• Users Online: 440
  • Print this page
  • Email this page

Table of Contents
Year : 2023  |  Volume : 34  |  Issue : 2  |  Page : 70-74

Self-removing antegrade tethered ureteric stents after tubeless percutaneous nephrolithotomy in the COVID-19 era: A prospective study from a university teaching hospital

1 Department of Urology and Renal Transplant, Kasturba Medical College, Manipal, Karnataka, India
2 Department of Urology, Kasturba Medical College, Manipal, Karnataka, India
3 Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK

Date of Submission07-Apr-2022
Date of Decision16-May-2022
Date of Acceptance31-May-2022
Date of Web Publication17-Jun-2023

Correspondence Address:
Arun Chawla
Department of Urology and Renal Transplant, Kasturba Medical College, Manipal, Karnataka
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/UROS.UROS_46_22

Rights and Permissions

Purpose: To assess the safety and efficacy of self-removing antegrade tethered stents after percutaneous nephrolithotomy (PNL) during the COVID-19 pandemic. Materials and Methods: Instead of routine placement of double-J stent which requires endoscopic removal, a tethered antegrade stent after tubeless PNL as an exit strategy followed by self-removal can obviate the need of early postoperative revisit. A prospective observational study in a university teaching hospital was conducted during the lockdown period from May 2021–June 2021 with the use of antegrade tethered stent in 30 patients and we studied the complications associated with it. Results: The average stone size among the patients was 2.4 cm (1.2–4.9). Postoperative visual analog scale (VAS) till the time of stent removal was 30.8 + 4.4 mm while the VAS at stent removal was 26.6 + 3.8 mm. None of the patients had urine leak or hemorrhage from the site of percutaneous access after self-removal of stent. Two (6.66 percent) patients had grade I and grade II modified Clavien–Dindo complication. The mean score of satisfaction with life scale (SWLS) Questionnaire was 31 (34–27). The present study demonstrates that tubeless PNL with antegrade tethered stent has the advantages of avoiding hospital visits for stent removal during COVID-19. Conclusion: The use of an antegrade threaded stent is safe, culminating in minimal morbidity and patient distress, and greater overall patient satisfaction.

Keywords: Antegrade stents, COVID-19, endourology, percutaneous nephrolithotomy, renal stones

How to cite this article:
Reddy BS, Kulshreshtha M, Reddy SJ, Pillai S, Chawla A, Shah M, Somani BK, Kankaria S. Self-removing antegrade tethered ureteric stents after tubeless percutaneous nephrolithotomy in the COVID-19 era: A prospective study from a university teaching hospital. Urol Sci 2023;34:70-4

How to cite this URL:
Reddy BS, Kulshreshtha M, Reddy SJ, Pillai S, Chawla A, Shah M, Somani BK, Kankaria S. Self-removing antegrade tethered ureteric stents after tubeless percutaneous nephrolithotomy in the COVID-19 era: A prospective study from a university teaching hospital. Urol Sci [serial online] 2023 [cited 2023 Oct 2];34:70-4. Available from: https://www.e-urol-sci.com/text.asp?2023/34/2/70/378892

  Introduction Top

The COVID-19 epidemic has presented urologic care with unprecedented challenges. Urologists throughout the world have reduced surgical and outpatient activities by up to 10%–20% of baseline levels to reduce the risk of transmission.[1],[2] Because the necessity for urological treatment has not decreased, new ideas and tactics were needed to help with care delivery.[3] The strain on the health-care system that can provide correct treatment, prevent viral spread, and triage critical procedures has been enormous as a result of COVID-19. Using and maintaining a reliable method to monitor ureteral stent placement and timely removal was one of the challenges faced by urologists amid COVID led lockdown. This became a critical part of their application. We expected concern and worry in these patients due to stent related symptoms (SRS), since a delay in stent removal increases anxiety and psychological load. Tubeless percutaneous nephrolithotomy (PNL) is one such procedure where postprocedure ureteral stent insertion is practiced by most urologists. A ureteral stent was previously described as being placed in an antegrade method at the completion of the tubeless PNL surgery.[4] The necessity to return to the hospital and undergo cystoscopy for stent removal is one of the main drawbacks, especially during the COVID lockdown period. Although most patients are treated using local anesthetic, some require regional or general anesthesia as well as short-term hospitalization, increasing the overall expense, morbidity, and risk of COVID transmission. Another downside is the lack of a percutaneous route for a second look in the event of postoperative imaging revealing residual stones.[5] Previously, it was believed that inserting the stent retrograde with the tether leaving through the urethra would prevent the necessity for this cystoscopy.[6] However, this has been linked to numerous patients prematurely removing their stents due to mistakenly pulling on the tether. We used an antegrade ureteral stent with a nonabsorbable suture connected in the renal pelvis, leaving the nephrostomy tract, to overcome these limitations and reduce patient re-visits to the hospital. After 1 week, the patient or relatives removed the stent from the flank themselves, avoiding the necessity for a hospital visit or a cystoscopy. We describe our experience using this method during the COVID-19 lockdown period, as well as its safety and patient-related results, in this study.

