Turk J Urol 2017; 43(3): 303-8 • DOI: 10.5152/tud.2017.58997
ENDOUROLOGY
Original Article
Factors associated with postoperative pain after retrograde intrarenal surgery for kidney stones Ural Oğuz1, Tolga Şahin2, Çağrı Şenocak2, Ekrem Özyuvalı2, Ömer Faruk Bozkurt2, Berkan Reşorlu3, Ali Ünsal4
Cite this article as: Oğuz U, Şahin T, Şenocak Ç, Özyuvalı E, Bozkurt ÖF, Reşorlu B. Factors associated with postoperative pain after retrograde intrarenal surgery for kidney stones. Turk J Urol 2017; 43: 303-8
ABSTRACT
Objective: We aimed to investigate factors related to early postoperative pain after retrograde intrarenal surgery (RIRS).
Material and methods: A prospective data analysis of 250 patients who underwent RIRS due to kidney stones was performed. Postoperative pain was evaluated in all patients by using visual analogue scale (VAS). Patients with severe pain (VAS score ≥7) were separated and included in Group I (n=46). While patients without pain or with insignificant pain were included in Group II (n=204). The impact of patient-related (age, gender, renal anomalies, shock wave lithotripsy history, preoperative hydronephrosis) stone-related (stone number, side, size, location and opacity) and operation-related (preoperative and postoperative ureteral Jstenting, ureteral injury, postoperative bleeding and fever, stone-free rates, size of access sheath, and sheath indwelling time) factors on early stage postoperative pain (if any) were investigated.
Department of Urology, Giresun University School of Medicine, Giresun, Turkey 1
Results: Female gender increased the risk for pain 3.6-fold (p0.05). But, stone burden was associated with pain. The mean stone burden of the patients were 16.87 mm (5-48 mm) and 12.6 mm (5-40 mm) in Groups I and II, respectively (p0.05). On the other hand, the intraureteral dwell time of ureteral access sheath in ureter during operation (sheath time) was significantly higher
305
Oğuz et al. Factors associated with postoperative pain after retrograde intrarenal surgery for kidney stones
Table 1. Associated factors with renal colic on the day of RIRS
Group I
Female
29
27.8
All
46 23
Side
Stone location
Male
Right Left All
Multiple
17 23 46 4
104
100
18.4
204
81.6
250
100
18.9
99
81.1
122
100
18.0
81.5
110
17.5
History of SWL
Absent
32
20.1
All
46
Preop. J-stenting
Preop. Hydronephrosis
Anticoagulant therapy
Renal anomaly
Stone opacity
Size of access sheath
Postop J-stenting
Initial residual fragments
Final residual fragments
All
Present Absent
Present
46 14 38 8
105 204
82.6
10
7
129
18.4
Lower pole
Chi-Square Analysis
72.1
25
Upper-middle pole
Total
75
11.6
Pelvis
Group II
n % n % n % Chi-Square p
Gender
Groups
19
88.3
82.0 81.6 17.4
146
128 250 23
9.6
100
100
Fisher'sExact
100 100
0.1
18.5
135
47
82.5
57
127
79.9
159
100
18.4
204
81.6
250
100
11.9
59
88.1
67
20
18.4 15.4 20.8
28
204 77
145
80
81.6 84.6 79.2
35
250 91
183
100
100
0.5
100 100
1.9
100
18.4
204
81.6
250
100
Present
14
16.5
71
83.5
85
100
All
Absent
Present
46 46 0
19.4 18.4 18.7 0.0
133 204 200
192
83.1
18.4
204
Present
7
36.8
12
All
46
Non- opaque
9
Opaque
37
All
46
14 Fr
18
11.5 Fr All
Absent
28 46 9
Present
37
Absent
27
All
Present All
Absent
Present All
46 19 46 31 15 46
16.8 18.4
204
26.5
25
17.1 18.4 18.1 18.9
179 204 127 77
18.4
204
19.2
156
15.4
148
15.8 18.4 25.3 18.4 15.5 29.4 18.4
81.3
100.0
46 39
81.6
4
All
Absent
80.6
48
204 56
204 168 36
204
165 250 246 4
81.6
250
63.1
19
231
81.6
250
73.5
34
82.9 81.6 81.9 81.1
216 250 155 95
81.6
250
80.8
193
84.6
175
84.2 81.6 74.7 81.6 84.4 70.5 81.6
57
250 75
250 199 51
250
0.988
100
46 32
0.871
100
All
Absent
0.002
100
0.154
100 100
Fisher'sExact
100 100 100
Fisher'sExact
100 100 100
1.1
100 100 100
0
100 100 100
0.14
100 100 100
2.8
100 100 100
4.3
100 100
0.471
0.158
0.694
1
0.057
0.291
0.995
0.701
0.094
0.038
Turk J Urol 2017; 43(3): 303-8 DOI:10.5152/tud.2017.58997
306 Table 1. Associated factors with renal colic on the day of RIRS (continued)
Group I
Groups
Group II
Total
Chi-Square Analysis
n % n % n % Chi-Square p
Bleeding
Absent
