Stented versus stentless pyeloplasty in adults: A systematic review of surgical outcomes and complications

Dear Editor, We read with great interest the systematic review by Mittal et al.[1] comparing stented versus stentless pyeloplasty in adults. The authors are to be congratulated for addressing a clinically relevant and quite underexplored question regarding adult pyeloplasty. However, we wish to mention a few aspects which definitely merit consideration: The pool sample of 5820 patients is dominated by a single national cohort study by Del Giudice et al.,[1] which accounts for nearly 83.7% of the total patients. This disproportionate representation can affect the final conclusions regarding the reintervention rates Among the 10 included studies, only one study by Farouk et al.[1] is a randomized controlled trial, while the others are either observational or retrospective studies. Drawing clinical practice recommendations from such evidence, using an algorithm stratified into three risk tiers, definitely merits some caution The authors have rightly identified the absence of standardized patient-reported outcome measures (PROMs) as the critical evidence gap. This is especially important because the primary reason for not using a stent is patient comfort. Without PROMs, the quality-of-life benefit of the stentless approach, which is the most compelling advantage, remains incompletely characterized The authors in their algorithm mention Differential Renal Function (DRF) >35% as one of the favorable factors to consider a stentless surgery. Logically, these better-functioning kidneys are likely to produce more urine, which would cause more stress on the pelvi–ureteric anastomosis The majority of cases in which stentless pyeloplasty was performed used some form of innovation, such as an indigo carmine test or a feeding tube saline test. The only study that did not use any of these innovations had a lower success rate. Furthermore, there is no mention of the type of suturing which was utilized, whether it was interrupted sutures or a continuous suture or a combination of both (that is, a couple of sutures taken at the point of spatulation being interrupted and the remaining being continuous). A discussion of these aspects would help readers decide which technical factors to consider when choosing a stentless pyeloplasty Most of these studies defined failure as T1/2 >20 min. Recent studies favor the use of gravity-assisted drainage or cortical transit time to define success.[2,3] Often, following a pyeloplasty, especially a nonreductive one, the T1/2 values are >20 min. Notwithstanding these limitations, we believe that this review makes a valuable contribution to the literature. The decision-making algorithm would serve as a very useful guide for the authors in deciding whether to stent during an adult pyeloplasty. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.