Strengths and Limitations of Strategy

Strength and limitation of search strategy

Aveyard (2015) says that every effort shall be undertaken to obtain the necessary literature which is relevant and vital in answering the study question. However, the methodology to this literature review is limited, as the author of this review is a novice researcher and for this reason, he had to conduct the research singlehandedly without research team support, who could help in reviewing each of the potential studies for appropriateness in the literature review. The other limit is that the author accessed the articles which are available for free for students regarding university subscription and RCNI subscription or studies which are generally available free of charge.

The secondary sources as well as sources which were not fully read in the original form, were not incorporated in the review. Aveyard (2015) warns not to utilise this form of practice because the Researcher is unable to evaluate the quality of that study and thus is also prompt to misrepresent its outcome.

Appraisal of retrieved primary papers.

Bettany- Saltikov (2012) highlights that incorporating a standardized appraisal tool is necessary in order to establish the quality of the particular paper and this could also increase the reliability and validity of findings. Once the articles have been selected, hard copies of papers had been obtained and then the standard quality of evaluation framework was developed by Cadwell et al. (Cadwell, Henshaw and Taylor, 2011) and this was implemented further. Therefore Cadwell et al. (2011) specified framework, together with the guidelines, has been utilized as it was recommended by Saltikov (2012) as an easy appraisal tool which has to be followed by a novice reviewerwhich could be the student nurse in this context. The template of Caldwell et al. (2011) was attached for reference in appendix 3.

This led to the conclusion involving all of the outcomes of the appraisal of Cadwell et al. and these could be highlighted in the manner that all seven retrieved articles were published in peer reviewed journals such as Holistic Nursing Practice, , International Journal of Urology, Urologic Nursing, BJU International, Journal of Endourology and BMC Urology. The titles were informative and accurately reflect the content, authors of these articles were credible as they hold academic and health related professional qualifications which are linked to the field of the study, the most well-structured abstracts to summarize the paper were presented with an exception to one article which is not a research but Quality/Performance Improvement Project and due to the same reason, only that paper, conversely to the remaining studies, received the project exemption from the approval of the local research ethics committee.. However, the Quality/Performance Improvement Project paper, which has been similar to the other five studies, clearly presents the rational, background, current state of knowledge, identifies gaps via up-to-date literature, conveys what the Researcher is going to achieve by conducting the project and also meets requirement of gaining consent from the service users. Subsequently, the methods of the research paper have been explained and analysed.

The next stage of this literature review includes summary of each selected article, followed by data analysis and synthesis.

Data Analysis and Synthesis. Why these seven articles? – A summary of each paper.

In order to reveal the associated themes, the papers were re-read a number of times to achieve familiarisation with the content and to assure that all seven papers addressing the question could be appropriate for the review. All of the retrieved articles were relevant and fulfilled the aim of this review, nevertheless, the data was insufficient due to various factors . The results could not, consequently, be combined statistically using meta-analysis methods, so the effects of the implemented methods were synthesized narratively. In order to summarize the extracted data, numerous tools have been utilized. These could be identified as the textual descriptions, grouping of similar data, charts to name a few.

The next stage of this review involved a short summary of each research paper followed by extraction of pertinent data which could be particularly focusing on information related to the PICOT/PEO components and themes.

Ucuzal and Serce (2017), in their descriptive research, determined effects of ureteral stenting on QOL of 75 patients of urology and outpatient clinics, who were selected by using non-probability random sampling methods. Outcomes were measured using a questionnaire form, the SF-Quality of Life Scale and the IPSS at two different points of time. Continue your journey with our comprehensive guide to Innate immune response in ischemic acute kidney injury.

Scarneciu et al. (2015) evaluated the indwelling ureteral stent prospective analysis using a randomized control trial design to measure prevalence of symptoms, tolerability , side effects and their impact on QOL in 2200 patients over a 10-year time period. Patients were randomly allocated one of the four types of stents as medical intervention, except cancer patients with long term indication for using particular stent type. Outcomes were measured using the QOLS and a questionnaire which had not been properly validated from the local clinic of urology and by the Emergency Clinical Hospital at 3 different points of time involving the day of implementing stent, 7 days after and 2 weeks after the removal of the stent.

