e3.0 (3.0\u0026ndash;3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.54\u003c/p\u003e\u003cp\u003e2.0 (1.0\u0026ndash;3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFrequency, n (%)\u003c/p\u003e\u003cp\u003e\u003cem\u003eNone to mild (0,1,2)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eStrong to severe\u003c/em\u003e (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 (39%)\u003c/p\u003e\u003cp\u003e35 (61%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (19%)\u003c/p\u003e\u003cp\u003e46 (81%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35 (61%)\u003c/p\u003e\u003cp\u003e22 (39%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrgency\u003c/p\u003e\u003cp\u003e\u003cem\u003emean rank*\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003emedian (IQR)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.32\u003c/p\u003e\u003cp\u003e2.0 (1.0\u0026ndash;3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.86\u003c/p\u003e\u003cp\u003e1.0 (0.0\u0026ndash;2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.82\u003c/p\u003e\u003cp\u003e1.0 (0.0\u0026ndash;2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.004*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrgency, n (%)\u003c/p\u003e\u003cp\u003e\u003cem\u003eNone to mild (0,1,2)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eStrong to severe\u003c/em\u003e (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33 (58%)\u003c/p\u003e\u003cp\u003e24 (42%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45 (79%)\u003c/p\u003e\u003cp\u003e12 (21%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45 (79%)\u003c/p\u003e\u003cp\u003e12 (21%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNocturia\u003c/p\u003e\u003cp\u003e\u003cem\u003emean rank*\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003emedian (IQR)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.26\u003c/p\u003e\u003cp\u003e2.0 (2.0\u0026ndash;3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.09\u003c/p\u003e\u003cp\u003e2.0 (2.0\u0026ndash;3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.65\u003c/p\u003e\u003cp\u003e1.0 (0.0\u0026ndash;2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.001*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNocturia, n (%)\u003c/p\u003e\u003cp\u003e\u003cem\u003eNone to mild (0,1,2)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eStrong to severe\u003c/em\u003e (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29 (51%)\u003c/p\u003e\u003cp\u003e28 (49%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40 (70%)\u003c/p\u003e\u003cp\u003e17 (30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46 (81%)\u003c/p\u003e\u003cp\u003e11 (19%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrge incontinence\u003c/p\u003e\u003cp\u003e\u003cem\u003emean rank*\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003emedian (IQR)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.97\u003c/p\u003e\u003cp\u003e1.0 (0.0\u0026ndash;2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.46\u003c/p\u003e\u003cp\u003e2.0 (1.0\u0026ndash;3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.57\u003c/p\u003e\u003cp\u003e1.0 (0.0\u0026ndash;2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrge incontinence, n (%)\u003c/p\u003e\u003cp\u003e\u003cem\u003eNone to mild (0,1,2)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eStrong to severe\u003c/em\u003e (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46 (81%)\u003c/p\u003e\u003cp\u003e11 (19%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37 (65%)\u003c/p\u003e\u003cp\u003e20 (35%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e54 (95%)\u003c/p\u003e\u003cp\u003e3 (5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHematuria\u003c/p\u003e\u003cp\u003e\u003cem\u003emean rank*\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003emedian (IQR)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.90\u003c/p\u003e\u003cp\u003e1.0 (0.0\u0026ndash;2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.14\u003c/p\u003e\u003cp\u003e2.0 (1.0\u0026ndash;2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.96\u003c/p\u003e\u003cp\u003e1.0 (0.0\u0026ndash;2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.315*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHematuria, n (%)\u003c/p\u003e\u003cp\u003e\u003cem\u003eNone to mild (0,1,2)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eStrong to severe\u003c/em\u003e (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50 (88%)\u003c/p\u003e\u003cp\u003e7 (12%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46 (81%)\u003c/p\u003e\u003cp\u003e11 (19%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e47 (83%)\u003c/p\u003e\u003cp\u003e10 (18%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e* Friedman\u0026rsquo;s test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis prospective observational study aimed to evaluate how patients with urolithiasis perceive and experience SRS preceding and following RIRS in cohort of patients with planned preoperative ureteral stenting. Our results showed a noticeable increase in back pain, bladder discomfort, urinary frequency, and urge incontinence on the first postoperative day compared to preoperative levels. However, by the seventh day, these symptoms had significantly decreased. In addition, urgency and nocturia improved already by day one after the procedure. Interestingly, there was a big discrepancy between the urgency and urge incontinence in the reported outcomes, partially attributable to false interpretation of the questions by the patients.\u003c/p\u003e\u003cp\u003eDouble-J stents are known to influence patients\u0026rsquo; overall well-being and quality of life. To better assess these symptoms, Joshi and colleagues developed the Ureteral Stent Symptom Questionnaire (USSQ), a standardized instrument that has helped streamline research on stent-related complications (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). They reported that 80% of patients with a DJ stent experienced at least one stent related symptom. Pain, voiding issues, and sexual dysfunction are among the most frequently reported. Despite its utility, the USSQ has not been fully validated in all languages, leading some centers to rely on more general or outdated scales, as it has been used in the present study. While it is often used in studies comparing stent types or evaluating medications, its use in large clinical trials is still limited.\u003c/p\u003e\u003cp\u003eAlthough SRS have been widely studied, their exact causes remain uncertain. One proposed mechanism involves urinary reflux during detrusor contractions, which increases intravesical pressure and may contribute to back pain (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Additionally, these contractions can cause the stent to move within the urinary tract, irritating the mucosa and resulting in pain or irritative symptoms (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAccuracy of stent placement also thought to influence symptom severity. Studies have indicated that a proximal coil lodged in a renal calyx or a distal coil extending across the bladder midline may be associated with worse pain and urinary symptoms (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Some findings suggest that proper stent sizing, avoiding midline crossing, reduces symptom burden. For instance, Taguchi et al. found that patients with midline-crossing stents experienced significantly worse SRS, including urgency, frequency, nocturia, and urge incontinence (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In our study, 49% of patients had a stent crossing the bladder midline. However, other research, like that by Abt et al., found no association between stent position and morbidity (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Overall, the evidence remains inconclusive.\u003c/p\u003e\u003cp\u003eThere is also limited data on how the physical properties of the stent might influence symptom severity (\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). While several studies have investigated stent materials, no consistent link has been established between the material type and symptom severity (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Bosio et al. compared loop-tail and standard DJ stents after flexible ureteroscopy and found no significant differences in symptoms two days or four weeks post-insertion (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eUrgency and frequency are generally thought to result from mechanical irritation of the bladder wall by the distal stent loop. These symptoms often ease at night, likely due to reduced physical activity and stent movement (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Although the precise pathophysiology behind SRS remains partially unclear, it is likely of multifactorial etiology resulting from both direct mechanical contact and increased pressure within the urinary tract due to reflux.