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Planned percutaneous nephrolithotomy in patients who initially presented with urosepsis: Analysis of outcomes and complications Planned percutaneous nephrolithotomy in patients who initially presented with urosepsis: Analysis...
Fahmy, Ahmed; Saad, Karim; Sameh, Wael; Elgebaly, Omar
2022-01-02 00:00:00
ARAB JOURNAL OF UROLOGY 2022, VOL. 20, NO. 1, 36–40 https://doi.org/10.1080/2090598X.2021.2002635 ORIGINAL ARTICLE Planned percutaneous nephrolithotomy in patients who initially presented with urosepsis: Analysis of outcomes and complications Ahmed Fahmy, Karim Saad, Wael Sameh and Omar Elgebaly Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt ABSTRACT ARTICLE HISTORY Received 9 May 2021 Objective: To compare the outcomes and complications of planned percutaneous nephro- Accepted 13 July 2021 lithotomy (PCNL) in patients with a prior urosepsis episode to those without. Patients and Methods: We recorded patients who presented initially with obstructive uro- KEYWORDS sepsis, as identified by systemic inflammatory response syndrome and obstructing kidney Percutaneous stones. We compared the surgical outcomes and complications among those patients who nephrolithotomy; urosepsis; had planned PCNL after control of prior urosepsis with urgent decompression and antibiotics outcomes; complications (Group A) to a group who presented for PCNL with no previous history of a septic presentations (Group B). A 1:1 matched-pair analysis was performed using four parameters (age, gender, body mass index, and American Society of Anesthesiologists classification) to eliminate poten- tial allocation bias. Primary outcomes included were stone-free rate (SFR) and complication rate. Secondary outcomes included were operative time, estimated blood loss, and duration of postoperative hospital stay. Results: A total of 80 patients underwent PCNL (48 male and 32 females) divided equally between both treatment groups, with a mean (interquartile range) age of 47 (19–75) years. There were no differences in demographic data or stone characteristics between both groups. Both groups had comparable SFRs (92.5% vs 97.5%, P = 0.212) and mean operative time (77 vs 74 min, P = 0.728) (Table 2). Patients in Group A had a significantly higher overall complications rate (35% vs 10%, P = 0.03) . There were no postoperative mortalities and the mean length of hospital stay was significantly longer in Group A patients compared to group B (4.2 vs 1.5 days, P = 0.042). Conclusions: : Planned PCNL after decompression for urolithiasis-related sepsis has compar- able operative time and SFR but higher complication rates and longer postoperative hospital stay. This is critical in counselling patients prior to definitive treatment of kidney stones after urgent decompression for urosepsis and for adequate preoperative planning and preparation. Abbreviations: ASA: American Society of Anesthesiologists; BMI: body mass index; ICU: intensive care unit; IQR: interquartile range; KUB: plain abdominal radiograph of the kidneys, ureters and bladder; PCN: percutaneous nephrostomy; PCNL: percutaneous nephrolithotomy; SFR: stone-free rate; URS; ureteroscopy; US: ultrasonography Introduction The influence of prior urosepsis on perioperative out- comes of PCNL has not been thoroughly investigated, Percutaneous nephrolithotomy (PCNL) is the minimally and whether prior urosepsis is associated with higher invasive procedure of choice for the management of intra- and postoperative complications remains unclear. large-volume and complex kidney stones because of The aim of the present study was to compare the out- its high efficacy and safety yielding high stone-free comes and complications of planned PCNL in patients rates (SFRs) [1]. Early diagnosis and prompt urgent with a prior urosepsis episode to those without. management of urosepsis related to obstructive uro- lithiasis is pivotal for improved clinical outcomes [2]. Patients and methods Renal decompression through percutaneous nephrostomy (PCN) or retrograde JJ stent is almost A retrospective review of the data of patients who always the first step in managing patients presenting underwent PCNL procedures for kidney stones in our with an obstructing stone and urosepsis followed by Urology Department between August 2016 and definitive treatment for the stone at a later stage, once March 2020 was carried out. Inclusion criteria were the patient’s general condition improves and sepsis con- patients aged >18 years who had kidney stones. trolled [3,4]. However, clinicians should counsel patients Patients with any contraindication for PCNL (such as that treatment of the stones may initially be more com- uncorrected coagulopathy or UTI), solitary kidney or plex, with increased hospital stay and stent time [5]. renal impairment were excluded from the study. The CONTACT Omar Elgebaly omarelgebaly@hotmail.com Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt © 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ARAB JOURNAL OF UROLOGY 37 study was approved by the local Ethics Committee. All microbiology results were re-assessed and Informed consent was obtained from all individual checked for patients in both groups before the endo- participants included in the study. scopic intervention. Patients with symptomatic and/or We recorded patients who presented initially with culture-confirmed UTI and high-risk patients with low obstructive urosepsis, as identified by systemic inflam - ASA classification received an appropriate course of matory response syndrome and obstructing kidney antibiotics, at least 1 week prior to the procedure. In stones [6]. We compared the surgical outcomes and case of negative urine culture, a single perioperative complications among those patients who had planned prophylactic dose of antibiotics was administrated PCNL after control of