Barnes, Bing and Tracy (2014) conducted a prospective randomised control trial to investigate the effects of the pulling out of the ureteric stent on quality of life or the complications which could emerge after the Ureteroscopy or Urolithiasis. Symptoms, pain and adverse events were measured in 68 randomly selected patients who completed USSQ questionnaire at three different points of time.

Abt et al. (2015)investigated prospectively assigned 74 patients into clinical investigation to determine whether education of fine quality service users influence the effect of ureteric stent and economic aspects of treatment in an undesirable manner. The impact of patient enhanced quality education was assessed by the correlation of SDQ on USSQ sub scoresthrough the utilisation of single items and economic aspects (abatement of work capacity, hospitalizations, necessity for medical or nursing intervention or counselling) were analysed as secondary end-points. The patients were surveyed once, on the day of the stent extraction. Limitation of the research was that it was randomized and the USSQ were not yet validated in German.

Tackitt, Eaton and Lentz (2016) conducted quality/performance project, where current practice were identified and evidence-based recommendations were developed. The project aimed to improve the healthcare of post-operative patients who went for ureteroscopy and reduce the rate of patients seeking information via clinical advice lines or through return to the Emergency Department (ED) within 30 days of surgery. The quality project took place in an outpatient urology clinic associated with an academic medical centre which reflected the collective procedures of ureteroscopy for patients with kidney stones are performed and patients are discharged to their homes the same day of their operation. Identification of the problem and the number of patients returning to the ED after surgery were acquired from retrospective chart audits. The information from the previous audit chart and the literature review were analysed in order to develop the script which could be implemented with the follow-up phone calls.

The script included questions about the most common lower urinary tract symptoms and also allowed the patient to report any other concerns. In addition to this, nominal data were collected in order to compare percentage and frequency of ED visits and nurse advice line within 30 days of ureteroscopy between compared groups of patients who did receive follow up phone call and the intervention group who did not.

Kim et al. (2015) performed randomized control trial in order to measure the effects of two different interventions such as the ureteral stent with the attached string and the ureteral stent without the attached sting. The patient preference and related parameters were evaluated on 114 randomly selected patients to a string group and a no string group within 7 days postoperatively.

Domains of USSQ and VAS tools were used to determine the patients preference and to rate the degree of pain during stent removal respectively.

Loh-Doyle et al. (2015) randomized control trias andl compared the several different forms of stent removal interventions such as cystoscopy in clinic, doctor’s office , cystoscopy in the operating room and self-string pulling. The patient experience and preference were evaluated based on the questionnaire of 571 responders out of all of the 680 visitors, who were invited to participate in anonymous survey during the visit on kidney stone website. The outcomes were measured using a Chi-square and ANOVA tests of psychometric analysis to identify significant difference among removal methods.

Population Characteristics

The studies selected in this review were conducted in 5 countries of 2398 participants from over the world and included males and females. None of the studies was conducted in the UK, however in one research which collected data form multiple countries (Loh-Doyle et al., 2015), 31 participants were identified from the UK population, which represented only 1% of all participants who had been included in this review.

All studies included adult participants with indwelling ureteral stents in order to prevent ureteral obstruction due to Urolithiasis with the exception of Scarneciu et al. (2015) who also included other indications. The ages of participants who were over 18 years old were reported in all studies except in Loh-Doyle et al. (2015).

Intervention and Control

All studies reported a rationale behind the development of the intervention and compered the impact of indwelled stent on patient’s quality of life against usual care or no intervention where the QOL of patients with ureteral stents were compared to people without kidney stones disease as has been outlined in the study of Ucuzal and Serce (2017). Two papers compered ureteral stent string group to control group with ureteral stent without the inclusion of the string( Barnes, Bing and Tracy (2014) , Kim et al. (2015)), while the other study compared four different types of stents and their impacts on QOL of patients with no control group (Scarneciu et al. (2015). Subsequently, two studies evaluated high quality of education or post procedural follow up impact on associated stent complications against standard care with no intervention as per the Abt et al. (2015), Tackitt, Eaton and Lentz (2016). Lastly one study evaluated pain and patient preference of four different methods of stent removal Loh-Doyle et al. (2015). Across all of the studies, the intervention and the implemented measuring tools and the frequency of data collection were heterogeneous.

