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MORBIDITY IN PATIENTS WITH INDWELLING URETERIC STENTSGIANNARINI ET AL .

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Predictors of morbidity in patients with indwelling ureteric stents: results of a prospective study using the validated Ureteric Stent Symptoms Questionnaire
Gianluca Giannarini, Francis X. Keeley Jr*, Francesca Valent, Francesca Manassero, Andrea Mogorovich, Riccardo Autorino and Cesare Selli
Department of Urology, University of Pisa, Pisa, Institute of Epidemiology, University of Udine, Udine, Urology Clinic, Second University of Naples, Naples, Italy, and *Bristol Urological Institute, Southmead Hospital, Bristol, UK
Accepted for publication 12 March 2010

Study Type Therapy (case series) Level of Evidence 4 OBJECTIVE To assess the predictors of morbidity in patients with indwelling ureteric stents using a validated questionnaire. PATIENTS AND METHODS

administered on days 7 and 28 after stent placement and on day 28 after removal. A plain abdominal X-ray was performed on days 7 and 28 after placement to determine stent location. Univariable and multivariable analyses tested the association of patient age, sex and body mass index (BMI), and stent side, length, calibre and distal loop location, with the index score of the various domains on days 7 and 28. RESULTS

health), while location of stent distal loop remained signicantly associated with the same ve domains (urinary symptoms, body pain, general health, work performance and sexual matters).

CONCLUSION Location of stent distal loop with respect to midline had the strongest association with most domains of the USSQ on both days 7 and 28 after stent placement. The visualization of stent distal loop crossing the midline may therefore identify patients at higher risk of post-procedural morbidity requiring early management.

Eighty-six consecutive patients with indwelling double-J ureteric stent of different length and size enrolled at an Italian tertiary academic centre were prospectively evaluated with the Italianvalidated Ureteric Stent Symptoms Questionnaire (USSQ), which explores the stent-related symptoms in six domains. Ureteric stents were placed for benign ureteric obstruction or after uncomplicated ureterorenoscopy, and were all removed after 28 days. The questionnaire was

All patients completed the study. At multivariable analysis, on day 7, sex, BMI and stent calibre were signicantly associated with one domain (general health, body pain and work performance, respectively), while location of stent distal loop was signicantly associated with ve domains (urinary symptoms, body pain, general health, work performanc, and sexual matters). On day 28, body mass index was signicantly associated with two domains (body pain and general

KEYWORDS quality of life, questionnaire, outcome measure, ureteric stent, morbidity, multivariable analysis

INTRODUCTION Ureteric stenting has become part of the routine urological armamentarium, but stentrelated discomfort is reported in a high proportion of patients, with a negative impact of variable amplitude on their health-related quality of life (HRQL) [1]. The need for reliable tools to objectively measure the symptom complex and to assess its inuence on daily activities is therefore warranted.

Joshi et al. [2] have developed and internally validated the Ureteric Stent Symptoms Questionnaire (USSQ), which is a selfadministered multi-dimensional instrument exploring the stent-related morbidity in six sections, including urinary symptoms, body pain, general health, work performance, sexual matters and additional problems. Each section has several questions, the answers of which are summed up to allocate an index score. It has good evaluative and discriminant properties, and

has been adopted in several clinical trials [38]. Although a plethora of studies have evaluated the incidence and characteristics of morbidity after indwelling ureteric stenting, only a few have attempted to specically investigate the factors predicting the occurrence and severity of the symptom complex. Consequently, the aim of the present prospective study was to objectively assess