  Materials and Methods Top

Study design

A prospective single-center study conducted at a tertiary care center over a 7-week lockdown period from May 2021 to June 2021 after obtaining Institutional Ethical clearance numbered IEC (IEC 342/2021). Antegrade stenting with nonabsorbable suture as a tether was inserted after tubeless PNL in (n = 30) patients during this period.

Patients and methodology

All patients (n = 30) underwent tubeless PNL (tract size <24 Fr) following which they underwent antegrade ureteral stenting with a 3-0 nylon suture acting as a tether attached to its proximal end that was left protruding through the nephrostomy tract. Informed consent was taken prior to the procedure from all patients included in the study. The inclusion criteria were single tract, preoperative normal renal function, no intraoperative complication and complete stone clearance. Stone size, location, number, density, site and type of percutaneous access were not included in the criteria. Patients who were scheduled for or expected to have staged second-look nephroscopy were not included in the study. All patients received one dose of a third-generation cephalosporin intravenously as a perioperative antimicrobial prophylaxis. Procedures were normally carried out under general anesthesia. All of the procedures were carried out by a single experienced surgeon (A. C) in collaboration with a resident. In all cases, retrograde ureteral catheterization was done initially. The procedure was carried out with the patient prone. To acquire PCS access, C-arm fluoroscopy with the Bull's eye method was employed in all cases. The tract was dilated using serial metal alken dilators under fluoroscopic guidance. A 20.8F nephroscope (Wolf, Germany) was used to remove the stones through a maximum of 24Fr Amplatz sheath. The stones were fragmented using pneumatic lithotripsy (Swiss lithoclast, EMS). After complete retrieval of stone fragments, patients had a ureteric stent (5Fr/26 cm; 6Fr/26 cm, Blueneem) [Figure 1] introduced in an antegrade fashion, with a 3-0 size nylon suture attached to it. The guidewire is withdrawn when the distal stent coil is placed in the bladder, leaving the proximal end of the stent protruding partially into the nephrostomy sheath. The nephroscope is now withdrawn from the sheath. During this technique, take care not to mistakenly tug on the stent's thread, which will draw the stent farther back into the sheath. To avoid sliding the tether entirely into the sheath, secure it with your fingertips on the exterior of the sheath. The proximal end of the stent is adjusted in the renal pelvis with a grasper so that it produces a good coil. After that, the nephroscope and sheath are both withdrawn at the same time. The stent being kept in place by a gentle twisting motion of the sheath and continual fluoroscopic surveillance of the proximal coil as the endoscope/sheath ensemble was withdrawn. The thread was introduced to the skin through the nephrostomy route, coiled safely outside the tract, and a small impermeable bandage was applied. Tramadol 50 mg intramuscularly given analgesia was utilized for the first 24 h after surgery. A 100 mm linear visual analog scale was used to assess the pain during the first 24 h (0 = no pain; 100 = intolerable pain).[7] At the time of discharge or after 24 h (whichever was earlier), the patient was shifted on oral analgesics including nonsteroidal anti-inflammatory drugs (paracetamol). Patients who were deemed fit for hospital discharge 6 h following the surgery were given the option of being discharged the same day if their hemodynamic status remained stable. Foley's catheter was retained till postoperative day 1 in other patients. All patients were explained in detail regarding the stent removal and SRS with video demonstration. A contact number was given to the patient for any stent related queries. A simple questionnaire [Figure 2] was given during the time of discharge and the patient was told to fill it within 7 days of stent removal. The threaded stent was removed 7–14 days after surgery by the patient themselves or attenders at home by simply pulling out the thread [Figure 3]. All patients were asked to follow-up after the lockdown was lifted as per the patient logistics. On follow–up, the stent-related questionnaire was evaluated, and patients underwent plain radiography and ultrasound for radio-opaque stones and noncontrast computed tomography for radiolucent stones for confirmation of complete stone clearance. Patients were also asked to fill the Satisfaction with Life Scale (SWLS) a 5-item questionnaire to access the QoL at follow-up [Details about the scoring system in Supplementary File].[8]
Figure 1: Antegrade tethered stent with prolene 3-0 at proximal end