\u003c/p\u003e\u003cp\u003ePharmacological strategies for managing SRS have gained attention in recent years, but little has been done to evaluate the effects of surgery alone. Bosio and colleagues examined DJ-related symptoms after semirigid and flexible RIRS using the USSQ, confirming that DJ stents significantly impair quality of life. They emphasized the importance of patient counseling and minimizing stent dwell time (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Our findings suggest that while RIRS initially intensifies certain symptoms, such as back and bladder pain, frequency, and urge incontinence, these effects are temporary. The procedure itself likely contributes to short-term irritation through mechanical manipulation, use of access sheaths, and laser lithotripsy, potentially causing edema, transient uroepithelial irritation, and elevated intrarenal pressure (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). However, symptom improvement by day seven suggests that these effects are reversible. The primary drivers of discomfort may stem more from the stone disease itself than the presence of the stent alone. The removal of stones likely helps reduce symptom burden over time. This trend was especially clear for urgency and nocturia, which improved immediately post-RIRS.\u003c/p\u003e\u003cp\u003eFew studies have explored how surgery alone, separate from stenting, affects symptom progression. Our findings provide evidence that while RIRS may temporarily worsen SRS, it ultimately contributes to their resolution within a short time frame.\u003c/p\u003e\u003cp\u003eThis study has several limitations that should be acknowledged. First, the sample size was relatively small and limited to a single center, which may restrict the broader applicability of the results. Second, the absence of a control group without surgery or stenting makes it difficult to isolate the specific role of RIRS in symptom variation. Third, we used a visual analog scale instead of a fully validated instrument like the USSQ due to unavailability of this instrument in the native language of patients, potentially limiting comparison with other research. Symptom reports were subjective and could have been influenced by individual pain thresholds or emotional states, which we did not formally assess. Moreover, we did not perform detailed subgroup analyses based on variables such as stent type, positioning, or sheath size. Lastly, data on the precise day of symptom improvement were missing in many patients, reducing the specificity of our findings regarding recovery timelines.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this prospective study, we observed that RIRS temporarily contributes in increasing certain SRS, particularly pain and urinary discomfort, within the first 24 hours postoperatively. However, these symptoms tend to significantly improve by the seventh postoperative day, suggesting that surgery itself may contribute to the early symptom burden but ultimately facilitates recovery. Our findings highlight the dynamic nature of stent-related symptoms in the perioperative period and suggest that counseling patients about this expected symptom could help manage postoperative expectations and improve satisfaction. Further larger, multicenter studies using validated assessment tools are needed to confirm these results and better understand the factors influencing symptom trajectories after RIRS.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest:\u0026nbsp;\u003c/strong\u003eThe authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical standards:\u0026nbsp;\u003c/strong\u003eThe study has been carried out in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The study was approved by the local Ethical Committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u0026nbsp;\u003c/strong\u003eA written consent was obtained from each patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment:\u0026nbsp;\u003c/strong\u003eNot applicable \u003cstrong\u003e\u003cem\u003e\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; contribution\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy conception - A.T., E.X.K., E.S., V.D.C., F.E., B.B.M., P.J.J., L.T., G.M., A.P.\u003c/p\u003e\n\u003cp\u003eStudy design - A.T., E.V., A.P.\u003c/p\u003e\n\u003cp\u003eData Collection - A.T., H.G.,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eManuscript drafting - A.P., E.V., S.M\u003c/p\u003e\n\u003cp\u003eManuscript editing and critical revision - E.S., V.D.C., F.E., B.B.M., P.J.J., L.T., G.M., A.S.D.R., A.O., M.C., V.J., A.T., M.B., R.E., L.N., A.P.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMarmar JL. The management of ureteral obstruction with silicone rubber splint catheters. J Urol. 1970 Sep;104(3):386\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eMardis HK, Hepperlen TW, Kammandel H. Double pigtail ureteral stent. Urology. 1979 Jul;14(1):23\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eBoeykens M, Keller EX, Bosio A, Wiseman OJ, Contreras P, Ventimiglia E, et al. Impact of Ureteral Stent Material on Stent-related Symptoms: A Systematic Review of the Literature. Vol. 45, European Urology Open Science. 