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the symptoms in patients with indwelling ureteric stents, using a comprehensive and validated instrument, such the USSQ, to identify predictors of morbidity. PATIENTS AND METHODS PATIENTS Between September 2008 and October 2009, 86 consecutive patients with indwelling ureteric stents were enrolled in this prospective study at the Department of Urology, University of Pisa, Italy. Institutional Review Board approval was not required. The study was conducted in accordance with the principles of the Helsinki Declaration, and all patients provided a written informed consent. Inclusion criteria were unilateral temporary stent placement to relieve acute benign ureteric obstruction (calculi, uretero-pelvic junction obstruction, ureteric stricture) or after diagnostic or therapeutic (ureteric calculi) ureterorenoscopy. Exclusion criteria were as follows: for men history of or current treatment for lower urinary tract symptoms, chronic bacterial prostatitis, chronic pelvic pain syndrome and prostate cancer; for women stress/urge/mixed urinary incontinence, lower urinary tract dysfunction and pregnancy; for both sexes chronic ureteric obstruction, obstruction due to malignancy, bleeding diathesis, history of bladder cancer, recurrent urinary tract infections, overactive bladder syndrome, neurological and psychiatric diseases, and concomitant medication with alpha-blockers, anticholinergics, analgesics and other drugs, possibly interfering with lower urinary tract function or pain assessment. We also excluded cases of complicated ureterorenoscopy, dened as: ureteric perforation or stricture; multiple, large (>2 cm) or impacted stones; operating time >30 min. A single-dose oral uoroquinolone was given 1 h before the endoscopic procedure. The same type of double-J ureteric stent (Percuex, Boston Scientic, Natick, MA, USA), with three different lengths (24, 26 and 28 cm), based on patients height with adjustments as needed according to Lee et al. [6], and three different calibres (4.8, 6 and 7 F) based on surgeons preference, were inserted in all cases by experienced urologists. An abdomen uoroscopy at the end of the procedure conrmed the correct stent

position, dened as complete proximal loop located in the renal pelvis and complete distal one in the bladder. All patients were discharged on the same day of stent placement. STUDY DESIGN The linguistically validated Italian version of the USSQ [9] was administered to all patients on days 7 and 28 after stent placement and on day 28 after removal. In all cases the stent was removed after 28 days, soon after administering the questionnaire. This indwelling time was routine practice at our centre for all patients requiring short-term ureteric stenting until the completion of the present trial. Moreover, we assumed that symptoms would have been completely resolved 28 days after stent removal and that answers to post-stent questionnaire would be representative of background pre-stent condition. A plain abdomen X-ray with full bladder was performed on days 7 and 28 after stent placement to evaluate whether the stent was correctly located and its distal loop had crossed the midline or not, based on the previously proposed hypothesis that a greater intravesical portion of the stent is associated with worse symptoms [5,10]. During the indwelling time, analgesic intake was standardized with paracetamol/codeine phosphate 500/30 mg up to four packets daily on demand and relief of lower urinary tract symptoms with tolterodine extended release 4 mg once daily on demand. No low-dose antibiotics or -blockers were given after stent placement. Patients were asked to keep a usage log of these medications to be lled on a daily basis. The total amount of medications was computed at the end of the stenting period. Stent-related complications (i.e. dislodgement, dened as either loop migrating into the ureter or obstruction due to encrustation) and readmissions due to complications (i.e. haematuria, symptomatic urinary tract infection, urosepsis) were also recorded. STATISTICAL ANALYSES Univariable and multivariable analyses were performed to identify clinical variables

associated with the index score of the various USSQ domains determined on days 7 and 28, and the total amount of analgesic and anticholinergic medications. For the purpose of the present study, the original additional problems section was split into two subsections, which were analysed separately: the former, which is referred to as the additional problems section, comprises the four questions A1A4; the latter comprises the single question GQ on global HRQL. Tested variables were patients age, sex and BMI, and stent side, length, calibre and distal loop location. The vast majority of variables were nonnormally distributed according to the KolmogorovSmirnov test for normality. Consequently, in univariable analyses, the associations between the clinical variables and the index scores of the USSQ domains, as well as the amount of drugs taken, were assessed with Wilcoxons rank-sum test for categorical variables and with Spearmans correlation coefcient for continuous variables (which were not categorized). Multiple linear regression was used to explore the association between these variables and the index scores of the USSQ domains determined on days 7 and 28, as well as the amount of drugs taken, adjusting for the potential mutual confounding effect of the variables on each other. All reported P values are two-sided, and statistical signicance was set at 0.05. All analyses were performed using SAS v9.1 software (SAS Institute, Inc., Cary, NC, USA).

