|Year : 2020 | Volume
| Issue : 3 | Page : 86-90
A prospective observational study on the utility of smartphone-based Ureteral Stent Tracker (UST) application in preventing cases of forgotten ureteral double-J stents
S Sengupta1, S Basu1, K Ghosh2
1 Department of Urology, RG Kar Medical College and Hospital, Kolkata, West Bengal, India
2 Department of Radiology, North Bengal Medical College and Hospital, Sushrutanagar, West Bengal, India
|Date of Submission||27-Sep-2020|
|Date of Acceptance||17-Dec-2020|
|Date of Web Publication||07-Aug-2021|
Dr. S Sengupta
Flat 4 D, Sarala Apartment, 7/2 Motijheel, Dumdum Road, Kolkata, West Bengal - 700 074
Source of Support: None, Conflict of Interest: None
Background: The use of ureteral stents is an integral part of daily urological practice. These need to be removed after a specified time limit. Unfortunately, some of the DJ stents are forgotten and hence retained. This is where the usefulness of smartphone-based Ureteral Stent Tracker (UST) application comes into play. In this study, we have aimed to evaluate the efficacy and usefulness of smartphone-based UST application and compare the results with basic appointment card system to prevent forgotten ureteral stents (FUS).
Patients and Methods: It is a prospective observational study including a total of 118 patients. They were divided into two groups. Those in group A, were recorded to UST application and those in group B, were provided with only the printed advice to remove their ureteral stent. The two groups were compared in terms of overdue days and lost to follow-up rates.
Results: Groups A and B were comparable with no statistically significant differences among the groups regarding age, educational level and laterality of the ureteral stent. The mean overdue days were 4.25 ± 3.627 and 11.49 ± 6.273 in group A and B respectively.
Conclusions: In our study, we checked the dashboard of the ST application every day to look for overdue days. Patients followed up with the stent tracker application had significantly less overdue days compared to those who were not. So, UST can be an important addition to daily urological practice to minimise the incidence of retained ureteral stents.
Keywords: Overdue, patient's smart phone, retained ureteral stent, ureteral stents
|How to cite this article:|
Sengupta S, Basu S, Ghosh K. A prospective observational study on the utility of smartphone-based Ureteral Stent Tracker (UST) application in preventing cases of forgotten ureteral double-J stents. Arch Int Surg 2020;10:86-90
|How to cite this URL:|
Sengupta S, Basu S, Ghosh K. A prospective observational study on the utility of smartphone-based Ureteral Stent Tracker (UST) application in preventing cases of forgotten ureteral double-J stents. Arch Int Surg [serial online] 2020 [cited 2022 Sep 29];10:86-90. Available from: https://www.archintsurg.org/text.asp?2020/10/3/86/323466
| Background|| |
The use of ureteral stents is an integral part of the daily urological practice. Double-J stents (DJ stents) are used in the management of urolithiasis, both before primary treatment to relieve acute obstruction and post-open or endo-urological stone extraction surgeries. They are also used to relieve ureteral obstruction from benign or malignant extrinsic causes, to promote ureteral healing following surgeries like ureteral re-implantation or ureteroureterostomy. In patients, with ureterovaginal fistula, DJ stents can help treat urinary leakage.
Most DJ stents are inserted as temporary measures and need removal as per guidelines based on the material of DJ stent used. Unfortunately, as much as 12% of DJ stents are retained or forgotten. These retained stents lead to recurrent urinary tract infection (UTI), haematuria, migration, encrustation and fragmentation., Sepsis and renal failure are known complications of forgotten ureteral stents (FUS). FUS increases the overall treatment costs and is one of the major cause of litigation faced by urologists. Removal of infected FUS is a challenge in itself and requires complicated endo-urologic procedures.
Therefore tracking of these patients are of utmost importance to avoid increased morbidity and healthcare cost. Different stent tracking and registry systems are in use including paper card registry, electronic patient registry,, and computer-based email, or short-message service (SMS) reminders. Smartphones are in widespread use even in lower-middle-income countries like India.
