Introduction: Prophylactic ureteral stenting in kidney transplantation has been proven to reduce urological complications, such as urine leakage and ureteral obstruction. However, there is no consensus on the optimal stent design. We aimed to compare the influence of double-J (or JJ) catheters and externally draining ureteric stents on the early recovery after living donor kidney transplantation.
Materials and Methods: Between April 2016 and October 2017 a prospective cohort study was performed in 80 recipients of living donor kidney transplants at the Radboud University Medical Center Nijmegen. The patients were divided in two cohorts, the first cohort received an externally draining ureteric stent (splint), in accordance with the standard protocol at the Radboud UMC. The second cohort received a JJ catheter to stent the ureterovesical anastomosis. The splint was removed after 5 days, followed by removal of the Foley catheter 2 days later. In patients treated with the JJ catheter, the Foley catheter was removed after 5 days and the JJ catheter after 2 to 3 weeks at the outpatient clinic by cystoscopy. Early recovery after surgery was daily monitored until patients were discharged. The primary outcome measure was the Quality of Recovery-40 (QoR-40) score. The Quality of Recovery-40 is a validated patient-rated questionnaire with a maximum score of 200, measuring 5 dimensions of recovery after surgery including comfort, emotions, physical independence, pain, and patient support. Secondary outcomes were components of pain scores, achievement of discharge criteria, length of hospital stay, and complications.
Results: The mean QoR-40 scores on postoperative day 5 of the recipients with JJ catheter and splint were 190.3 (SD 8.0) and 185.0 (SD 13.9) respectively, p 0.02. The course of the QoR-40 scores during the first 5 days is depicted in Figure 1. Furthermore, when compared to patients with a splint, patients with a double J stent reached the discharge criteria earlier, and consequently their length of hospital stay was significantly shortened with 1 or 2 days. Daily pain scores were comparable between both groups, except for slightly raised pain scores in the double J group on postoperative days 1 and 2. Early urological complications were similar between the two groups.
Discussion: In accordance to the validated QoR-40 questionnaire, the difference of 6.3 on postoperative day 5 is a clinically relevant improvement in postoperative recovery, as result of the JJ catheter. This is also supported by the fact that patients with a JJ catheter could be discharged earlier without making concessions to postoperative complication rates. The increased pain scores in the JJ catheter group on the first postoperative days can be explained by earlier mobilization.
Conclusion: Double J stenting improves the early postoperative recovery after living donor kidney transplantation, when compared to externally draining ureteric stents.