Outcomes

Retrieved trials were insufficiently similar as the studies looked at various outcomes. Consequently the results could not be combined statistically using the meta-analysis method, so the effects of the implemented methods were synthesized narratively via numerous tools such as textual descriptions, grouping of similar data and charts which have been utilized in order to summarise the extracted data. None of the studies looked at outcomes that measure effectiveness of pharmacological methods in relieving adverse effect of ureteral stents.

Type of design

Out of the seven prospective trials, four of these were randomized, two non-randomized which recruited participants selectively due to the nature of the research and the necessity of consent and one study included anonymous survey through website.

Three had been of that the good levels and the remaining four are of fair level in their quality of evidence according to “Hierarchy of evidence” by Evans (2003).

Tools measuring outcomes.

In order to unify measures of outcomes which evaluate the influence of ureteral stent and enable the comparison between the effectiveness of every method, adequate tools must have been developed. Patient’s qol with ureteral stent is a running theme throughout the articles. Ucuzal and Serce (2017), Scarneciu et al. (2015), Barnes, Bing and Tracy (2014) discuss the associated complications and side effects of the ureteral sents with regards to the impact of particular domains of the life of the patient. It is well known that ureteral stent can have remarkable negative influence on patent health related quality of life. The tool USSQ contains 36 questions to evaluate the symptoms and effect on QOL of patents with ureteric stent and addresses six domains of health which are being influenced and these could be identified as the urinary symptoms; pain; general health; work capacity; sexual matters and other problems. The tool has been developed and validated by Joshi et al.(Joshi et al., 2003). The tool formulated the standard outcome measures for evaluation of ureteric stent symptoms worldwide and this was completely validated in other languages for example French (Puichaud et al., 2010) and Spanish (Olvera-Posada et al., 2014) and German (Abt et al., 2017).

However, in selected papers in this review, the complications and side effects due to indwelled ureteric stent have been measured and evaluated except validated USSQ (Barnes, Bing and Tracy, 2014) (Kim et al., 2015) ) , also with other predesigned tools such as VAS (Barnes, Bing and Tracy, 2014),(Kim et al., 2015), SF-36 ((Ucuzal and Serce, 2017) , FlaganQoL (Scarneciu et al., 2015), IPSS (Ucuzal and Serce, 2017), or other self-developed tools (Scarneciu et al., 2015) , (Abt et al., 2015), (Loh-Doyle et al., 2015). Regardless of the type of the tool used, each outcome points out the effectiveness of method which has been implemented in order to manage ureteral stent complications, therefore, the obtained results might have potential implications in terms of standard clinical practices, patient care, counselling as well as further stent symptoms management researches.

Themes and Discussion

This chapter focuses on extracting themes from the selected papers and the analysis of the effectiveness of management strategies.

Theme 1. LUTS and Pain – reducing negative symptoms.

Each article has reported about stent related morbidity such as LUTS or associated pain.

Ucuzal and Serce (2017) determined an increase of lower urinary symptoms and significantly reduced quality of life in patients with ureteral stent. (Scarneciu et al., 2015) reported significant increase of impairment of QOL and a statistically considerable increase in incidence of numerous side effects due to ureteral stent utilisation such as urinary frequency, dysuria, urgency and microscopic haematuria. Barnes, Bing and Tracy (2014) reported that stent extraction string does not increase stent related urinary symptoms in comparison to the stents which do not contain strings and also there is no difference of pain level during sent removal regardless of the removal method (self-removal and cystoscopy). Furthermore the study provides the evidence that the stent extraction string does not increase stent related urinary symptoms of complications which is an important information regarding the other benefits which have been finalised and highlighted in the further analysis. Abt et al.(2015) measured the influence of enhanced education regarding complications due to ureteric stenting on the patients and concluded that improved’ knowledge of patients by providing fine-quality education could reduce low ureteral track symptoms, however no relevant impact of better information on pain could be determined.

