Maher Aldemerdash^1*, Ali Hussain AlShaqaq², Abdulnaser AlAbadi¹, Fahad E AlOtaibe¹, Khalid Bel'eed-Akkari¹, Yousef Saleh Alsowayan³

¹Multi-Organ Transplant Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia

²Department of Nephrology, Johns Hopkins Aramco Healthcare Dhahran, Saudi Arabia

³Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia

^*Corresponding author:Maher Aldemerdash, Multi-Organ Transplant Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia.

Received: July 11, 2025;Accepted: July 28, 2025;Published: August 08, 2025

Article Information

Citation: Maher Aldemerdash, Ali Hussain AlShaqaq, Abdulnaser AlAbadi, Fahad E AlOtaibe, Khalid Bel'eed-Akkari, Yousef Saleh Alsowayan. Early versus Late Ureteral Stent Removal in Kidney Transplantation: A Systematic Review and Meta- Analysis of Urological Outcomes. Archives of Nephrology and Urology. 8 (2025): 94-105.

DOI: 10.26502/anu.2644-2833102

Abstract

Keywords

Kidney transplantation; Ureteral stent; and Urinary tract infection; Ureteric leak

Article Details

Introduction

Kidney transplantation is a life-saving procedure for patients with end- stage renal disease, offering improved quality of life and longevity compared to dialysis [2, 3]. As surgical techniques and immunosuppressive regimens have advanced, the success rates of kidney transplants have significantly improved over the past decades [4]. However, post-transplant complications remain a concern, with urological complications being among the most common [5].

One of the key strategies to prevent urological complications, particularly ureteral obstruction and urinary leakage, is the placement of a ureteral stent during transplantation [6]. This small tube, typically made of flexible plastic, is inserted to maintain patency of the ureter and facilitate urinary drainage from the transplanted kidney to the bladder [6]. While ureteral stenting has become a standard practice in many transplant centers, there is ongoing debate regarding the optimal timing for stent removal [7]. The use of ureteral stents in kidney transplantation is associated with both benefits and potential risks [6]. On one hand, stents can reduce the incidence of major urological complications such as ureteral stenosis and leakage, which can lead to graft dysfunction or loss if left untreated [7]. On the other hand, prolonged stent placement may increase the risk of urinary tract infections (UTIs), hematuria, bladder irritation, and stent migration or encrustation [8].

Given these considerations, the timing of stent removal becomes a critical decision in post-transplant care. Traditionally, many centers have adopted a conservative approach, leaving the stent in place for several weeks to months after transplantation [1]. This practice aims to ensure complete healing of the ureterovesical anastomosis before stent removal [6]. However, recent studies have suggested that earlier stent removal may be equally effective in preventing urological complications while potentially reducing stent- related morbidity [9, 10].

The concept of early stent removal, typically defined as removal within 3 weeks post-transplantation, has gained attention in recent years. Proponents argue that early removal can decrease the risk of stent-related UTIs, reduce patient discomfort, and simplify post-transplant management [7, 9, 10]. Additionally, early removal may lead to cost savings by reducing the need for additional procedures and antibiotic treatments [11]. However, concerns persist about whether early removal might compromise the protective effects of stenting against major urological complications. Despite the importance of this issue, there is a lack of consensus in the transplant community regarding the optimal timing for ureteral stent removal. Various studies have reported conflicting results, with some favoring early removal and others supporting a more conservative approach [12-14]. This lack of agreement highlights the need for a comprehensive analysis of the available evidence to guide clinical decision- making.

The primary objectives of this systematic review and meta-analysis are to compare the incidence of urological complications, UTIs, and other stent-related morbidities between early and late ureteral stent removal groups.

Methods

In this meta-analysis, the Cochrane Handbook for Systematic Reviews and Interventions [15] and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards were meticulously followed [16].

Study Selection and Data Sources

A systematic search was conducted in PubMed, Web of Science, Cochrane Library, and Scopus databases up to July 2024. The search strategy aimed to identify studies comparing outcomes of early versus late removal of ureteral stents following kidney transplantation. Detailed search strategy is shown in appendix 1.

Inclusion Criteria

Studies eligible for inclusion were randomized controlled trials (RCTs), prospective and retrospective comparative studies that evaluated outcomes such as UTI, ureteric leakage, ureteral stenosis, hydronephrosis, urinoma, and stent migration in adult patients undergoing kidney transplantation. Studies reporting comparative data on early (defined as within the first few weeks’ post-transplant) versus late (after several weeks post-transplant) removal of ureteral stents were included.

