Ureteroscopy is an established treatment modality for ureteric calculi. Following ureteroscopic stone treatment, placement of a double-J (DJ) ureteral stent is commonly performed to maintain urinary drainage, reduce the consequences of postoperative ureteral oedema and facilitate passage of residual fragments. However, stent placement is not without morbidity. Patients may experience lower urinary tract symptoms, flank pain, suprapubic discomfort, haematuria and disturbances in daily activities during the period of stent indwelling.

The symptoms associated with ureteral stents are multifactorial. Proposed mechanisms include mechanical irritation of the bladder trigone by the distal coil, vesicoureteral reflux during voiding, ureteral spasm and local mucosal irritation. Stent characteristics, including length, configuration and material, may also influence symptom severity. The impact of these symptoms can extend beyond physical discomfort and affect sleep, work performance, sexual activity and overall quality of life.

Haleblian and colleagues reviewed the role of ureteral stenting in urinary stone management and highlighted the need to balance the potential benefits of stenting against its associated morbidity.¹ Nabi and colleagues, in a systematic review and meta-analysis, evaluated the outcomes of stenting following uncomplicated ureteroscopy and demonstrated that routine stenting is associated with both potential benefits and disadvantages.²

The Ureteral Stent Symptom Questionnaire (USSQ), developed and validated by Joshi and colleagues, provides a multidimensional instrument for assessing the impact of ureteral stents. It evaluates urinary symptoms, body pain, general health, work performance, sexual matters and additional problems.³ The questionnaire has subsequently been used in several clinical studies evaluating stent-related morbidity.

Previous studies have reported considerable variation in the prevalence and severity of stent-associated symptoms. Joshi and colleagues demonstrated a high prevalence of urinary symptoms among patients with indwelling ureteral stents.⁴ Bosio and colleagues reported substantial urinary and pain-related morbidity following semirigid and flexible ureteroscopy.⁵ More recently, the multicentre STENTS study evaluated the longitudinal pattern of stent-associated symptoms and identified changes in symptom burden during the postoperative period and following stent removal.⁶

Although the literature establishes that ureteral stents can affect patient comfort and quality of life, the pattern of symptoms and their subsequent changes following stent removal remain clinically relevant outcomes, particularly in routine clinical practice.

The present study was undertaken to evaluate the prevalence and pattern of DJ stent-related symptoms following semirigid ureteroscopy for ureteric calculi using the USSQ and to compare symptom scores during the indwelling period with those recorded four weeks after stent removal.

Study design and setting

This prospective observational study was conducted in the Department of Urology, Government General Hospital, Guntur, Andhra Pradesh, India, between January 2024 and September 2024. The study was approved by the Institutional Ethics Committee. Written informed consent was obtained from all participants in a language understood by them before enrolment.

Study population

A total of 110 consecutive adult patients undergoing semirigid ureteroscopy for ureteric calculi, followed by DJ ureteral stent placement, were included in the study. All patients underwent semirigid ureteroscopy. Patients undergoing flexible ureteroscopy or DJ stenting for indications other than ureteric calculi were not included.

Sample-size calculation

The sample size was estimated using a previously reported prevalence of urinary symptoms among patients with indwelling ureteral stents. Joshi et al. reported that 80% of patients experienced at least one urinary symptom in their prospective study of ureteral stent-related morbidity.⁴

Using an anticipated prevalence of 80%, a 95% confidence level and an absolute precision of 8%, the sample size was calculated using the formula:

n = Z² × p × (1 − p) / d²

Where:

• Z = 1.96 (95% confidence level)
• p = 0.80 (anticipated prevalence of stent-related urinary symptoms)
• d = 0.08 (absolute precision of 8%)

Substituting the values:

n = (1.96)² × 0.80 × (1 − 0.80) / (0.08)²

n = 3.8416 × 0.80 × 0.20 / 0.0064

n = 96.04 ≈ 96 patients

Allowing for approximately 10% potential attrition:

Adjusted sample size = 96.04 / (1 − 0.10)

Adjusted sample size = 96.04 / 0.90

Adjusted sample size = 106.7 ≈ 107 patients

The final target sample size was increased to 110 patients. Accordingly, 110 consecutive eligible patients were enrolled in the study.

Surgical procedure and stent placement

All procedures were performed under spinal anaesthesia using semirigid ureteroscopy. Pneumatic lithotripsy was used for stone fragmentation. Following ureteroscopic treatment, a unilateral 4.7 Fr × 26 cm DJ ureteral stent was placed in all patients. Postoperative medical management included analgesics, antibiotics, silodosin 8 mg and mirabegron 25 mg, administered together at bedtime. All patients received the same silodosin and mirabegron regimen.