2022. \u003c/li\u003e\n\u003cli\u003eEl-Faqih SR, Shamsuddin AB, Chakrabarti A, Atassi R, Kardar AH, Osman MK, et al. Polyurethane internal ureteral stents in treatment of stone patients: Morbidity related to indwelling times. Journal of Urology. 1991;146(6). \u003c/li\u003e\n\u003cli\u003eDe Coninck V, Keller EX, Somani B, Giusti G, Proietti S, Rodriguez-Socarras M, et al. Complications of ureteroscopy: a complete overview. Vol. 38, World Journal of Urology. 2020. \u003c/li\u003e\n\u003cli\u003eBosio A, Alessandria E, Dalmasso E, Peretti D, Agosti S, Bisconti A, et al. How bothersome double-J ureteral stents are after semirigid and flexible ureteroscopy: a prospective single-institution observational study. World J Urol. 2019 Jan;37(1):201\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eHo CH, Chen SC, Chung SD, Lee YJ, Chen J, Yu HJ, et al. Determining the appropriate length of a double-pigtail ureteral stent by both stent configurations and related symptoms. J Endourol. 2008 Jul;22(7):1427\u0026ndash;31. \u003c/li\u003e\n\u003cli\u003eTaguchi M, Yoshida K, Sugi M, Matsuda T, Kinoshita H. A ureteral stent crossing the bladder midline leads to worse urinary symptoms. Cent European J Urol. 2017;70(4). \u003c/li\u003e\n\u003cli\u003eJoshi HB, Newns N, Stainthorpe A, MacDonagh RP, Keeley FX, Timoney AG. Ureteral stent symptom questionnaire: development and validation of a multidimensional quality of life measure. J Urol. 2003 Mar;169(3):1060\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eRamsay JW, Payne SR, Gosling PT, Whitfield HN, Wickham JE, Levison DA. The effects of double J stenting on unobstructed ureters. An experimental and clinical study. Br J Urol. 1985 Dec;57(6):630\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eMosli HA, Farsi HM, al-Zimaity MF, Saleh TR, al-Zamzami MM. Vesicoureteral reflux in patients with double pigtail stents. J Urol. 1991 Oct;146(4):966\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eChew BH, Knudsen BE, Nott L, Pautler SE, Razvi H, Amann J, et al. Pilot study of ureteral movement in stented patients: first step in understanding dynamic ureteral anatomy to improve stent comfort. J Endourol. 2007 Sep;21(9):1069\u0026ndash;75. \u003c/li\u003e\n\u003cli\u003eThomas R. Indwelling ureteral stents: impact of material and shape on patient comfort. J Endourol. 1993 Apr;7(2):137\u0026ndash;40. \u003c/li\u003e\n\u003cli\u003eAl-Kandari AM, Al-Shaiji TF, Shaaban H, Ibrahim HM, Elshebiny YH, Shokeir AA. Effects of proximal and distal ends of double-J ureteral stent position on postprocedural symptoms and quality of life: a randomized clinical trial. J Endourol. 2007 Jul;21(7):698\u0026ndash;702. \u003c/li\u003e\n\u003cli\u003eGiannarini G, Keeley FX, Valent F, Manassero F, Mogorovich A, Autorino R, et al. Predictors of morbidity in patients with indwelling ureteric stents: results of a prospective study using the validated Ureteric Stent Symptoms Questionnaire. BJU Int. 2011 Feb;107(4):648\u0026ndash;54. \u003c/li\u003e\n\u003cli\u003eTaguchi M, Yoshida K, Sugi M, Matsuda T, Kinoshita H. A ureteral stent crossing the bladder midline leads to worse urinary symptoms. Cent European J Urol. 2017;70(4):412\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eAbt D, Mordasini L, Warzinek E, Schmid HP, Haile SR, Engeler DS, et al. Is intravesical stent position a predictor of associated morbidity? Korean J Urol. 2015 May;56(5):370\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eDamiano R, Autorino R, De Sio M, Cantiello F, Quarto G, Perdon\u0026agrave; S, et al. Does the size of ureteral stent impact urinary symptoms and quality of life? A prospective randomized study. Eur Urol. 2005 Oct;48(4):673\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eCandela J V, Bellman GC. Ureteral stents: impact of diameter and composition on patient symptoms. J Endourol. 1997 Feb;11(1):45\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eErturk E, Sessions A, Joseph J V. Impact of ureteral stent diameter on symptoms and tolerability. J Endourol. 2003 Mar;17(2):59\u0026ndash;62. \u003c/li\u003e\n\u003cli\u003eLennon GM, Thornhill JA, Sweeney PA, Grainger R, McDermott TE, Butler MR. \u0026ldquo;Firm\u0026rdquo; versus \u0026ldquo;soft\u0026rdquo; double pigtail ureteric stents: a randomised blind comparative trial. Eur Urol. 1995;28(1):1\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eLee C, Kuskowski M, Premoli J, Skemp N, Monga M. Randomized evaluation of Ureteral Stents using validated Symptom Questionnaire. J Endourol. 2005 Oct;19(8):990\u0026ndash;3. \u003c/li\u003e\n\u003cli\u003eBosio A, Alessandria E, Agosti SC, Vitiello F, Vercelli E, Bisconti A, et al. Loop-tail stents fail in reducing stent-related symptoms: results of a prospective randomised controlled trial. BJU Int. 2022 Jan;129(1):123\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eMiyaoka R, Monga M. Ureteral stent discomfort: Etiology and management. Indian J Urol. 2009;25(4):455\u0026ndash;60. \u003c/li\u003e\n\u003cli\u003eJoshi HB, Okeke A, Newns N, Keeley FX, Timoney AG. Characterization of urinary symptoms in patients with ureteral stents. Urology. 