Data Extraction

Data were extracted independently by two reviewers using a standardized data extraction form. Extracted data included study design, timing of stent removal (early vs. late), study groups, sample size, participant demographics (age, sex), follow-up duration, and summary of the studies.

Quality Assessment

The quality of the included studies was assessed using different tools based on the study design. For RCTs, the revised Cochrane risk-of-bias tool (RoB 2) was used, evaluating domains such as randomization process, deviations from intended interventions, missing outcome data, measurement of outcomes, and selection of the reported result [17]. For cohort studies, the Newcastle-Ottawa Scale (NOS) was used, assessing selection, comparability, and outcome domains. Studies were classified as having low, moderate, or high risk of bias [18].

Data Synthesis and Analysis

Meta-analysis was conducted using RevMan software 5.4 version. Pooled odds ratios (OR) with 95% confidence intervals were calculated for dichotomous outcomes. Statistical heterogeneity was assessed using the p value of heterogeneity below 0.1 considered indicative of substantial heterogeneity. Random effect model and sensitivity analyses were performed to explore sources of heterogeneity.

Subgroup analysis

Subgroup analyses categorized studies based on specific time intervals for early versus late stent removal (e.g., within the first week, second week, or third week post- transplantation). This approach aimed to evaluate whether the observed effects on outcomes such as UTIs, ureteric leakage, and other complications varied depending on the precise timing of stent removal.

Results

The study selection process involved an initial identification of 2066 records from PubMed, Web of Science, Cochrane Library, and Scopus. After removing 749 duplicates, 1317 records underwent title and abstract screening, resulting in the exclusion of 1294 records. Full-text screening of 23 remaining articles led to the exclusion of 9 studies, primarily due to their nature as conference abstracts, reviews, or being unrelated to the study's focus. Ultimately, 14 studies were included in the systematic review, with all 14 also included in the subsequent meta-analysis [1, 11-14, 19-27].

Baseline and summary of the included studies

In this review, there are 8 RCTs [11, 12, 14, 19, 21-24] and 6 other study designs, including retrospective [1, 13, 20, 26] and prospective comparative studies [25, 27]. Participants' ages ranged broadly across studies, ranged between 30.8 and 45.6 years; male participants were predominant across most groups. Follow-up periods ranged from one month to nine months, with the majority of studies conducting follow- ups at three months post-transplantation to assess urological outcomes and complications. Further details are shown in table 1.

Quality assessment

Regarding the included RCTS, 7 studies were judged as having some concerns due to lack of information about deviations from intended intervention, bias in the measurement of the outcome, or selection of the reported results. Ramamoorthy et al. 2018 was judged as having high risk of bias as it was non randomized study. Figure 2 and Figure 3

Figure 1: PRISMA flow diagram of study selection.

Table 1: Summary and baseline of the included studies.

Figure 2: Risk of bias assessment for randomized controlled trials (RCTs).

Figure 3: Risk of bias assessment for observational studies.

Table 2: Quality assessment of the included observational studies.

Regarding the included observational studies, 4 studies were rated as having good quality [1, 20, 25, 26], and Yuksel et al. 2017 was judged as having fair quality [27].

On the other hand, Coskun et al. 2011 was judged as having poor quality due to insufficient data the three main domains [13].

Outcomes

Primary outcomes

Incidence of urinary tract infection (UTI)

When ureteral stents were removed within the first week post-transplantation, the early removal group demonstrated a reduced incidence of UTIs compared to the late removal group (OR = 0.33 [0.21, 0.50], P < 0.00001), and the data were homogenous (P = 0.30; I² = 17%).

Similarly, when stents were removed within the second week post-transplantation, the early removal group demonstrated a reduced incidence of UTIs compared to the late removal group (OR = 0.39 [0.18, 0.86], P = 0.02), and the data were homogenous (P = 0.18; I² = 41%). When stents were removed within the third week post-transplantation, there was insignificant difference between the early removal group and the late removal group in the incidence of UTIs (OR = 0.65 [0.39, 1.08], P = 0.004), but the data were heterogeneous (P = 0.08; I² = 49%). This heterogeneity was resolved by excluding Dadkhah et al. 2016 (P = 0.20; I² = 33%). After resolving heterogeneity, the early removal group demonstrated a reduced incidence of UTIs compared to the late removal group (OR = 0.57 [0.37, 0.89], P = 0.01).

