Utility of Post-ureteroscopy Lesion Scale (PULS) in Per-operative Decision-Making for the Need of Double J Stent

Objectives: To assess the applicability of the post ureteroscopy lesion scale (PULS) as an objective measure to define the need for double J (DJ) stent placement after ureterorenoscopy (URS). Methods: Between June and December 2020 a cross-sectional study was conducted at a university hospital. All patients fulfilling the inclusion criteria undergoing URS for renal or ureteric stones were included. At the completion of procedures, the ureter was carefully inspected for injury. Lesions were classified using PULS scoring by the operating surgeon, another consultant, and the resident. The primary outcome was to validate the PULS score against the surgeon’s decision for postoperative stenting and to assess its reliability. Results: A total of 126 patients were included with a mean age of 43.42±15.3 years. The mean stone size was 9.42±3.60mm. DJ stents were placed in 81 cases (62.4%). All of the 38 (30.1%) patients with a significant residual fragment were stented. Ureteric injury of grade 1 was observed in 66 patients (52.3%), of which 22 (33%) had DJ stenting. PULS grade 2 injuries were observed in 22 patients (17.4%), and 95% were stented. With a PULS score of > 2 almost all (97.8%) were stented. Inter-rater reliability of PULS scoring was high among the consultants (Kendall’s W=0.89, p<0.005). Conclusion: DJ stent placement was observed in 33%, 95%, and 98% of patients with PULS grade 1, 2, and >2 injury respectively. In patients with no residual fragment, the need for DJ stenting can be objectively defined using the PULS scoring system as it has high specificity and good interrater reliability.