RESULTS No patients were lost to follow-up. Baseline patient characteristics are detailed in Table 1. In each patient, the location of stent distal loop determined with plain abdomen X-ray did not vary between days 7 and 28. DOMAIN SCORE The index scores for the various USSQ domains over the study period are reported in Fig. 1. For all domains but sexual matters (P = 0.15), a signicant decrease in the score, reecting an improvement in symptoms, was observed between days 7 and 28 (P < 0.001).

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TABLE 1 Baseline characteristics of the study cohort (n = 86) Characteristic Age, years Sex Body mass index, kg/m2 Subjects with employment status Median (range) or n (%) 53 (1874) 50 (58) 36 (42) 24.6 (18.729.8) 5 (6) 60 (70) 0 (0) 21 (24) 68 (79) 18 (21) 41 (48) 45 (52) 25 (29) 44 (51) 17 (20) 21 (24) 49 (57) 16 (19) 40 (47) 46 (53)

MEDICATION CONSUMPTION The median numbers of paracetamol/codeine packets and tolterodine tablets taken in the study period were 17 (range 035) and six (range 028), respectively. Figure 2 shows the consumption of medications to relieve stentrelated symptoms as a function of time. For both medications, a signicant decrease in intake was observed between days 7 and 28 (P < 0.01). COMPLICATIONS Neither stent-related complications nor readmissions due to complications were recorded. PREDICTORS OF MORBIDITY In the univariable analysis, on day 7, all the tested variables except for stent side and length were found to be signicantly associated with at least one domain (Table 2). The same variables also retained their signicant predicting value at the analysis on day 28, albeit the number of domains was lower (Table 3). Younger age, male sex, higher BMI, larger calibre and distal loop crossing the midline were associated with worse symptoms. Sex, BMI, stent length and distal loop location were signicantly associated with the number of analgesics (P < 0.01, P < 0.001, P = 0.026 and P < 0.001, respectively), while BMI and distal loop location were signicantly associated with the number of anticholinergics (P < 0.01 for both). In the multivariable analysis, on day 7, sex, BMI and stent calibre were signicantly associated with one domain (general health, urinary symptoms and work performance, respectively), while location of stent distal loop was signicantly associated with ve domains (urinary symptoms, body pain, general health, work performance and sexual matters) (Table 4). On day 28, BMI was signicantly associated with two domains (urinary symptoms and general health), while location of stent distal loop was signicantly associated with ve domains (urinary symptoms, body pain, general health, work performance and sexual matters) (Table 5). Only distal loop location was signicantly associated with the number of analgesics

Male Female Student Employed Unemployed Retired Active Inactive Right Left 24 26 28 4.8 6 7 Crossing the midline Not crossing the midline

Subjects reporting to be sexually active Stent side Stent length (cm)

Stent calibre (F)

Stent distal loop location

FIG. 1. Index score for the various Ureteric Stent Symptoms Questionnaire domains determined on days 7 and 28 after stent placement and on day 28 after stent removal. (a) Urinary symptoms; (b) body pain; (c) general health; (d) work performance; (e) sexual matters; and (f) additional problems.

(a) 40 30 20 10 0
Day 7 Day 28 After removal

(b) 40 35 30 25 20 15 10 5 0
Day 7 Day 28 After removal

(c) 20 15 10 5 0
Day 7 Day 28 After removal

(d)
7 6 5 4 3 2 1 0 Day 7 Day 28 After removal

(e)
6 5 4 3 2 1 0
Day 7 Day 28 After removal

(f)
6 5 4 3 2 1 0 Day 7 Day 28 After removal

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taken (P < 0.001), while BMI and distal loop location were signicantly associated with the number of anticholinergics taken (0.006 and P < 0.001, respectively). As distal loop location was found to have an important impact on symptoms, we undertook a post hoc analysis to assess whether distal loop location was not merely a result of stent length. According to Fishers exact test, the association between these two variables was not statistically signicant (P = 0.195).

