Does Omitting a Ureteral Stent Affect the Outcomes of Uncomplicated Ureteroscopy for Ureteral and Kidney Stones in Adults? Results from a Systematic Review and Meta-Analysis of Comparative Randomized Trials by the EAU Endourology Section

32 RCTs and 3,572 patients find routine double-J stenting after ureteroscopy increases morbidity without improving stone clearance

Journal: World Journal of Urology | Published: 2026-06-13 | Type: Systematic Review, Meta-Analysis | PMID: 42287462 Authors: Cormio Angelo et al. (University of Foggia; EAU Endourology Section) Funding/COI: Funding not disclosed. Four co-authors — Castellani, Gauhar, Yuen, and Somani — sit on the editorial board of the publishing journal, World Journal of Urology.

Summary

After uncomplicated ureteroscopy for kidney or ureteral stones, surgeons routinely insert a double-J (DJ) stent — a small tube bridging kidney to bladder — to reduce swelling and protect the ureter. This meta-analysis of 32 RCTs finds that omitting the stent cuts postoperative pain by 37–45%, slashes analgesic use by up to 82%, and eliminates the dysuria and urgency the stent itself causes — all without affecting stone clearance or serious complication rates. Routine stenting appears to be a habit that harms more than it helps.

Claims

• Operative time: Stent omission shortened surgery by a mean of 6.91 minutes
• Postoperative pain: 37–45% risk reduction in days 1–15 pain scores (VAS)
• Analgesic use: 55–82% reduction in analgesic requirements
• Dysuria: 65% reduction
• Urinary urgency: 81% reduction
• Hematuria: 52–57% reduction
• General health (USSQ): Superior scores at weeks 2–4 in stent-free patients
• Stone-free rate: Equivalent between stented and unstented groups
• Fever, UTI, urinary retention, ureteral stenosis, readmission: No significant difference between groups
• Pre-stented patients: Overnight ureteral catheter (<24 h) identified as a comparable alternative to DJ stenting

Study Quality

This is a methodologically respectable systematic review and meta-analysis of 32 prospective RCTs totaling 3,572 patients, following PRISMA 2020 guidelines with a comprehensive search of PubMed, Cochrane CENTRAL, and Scopus without date restriction. Use of the Cochrane Risk of Bias 2 (RoB 2) tool is appropriate, and the PICOS framework for inclusion criteria adds rigor.

The quality of the underlying trials is the main weakness: only 7 of 32 included RCTs demonstrated low risk of bias across all domains, 19 showed "some concerns," and 6 were rated high overall risk of bias. The wide analgesic reduction range (55–82%) likely reflects that heterogeneity. The conclusions rest on a mixed evidence base, and the precise effect sizes should be held loosely even if the direction of the findings is consistent.

Red Flags

• Editorial board COI: Four co-authors (Castellani, Gauhar, Yuen, Somani) sit on the editorial board of the journal that published this paper; independent peer review integrity cannot be verified
• Funding undisclosed: No source listed; unclear whether device or pharma interests were involved
• Poor underlying trial quality: Only 7/32 (22%) included RCTs rated low risk of bias; 6 rated high risk
• Wide effect size ranges: The 55–82% spread in analgesic reduction signals substantial heterogeneity across pooled trials
• No pediatric data: Search included children; zero pediatric RCTs were found — conclusions apply to adults only
• "Uncomplicated URS" scope: Results may not generalize to complex cases (solitary kidney, ureteral injury, large stone burden) — the exact scenarios where stenting is most commonly defended

Strengths

• Large pooled sample: 3,572 patients across 32 RCTs
• RCTs only — no observational studies included, limiting confounding
• PRISMA 2020 compliant with Cochrane RoB 2 bias assessment
• No date restriction on search, reducing publication-era bias
• Multiple patient-reported outcomes assessed beyond stone-free rate (VAS, USSQ, LUTS)
• Conducted under EAU Endourology Section backing, indicating specialty society endorsement

Verdict

The editorial board COI is a legitimate concern and deserves disclosure, but it doesn't sink the findings. The underlying dataset — 32 RCTs, 3,572 patients — is large enough that the direction of the results is unlikely to reverse. What this paper does well is provide a substantial basis for questioning a widespread surgical default: routine post-ureteroscopy DJ stenting causes real patient suffering (pain, dysuria, urgency, hematuria) and the pooled RCT evidence finds no compensating benefit in stone clearance or serious complications. Risk-of-bias quality across included trials is mediocre, so precise effect sizes shouldn't be quoted as settled fact. But for anyone interested in evidence-based procedural practice or urolithiasis surgery, this is a useful anchor paper on a question that affects millions of stone procedures annually.