Management of FUS may require urological expertise with complex urological procedures for removal like Extracorporeal Shock wave Lithotripsy (ESWL), Ureteroscopic Lithotripsy (URS-L) or Percutaneous Nephrolithotomy (PCNL) or even open and laparoscopic techniques.,,, FUS is also a major cause of litigations faced by practising urologists. In a study by Osman and Collins, major causes of patient dissatisfaction with care was postoperative related claims out of which, FUS were 23 cases in a total of 168 claims.
Several stent tracking systems were popularised. Card registry system, introduced by Tang et al., was concluded to be ineffective. Thomas et al. evaluated the ureteral stent logbook system but a bulk of the patients were unaccounted as stent removal was not documented properly. These written systems were cumbersome and needed a lot of paperwork. Computer-based system for stent tracking worked wonders in bringing down overdue times significantly.,, Few electronic stent registers, sent SMS reminders instead of e-mails.,
In this study, we intend to use smart phone-based ureteral stent tracking application on patients discharged with ureteral stents in situ. As, we mainly cater to the needs of low socioeconomic population where cell phone has just made its way into the patients' life, the usefulness of this application to prevent retained ureteral stents was analysed.
| Patients and Methods|| |
This is a prospective longitudinal observational study conducted in a tertiary care centre in Kolkata, catering to the needs of urological patients. The study duration is between May, 2019 and May, 2020. Study was conducted as per guidelines of the Declaration of Helsinki. A written consent was taken in the patients' native language regarding enrolment in this study design. Patients between 18 years to 65 years who underwent ureteral stenting following URS-L, PCNL, open ureterolithotomy and ESWL were included in the study. Only patients or their caregivers, who had a cell phone, were included in the study. Patients with long indwelling stents for malignancy were excluded.
One hundred and eighteen patients were included in the study population. Only open end, 6 French (F)/26 cm DJ stent were used. The same manufacturer manufactured all the stents. These stents were made available free of cost by the Health Ministry of West Bengal, India. We usually removed indwelling stents 3 weeks after surgery as per institutional protocol. Patients received alpha-blockers (e.g. tamsulosin) on demand for stent-related symptoms.
Patients were divided into two groups. In group A, 59 patients were allocated to the stent tracker (ST) application group, which is available in Google play store, running on a smart android phone in addition to a printed advice on stent removal date and complications. The dashboard of ST application was followed every day. In group B, which also consisted of 59 subjects, only the printed advice was provided and they were asked to return to the hospital on a scheduled date with urine culture report for stent removal.
The education level of the patient population was divided into three categories. Primary meant education level of minimum class 1 standard and ≤6th standard. Higher education signified patients who had cleared matriculation at least (i.e. 10th standard). Those who had bachelor degree from college or were pursuing the same were grouped as university education.
DJ stents used in our hospital are made of polyurethane. We follow the protocol of keeping the DJ stents not more than 6 weeks, if it is introduced for temporary reasons. There is a correlation between indwelling time of ureteral stents, encrustation and biofilm formation. These infected and encrusted FUS can lead to urinary tract obstruction, infection, septic shock and even death.
In both groups, the patients and their caregivers were also verbally informed about the presence of stent and all the complications that might arise, if advice was ignored. For ethical and medico-legal reasons, the maximum waiting period for the patients who did not return to the hospital for stent removal was limited to 6 weeks, after which they were contacted over phone individually. The two groups were compared in terms of overdue times and lost to follow-up rates.
This ST application can only be downloaded by registered urologists from Google play store. This application allows the physicians to monitor the overdue, incomplete and complete sections and tracks the patients. Each created profile shows patient information including address, phone number, and stent insertion date, laterality, proposed stent removal date and extraction date if stent has already been removed [Figure 1] and [Figure 2].
|Figure 1: Patients' demographic and operative details as recorded in the stent tracking application with contact numbers|
Click here to view
The results were presented as mean ± standard deviation (SD). The Student's t test and Mann-Whitney u test were used to compare independent quantitative data. Qualitative data was compared using Chi-square test. Statistical significance was assessed with two-tailed test and P was considered significant if less than 0.05. We used IBM SPSS 26.0 for statistical analysis.
| Results|| |
The subjects in the study population had a mean age (in years) of 34.76 ± 11.75 standard deviation (SD). Seventy five males (63.55%) and 43 females (36.44%) formed the study population.