Stent removal and follow-up

DJ stent removal was performed using rigid cystoscopy at approximately three weeks after the index procedure. The median stent dwell time was 22 days (IQR 17–25).

Patients were assessed at two time points:

1. Postoperative day 7 ±1 day, while the DJ stent was in situ.
2. Four weeks ±7 days after DJ stent removal.

Assessment of stent-related symptoms

Stent-related symptoms were assessed using the Ureteral Stent Symptom Questionnaire (USSQ), a multidimensional questionnaire developed by Joshi and colleagues.³ The questionnaire evaluates six domains:

1. Urinary symptoms.
2. Body pain.
3. General health.
4. Work performance.
5. Sexual matters.
6. Additional problems.

The questionnaire was administered with interviewer assistance, using Hindi and Telugu according to the patient's language comprehension. A Hindi linguistic and cultural validation of the USSQ has previously been published.⁷ However, the Telugu version used for communication in this study had not undergone formal linguistic validation. This limitation was considered during interpretation of the questionnaire results.

Individual symptoms recorded during the indwelling period included urinary frequency, urgency, dysuria, flank pain, suprapubic or bladder pain, visible haematuria, urinary incontinence or leakage and sleep disturbance.

Postoperative events, including analgesic use, unplanned hospital visits and clinically diagnosed urinary tract infection, were also recorded. Urinary tract infection was documented based on the treating clinician's diagnosis; a uniform urine culture-based diagnostic criterion was not applied.

Study outcomes

The primary outcome was the prevalence and pattern of individual stent-related symptoms on postoperative day 7. The secondary outcome was the change in USSQ domain scores between postoperative day 7 and four weeks after stent removal.

Statistical analysis

Statistical analysis was performed using IBM SPSS Statistics version 20.0. Categorical variables were expressed as frequencies and percentages. Continuous variables were summarised using mean and standard deviation or median and interquartile range, as appropriate. Paired USSQ domain scores recorded on postoperative day 7 and four weeks after stent removal were compared using the two-sided Wilcoxon signed-rank test. A p-value of less than 0.05 was considered statistically significant. Since six USSQ domains were assessed, a Bonferroni-adjusted significance threshold of 0.0083 was also considered.

Demographic and clinical characteristics

A total of 110 patients were included in the study. The mean age was 39.8 ± 12.6 years. There were 69 males (62.7%) and 41 females (37.3%). Right-sided ureteric calculi were present in 57 patients (51.8%), while 53 patients (48.2%) had left-sided calculi. The mean stone size was 11.7 ± 3.6 mm. All 110 patients underwent semirigid ureteroscopy with pneumatic lithotripsy and unilateral DJ stent placement. The mean operative duration was 47.6 ± 15.9 minutes. Complete stone clearance was achieved in 102 patients (92.7%), while eight patients (7.3%) had incomplete clearance. The median DJ stent dwell time was 22 days (IQR 17–25).

Table 1. Baseline demographic and clinical characteristics

Prevalence and pattern of symptoms during the indwelling period

The most frequently reported symptoms on postoperative day 7 were urinary urgency, reported by 81 patients (73.6%), and urinary frequency, reported by 79 patients (71.8%). Flank pain was reported by 70 patients (63.6%), while 66 patients (60.0%) experienced dysuria or burning micturition. Sleep disturbance was reported by 54 patients (49.1%), and suprapubic or bladder pain by 50 patients (45.5%). Visible haematuria was reported by 37 patients (33.6%). Urinary incontinence or leakage was the least frequently reported symptom, occurring in 14 patients (12.7%).

Table 2. Prevalence of individual stent-related symptoms on postoperative day 7

During the postoperative period up to the first assessment, 76 patients (69.1%) required analgesics. Six patients (5.5%) had an unplanned hospital visit, and three patients (2.7%) were diagnosed with a urinary tract infection based on clinical assessment.

Comparison of USSQ scores before and after stent removal

Complete paired USSQ data were available for all 110 patients. Comparison of domain scores obtained on postoperative day 7 with those recorded four weeks after stent removal demonstrated a statistically significant reduction in all six domains. The median urinary symptom score decreased from 29 (IQR 26–31.75) during the indwelling period to 16 (IQR 15–18) after stent removal (p<0.001). The median body pain score decreased from 18 (IQR 14–21) to 3 (IQR 2–3) (p<0.001). The general health score decreased from 12 (IQR 11–14) to 6 (IQR 6–7) (p<0.001). The median work performance score decreased from 6 (IQR 5–7) to 5 (IQR 4–6), while the sexual matters score decreased from 3 (IQR 2–4) to 2 (IQR 2–3). Both changes were statistically significant (p<0.001).