Overall, the pooled analysis of 14 studies including 3096 patients, showed a significant reduction in the incidence of UTI in the early group compared with the late group (OR = 0.46 [0.32, 0.66], P < 0.0001), but the date were heterogeneous (P = 0.04; I² = 44%). After resolving heterogeneity by excluding Dadkhah et al. 2016 (P = 0.12; I² = 33%), the results remained significant (OR = 0.43 [0.31, 0.60], P < 0.00001).

Ureteric Leakage

When ureteral stents were removed within the first week post-transplantation, the early removal group demonstrated a high incidence of ureteric leakage compared to the late removal group (OR = 4.71 [1.65, 13.44], P = 0.004), and the data were homogenous (P = 0.96; I² = 0).

When stents were removed within the third week post- transplantation, there was insignificant difference between the early removal group and the late removal group in the incidence of ureteric leakage (OR = 0.54 [0.12, 2.50], P = 0.43), and the data were homogenous (P = 0.36; I² = 0).

Overall, the pooled analysis of 8 studies including 2035 patients, showed a significant increase in the incidence of ureteric leakage in the early group compared with the late group (OR = 2.54 [1.22, 5.27], P = 0.01), and the date were homogenous (P = 0.37; I² = 7%).

Figure 4: Forest plot of early versus late stent removal on urinary tract infection incidence.

Figure 5: Forest plot of early versus late stent removal on ureteric leakage incidence.

Secondary outcomes

Ureteral Stenosis

There was insignificant difference between the early removal group and the late removal group in the incidence of ureteral stenosis (OR = 0.70 [0.17, 2.85], P = 0.62), and the data were homogenous (P = 0.90; I² = 0).

Figure 6: Forest plot of early versus late stent removal on ureteral stenosis incidence.

Hydronephrosis

Also, there was insignificant difference between the early removal group and the late removal group in the incidence of ureteral stenosis (OR = 1.07 [0.43, 2.62], P = 0.89), and the data were homogenous (P = 0.89; I² = 0).

Figure 7: Forest plot of early versus late stent removal on hydronephrosis incidence.

Urinoma

Similarly, there was insignificant difference between the early removal group and the late removal group in the incidence of ureteral stenosis (OR = 0.40 [0.10, 1.65], P = 0.21), and the data were homogenous (P = 0.82; I² = 0).

Stent migration

Finally, there was insignificant difference between the early removal group and the late removal group in the incidence of stent migration (OR = 0.58 [0.22, 1.55], P = 0.28), and the data were homogenous (P = 0.31; I² = 5%).

Figure 8: Forest plot of early versus late stent removal on urinoma incidence.

Figure 9: Forest plot of early versus late stent removal on stent migration incidence.

Discussion

Our meta-analysis provides compelling evidence that early removal of ureteral stents following kidney transplantation is associated with a significantly reduced incidence of UTIs compared to late removal. This effect was consistent across different time intervals for early removal, with the most pronounced benefit observed when stents were removed within the first week post-transplantation. The reduced UTI risk with early stent removal may be attributed to several factors. Firstly, the presence of a foreign body in the urinary tract for an extended period provides a surface for bacterial colonization and biofilm formation, increasing infection risk [28]. Early removal eliminates this nidus for infection. Secondly, prolonged stent placement can cause local irritation and inflammation of the urinary tract, potentially compromising its natural defense mechanisms against pathogens [20].

However, our analysis also revealed a higher incidence of ureteric leakage associated with very early stent removal (within the first week). This finding suggests that while early removal confers benefits in terms of UTI prevention, it may compromise the initial healing and sealing of the ureterovesical anastomosis [1]. The optimal timing for stent removal likely involves balancing these competing risks.

Moreover, our analysis found no significant differences between early and late stent removal groups in terms of other urological complications such as ureteral stenosis, hydronephrosis, urinoma formation, and stent migration. This suggests that early stent removal does not compromise the overall structural integrity of the urinary tract reconstruction, provided it is not done too early. The heterogeneity observed in some of our analyses, particularly for UTI incidence when stents were removed in the third week, highlights the complexity of this clinical decision. Factors such as surgical technique, patient characteristics, and post-operative care protocols may influence outcomes and contribute to the observed variability between studies.