One hundred and four (88.13%), 10 (8.4%) and 4 (3.38%) were classified as primary, higher and university categories respectively. Seventy-one (60.16%) and 47 (39.83%) patients had stent on the left and right side respectively. None of the patients had bilateral DJ stent in situ.
The mean age composition (in years) of group A and B was 34.76 ± 11.75 and 35.30 ± 11.81 respectively. Most of the patients (88.13%) were educated only up to the primary level in either group. Males made up 59.32% and 67.79% of the patients in group A and B respectively. Both the groups had majority of the stents on the left side [Table 1] and [Table 2].
There was no statistically significant difference between the two groups in terms of age, sex, education level and laterality of the stents. In group A, only 8 subjects (13.55%) reported on the day of appointment for their stent removal. In group B, only 1 patient (1.69%) reported on the day of appointment. All the patients in group A and 55 patients (93.22%) in group B, who missed their appointment, returned for stent removal within 6 weeks of insertion of stent. The remaining 4 patients (6.77%) in group B were called over phone after 6 weeks and subsequently got their stents removed. The mean overdue (days) in group A and group B was 4.2542 ± 3.62 (SD) and 11.49 ± 6.27 (SD) respectively. A part of the reason for the delay in either group was that we run the urology outpatient department in our hospital biweekly. The major reason cited by the patients were failure to understand the instructions, poor state of transportation due to lockdown imposed due to covid-19 pandemic and personal and familial health issues.
All stents were removed in both groups. Among, those who did not return, statistical evaluation revealed that group A patients had significantly less overdue times (p = 0.001) and lost to follow-up cases as compared to group B.
| Discussion|| |
With the technological advancement in urological practice, endo-urological procedures make up the majority of the workload of most urologists. DJ stenting is an integral part of these procedures along with management of ureterovaginal fistula, as well as benign and malignant ureteral obstructions. These increased the complications from stent insertions to retained or forgotten stents.
In this study, no sex predilection for retained ureteral stents were noted. In a similar study by Divakaruni et al., males were 2.5 times more likely to have FUS compared to females. The distribution of patients with education level was exactly the same in the two groups in our study and showed no correlation with FUS incidence.
With the revolutionary expansion of the telecom industry in India, cell phones are no more the thing of the future. Medical applications can be run in smartphones. In our study, we checked the dashboard of the ST application every day to look for over dues. Patients were automatically reminded of the stent removal appointment by SMS. We could track down all the patients and get their stents removed without complications. In a similar study by Ziemba et al., defaulters could be easily traced with ST application. Another study of a shorter duration by Ulker V et al., the group followed by ureteral stent tracker application has statistically significant less overdue time compared to control.
There are some limitations despite advantages of ST application. We allotted patients in two groups based on the sequence of their presentation to the institution. We didn't follow any strict randomisation protocol. A study of a longer duration with more study population can provide us with more valuable data. This application is not integrated to our institutional medical registry so it is the responsibility of all the urologists to fill in the patient details in the application manually separately. India still has a majority of the population without a cell phone. We had been trying to cut down this shortcoming by reaching out to the patients through the primary health care setup in their locality and through several non-profit organisations.
| Conclusion|| |
We conclude that smart phone-based ureteral stent tracking application can minimise overdue days and minimise the incidence of retained ureteral stents with its antecedent complications. Age, sex, educational level and laterality had no predilection for forgotten ureteral stents. ST application is quite new to our practise but is already having a positive impact in our daily practise. It's secure and easy to use application allows urologists to effectively track their patients with indwelling stents and identify the defaulters at the onset.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lange D, Bidnur S, Hoag N, Chew BH. Ureteral stent associated complications--Where we are and where we are going. Nat Rev Urol 2015;12:17-25.