of variable bothersomeness during the indwelling time. Interestingly, except for sexual matters, a signicant improvement with time in the symptom score was found for all domains. The development of symptom tolerance with time has been described in one study. Irani et al. [13] found that dysuria and haematuria signicantly improved with time, but pain and

general tolerance remained unchanged. Admittedly, the temporal evolution of symptoms might be inuenced by the therapy delivered to alleviate pain and urinary symptoms, and thus the apparent development of tolerance with time remains to be proven in the absence of active intervention. This will probably be difcult to ascertain, however, since it currently appears unethical to deny effective treatments to
FIG. 2. Proportion of patients taking analgesic (red bars) and anticholinergic (green bars) medications for stent-related symptoms as a function of time.

100 90 % of patients taking medications

DISCUSSION To the best of our knowledge, the present prospective study is the rst to assess the predictors of morbidity related to indwelling ureteric stenting using an ad hoc constructed, comprehensive and validated questionnaire, such the USSQ. In line with previous representative studies on the subject [11,12], we conrm that stentrelated morbidity is high, in that all patients in our series experienced one or more symptoms

80 70 60 50 40 30 20 10 0 Day 7 Day 28 After removal

TABLE 2 Univariate analysis assessing predictors of morbidity on day 7 after stent placement Urinary symptoms P 0.398 0.068 <0.001 0.207 0.822 0.219 <0.001 Body pain P 0.475 <0.001 0.005 0.927 0.377 0.468 <0.001 General health P 0.787 <0.001 <0.001 0.820 0.128 0.005 <0.001 Work performance P 0.395 0.006 0.066 0.859 0.310 0.024 <0.001 Sexual matters P 0.005 0.211 0.667 0.575 0.435 0.404 <0.001 Additional problems P 0.079 <0.001 0.054 0.746 0.164 0.809 0.968 General quality of life P 0.872 0.093 <0.001 0.861 0.087 0.034 0.120

Variable Age Gender Body mass index Side Length Calibre Distal loop location

TABLE 3 Univariate analysis assessing predictors of morbidity on day 28 after stent placement Urinary symptoms P 0.145 0.159 <0.001 0.616 0.570 0.367 <0.001 Body pain P 0.436 0.001 0.029 0.727 0.139 0.248 <0.001 General health P 0.156 0.418 0.133 0.437 0.557 0.182 <0.001 Work performance P 0.090 0.330 0.090 0.109 0.460 0.069 <0.001 Sexual matters P 0.028 0.090 0.328 0.745 0.601 0.959 <0.001 Additional problems P 0.433 0.657 0.686 0.356 0.497 0.047 0.445 General quality of life P 0.216 0.250 0.105 0.483 0.682 0.140 0.670

Variable Age Gender Body mass index Side Length Calibre Distal loop location

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TABLE 4 Multivariate analysis assessing predictors of morbidity on day 7 after stent placement Urinary symptoms P 0.045 0.347 8.082 0.059 2.998 0.788 0.089 0.590 11.680 0.047 0.618 0.892 0.598 <0.001 Work performance P 0.011 0.625 5.710 0.634 0.305 0.199 0.679 1.534 2.023 0.166 0.736 0.110 0.010 <0.001 Additional problems P 0.020 0.081 0.567 0.537 0.170 0.482 0.141 0.192 0.132 0.224 0.196 0.359 0.468 0.722 General quality of life P 0.005 0.531 0.403 0.522 0.185 0.104 0.053 0.411 0.364 0.056 0.685 0.616 0.059 0.157

Variable Age (per year) Gender (male vs female) Body mass index (per unit) Side (right vs left) Length (per cm) Calibre (per F) Distal loop location (crossing vs not crossing the midline)

Body pain P 0.120 0.318 3.352 0.732 1.842 4.902 1.068 3.478 13.033 0.321 0.219 0.514 0.219 <0.001

General health P 0.012 0.731 1.392 0.010 0.459 0.294 0.016 1.457 1.992 0.303 0.805 0.974 0.087 <0.001

Sexual matters P 0.087 0.229 0.488 0.777 0.621 0.674 0.612 0.486 4.649 0.113 0.371 0.299 0.317 <0.001

, parameter estimate.