The additional problems score decreased from 8 (IQR 7–10) to 4 (IQR 3.25–5) (p<0.001).

Table 3. Comparison of USSQ domain scores during the indwelling period and after stent removal

Paired comparisons were performed using the two-sided Wilcoxon signed-rank test. All comparisons remained statistically significant using a Bonferroni-adjusted significance threshold of 0.0083.

A reduction in scores was observed in all 110 patients in the urinary symptoms, body pain and general health domains. Improvement in work performance was observed in 65 patients (59.1%), with unchanged scores in 18 (16.4%) and higher scores in 27 (24.5%). In the sexual matters domain, 63 patients (57.3%) had lower scores, 20 (18.2%) had unchanged scores and 27 (24.5%) had higher scores. In the additional problems domain, 103 patients (93.6%) had lower scores, three (2.7%) had unchanged scores and four (3.6%) had higher scores.

Ureteral stent placement following ureteroscopy is a common practice in the management of ureteric calculi. Although stents provide postoperative drainage and may be useful in selected clinical situations, their presence can result in substantial patient discomfort. The present study evaluated the pattern of stent-related symptoms in 110 patients undergoing semirigid ureteroscopy and assessed changes in symptom scores following stent removal.

The principal finding was the high prevalence of storage urinary symptoms during the indwelling period. Urgency was reported by 73.6% of patients and frequency by 71.8%. Flank pain and dysuria were also common, affecting 63.6% and 60.0% of patients, respectively. These findings indicate that urinary irritation and pain constitute important components of the symptom burden associated with ureteral stents.

The findings are consistent with earlier studies evaluating stent-related morbidity. Joshi and colleagues, in their prospective assessment of patients with unilateral ureteral stents, reported that 80% of patients who completed their study experienced at least one urinary symptom.⁴ In a subsequent study, Joshi and colleagues demonstrated that indwelling ureteral stents were associated with bothersome urinary symptoms and impaired quality of life.⁸ These studies established the importance of systematically assessing symptoms rather than relying solely on routine clinical follow-up.

Bosio and colleagues evaluated symptoms following semirigid and flexible ureteroscopy in a prospective observational study involving 232 patients. They reported substantial rates of urinary frequency, urgency, burning micturition and pain during the stent indwelling period.⁵ The high prevalence of urgency, frequency and pain in the present study is broadly consistent with these observations. However, direct comparison of symptom percentages should be interpreted cautiously because of differences in patient populations, assessment methods and follow-up schedules.

The mechanism of stent-related symptoms is multifactorial. Irritation of the bladder trigone by the distal coil may contribute to urgency, frequency and dysuria. Vesicoureteral reflux during micturition may contribute to flank pain, while mechanical irritation and local inflammation may contribute to haematuria and discomfort. Stent length and configuration may also influence the severity of urinary symptoms. Ho and colleagues demonstrated an association between stent configuration and irritative urinary symptoms, highlighting the importance of appropriate stent positioning and length.⁹ In the present study, all patients received a stent of the same dimensions, limiting variation in stent size within the cohort.

Pain was another prominent component of stent-associated morbidity. Flank pain was reported by nearly two-thirds of patients, while suprapubic or bladder pain occurred in 45.5%. These symptoms can interfere with sleep and daily activities. In the present cohort, sleep disturbance was reported by 49.1% of patients, and 69.1% required analgesics during the early postoperative period. These findings emphasise that stent-related morbidity extends beyond urinary symptoms and can have a meaningful effect on patient comfort.

The USSQ provides a structured method for evaluating these multidimensional effects. Developed by Joshi and colleagues, it assesses urinary symptoms, body pain, general health, work performance, sexual matters and additional problems.³ Its use allows symptom burden to be assessed systematically across different aspects of daily life. A Hindi linguistic and cultural validation of the USSQ has also been published, supporting its use in an Indian clinical context when that validated version is administered.⁷ However, the use of both Hindi and Telugu in the present study, without a formally validated Telugu version, represents a potential source of measurement variability.

In the present study, all six USSQ domains demonstrated statistically significant reductions in scores four weeks after stent removal. The largest absolute median reductions were observed in body pain and urinary symptoms. The median body pain score decreased from 18 to 3, while the urinary symptom score decreased from 29 to 16. These changes suggest that the physical discomfort and urinary irritation experienced during the indwelling period were substantially lower at the post-removal assessment.