Divakaruni N, Palmer CJ, Tek P, Bjurlin MA, Gage MK, Robinson J, et al
. Forgotten ureteral stents: Who's at risk? J Endourol 2013;27:1051-4.
Kawahara T, Ito H, Terao H, Yoshida M, Matsuzaki J. Ureteral stent encrustation, incrustation, and coloring: Morbidity related to indwelling times. J Endourol 2012;26:178-82.
Lynch MF, Ghani KR, Frost I, Anson KM. Preventing the forgotten ureteric stent: Results from the implementation of an electronic stent register. BJU Int 2007;99:245-6.
Singh V, Srinivastava A, Kapoor R, Kumar A. Can the complicated forgotten indwelling ureteric stents be lethal? Int Urol Nephrol 2005;37:541-6.
Tang VC, Gillooly J, Lee EW, Charig CR. Ureteric stent card register-a 5-year retrospective analysis. Ann R Coll Surg Engl 2008;90:156-9.
Lynch MF, Ghani KR, Frost I, Anson KM. Preventing the forgotten ureteral stent: Implementation of a web-based stent registry with automatic recall application. Urology 2007;70:423-6.
Sancaktutar AA, Tepeler A, Soylemez H, Penbegul N, Atar M, Bozkurt Y, et al
. A solution for medical and legal problems arising from forgotten ureteral stents: Initial results from a reminder short message service (SMS). Urol Res 2012;40:253-8.
Pais VM Jr, Chew B, Shaw O, Hyams ES, Matlaga B, Venkatesh R, et al
. Percutaneous nephrolithotomy for removal of encrusted ureteral stents: A multicenter study. J Endourol 2014;28:1188-91.
Aravantinos E, Gravas S, Karatzas AD, Tzortzis V, Melekos M. Forgotten, encrusted ureteral stents: A challenging problem with an endourologic solution. J Endourol 2006;20:1045-9.
Lam JS, Gupta M. Tips and tricks for the management of retained ureteral stents. J Endourol 2002;16:733-41.
Bhansali M, Patankar S, Dobhada S. Laparoscopic management of a retained heavily encrusted ureteral stent. Int J Urol 2006;13:1141-3.
Duty B, Okhunov Z, Okeke Z, Smith A. Medical malpractice in endourology: Analysis of closed cases from the State of New York. J Urol 2012;187:528-32.
Osman NI, Collins GN. Urological litigation in the UK National Health Service (NHS): An analysis of 14 years of successful claims. BJU Int 2011;108:162-5.
Thomas AZ, Casey RG, Grainger R, McDermott T, Flynn R, Thornhill JA. The forgotten ureteric JJ stent and its prevention: A prospective audit of the value of a ureteric stent logbook. Ir J Med Sci 2007;176:117-9.
McCahy PJ, Ramsden PD. A computerized ureteric stent retrieval system. Br J Urol 1996;77:147-8.
Ather MH, Talati J, Biyabani R. Physician responsibility for removal of implants: The case for a computerized program for tracking overdue double-J stents. Tech Urol 2000;6:189-92.
Baumgarten AC, Rydberg MG, Bates JN, Teigland JM, Roy OP. Reducing the incidence of retained double-J ureteral stents: A multidisciplinary approach. Urol Pract 2016;3:325-31.
Sabharwal S, Macaden AR, Abrol N, Mukha RP, Kekre NS. A novel computer based stent registry to prevent retained stents: Will patient directed automated short message service and letter generator help? Indian J Urol 2014;30:150-2.
] [Full text]
Ziemba JB, Ludwig WW, Ruiz L, Carvalhal E, Matlaga BR. Preventing the forgotten ureteral stent by using a mobile point-of-care application. J Endourol 2017;31:719-24.
Ulker V, Atalay HA, Cakmak O, Yucel C, Celik O, Kozacioglu Z. Smartphone-based stent tracking application for prevention of forgotten ureteral double-J stents: A prospective study. Int Braz J Urol 2019;45:376-83.
[Figure 1], [Figure 2]
[Table 1], [Table 2]