2002 Apr;59(4):511\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eSt\u0026auml;chele L, Stekhoven DJ, Birzele JA, Risch M, Strebel RT. Impact of retrograde intrarenal surgery on biomarkers that are associated with renal parenchyma injury, a preliminary study. World J Urol. 2022 Mar;40(3):841\u0026ndash;7. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Stent-related symptoms, ureteral stenting, RIRS, ureteroscopy, lithotripsy","lastPublishedDoi":"10.21203/rs.3.rs-7152265/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7152265/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eTo assess the perception and severity of stent-related symptoms (SRS) in patients undergoing retrograde intrarenal surgery (RIRS).\u003c/p\u003e\u003ch2\u003eMaterial and methods\u003c/h2\u003e\u003cp\u003eA prospective observational study was performed including patients with single or multiple renal stones undergoing ureteral stenting and scheduled for a definitive RIRS. SRS were evaluated at 3 timepoints: pre-operatively on the day of RIRS, as well as on the 1st and 7th postoperative day following RIRS. Bladder pain, back pain, hematuria, urgency, frequency, nocturia, and urge incontinence were evaluated using a visual analog scoring (VAS) system.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 57 patients were included. The patients reported a significant rise in back pain at day 1 after RIRS (mean rank 2.25 on a scale of 0 to 5) compared to preoperative scores (2.06), with a significant decrease at day 7 following RIRS (1.68) (p\u0026thinsp;=\u0026thinsp;0.003). A similar pattern was observed for bladder pain, frequency and urge incontinence (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). As for urgency and nocturia, these SRS steadily decreased from baseline to day 1, and in turn from day 1 to day 7 after RIRS (p\u0026thinsp;=\u0026thinsp;0.004 and p\u0026thinsp;=\u0026thinsp;0.003, respectively). Hematuria was the only SRS which did not show any significant differences over the 3 evaluated timepoints.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eRIRS temporarily increases certain SRS, particularly pain and urinary discomfort within the first 24 hours postoperatively. These symptoms tend to improve by the 7th postoperative day, suggesting that surgery itself may contribute to the early symptom burden but ultimately facilitates recovery.\u003c/p\u003e","manuscriptTitle":"How Does RIRS Impact on Stent-Related Symptoms? Insights from a Prospective Observational Study by EAU-YAU Endourology and Urolithiasis Working Group","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-31 10:33:39","doi":"10.21203/rs.3.rs-7152265/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-15T13:57:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-13T11:24:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"254489508586694847949388034598705842273","date":"2025-09-04T00:18:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"256108975351062244298270036295027201854","date":"2025-08-23T11:33:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-12T11:18:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-09T11:51:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"10775686256536703322019559619634614835","date":"2025-07-31T09:06:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"35374891782305217293854902675398067343","date":"2025-07-29T05:49:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-29T05:35:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-28T17:56:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-28T14:47:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Urology","date":"2025-07-17T21:20:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"858cfe6f-80f2-4462-a407-bdf150bb921a","owner":[],"postedDate":"July 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T16:10:20+00:00","versionOfRecord":{"articleIdentity":"rs-7152265","link":"https://doi.org/10.1007/s00345-025-06007-3","journal":{"identity":"world-journal-of-urology","isVorOnly":false,"title":"World Journal of Urology"},"publishedOn":"2025-11-10 15:57:14","publishedOnDateReadable":"November 10th, 2025"},"versionCreatedAt":"2025-07-31 10:33:39","video":"","vorDoi":"10.1007/s00345-025-06007-3","vorDoiUrl":"https://doi.org/10.1007/s00345-025-06007-3","workflowStages":[]},"version":"v1","identity":"rs-7152265","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7152265","identity":"rs-7152265","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}