TABLE 5 Multivariate analysis assessing predictors of morbidity on day 28 after stent placement Urinary symptoms P 0.055 0.143 5.138 0.097 2.740 1.375 0.01 0.909 3.401 0.025 0.270 0.979 0.304 <0.001 Work performance P 0.047 0.062 1.826 0.283 0.064 0.817 0.198 1.034 0.847 0.791 0.218 0.487 0.060 <0.001 Additional problems P 0.002 0.863 0.629 0.515 0.017 0.616 0.202 0.285 0.054 0.907 0.119 0.212 0.306 0.890 General quality of life P 0.010 0.184 0.246 0.688 0.117 0.108 0.070 0.326 0.143 0.213 0.665 0.494 0.168 0.565

Variable Age (per yr) Gender (male vs female) Body mass index (per unit) Side (right vs left) Length (per cm) Calibre (per F) Distal loop location (crossing vs not crossing the midline)

Body pain P 0.068 0.480 5.109 0.518 1.019 1.676 0.139 2.677 6.413 0.161 0.601 0.916 0.241 <0.001

General health P 0.045 0.177 2.526 0.350 0.577 0.917 0.263 1.240 0.375 0.031 0.402 0.560 0.113 <0.001

Sexual matters P 0.026 0.091 0.206 0.856 0.181 0.690 0.211 0.104 1.847 0.275 0.116 0.320 0.731 <0.001

, parameter estimate.

patients experiencing disturbing symptoms, such as anticholinergics and, as recently shown, -blockers [3,7,14]. The lack of signicant improvement in sexual function might be due to the small sample size. Alternatively, we postulate that sexual function takes a longer time to recover than other physiological functions or activities. The evaluation of predictors of stent-related morbidity has received marginal attention so far. Only three studies investigated the impact of putative clinical determinants of morbidity [5,10,13], and were all limited by

methodological shortcomings, such as the use of non-validated questionnaires, small sample size in Irani et al. [13], and inappropriate statistical analyses in Rane et al. [10]. Irani et al. [13] found that sex and sexage interaction, but not age and type of occupation, were signicantly associated with pain at week 1, with younger men experiencing the highest discomfort. Rane et al. [10] analysed the impact on symptoms of stent characteristics only, such as length of intravesical portion, calibre, degree of completeness of distal loop and distal loop location with respect to midline. They found

that an incomplete distal loop and distal loop crossing the midline were the most signicant factors associated with the symptom complex. However, a multivariable analysis was not performed. El-Nahas et al. [5] found that positive urine culture, distal loop crossing the midline, intracalyceal location of the proximal loop and longer stent indwelling time were all signicantly associated with discomfort on multivariable analysis. Three other studies evaluated the association of single variables with stent-related symptoms measured with USSQ [4,6]. In a

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randomized trial, a smaller stent calibre (4.8 vs 6 F) was not found to be associated with fewer symptoms or better HRQL [4]. In a small non-randomized trial assessing short-term morbidity, stent brand was found to have a signicant impact on urinary symptoms, but not on pain or general health [6]. In a recent randomized trial assessing short-term morbidity, no signicant differences were found with regard to pain score or analgesic consumption between two experimental stents (short distal loop and long distal loop) and two marketed stents [8]. However, patients with a short distal loop stent had lower pain scores on day 4 and lower analgesic consumption on day 1 after placement, when pain peaked in all stent groups. These studies suggest that stent material and design may play a signicant role in the aetiology of the symptom complex, albeit to a lesser extent than investigators expected. Finally, one recent Italian study prospectively assessed the impact of ureteric stenting on sexual function in both sexes using the International Index of Erectile Function-5 and Female Sexual Function Index. In multivariable analysis, sex and indwelling time, but not age or stent length and calibre, were signicantly associated with sexual dysfunction, with male sex and longer stenting time being associated with worse function [15]. A primary limitation, however, was the use of linguistically non-validated questionnaires. Moreover, with International Index of Erectile Function-5 the evaluation of pain during intercourse, which is a commonly reported complaint (64 and 45% of men after 7 and 28 days of stent permanence, respectively, in our validation series [16]), remains unexplored. In the present study, stent distal loop location had the strongest association with most USSQ domains at multivariable analysis, on both days 7 and 28 after placement, and with the number of both analgesics and anticholinergics taken. Stent distal loop crossing the midline was associated with worse symptoms, possibly due to the longer intravesical portion or direct contact with the contralateral side bladder wall. This nding corroborates data of previous preliminary studies [5,10]. However, no signicant correlation was found between stent length and distal loop location, as one might intuitively have expected. As shown in one small study [17], stent length and location of