44
18.2
197
81.8
241
100
All
46
18.4
204
81.6
250
100
Present
4
36.4
7
63.6
11
Fever / Infection
Ureteral injury
Present Absent All
Absent
Present All
2
42 46 38 8
46
22.2 17.6 18.4 18.4 18.6 18.4
7
197 204 169 35
204
77.8 82.4 81.6 81.6 81.4 81.6
9
239
Fisher'sExact
100 100
Fisher'sExact
100
250
100
43
100
207 250
100
0
0.673
0.123
1
100
RIRS: retrograde intrarenal surgery
in Group I. Mean sheath times were 46.57 min (15-110 min) and 41.54 min (15-140 min) in Groups I and II, respectively (p0.05) (Table 2). Major complications as classified according to Satava III or Clavien III–V criteria did not occur in the study group. Grade I ureteral injury was experienced in 8 (17.4%) and 35 patients (17.1%) in Groups I and II, respectively (p>0.05) (Table 1). The presence of ureteral J stents implanted pre-and postoperatively did not affect postoperative pain, and severity of postoperative pain was statistically comparable between two groups (p>0.05). In addition, the presence of preoperative hydronephrosis, the history of SWL, postoperative fever and macrosopic hematuria did not significantly differ between the two groups (p>0.05). Although 4 patients in Group II were using an anticoagulant therapy during the surgery, postoperative macroscopic hematuria did not statistically differ between two groups (3.4% vs. 4.3%) (p>0.05) (Tables 1 and 2). Postoperative hospitalization time was significantly higher in patients with severe renal pain (1.5 days (1-5) vs. 1.1 days (1-2) in Groups I and II, respectively) (p0.05). In addition, postoperative macroscopic hematuria, and preoperative hydronephrosis were not associated with postoperative pain (p>0.05). Another important finding of our study was that ureteral injury was not also associated with the postoperative pain. None of the patients experienced high grade (grades 2-4) ureteral injury as described by Traxer and Thomas.[17] Besides, rates of grade 1 injury did not significantly differ between the two groups (p>0.05). According to our results, patient-stone-and operation-related factors were associated with postoperative pain. The most important patient-related factor was female gender. Tighe et al.[18] showed that female patients had greater mean pain scores on postoperative day 1 for a variety of surgical procedures, with an overall odds ratio of 1.16. Our study also demonstrated that
female gender was significantly associated with postoperative pain after RIRS on the operation day. Male/female ratio was 0.7 and 1.7 in Groups I and II, respectively. While in our study group 27.9% of the female, and 11.6% of the male patients postoperatively experienced severe renal colic (p0.05). Higher residual stone fragment rate was detected in patients with severe pain. The major limitation of the study is that, although ours was a prospective study, CT was not used routinely to detect residual fragments after the surgery to avoid radiation exposure. Despite the shortcomings, this is an important study to be considered as a guidance for further investigations needed about postoperative pain after the RIRS procedure. Postoperative pain is an important entity that the surgeons have to be aware of. According to our results, patient-, stone- and operation-related factors associated with the early postoperative pain after RIRS were female gender, stone size and the sheath time. Ethics Committee Approval: Ethics committee approval was received for this study from the ethics committee of Keçiören Training and Research Hospital. Informed Consent: Written informed consent was obtained from patients who participated in this study. Peer-review: Externally peer-reviewed. Author Contributions: Concept – U.O.; Design – B.R., U.O.; Supervision – B.R., U.O.; Resources – U.O.; Materials – U.O.; Data Collection and/or Processing – T.Ş., E.Ö., U.O., Ç.Ş., Ö.F.B.; Analysis and/or Interpretation – U.O.; Literature Search – U.O.; Writing Manuscript – U.O.; Critical Review – U.O., Ç.Ş., Ö.F.B., B.R., A.Ü. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support.