Click here to view
Figure 2: Questionnaire related to stent symptoms

Click here to view
Figure 3: Antegrade stent from the nephrostomy tract after the procedure

Click here to view

Outcomes measures

The feasibility, usefulness, and safety of this technique in maintaining patient safety during the COVID-19 era were assessed. Patients in our study were also evaluated for the difficulty of removing the stent, any stent-related problems (urine leaking from the flank, fever, and postoperative discomfort), and the length of their hospital stay.

  Results Top

The data regarding patient demographics and characteristics are summarized in [Table 1], whereas the results are mentioned in [Table 2]. The average tramadol dose needed for analgesia in <24 h postoperatively was 81.5 mg, whereas the mean visual analog scale (VAS) score was 30.8 mm. During stent removal, the mean VAS score was 26.6 mm.
Table 1: Patient demographics, preoperative and intra-operative variables

Click here to view
Table 2: Postoperative variables

Click here to view

There were no urinary leaks from the percutaneous access site in any of the patients, either while the stent was in place or after it was removed. Two (6.66%) cases had postoperative infection which was defined by one of the following signs:

Infection acquired postoperatively was recognized as any one of these signs: pyrexia >38C (>100.4F), leukocytosis >11,000/mm3, or presence of >5 pus cells in urine/high-power field. These patients were treated by suitable antibiotics after a urine culture and sensitivity test. The mean hemoglobin drop was 0.35 g/dL and no patient needed blood transfusion in the postoperative period. The average duration of hospital stay was 22.6 h.

The thread growing from the patient's flank did not create any discomfort or suffering. All stents were successfully removed by patients themselves by removing the thread without substantial discomfort, and there was no tether breaking or other problem while doing so; there were no cases of bleeding from the percutaneous tract or hematuria as a result of this. None of the patients were reported to have significant perinephric fluid collection and all 30 patients were stone free on follow-up. There were no patients who needed to be readmitted due to discomfort, infection, or blockage, and no long-term complications were discovered during follow-up. The complications classified based on modified Clavien–Dindo classification showed only 2 patients with complications: one patient each with grade 1 and grade 2 complications.

On assessment of the Qol using the SWLS Questionnaire, the mean score was 31 with a maximum score of 34 and a minimum score of 27, which lie in the satisfied and extremely satisfied groups as per the scoring system in [Table 3].
Table 3: Quality of life scores at follow up as per Satisfaction With Life Scale scoring

Click here to view

  Discussion Top

The strain on the health-care system to provide appropriate treatment, prevent virus transmission, and triage essential surgeries has been enormous as a result of COVID-19. During the COVID-19 pandemic, urological associations from many nations and reference institutions have produced guidelines on urology care. Various guidelines recommend postponing normal treatments in light of this.[7] Various global urological societies have also suggested delaying invasive procedures in case of nonemergency conditions such as stent removal poststraightforward PNL cases.[7]

During the pandemic, we have managed renal calculi with ESWL, fURS (flexible ureterorenoscopy) with retrograde tethered stent, and PNL with antegrade stent. ESWL was done in patients with small renal calculi, but most of the patients were skeptical about the procedure due to anxiety regarding pain and need for a repeat procedure due to incomplete clearance. It was also not suitable for all types of calculi. fURS with retrograde tethered stent through the urethra was also used for renal calculi, the stent was removed by the patients themselves which avoided the patients revisit for stent removal. However, fURS has selective indications in minimal invasive management of Renal stone.

