Main Article Content
Background and Objective
Double J (JJ) ureteric stenting represents one of the most significant causes of patient discomfort and dissat-isfaction following endourological procedures. At our institution, a large tertiary referral centre for complex stones, standard JJ stent removal was previously undertaken with a flexible cystoscope (FC) in the endoscopy department by a doctor. The pathway was prone to delays through capacity constraints and prioritization being given to cancer investigations. The Isiris® is a single-use stent removal system consisting of a ‘camera on chip’ disposable FC with an integrated grasper. We examine the feasibility of a nurse-led stent removal service using Isiris®, performed as an office-based procedure, and its effect on waiting times.
Material and Methods
A specialist stone nurse undertook training in FC approved by the British Association of Urological Surgeons (BAUS) and the British Association of Urological Nurses (BAUN). Once competency was reached, a nurse-led service was offered to patients in the outpatient setting. A prospective database from April 2018 to March 2020 was maintained to include patient data for stent removals in the nurse-led clinic using Isiris®. This was compared to a retrospective dataset of FC and stent removal between July 2016 and December 2016, per-formed by a doctor in the endoscopy department. The delays in stent removal compared to the ‘ideal’ stent removal date (planned date plus or minus 3 days tolerance allowed) were compared between the two pathways.
The specialist nurse undertook BAUS theory training and competency was reached using an approved BAUS/BAUN competency package. 414 stent removals were booked in the nurse group, of which 395 were undertaken. 291 of 395 (74%) patients in the nurse removal Isiris® group had their stent removed on time, whereas only 16 of 54 (30%) patients had their stents removed on time in the FC stent removal group. A delay of more than 21 days was seen in 22% of FC group vs only 2% in the nurse-led Isiris® group. Both planned removal and actual stent dwell time were longer in the FC group compared to Isiris® group (p < 0.0001). There were no major complications with the use of Isiris® for stent removal in the nurse-led clinic. Conclusion
This study has demonstrated that it is feasible to introduce a nurse-led stent removal service. The introduction of this service using the Isiris® system has led to a reduction in delays of stent removal, which is likely to trans-late into significant quality of life improvement for patients and economic benefits for the healthcare system.
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Copyright of articles published in all DPG titles is retained by the author(s). The author(s) grants DPG the rights to publish the article and identify itself as the original publisher. The author grants DPG exclusive commercial rights to the article. The author grants any party the rights to use the article freely for non-commercial purposes provided that the original work is properly cited.
2. Hughes B, Wiseman OJ, Thompson T, et al. The dilemma of post-ureteroscopy stenting. BJU Int 2014 Feb;113(2):184–5.
3. Mangera A, Parys B. BAUS Section of Endourology national Ureteroscopy audit: setting the standards for revalidation. J Clin Urol 2013 Jan 1;6(1):45–9.
4. Flexible Cystoscopy: Training and Assessment Guideline; Second edition November 2017. Available at: https:// www.baus.org.uk/_userfiles/pages/files/Publications/ BAUN%20BAUS%20Flexible%20Cystoscopy%20 Guidelines%20-%20November%202017.pdf
5. Taylor JM, Pearce I, O’Flynn KJ. Nurse-led cystoscopy: the next step. BJU Int 2002 Jul;90(1):45–6.
6. Crowe H. Advanced urology nursing practice. Nat Rev Urol 2014;11(3):178–82.
7. Doizi S, Kamphuis G, Giusti G, et al. First clinical evaluation of a new single-use flexible cystoscope dedicated to double-J stent removal (IsirisTM): a Euro-pean prospective multicenter study. World J Urol 2017 Aug;35(8):1269–75.
8. National Safety Standards for Invasive Procedures (NatSSIPs); September 2015. Available at: https:// improvement.nhs.uk/documents/5405/NatSSIPs_Fi-nal_updated_June_2019.pdf.
9. Flexible Cystoscopy: Performance Criteria, Training and Assessment Logbook; Second edition, November 2017. Available at: https://www.baus.org.uk/_userfiles/pages/ files/Publications/BAUN%20BAUS%20Flexible%20 Cystoscopy%20Performance%20Criteria_%20Train-ing%20and%20Assessment%20Logbook%20-%20 November%202017.pdf
10. Talso M, Emiliani E, Baghdadi M, et al. The new grasper-integrated single use flexible cystoscope for double J stent removal: evaluation of image quality, flow and flexibility. World J Urol 2017 Aug;35(8):1277–83.
11. Smith PM, Harbias A, Robinson R, et al. Isiris: A novel method of removing foreign bodies from the lower urinary tract to avoid unnecessary hospitalization and anesthesia. J Endourol Case Rep 2016;2(1):144–7.
12. Phan YC, Cobley J, Mahmalji W. Cost analysis and service delivery on using Isiris α™ to remove ureteric stents. J Endolum Endourol [Internet]. 2018Apr.16 [cited 2020Jun.12];1(1):e3-e16. Available at: https:// jeleu.com/index.php/JELEU/article/view/5
13. Oderda M, Antolini J, Falcone M, et al. Cost-effectiveness analysis of a single-use digital flexible cystoscope for double J removal. Urologia 2020 Feb;87(1):29–34.
14. Baston EL, Wellum S, Bredow Z, et al. Office-based ureteric stent removal is achievable, improves clinical flexibility and quality of care, whilst also keeping surgeons close to their patients. Cent European J Urol 2018;71(2):196–201.
15. Sapre N, Bugeja P, Hayes E, et al. Nurse-led flexible cystoscopy in Australia: initial experience and early results. BJU Int 2012 Dec;110 Suppl 4:46–50.
16. Hennessey DB, Fojecki GL, Papa NP, et al. Single-use disposable digital flexible ureteroscopes: an ex vivo assessment and cost analysis. BJU Int 2018;121 Suppl 3:55–61.
17. Joshi HB, Newns N, Stainthorpe A, et al. Ureteral stent symptom questionnaire: development and validation of a multidimensional quality of life measure. J Urol 2003 Mar;169(3):1060–4.
18. Sali GM, Joshi HB. Ureteric stents: Overview of current clinical applications and economic implications. Int J Urol 2020 Jan;27(1):7–15.
19. Staubli SEL, Mordasini L, Engeler DS, et al. Economic Aspects of Morbidity Caused by Ureteral Stents. Urol Int 2016;97(1):91–7.
20. Oliver R, Wells H, Traxer O, et al. Ureteric stents on extraction strings: a systematic review of literature. Urolithiasis 2018 Apr;46(2):129–36.
21. Tran MGB, Sut MK, Collie J, Neves JB, Al-Hayek S, Armitage JN, et al. Development of a disease-specific ureteral calculus patient reported outcome measurement instrument. J Endourol 2018;32(6):548–58.
22. Ragab M, Baldin N, Collie J, Tran MGB, Al-Hayek S, S Parsy K, et al. Qualitative exploration of the renal stone patients’ experience and development of the renal stone-specific patient-reported outcome measure. BJU Int 2020 Jan;125(1):123–32.