References 1. Wendt-Nordahl G, Mut T, Krombach P, Michel MS, Knoll T. Do new generation flexible ureterorenoscopes offer a higher treatment success than their predecessors? Urol Res 2011;39:185-8. 2. Rajamahanty S, Grasso M. Flexible ureteroscopy update: indications, instrumentation and technical advances. Indian J Urol 2008;24:532-7. [CrossRef] 3. Lim SH, Jeong BC, Seo SI, Jeon SS, Han DH. Treatment outcomes of retrograde intrarenal surgery for renal stones and predictive factors of stone-free. Korean J Urol 2010;51:777-82. [CrossRef]
4. Resorlu B, Unsal A, Gulec H, Oztuna D. A new scoring system for predicting stone-free rate after retrograde intrarenal surgery: the “resorlu-unsal stone score”. Urology 2012;80:512-8. [CrossRef] 5. Cansino Alcaide JR, Reinoso Elbers J, López Sánchez D, Pérez González S, Rodriguez, Aguilera Bazán A, et al. Flexible ureterorenoscopy (URS): technique and results. Arch Esp Urol 2010;63:862-70. [CrossRef] 6. Schoenthaler M, Wilhelm K, Katzenwadel A, Ardelt P, Wetterauer U, Traxer O, et al. Retrograde intrarenal surgery in treatment of nephrolithiasis: is a 100% stone-free rate achievable? J Endourol 2012;26:489-93. 7. Oguz U, Resorlu B, Ozyuvali E, Bozkurt OF, Senocak C, Unsal A. Categorizing Intraoperative Complications of Retrograde Intrarenal Surgery. Urol Int 2014;92:164-8. [CrossRef] 8. Atis G, Resorlu B, Gurbuz C, Arikan O, Ozyuvali E, Unsal A, et al. Retrograde intrarenal surgery in patients with horseshoe kidneys. Urolithiasis 2013;41:79-83. [CrossRef] 9. Pedersen KV, Olesen AE, Osther PJ, Arendt-Nielsen L, Drewes AM. Prediction of postoperative pain after percutaneous nephrolithotomy: can preoperative experimental pain assessment identify patients at risk? Urolithiasis 2013;41:169-77. 10. Woldu SL, Weinberg AC, Bergman A, Shapiro EY, Korets R, Motamedinia P, et al. Pain and analgesic use after robot-assisted radical prostatectomy. J Endourol 2014;28:544-8. [CrossRef] 11. Pini G, Goezen AS, Schulze M, Hruza M, Klein J, Rassweiler JJ. Small-incision access retroperitoneoscopic technique (SMART) pyeloplasty in adult patients: comparison of cosmetic and postoperative pain outcomes in a matched-pair analysis with standard retroperitoneoscopy: preliminary report. World J Urol 2012;30:605-11. [CrossRef] 12. Zargar-Shoshtari K, Anderson W, Rice M. Role of emergency ureteroscopy in the management of ureteric stones: analysis of 394 cases. BJU Int 2015;115:946-50. [CrossRef] 13. Singh BP, Prakash J, Sankhwar SN, Dhakad U, Sankhwar PL, Goel A, et al. Retrograde intrarenal surgery vs extracorporeal shock wave lithotripsy for intermediate size inferior pole calculi: a prospective assessment of objective and subjective outcomes. Urology 2014;83:1016-22. [CrossRef] 14. Mustafa M. The role of stenting in relieving loin pain following ureteroscopic stone therapy for persisting renal colic with hydronephrosis. Int Urol Nephrol 2007;39:91-4. [CrossRef] 15. Torricelli FC, De S, Hinck B, Noble M, Monga M. Flexible ureteroscopy with a ureteral access sheath: when to stent? Urology 2014;83:278-81. 16. Byrne RR, Auge BK, Kourambas J, Munver R, Delvecchio F, Preminger GM. Routine ureteral stenting is not necessary after ureteroscopy and ureteropyeloscopy: a randomized trial. J Endourol 2002;16:9-13. [CrossRef] 17. Traxer O, Thomas A. Prospective evaluation and classification of ureteral wall injuries resulting from insertion of a ureteral access sheath during retrograde intrarenal surgery. J Urol 2013;189:580-4. [CrossRef] 18. Tighe PJ, Riley JL 3rd, Fillingim RB. Sex differences in the incidence of severe pain events following surgery: a review of 333,000 pain scores. Pain Med 2014;15:1390-404. [CrossRef]
ENDOUROLOGY
Original Article
Factors associated with postoperative pain after retrograde intrarenal surgery for kidney stones Ural Oğuz1, Tolga Şahin2, Çağrı Şenocak2, Ekrem Özyuvalı2, Ömer Faruk Bozkurt2, Berkan Reşorlu3, Ali Ünsal4
Cite this article as: Oğuz U, Şahin T, Şenocak Ç, Özyuvalı E, Bozkurt ÖF, Reşorlu B. Factors associated with postoperative pain after retrograde intrarenal surgery for kidney stones. Turk J Urol 2017; 43: 303-8
ABSTRACT
Objective: We aimed to investigate factors related to early postoperative pain after retrograde intrarenal surgery (RIRS).