Proietti et al. proposed that a stent with external wire be considered following operations with no issues (stone-free) in order to prevent a hospital visit for its removal.[9] Threaded or tethered stents can be considered as a suitable option as an effective exit strategy. In certain patients who required PNL, avoiding postprocedural 41 hospital visits, decreasing risk of viral transmission while maintaining quality patient care in post-PNL patients has proven to be a difficult task during COVID times. Hence, in order to avoid a revisit to hospital for stent removal, we had to place a threaded stent for self-removal of the stent by the patient, as placement of retrograde threaded stent was difficult post-PNL we had placed a threaded stent in antegrade fashion. In the past, various studies have been done using antegrade and retrograde tethered ureteral stents in posttubeless PNL cases with positive outcomes.[4],[5],[6],[10],[11],[12]

However, the use of antegrade tethered stents was thought to be associated with increased patient discomfort due to a threads hanging from exit site onto the flank area, risk of accidental dislodgement, and poor self-care. Moreover, it carries a theoretical risk of urine leak, infections and hemorrhage after stent removal due to clot dislodgement.[10] Our study shows that antegrade ureteral stenting with thread in posttubeless prone PNL patients is effective with nil to minimum postoperative complications, with only one patient having grade II complication based on modified Clavien classification. It improved patient compliance in terms of self-removal of stents, decreasing the need of repeated hospital visits and invasive procedures for stent removal. Patients were also included in their own postoperative care plan thanks to the use of stents with threads, which allowed them to organize their stent removal at a mutually suitable time without the possibility of “forgotten stents.”

It was observed in our study that all the patients had no difficulty in carrying out their daily activity postprocedure. It has been demonstrated that when patients have a more active role in their health-care decisions, they feel more confident, which promotes adherence to treatment plans, reduces anxiety, improves clinical results, and lowers health-care costs.[13] This was reflected in our study, as all patients followed the instructions of self-stent removal at home followed by informing the treating clinician team regarding the same. Other benefits during COVID times include lower health-care expenditures, lower anxiety among patients owing to stent removal delays, and lower health-care costs by eliminating needless hospital visits.[13],[14] And also, threaded stent can be used for relook PNL even though none of our patients required the same.

The use of antegrade threaded stents allowed better postoperative stent care in post-PNL patients amid the lack of fully functioning hospital infrastructure during COVID-19 lockdown. The patient satisfaction also increased in view of self-stent removal and avoiding a re-visit to hospital for the same. Patients' quality of life was not hampered because the majority of patients were very satisfied, as measured by the SWLS, and they were able to carry out all routine day-to-day activities normally.

Keeping in view of the present COVID-19 situation, which has till now had multiple strains such as delta and omicron and bringing about multiple waves of COVID-19, the use of antegrade threaded stent in the armamentarium endourological management of stones is worth considering.

Although this study showed antegrade stenting with thread to be safe without complications, the number of patients included in our study was relatively small. Furthermore, the study was conducted at a single center, so the acceptability of its application across different health-care institutions and patient population needs further evaluation.


  • Since the study was conducted during the COVID-19 pandemic as an innovation to overcome a difficult situation, we did not have a control group to compare our study results
  • The other limitation of our study was that we had used a standard sized length of tethered stent (26 cm) for all the patients, which might have caused disproportionate SRS.

  Conclusion Top

Tubeless PNL with antegrade tethered stent followed by patient directed self-removal of stent has the advantages of avoiding extra hospital visit and procedure for stent removal during the COVID-19 era. The use of antegrade threaded stent is safe, with least modified Clavien complications, patient distress, with greater overall patient satisfaction.

Data availability statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  Supplementary Materials Top

Satisfaction with Life Scale

A 5-item scale designed to measure global cognitive judgments of one's life satisfaction.

Participants indicate how much they agree or disagree with each of the 5 items using a 7-point scale that ranges from 7 strongly agree to 1 strongly disagree.

The scoring system is validated and free to be used.