proximal and distal loop signicantly changed with varying patient position. It is therefore plausible that even if a stent of appropriate length is correctly placed that is, with the shortest possible intrarenal and intravesical portion its position may then vary. Further research in this area is warranted. In addition, BMI, which has never been previously investigated as a possible predictor of morbidity, showed a signicant association with urinary symptoms, general health and number of anticholinergics taken, thereby conrming the notion that overweight patients are more prone to experiencing lower urinary tract symptoms [18,19]. There are some limitations to the present study. First, albeit prospective, the study was not randomized for stent length and calibre, and thus a bias could have been introduced. Second, the present series included a well selected cohort of patients without lower urinary tract dysfunction or malignant obstruction and undergoing uncomplicated ureterorenoscopy. One might argue that in cases of underlying voiding dysfunction, chronic ureteric obstruction or longer and complicated upper urinary tract manipulation, the symptom complex is worse, with the result that the present predictors might not apply. Likewise, only a single type of stent was used in our study. It has been shown that symptoms can vary according to some stent properties (design, material and coating) [6,20]. Third, we did not evaluate previously investigated stent-related variables, such as length of intravesical portion, degree of completeness of distal loop, and intracalyceal location of proximal loop, but this was deliberately done. In fact, while degree of completeness of distal loop and intracalyceal location of proximal loop were not applicable in our study, since a correct stent placement was by denition the one with a complete loop in both the renal pelvis and the bladder, the length of intravesical portion appears to be a cumbersome variable to determine compared with binary distal loop location (i.e. crossing the midline or not). Finally, the 4week indwelling time for ureteric stenting after uncomplicated ureterorenoscopy could be deemed inappropriately long, since it is current practice to leave indwelling ureteric stents for a far shorter time [21]. As a result of the present study, patients following uncomplicated ureterorenoscopy at our institution are now stented for only 1 week. It would thus be highly desirable also to

evaluate stent-related morbidity in the immediate postoperative period (i.e. days) using ad hoc tools. Further well designed trials of adequate power are needed to determine which clinical factors and stent characteristics are responsible for the stent-related symptom complex. Based on the present ndings, investigators will need to incorporate BMI and distal loop location as potential variables of interest. In conclusion, in the present study the location of stent distal loop with respect to midline had the strongest association with most USSQ domains on both days 7 and 28 after stent placement. The visualization of stent distal loop crossing the midline could therefore help to identify patients at higher risk of post-procedural morbidity requiring early management.

CONFLICT OF INTEREST None declared.

REFERENCES 1 2 Tolley D. Ureteric stents, far from ideal. Lancet 2000; 356: 87273 Joshi HB, Newns N, Stainthorpe A, McDonagh RP, Keeley FX Jr, Timoney AG. Ureteral stent symptom questionnaire: development and validation of a multidimensional quality of life measure. J Urol 2003; 169: 1060 4 Deliveliotis C, Chrisofos M, Gougousis E, Papatsoris A, Dellis A, Varkarakis IM. Is there a role for alpha1-blockers in treating double-J stent-related symptoms? Urology 2006; 67: 359 Damiano R, Autorino R, De Sio M et al. Does the size of ureteral stent impact urinary symptoms and quality of life? A prospective, randomized study. Eur Urol 2005; 48: 6738 El-Nahas AR, El-Assmy AM, Shoma AM, Eraky I, El-Kenawy MR, ElKappany HA. Self-retaining ureteral stents: analysis of factors responsible for patients discomfort. J Endourol 2006; 20: 337 Lee C, Kuskowski M, Premoli J, Skemp N, Monga M. Randomized evaluation of ureteral stents using validated symptom

