Routine DJ Stenting After RIRS and URSL Is Not Necessary
Routine post-operative DJ stenting should be omitted after uncomplicated RIRS and URSL procedures, as it increases morbidity without improving outcomes. 1
Evidence-Based Recommendation
The most recent 2025 European Association of Urology guidelines explicitly state that routine post-URS stenting is unnecessary after uncomplicated procedures and may increase morbidity. 1 This represents the strongest current guidance and supersedes older recommendations.
The 2016 American Urological Association guidelines similarly provide a strong recommendation (Grade A evidence) that stenting may be omitted in patients meeting specific safety criteria. 1
When Stenting Can Be Safely Omitted
You can confidently avoid DJ stenting when ALL of the following conditions are met:
- No suspected ureteral injury during the procedure 1
- No evidence of ureteral stricture or anatomical impediments 1
- Normal contralateral kidney function 1
- No renal functional impairment 1
- No secondary URS procedure planned 1
- Minimal or no residual stone fragments 1
Mandatory Indications for DJ Stenting
Stenting remains essential in these specific clinical scenarios:
- Ureteral trauma or perforation during the procedure 1, 2
- Significant bleeding requiring tamponade 1
- Pre-existing ureteral stricture 1, 2
- Solitary kidney 1, 2
- Renal insufficiency 1, 2
- Large residual stone burden requiring drainage 1, 2
- Active UTI or sepsis at time of procedure 1, 2
- Pregnancy 1
Evidence Supporting Stent Omission
The rationale for avoiding routine stenting is compelling:
Stent-related morbidity is substantial: DJ stents cause bothersome lower urinary tract symptoms, pain, and temporarily reduced quality of life in most patients. 1 Specific complications include:
- Stent migration occurs in approximately 5% of cases 1, 3
- UTI risk ranges from 2-6% 1, 3
- Stent encrustation and breakage 1
- Obstruction from the stent itself 1
No improvement in stone-free rates: Multiple studies demonstrate that routine stenting does not enhance stone clearance after uncomplicated procedures. 1
Additional procedures required: Unless a pull-string is attached, secondary cystoscopy under anesthesia is necessary for stent removal, adding cost and patient burden. 1
Critical Nuance: Perirenal Fat Stranding
One important caveat emerges from recent research: in patients with perirenal fat stranding (PFS) detected on imaging, DJ stent insertion following URS significantly increases postoperative infectious complications. 4 In this specific population, stenting led to higher rates of fever (75% vs 44.2%), UTI (60% vs 28.9%), and urosepsis (25% vs 5.8%). 4 This represents a scenario where stenting may actually worsen outcomes.
Optimizing Stent Duration When Required
When stenting is clinically indicated, duration should be minimized to less than 14 days to reduce adverse events and antibiotic requirements. 5 Longer durations (>15 days) significantly increase febrile complications and pain. 5
Alpha-blockers (such as tamsulosin) improve stent tolerability and should be prescribed when stents are placed. 1
Common Pitfalls to Avoid
- Do not stent reflexively "just to be safe" after straightforward procedures—this increases complications without benefit 1
- Do not leave stents in longer than necessary—aim for removal within 14 days when possible 5
- Do not ignore clear indications for stenting (trauma, stricture, solitary kidney)—these patients require drainage 1, 2
- Do not stent patients with perirenal fat stranding unless absolutely necessary—this increases infection risk 4
Practical Algorithm
After completing RIRS/URSL, ask:
- Was there any ureteral injury, perforation, or significant bleeding? → YES = STENT
- Is there a stricture or anatomical obstruction? → YES = STENT
- Is this a solitary kidney or impaired renal function? → YES = STENT
- Is there a large residual stone burden? → YES = STENT
- Is the patient pregnant? → YES = STENT
- Was there active infection/sepsis? → YES = STENT
If all answers are NO → OMIT STENTING 1