Scale: Instructions: Below are five statements that you may agree or disagree with. Using the 1-7 scale below, indicate your agreement with each item by placing the appropriate number on the line preceding that item. Please be open and honest in your responding.

  • 7 - Strongly agree
  • 6 - Agree
  • 5 - Slightly agree
  • 4 - Neither agree nor disagree
  • 3 - Slightly disagree
  • 2 - Disagree
  • 1 - Strongly disagree

Q1. In most ways my life is close to my ideal.

Q2. The conditions of my life are excellent.

Q3. I am satisfied with my life.

Q4. So far I have gotten the important things I want in life.

Q5. If I could live my life over, I would change almost nothing.


Though scoring should be kept continuous (sum up scores on each item), here are some cut-offs to be used as benchmarks.

  • 31-35 Extremely satisfied
  • 26-30 Satisfied
  • 21-25 Slightly satisfied
  • 20 Neutral
  • 15-19 Slightly dissatisfied
  • 10-14 Dissatisfied
  • 5-9 Extremely dissatisfied

  References Top

Tan YQ, Wu QH, Chiong E. Preserving operational capability while building capacity during the COVID-19 pandemic: A tertiary urology centre's experience. Urology 2020;142:36-7.  Back to cited text no. 1
Luciani LG, Mattevi D, Cai T, Giusti G, Proietti S, Malossini G. Teleurology in the time of covid-19 pandemic: Here to stay? Urology 2020;140:4-6.  Back to cited text no. 2
Ho HC, Hughes T, Bozlu M, Kadıoğlu A, Somani BK. What do urologists need to know: Diagnosis, treatment, and follow-up during COVID-19 pandemic. Turk J Urol 2020;46:169-77.  Back to cited text no. 3
Bellman GC, Davidoff R, Candela J, Gerspach J, Kurtz S, Stout L. Tubeless percutaneous renal surgery. J Urol 1997;157:1578-82.  Back to cited text no. 4
Agrawal MS, Sharma M, Agarwal K. Tubeless percutaneous nephrolithotomy using antegrade tether: A randomized study. J Endourol 2014;28:644-8.  Back to cited text no. 5
Yew J, Bellman G. Modified “tubeless” percutaneous nephrolithotomy using a tail-stent. Urology 2003;62:346-9.  Back to cited text no. 6
Gravas S, Fournier G, Oya M, Summerton D, Scarpa RM, Chlosta P, et al. Prioritising urological surgery in the COVID-19 era: A global reflection on guidelines. Eur Urol Focus 2020;6:1104-10.  Back to cited text no. 7
Diener E, Emmons RA, Larsen RJ, Griffin S. The satisfaction with life scale. J Pers Assess 1985;49:71-5.  Back to cited text no. 8
Proietti S, Gaboardi F, Giusti G. Endourological stone management in the era of the COVID-19. Eur Urol 2020;78:131-3.  Back to cited text no. 9
Choi M, Brusky J, Weaver J, Amantia M, Bellman GC. Randomized trial comparing modified tubeless percutaneous nephrolithotomy with tailed stent with percutaneous nephrostomy with small-bore tube. J Endourol 2006;20:766-70.  Back to cited text no. 10
Shpall AI, Parekh AR, Bellman GC. Tubeless percutaneous nephrolithotomy with antegrade stent tether: Clinical experience. J Endourol 2007;21:973-6.  Back to cited text no. 11
Kim DJ, Son JH, Jang SH, Lee JW, Cho DS, Lim CH. Rethinking of ureteral stent removal using an extraction string; what patients feel and what is patients' preference?: A randomized controlled study. BMC Urol 2015;15:121.  Back to cited text no. 12
Pereira Azevedo N, Gravas S, de la Rosette J. Mobile health in urology: The good, the bad and the ugly. J Clin Med 2020;9:1016.  Back to cited text no. 13
Gautham M, Iyengar MS, Johnson CW. Mobile phone-based clinical guidance for rural health providers in India. Health Informatics J 2015;21:253-66.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]


    Similar in PUBMED
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
Materials and Me...
Supplementary Ma...
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded82    
    Comments [Add]    

Recommend this journal