Does preoperative ureteral stenting improve outcomes in RIRS? A comparative analysis

Background: Retrograde intrarenal surgery (RIRS) is a well-established minimally invasive treatment for renal stones. Preoperative ureteral stenting (staged procedure) is often used to facilitate ureteral access, yet it requires two procedures and prolonged stent dwell time. This study compares the safety, efficacy, radiation exposure, and stent related morbidity of nonstented primary RIRS (single-stage) versus stented secondary RIRS (two-stage) in a large patient cohort. Methods: This retrospective comparative analysis included 389 patients who underwent unilateral RIRS for renal stones ⩽2 cm. Group A (nonstented primary RIRS, n = 213) underwent single-stage RIRS without preoperative stenting. Group B (stented secondary RIRS, n = 176) underwent double-J stent placement 1–2 weeks prior to RIRS. Outcome measures included operative time, ureteral access sheath (UAS) insertion success, stone-free rate (SFR), complications, hospital stay, radiation exposure (fluoroscopy time during RIRS and total fluoroscopy time including initial stent placement), and the rate of procedure postponement due to underdilation of the ureter and stent-related morbidity including unscheduled healthcare visits and hospital admissions between procedures. Statistical analysis used chi-square, t -test, and multivariable regression. Results: The pre-stented group had significantly shorter operative time (38.2 ± 14.8 min vs 48.1 ± 18.4 min, p < 0.001), higher UAS insertion success (93.2% vs 78.9%, p < 0.001), and lower fluoroscopy time during the RIRS procedure (41.6 ± 17.9 s vs 59.3 ± 21.6 s, p < 0.001). Total fluoroscopy time (including initial stent placement) remained higher in the stented group (87.5 ± 30.2 s vs 59.3 ± 21.6 s, p < 0.001) due to the separate stent placement. Stone-free rate was slightly but significantly higher in the stented group (91.5% vs 87.3%, p = 0.038). The non-stented group had a significantly higher rate of procedure postponement because of underdilated ureter (13.6% vs 2.8%, p < 0.001). Complication rates and hospital stay were comparable between groups. However, patients in the stented group experienced significant stent-related morbidity between procedures, with 12.5% requiring unscheduled urological evaluations and 5.1% requiring hospital admission for stent-related symptoms. Conclusion: Preoperative stenting improves RIRS outcomes but adds radiation, an extra procedure, and stent-related morbidity. Nonstented RIRS avoids these but risks access failure. Selection should be individualized.