A commentary on ‘Self-expanding metal ureteral stent for ureteral stricture: experience of a large-scale prospective study from a high-volume center–cross-sectional study’ (Int J Surg 2021; 95: 106161)

Dear Editor,

Ureteral stricture is a complex and challenging disease for urologists. Upper urinary tract obstruction due to ureteral stricture can lead to hydronephrosis, which can cause more serious complications1. Currently, a mountain of evidence has been reported that repair and reconstructive surgery can achieve higher cure rates and is considered the de facto standard for ureteral stenosis2–4. However, the recurrent ureteral stricture is still an inevitable trouble. The main aim of surgery is to relieve ureteral obstruction and protect renal function. Nevertheless, it is also important to improve the quality of life of patients with incurable diseases (such as advanced malignancies) who are not eligible for surgery or do not want to undergo complicated surgery5. However, in the real world, the etiology of ureteral stricture is very complex, so it is not enough to evaluate the effect of surgical methods solely with the goal of a cure. Therefore, how to choose the ideal maintenance treatment for ureteral stenosis is of great significance.

Percutaneous nephrostomy tubes or double J stents to relieve upper ureteral obstruction are the most common treatment in clinical practice. However, percutaneous nephrostomy tubes may cause skin erosion, urinary tract infection, and tube obstruction, which negatively affects the quality of life6,7. Although the success rate of double J stent insertion is high, stent-changing is required every 3–6 months, which brings considerable inconvenience and costs to patients8. Thus, a novel procedure is urgently needed to manage ureteral strictures. Recently, we read with great enthusiasm the article by Gao et al 9. We sincerely congratulate the authors for publishing an excellent prospective study regarding self-expanding metal ureteral stent (URS) for ureteral stricture: Experience of a large-scale prospective study from a high-volume center–cross-sectional study. The authors assess the safety and effectiveness of self-expanding metal URSs in ureteral strictures and found that URS was safe and effective for ureteral strictures with limited complications and good long-term results. In addition, stricture of the distal ureter was an independent risk factor for stent failure (HR: 1.77, 95% CI: 1.15–2.73, P=0.009). For those who are not suitable for surgical reconstruction, the URS is alternative management.

While the present study was well designed and conducted with high quality, there are a few points of concern that we would like to raise. First, the authors found that 73.2% (115/157) of the stents were retained in situ, however, ~27% of the stents were displaced. What should we do during the procedure to reduce displacement? In addition, what should we do for early dislodgement after placement of URS for ureteral wall stenosis? Second, in patients with ureteral bladder wall segment stenosis and multiple or total ureteral stenoses, does the placement of stents lead to vesicoureteral reflux? Third, is it necessary to place more than two stents when the length of the URS stent is smaller than the stenosis segment, or when there are multiple stenoses? What method should be used for the placement of two stents to make a perfect docking? Fourth, how long can the stent be left in the body? During this period, what should we do if the stent develops a stone scale?

Overall, we thank Gao et al. from the bottom of our hearts for their concerted efforts in investigating the therapeutic efficiency of URS in ureteral stricture. They have made a meaningful step forward on this important topic. URS is an efficient and safe procedure. However, more prospective studies and/or high-quality case-matched comparative studies are needed in the future to further clarify the advantages and disadvantages of URS.

Ethical approval

Ethical approval is not required.

Sources of funding

None to declare.

Author contribution

Z.T.: writing. S.F. and J.Z.: data collections and analysis. J.W.: study design.

Conflicts of interest disclosure

The authors declare that they have no conflict of interest.

Research registration unique identifying number (UIN)

None.

Guarantor

Jiansong Wang.

Provenance and peer review

Commentary, internally reviewed.