Material and methods: A prospective data analysis of 250 patients who underwent RIRS due to kidney stones was performed. Postoperative pain was evaluated in all patients by using visual analogue scale (VAS). Patients with severe pain (VAS score ≥7) were separated and included in Group I (n=46). While patients without pain or with insignificant pain were included in Group II (n=204). The impact of patient-related (age, gender, renal anomalies, shock wave lithotripsy history, preoperative hydronephrosis) stone-related (stone number, side, size, location and opacity) and operation-related (preoperative and postoperative ureteral Jstenting, ureteral injury, postoperative bleeding and fever, stone-free rates, size of access sheath, and sheath indwelling time) factors on early stage postoperative pain (if any) were investigated.
Department of Urology, Giresun University School of Medicine, Giresun, Turkey 1
Results: Female gender increased the risk for pain 3.6-fold (p0.05). But, stone burden was associated with pain. The mean stone burden of the patients were 16.87 mm (5-48 mm) and 12.6 mm (5-40 mm) in Groups I and II, respectively (p0.05). On the other hand, the intraureteral dwell time of ureteral access sheath in ureter during operation (sheath time) was significantly higher
305
Oğuz et al. Factors associated with postoperative pain after retrograde intrarenal surgery for kidney stones
Table 1. Associated factors with renal colic on the day of RIRS
Group I
Female
29
27.8
All
46 23
Side
Stone location
Male
Right Left All
Multiple
17 23 46 4
104
100
18.4
204
81.6
250
100
18.9
99
81.1
122
100
18.0
81.5
110
17.5
History of SWL
Absent
32
20.1
All
46
Preop. J-stenting
Preop. Hydronephrosis
Anticoagulant therapy
Renal anomaly
Stone opacity
Size of access sheath
Postop J-stenting
Initial residual fragments
Final residual fragments
All
Present Absent
Present
46 14 38 8
105 204
82.6
10
7
129
18.4
Lower pole
Chi-Square Analysis
72.1
25
Upper-middle pole
Total
75
11.6
Pelvis
Group II
n % n % n % Chi-Square p
Gender
Groups
19
88.3
82.0 81.6 17.4
146
128 250 23
9.6
100
100
Fisher'sExact
100 100
0.1
18.5
135
47
82.5
57
127
79.9
159
100
18.4
204
81.6
250
100
11.9
59
88.1
67
20
18.4 15.4 20.8
28
204 77
145
80
81.6 84.6 79.2
35
250 91
183
100
100
0.5
100 100
1.9
100
18.4
204
81.6
250
100
Present
14
16.5
71
83.5
85
100
All
Absent
Present
46 46 0
19.4 18.4 18.7 0.0
133 204 200
192
83.1
18.4
204
Present
7
36.8
12
All
46
Non- opaque
9
Opaque
37
All
46
14 Fr
18
11.5 Fr All
Absent
28 46 9
Present
37
Absent
27
All
Present All
Absent
Present All
46 19 46 31 15 46
16.8 18.4
204
26.5
25
17.1 18.4 18.1 18.9
179 204 127 77
18.4
204
19.2
156
15.4
148
15.8 18.4 25.3 18.4 15.5 29.4 18.4
81.3
100.0
46 39
81.6
4
All
Absent
80.6
48
204 56
204 168 36
204
165 250 246 4
81.6
250
63.1
19
231
81.6
250
73.5
34
82.9 81.6 81.9 81.1
216 250 155 95
81.6
250
80.8
193
84.6
175
84.2 81.6 74.7 81.6 84.4 70.5 81.6
57
250 75
250 199 51
250
0.988
100
46 32
0.871
100
All
Absent
0.002
100
0.154
100 100
Fisher'sExact
100 100 100
Fisher'sExact
100 100 100
1.1
100 100 100
0
100 100 100
0.14
100 100 100
2.8
100 100 100
4.3
100 100
0.471
0.158
0.694
1
0.057
0.291
0.995
0.701
0.094
0.038
Turk J Urol 2017; 43(3): 303-8 DOI:10.5152/tud.2017.58997
306 Table 1. Associated factors with renal colic on the day of RIRS (continued)
Group I
Groups
Group II
Total
Chi-Square Analysis
n % n % n % Chi-Square p
Bleeding
Absent
44
18.2
197
81.8
241
100
All
46
18.4
204
81.6
250
100
Present
4
36.4
7
63.6
11
Fever / Infection
Ureteral injury
Present Absent All
Absent
Present All
2
42 46 38 8
46
22.2 17.6 18.4 18.4 18.6 18.4
7
197 204 169 35
204
77.8 82.4 81.6 81.6 81.4 81.6
9
239
Fisher'sExact
100 100
Fisher'sExact
100
250
100
43
100
207 250