Tackitt, Eaton and Lentz (2016) have stated that follow up services of nursing improves the understanding of the patient regarding the side-effects of the stent which is vital to either avoid or manage post-operative complication or seek help when necessary.

Kim et al. (2015) stated that no statistically significant difference was discovered within the lists of the urinary symptoms and the measure of pain between two groups of patient, who had been utilising the stents attached with the string and the stents which did not have any stent. However, the no string group had much higher VAS score on extraction than the string group despite the use of 2% lidocaine jelly or analgesic, therefore patients with the string group who have had experienced and noted the difference between both extraction methods namely the cystoscopy and pulling the string, preferred the second method.

In study of Loh-Dole et el. (2015), it has been found that after removal of the ureteric stent some patients did experience the measures of delayed pain, mild delayed pain and sever delayed pain in the extent of 35,4%, 32.3% and 23.7% respectively. Delayed pain after removing stent had been most frequently reported by self-removal string group, however, the lowest average pain during the stent removal was reported by self-removal method via dangler-string at home and Cystoscopy in operating room. The difference in level of the pain between these two methods were not statistically significant.

From analysis of these papers it is evident that ureteral stenting influence negatively on the quality of life in terms of LUTS, the incurrence of the associated costs or the duration of the time which has to be endured by the patient regarding the phase of suffering and pain.

Finding of these articles are consistent with the literature (Haleblian et al., 2008),(Joshi et al., 2003) confirming the presence of stent associated complications. Due to the fact that no “effective analgesia” or “perfect stent” has been invented yet (Al-Aown et al., 2010), there is still a necessity to seek an optimal stent management strategy.

Theme 2. Cost effectiveness.

Five of six studies reported the influence on ureteric stent ono the financial aspects which have to be experienced borne.

Barnes, Bing and Tracy (2014) reported no significant difference in the rate of ER visits and post-operative phone calls or complications between the groups of patients who utilised strings and who did not utilise the string added stent(P= 0.71 and 0.79 respectively). All patients with string stents were able to remove their stents successfully by themselves at home without any post complication expect that of one patient who asked for assistance in clinic with removal of his stent due to anxiety. In addition to this, Barnes, Bing ad Tracy (2014) found no difference in the work performance in those with a stent string and in those with no string. However, self-string removal may lead to substantial health care and patient cost savings where the self- esxtraction method at home eliminates the need of outpatient visit which could lead for a hospital and also reduce the indwelling time for the stent which could result in rapid recovery and consequently, could decrease potentially fewer lost days at work and lastly, could dismiss the travel cost as well.

Abt et al. (2015) have not found any evidence confirming the relevant influence of high quality patient education on the various aspects such as working capacity, the number of medical consultations or hospitalization.

A significant decrease of 11% in the rate of ED visits but no change in the number of advice Line calls for group of patients who did receive the follow up phone calls contrary to the patients who did not get reported by Tackitt, Eaton and Lentz (2016). A nurse could improve the understanding by the patients through the utilisation of telephone based communication regarding the current symptoms of theirs and control their condition independently without unnecessary visit to the ED, which is a cost effective way of managing the patients and reduce hospital appointments.

Kim et al. (2015) had stated that no difference was found in terms of work performance between no string and string extraction groups.

Loh-dole 2015 reported that only 8.5% of patients returned to emergency care out of a third of all responders who experienced delayed mid-to- severe pain after stent removal. Most of these patients removed their strings by themselves at home.

This way, the patients can save time and money for travelling, minimizing cost of health care service and, most importantly, reduce time of morbidity

Theme 3. Stent dwell time.