Our results align closely with Wang et al. (2022) and Cai et al. (2018), showing a similar magnitude of UTI risk reduction [9, 10]. Specifically, we found an overall odds ratio of 0.46 for UTI incidence with early removal, comparable to the relative risks of 0.42 and 0.43 reported by Wang et al. and Cai et al., respectively. However, our study provides additional granularity by stratifying early removal timing, revealing benefits even within the first week post-transplantation.

Regarding major urological complications, our findings are consistent with all three studies in showing no significant differences between early and late removal groups for most complications. This includes ureteral stenosis, hydronephrosis, and urinoma formation. However, our analysis revealed an increased risk of ureteric leakage with very early (within one week) stent removal, a nuance not captured in these previous meta-analyses. This finding adds an important consideration to the risk-benefit analysis of early stent removal.

Our study's larger sample size (3096 patients) and inclusion of both randomized and observational studies may provide a more comprehensive picture than Cai et al. (2018) [10], which included only RCTs, or Visser et al. (2019) [7], which included conference abstracts. This broader inclusion criteria allows for a more real-world representation of outcomes across various clinical settings. Additionally, our subgroup analysis based on specific time intervals for stent removal offers more detailed guidance for clinical decision- making compared to the broader categorizations used in previous meta-analyses.

The results of our meta-analysis have important implications for post-transplant urological management. The clear reduction in UTI risk with early stent removal, particularly after the first week, suggests that many transplant centers could safely adopt earlier removal protocols. This could lead to reduced antibiotic use, shorter hospital stays, and improved patient comfort [29,11].

However, the increased risk of ureteric leakage with very early removal underscores the need for careful patient selection and close monitoring if adopting a very early removal strategy. It may be prudent to reserve removal within the first week for low-risk patients with optimal surgical outcomes. The lack of significant differences in other urological complications between early and late removal groups is reassuring. It suggests that concerns about increased rates of strictures or other long-term complications with early removal may be overstated, provided removal is not done too early. A key strength of our study is its comprehensive nature, including a large number of patients from diverse clinical settings. The stratification of early removal timing provides more granular insights than previous meta-analyses. Additionally, our rigorous methodology, including thorough quality assessment of included studies and careful handling of heterogeneity, enhances the reliability of our findings.

However, several limitations should be acknowledged. First, the included studies varied in their definitions of "early" and "late" removal, which could introduce some imprecision in our pooled estimates. Second, the retrospective nature of some included studies may introduce bias. Third, we were unable to account for factors such as surgical technique, immunosuppression regimens, and patient comorbidities, which could influence outcomes. Finally, the follow-up periods in most studies were relatively short, limiting our ability to assess long-term complications.

Conclusion

In conclusion, our meta-analysis supports the practice of early ureteral stent removal following kidney transplantation, particularly within the second- or third-week post-transplant. This approach appears to significantly reduce the risk of UTIs without increasing other urological complications. However, very early removal (within the first week) should be approached cautiously due to the increased risk of ureteric leakage. We recommend that transplant centers consider adopting protocols for stent removal between 1-3 weeks post-transplant for suitable patients, while maintaining close follow-up. Future prospective studies with longer follow-up periods and standardized removal time points would further refine our understanding of optimal stent management in kidney transplantation.

Acknowledgements

The authors declare no acknowledgements and received no specific funding for this work.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Trial registration: Not applicable.

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Related PubMed Articles

1. Early Removal of Ureteral Stent After Kidney Transplant Could Decrease Incidence of Urinary Tract Infection: A Systematic Review and Meta-Analysis.
2. Early versus late ureteric stent removal after kidney transplantation.
3. Outcomes of Early Simultaneous Removal of Ureteric Stent With Indwelling Urethral Catheter After Kidney Transplant in Pediatric Recipients: A 10-Year Review.
4. Timing of Ureteric Stent Removal and Occurrence of Urological Complications after Kidney Transplantation: A Systematic Review and Meta-Analysis.
5. [Benefits and risks of early versus late ureteric stent removal after kidney transplantation].
6. Early versus late ureteric stent removal after kidney transplantation.
7. Early double J stent removal in renal transplant patients to prevent urinary tract infection - systematic review and meta-analysis of randomized controlled trials.