100
0
0.673
0.123
1
100
RIRS: retrograde intrarenal surgery
in Group I. Mean sheath times were 46.57 min (15-110 min) and 41.54 min (15-140 min) in Groups I and II, respectively (p0.05) (Table 2). Major complications as classified according to Satava III or Clavien III–V criteria did not occur in the study group. Grade I ureteral injury was experienced in 8 (17.4%) and 35 patients (17.1%) in Groups I and II, respectively (p>0.05) (Table 1). The presence of ureteral J stents implanted pre-and postoperatively did not affect postoperative pain, and severity of postoperative pain was statistically comparable between two groups (p>0.05). In addition, the presence of preoperative hydronephrosis, the history of SWL, postoperative fever and macrosopic hematuria did not significantly differ between the two groups (p>0.05). Although 4 patients in Group II were using an anticoagulant therapy during the surgery, postoperative macroscopic hematuria did not statistically differ between two groups (3.4% vs. 4.3%) (p>0.05) (Tables 1 and 2). Postoperative hospitalization time was significantly higher in patients with severe renal pain (1.5 days (1-5) vs. 1.1 days (1-2) in Groups I and II, respectively) (p0.05). In addition, postoperative macroscopic hematuria, and preoperative hydronephrosis were not associated with postoperative pain (p>0.05). Another important finding of our study was that ureteral injury was not also associated with the postoperative pain. None of the patients experienced high grade (grades 2-4) ureteral injury as described by Traxer and Thomas.[17] Besides, rates of grade 1 injury did not significantly differ between the two groups (p>0.05). According to our results, patient-stone-and operation-related factors were associated with postoperative pain. The most important patient-related factor was female gender. Tighe et al.[18] showed that female patients had greater mean pain scores on postoperative day 1 for a variety of surgical procedures, with an overall odds ratio of 1.16. Our study also demonstrated that
female gender was significantly associated with postoperative pain after RIRS on the operation day. Male/female ratio was 0.7 and 1.7 in Groups I and II, respectively. While in our study group 27.9% of the female, and 11.6% of the male patients postoperatively experienced severe renal colic (p0.05). Higher residual stone fragment rate was detected in patients with severe pain. The major limitation of the study is that, although ours was a prospective study, CT was not used routinely to detect residual fragments after the surgery to avoid radiation exposure. Despite the shortcomings, this is an important study to be considered as a guidance for further investigations needed about postoperative pain after the RIRS procedure. Postoperative pain is an important entity that the surgeons have to be aware of. According to our results, patient-, stone- and operation-related factors associated with the early postoperative pain after RIRS were female gender, stone size and the sheath time. Ethics Committee Approval: Ethics committee approval was received for this study from the ethics committee of Keçiören Training and Research Hospital. Informed Consent: Written informed consent was obtained from patients who participated in this study. Peer-review: Externally peer-reviewed. Author Contributions: Concept – U.O.; Design – B.R., U.O.; Supervision – B.R., U.O.; Resources – U.O.; Materials – U.O.; Data Collection and/or Processing – T.Ş., E.Ö., U.O., Ç.Ş., Ö.F.B.; Analysis and/or Interpretation – U.O.; Literature Search – U.O.; Writing Manuscript – U.O.; Critical Review – U.O., Ç.Ş., Ö.F.B., B.R., A.Ü. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support.