The reduction in general health scores also suggests improvement in patients' perceived overall health status after the stent was no longer present. However, the changes in work performance and sexual matters were less pronounced. Although the median scores in these domains decreased, individual-level improvement was observed in only 59.1% and 57.3% of patients, respectively. This difference may reflect the influence of factors beyond the physical presence of the stent, including postoperative recovery, occupational demands and individual circumstances. The findings also indicate that improvement in urinary symptoms and pain does not necessarily translate into uniform improvement across all quality-of-life domains.

The multicentre STENTS study by Harper and colleagues provides important longitudinal evidence regarding stent-associated symptoms following ureteroscopy for urinary stones. The investigators assessed symptoms at multiple time points, including after stent removal, and demonstrated that symptom burden changes over time.⁶ The reduction in USSQ scores observed in the present study is consistent with the broader observation that symptoms improve following removal of the indwelling device. Nevertheless, the present study used only two assessment time points and therefore cannot describe the detailed trajectory of symptom development during the entire postoperative period.

Pharmacological treatment has been investigated as a strategy to reduce stent-related discomfort. Alpha-blockers may reduce smooth muscle activity and ureteral spasm, while beta-3 adrenergic agonists may help alleviate storage urinary symptoms. Meta-analyses by Lamb and colleagues and Zhou and colleagues reported benefits of pharmacological interventions, particularly alpha-blockers and antimuscarinic-based regimens, in reducing selected stent-related symptoms.¹⁰,¹¹ All patients in the present study received silodosin and mirabegron. Consequently, the symptom prevalence observed in this cohort represents the symptom burden under this postoperative treatment regimen. The study was not designed to compare pharmacological treatment strategies, and no conclusion regarding the independent efficacy of either medication or their combination can be drawn.

The importance of stent design and alternative stent configurations has also been explored. Dellis and colleagues reviewed engineering and pharmacological approaches to reducing stent-related symptoms.¹² More recently, Bosio and colleagues evaluated a pigtail suture stent as an alternative to conventional DJ stents and reported a reduction in stent-related symptoms in their prospective multicentre study.¹³ These developments highlight the continuing effort to reduce stent-related morbidity through both pharmacological and device-related approaches.

The present study has several clinically relevant observations. First, it demonstrates that storage urinary symptoms and pain are common during the early period following semirigid ureteroscopy with DJ stenting. Second, it provides paired symptom assessments in all 110 patients, allowing within-patient comparison of scores during the indwelling period and after stent removal. Third, the use of a uniform stent size and a consistent postoperative medication regimen reduces some sources of variation within the cohort.

However, the findings should be interpreted in the context of the study limitations. The study was conducted at a single institution, which may limit generalisability. There was no unstented control group; therefore, the study cannot distinguish the contribution of the stent from other postoperative factors. The absence of a preoperative baseline USSQ assessment limits the ability to determine the extent to which postoperative scores differed from patients' pre-existing symptom status. The study also included only two assessment time points and did not evaluate symptom trajectories during the entire period of stent indwelling. The questionnaire was administered with interviewer assistance using Hindi and Telugu; although a Hindi-validated version was available, the Telugu version had not undergone formal linguistic validation, potentially introducing language-related measurement variability. Urinary tract infection was recorded based on clinical diagnosis without a uniform urine culture-based definition, which may have resulted in variability in case ascertainment. Finally, all patients received silodosin and mirabegron, and the study was not designed to evaluate the independent effect of these medications on stent-related symptoms.

Despite these limitations, the study provides prospective observational data on the pattern of DJ stent-related symptoms following semirigid ureteroscopy in a routine clinical setting. The marked reduction in symptom scores after stent removal supports the importance of appropriate patient counselling, symptom management and adherence to planned stent removal.

DJ ureteral stent placement following semirigid ureteroscopy for ureteric calculi was associated with a considerable burden of urinary symptoms and pain during the indwelling period. Urinary urgency, frequency, flank pain and dysuria were the most frequently reported symptoms. Paired assessment demonstrated statistically significant reductions in all six USSQ domain scores four weeks after stent removal.

These findings highlight the importance of counselling patients regarding expected stent-related symptoms, providing appropriate symptomatic treatment and ensuring timely stent removal. Further multicentre studies incorporating preoperative baseline assessment and serial postoperative evaluations may help better characterise the evolution of stent-related symptoms and identify factors associated with greater symptom burden.

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