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questionnaire. J Endourol 2005; 19: 990 3 7 Damiano R, Autorino R, De Sio M, Giacobbe A, Palumbo IM, DArmiento M. Effect of tamsulosin in preventing ureteral stent-related morbidity: a prospective study. J Endourol 2008; 22: 6516 8 Lingeman JE, Preminger GM, Goldscher ER, Krambeck AE, Comfort Study Team. Assessing the impact of ureteral stent design on patient comfort. J Urol 2009; 181: 25817 9 Giannarini G, Keeley FX Jr, Valent F et al. The Italian linguistic validation of the Ureteral Stent Symptoms Questionnaire. J Urol 2008; 180: 624 8 10 Rane A, Saleemi A, Cahill D, Sriprasad S, Shrotri N, Tiptaft R. Have stentrelated symptoms anything to do with placement technique? J Endourol 2001; 15: 7415 11 Joshi HB, Stainthorpe A, McDonagh RP, Keeley FX Jr, Timoney AG. Indwelling ureteral stents: evaluation of symptoms, quality of life and utility. J Urol 2003; 169: 10659 12 Nabi G, Cook J, NDow J, McClinton S. Outcomes of stenting after uncomplicated ureteroscopy: systematic

13

14

15

16

17

review and meta-analysis. BMJ 2007; 334: 572 Irani J, Siquier J, Pirs C, Lefebvre O, Dor B, Aubert J. Symptom characteristics and the development of tolerance with time in patients with indwelling double-pigtail ureteric stents. BJU Int 1999; 84: 2769 Beddingeld R, Pedro RN, Hinck B, Kreidberg C, Feia K, Monga M. Alfuzosin to relieve ureteral stent discomfort: a prospective, randomized, placebo controlled study. J Urol 2009; 181: 1706 Sighinol MC, Micali S, De Stefani S et al. Indwelling ureteral stents and sexual health: a prospective, multivariate analysis. J Urol 2007; 178: 22931 Giannarini G, Mogorovich A, Selli C, Keeley FX Jr. Re: Indwelling ureteral stents and sexual health: a prospective, multivariate analysis. M. C. Sighinol, S. Micali, S. De Stefani, A. Mofferdin, M. Grande, M. Giacometti, N. Ferrari, M. Rivalta and G. Bianchi. J Urol 2007; 178: 229231. J Urol 2008; 180: 11889 Chew BH, Knudsen BE, Nott L et al. Pilot study of ureteral movement in stented patients: rst step in understanding dynamic ureteral anatomy to improve stent comfort. J Endourol 2007; 21: 1069 75

18 Tubaro A, Palleschi G. Overactive bladder: epidemiology and social impact. Curr Opin Obstet Gynecol 2005; 17: 507 11 19 Parsons JK, Sarma AV, McVary K, Wei JT. Obesity and benign prostatic hyperplasia: clinical connections, emerging etiological paradigms and future directions. J Urol 2009; 182 (Suppl. 6): S2731 20 Chew BH, Duvdevani M, Denstedt JD. New developments in ureteral stent design, materials and coatings. Expert Rev Med Devices 2006; 3: 395403 21 Auge BK, Sarvis JA, Lesperance JO, Preminger GM. Practice patterns of ureteral stenting after routine ureteroscopic stone surgery: a survey of practicing urologists. J Endourol 2007; 21: 128791 Correspondence: Gianluca Giannarini, MD, Department of Urology, University of Pisa, Ospedale di Cisanello, via Paradisa 2, I-56124 Pisa, Italy. e-mail: gianluca.giannarini@hotmail.it Abbreviations: BMI, body mass index; HRQL, health-related quality of life; USSQ, Ureteric Stent Symptoms Questionnaire.

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