Three of four papers did not collect date in regards to duration of stent dwell time Ucuzal and Serce (2017),Tackitt, Eaton and Lentz (2016), Loh-Doyle et al. (2015). Scarneciu et al., (2015) in their study concluded that regardless of type, all the implemented ureteral stents could decrease patient QOL significantly due to the presence of foreign body. However after the initial 14 days and its suppression the mean score showed that morbidity level coming closer to the score at the baseline which patients had before stent implementation.

Barnes, Bing and Tracy (2014) reported that patients without a string had a significantly longer period with the postoperative ureteric stent in comparison to patients with stent string (10.6 VS 6.3 days, P0.001) Moreover, one patient, who had stent without string had suffered considerable complications in the follow up and has retained ureteric stent for 6 months. (Abt et al., 2015) reported that median stent indwelling time of 30days (from 8 to 94days) Kim et al. (2015) stated that stents were removed in outpatient’s clinic on the first post operation appointment which took place within 7 days after insertion. The average duration of having stents were similar for both groups: strings for 5.97days vs no strings for 6.28days. Lower urinary symptoms are caused by mechanical irritation on the bladder muscle, and regardless of the type of stent, the symptoms are still present and are the main cause of patient complications. Reducing time of indwelling stent could seem to be a very reasonable and practical strategy. Patients could select the option to have a string left for them to pull the string by themselves at home or at the clinic. Other benefit of self-removal is that invasive methods such as Cystoscopy increases risk of infection, as it involves the insertion of new foreign body. The important outcome of this review is that none of the intervention implemented in management strategies had negative impacts of patient quality of life and did not worsen the symptoms. Some strategies clearly show a positive impact on some of the dimensions of the QOL of the patients.

Implication in Nursing practice

It is apparent that non-pharmacological factors are needed to be achieved in order to decrease the stent associated complications. It has been suggested that although providing high quality education to patients is cost effective, however, the role of patient education in reducing the rate of occurrence and complications is uncertain. Integrating patient education and patient choice of the stent removal via string is important in reducing time duration for stent indwelling and cost control for health services as well as for the patient. A threshold of stent side effects knowledge is required to provide high quality education regarding urethral stent management which could have the potential to improve patient quality of life.

Strengths & Weaknesses of this review

The highest quality of literature review such as those conducted by the Cochrane Centre and the Campbell Collaboration usually involved a team of reviewers in order to decrease bias and to increase the truthfulness of the results (Bettany-Saltikov, 2012). This literature review is conducted by the student nurses without team support. Moreover the student is a novice in conducting systematic literature review and had limited time, therefore the level of the outcome of the bias might be increased and the quality considerably could be decreased. It also needs to be acknowledged that this review has been limited to studies available in English. Lack of standardisation of the measures of the outcome, length of trial and duration of stenting was difficult to analyse.

The strength of this review was that most of the trials have large sample sizes and one research lasted for 10 years.

Conclusion

Despite major discoveries in relation to ureteral stent complications in last 3 decades, side effects remain a problem.

The aim of his systematic literature review has been to evaluate the effectiveness of non-pharmacological methods in managing complications caused by ureteral stent. This review supports, updates and supplements the findings of previous reviews about QOL of patients with Ureteral stent especially in respect of non-pharmacological methods. Despite limitations in methodology and in the possible measuring tools and heterogeneous data obtainment, a few generalisation had been made from these studies.It has been identified that combining different management strategies is of benefit to patients with ureteral stent regarding the diminishing urinary symptoms, associated cost for patients and healthcare services and lastly the shortening of the duration of suffering

The result of this literature review states clearly that in dwelling into a foreign body, an ureteral stent causes complications and decreases the quality of life. However, combining the different strategies such as self-string removal at home, high quality patient education, nursing telephone follow up, have a positive effect on patient QOL. As discussed previously, the outcomes of this literature review have found that implementing non-pharmacological management strategies reduce the duration of suffering substantially and also are cost effective in terms of minimizing the rate of ED post-operative visits or could as well reduce the need of travelling to clinic in order to remove a stent.

A further research regarding the subject matter of the reduction of the stent related complications is necessary. Non-pharmacological strategies should be considered in addition to standard management.