References 1. Wendt-Nordahl G, Mut T, Krombach P, Michel MS, Knoll T. Do new generation flexible ureterorenoscopes offer a higher treatment success than their predecessors? Urol Res 2011;39:185-8. 2. Rajamahanty S, Grasso M. Flexible ureteroscopy update: indications, instrumentation and technical advances. Indian J Urol 2008;24:532-7. [CrossRef] 3. Lim SH, Jeong BC, Seo SI, Jeon SS, Han DH. Treatment outcomes of retrograde intrarenal surgery for renal stones and predictive factors of stone-free. Korean J Urol 2010;51:777-82. [CrossRef]
4. Resorlu B, Unsal A, Gulec H, Oztuna D. A new scoring system for predicting stone-free rate after retrograde intrarenal surgery: the “resorlu-unsal stone score”. Urology 2012;80:512-8. [CrossRef] 5. Cansino Alcaide JR, Reinoso Elbers J, López Sánchez D, Pérez González S, Rodriguez, Aguilera Bazán A, et al. Flexible ureterorenoscopy (URS): technique and results. Arch Esp Urol 2010;63:862-70. [CrossRef] 6. Schoenthaler M, Wilhelm K, Katzenwadel A, Ardelt P, Wetterauer U, Traxer O, et al. Retrograde intrarenal surgery in treatment of nephrolithiasis: is a 100% stone-free rate achievable? J Endourol 2012;26:489-93. 7. Oguz U, Resorlu B, Ozyuvali E, Bozkurt OF, Senocak C, Unsal A. Categorizing Intraoperative Complications of Retrograde Intrarenal Surgery. Urol Int 2014;92:164-8. [CrossRef] 8. Atis G, Resorlu B, Gurbuz C, Arikan O, Ozyuvali E, Unsal A, et al. Retrograde intrarenal surgery in patients with horseshoe kidneys. Urolithiasis 2013;41:79-83. [CrossRef] 9. Pedersen KV, Olesen AE, Osther PJ, Arendt-Nielsen L, Drewes AM. Prediction of postoperative pain after percutaneous nephrolithotomy: can preoperative experimental pain assessment identify patients at risk? Urolithiasis 2013;41:169-77. 10. Woldu SL, Weinberg AC, Bergman A, Shapiro EY, Korets R, Motamedinia P, et al. Pain and analgesic use after robot-assisted radical prostatectomy. J Endourol 2014;28:544-8. [CrossRef] 11. Pini G, Goezen AS, Schulze M, Hruza M, Klein J, Rassweiler JJ. Small-incision access retroperitoneoscopic technique (SMART) pyeloplasty in adult patients: comparison of cosmetic and postoperative pain outcomes in a matched-pair analysis with standard retroperitoneoscopy: preliminary report. World J Urol 2012;30:605-11. [CrossRef] 12. Zargar-Shoshtari K, Anderson W, Rice M. Role of emergency ureteroscopy in the management of ureteric stones: analysis of 394 cases. BJU Int 2015;115:946-50. [CrossRef] 13. Singh BP, Prakash J, Sankhwar SN, Dhakad U, Sankhwar PL, Goel A, et al. Retrograde intrarenal surgery vs extracorporeal shock wave lithotripsy for intermediate size inferior pole calculi: a prospective assessment of objective and subjective outcomes. Urology 2014;83:1016-22. [CrossRef] 14. Mustafa M. The role of stenting in relieving loin pain following ureteroscopic stone therapy for persisting renal colic with hydronephrosis. Int Urol Nephrol 2007;39:91-4. [CrossRef] 15. Torricelli FC, De S, Hinck B, Noble M, Monga M. Flexible ureteroscopy with a ureteral access sheath: when to stent? Urology 2014;83:278-81. 16. Byrne RR, Auge BK, Kourambas J, Munver R, Delvecchio F, Preminger GM. Routine ureteral stenting is not necessary after ureteroscopy and ureteropyeloscopy: a randomized trial. J Endourol 2002;16:9-13. [CrossRef] 17. Traxer O, Thomas A. Prospective evaluation and classification of ureteral wall injuries resulting from insertion of a ureteral access sheath during retrograde intrarenal surgery. J Urol 2013;189:580-4. [CrossRef] 18. Tighe PJ, Riley JL 3rd, Fillingim RB. Sex differences in the incidence of severe pain events following surgery: a review of 333,000 pain scores. Pain Med 2014;15:1390-404. [CrossRef]