prior urosepsis with urgent before the endoscopic intervention. This was per- decompression and antibiotics (Group A) to a cohort formed under the supervision of the microbiology group who presented for PCNL with no previous his- team. tory of a septic presentations (Group B). Demographic data including patient age, sex, body Intervention mass index (BMI), American Society of Anesthesiologists (ASA) classification, stone character- All procedures were performed under general anaes- istics, intraoperative events, outcomes of the proce- thesia. After a cystoscopic retrograde ureteric catheter dures, and postoperative hospital stay were collected was fixed, with the patient in the lithotomy position, by reviewing hospital medical records. the patient was placed in the prone position. The skin The stone length was calculated according to the was punctured at the posterior axillary line under mul- longest diameter, and the stone burden was calcu- tidirectional C-arm fluoroscopic guidance (BV Pulsera, lated by multiplying its length by its width. The Philips Medical Systems, Eindhoven, the Netherlands) operative duration was calculated from the time of and posterior calyx was entered with 18-G translumbar initial cystoscopic ureteric catheter placement until angioplasty needle (Boston Scientific, Natick, MA, USA). securing the nephrostomy tube. Stone-free status In some cases (16 patients in Group A), access to the was defined as no residual fragments of ≥4 mm on pelvicalyceal system was obtained via the nephrost- plain abdominal radiograph of the kidneys, ureters omy tube tract. and bladder (KUB) and ultrasonography (US) of the Before beginning tract dilatation, all planned tracts urinary tract after 1 month. The haemoglobin deficit were established, working and safety guidewires were was the difference between the preoperative level secured inside the pelvicalyceal system. Dilatation of and its level 12-h postoperatively. All procedures the tract was achieved with coaxial telescopic dilators were performed or supervised by a single senior (Karl Storz Endoskope, Tuttlingen, Germany). A 30-F endourologist with a high expertise in percutaneous Amplatz sheath (Boston Scientific Corp., Natick, MA, renal surgery to ameliorate potential performance USA) and a 27-F semi-rigid nephroscope (Karl Storz bias when procedures are not performed in Endoskope) were used for all procedures. Pneumatic a uniform way. lithotripsy (Swiss Lithoclast, EMS, Nyon, Switzerland) A 1:1 matching of the patients based on their pro- was utilised for stone disintegration. Stone-free status pensity scores was performed, to eliminate potential was confirmed intraoperatively both endoscopically allocation bias, using a logistic regression model, with and fluoroscopically. A nephrostomy tube (22 F) was prior urosepsis as the dependent variable in relation to placed at the end of the procedure. the following baseline characteristics: age, sex, BMI, ASA classification. We did not include stone character- Postoperative evaluation and follow up istics in the matching criteria, because this would have limited the number of patients included in the study. Renal US and KUB were performed before removal of the nephrostomy tube for detection of residual stones. Any residual stone of >10 mm accessible through the Preoperative evaluation existing nephrostomy tracts was treated by a second Upon complete urosepsis control in Group A patients, session of PCNL, while ESWL was used for residual a planned elective PCNL was scheduled for these fragments of 4–10 mm. All patients underwent renal patients. On admission for elective PCNL, patients US after 1 month for confirmation of stone-free status, were re-evaluated regarding their fitness for the endo- which was defined as no residual fragments of ≥4 mm. scopic intervention at a dedicated pre-assessment clinic in conjunction with the anaesthesia team. Outcome measures Preoperative and admission-related data included urine analysis, urine culture, blood culture, full blood Primary outcomes included were SFR and complica- count, biochemistry study, renal US, KUB, and whole tion rate. The SFR was defined as the absence of any abdominal CT were obtained and evaluated upon residual stones of ≥4 mm on postoperative imaging admission. performed 1 month after PCNL. Postoperative 38 A. FAHMY ET AL. complications were assessed and graded according to Among patients in Group A, emergency decompres- the modified Clavien–Dindo classification [7]. Major sion was achieved via PCN in 28 (70%) and JJ stent complications were defined as Clavien–Dindo Grade placement in 12 (30%). In all, 13 patients (32.5%) III–V. All complications were defined as those occurring required admission to the intensive care unit (ICU) at within the first month postoperatively or before dis- initial presentation of urosepsis. The median (IQR) time charge, whichever the longer time frame. Secondary interval between initial PCN or JJ stent during the outcomes included operative time, estimated blood urosepsis episode and their elective PCNL was 37 loss, and duration of postoperative hospital stay. (10–92) days. A positive urine culture on presentation was obtained in 36 patients (90%) who initially pre- sented with urosepsis. The organisms identified were Statistical methods Escherichia coli (17 patients, 67.5%), Pseudomonas (five, Continuous variables were expressed as mean (± SD). If 12.5%), Klebsiella (three 3,7.5%) and Proteus the parametric test assumptions were met, the Student’s (one, 2.5%). t-test was used for comparing between the two groups, There were no differences in demographic data or while the Mann–Whitney U-test was used if the para- stone characteristics between the groups. Both groups metric test assumptions were not met. Categorical vari- had comparable SFRs (92.5% vs 97.5%, P = 0.212) and ables were expressed as frequency (n) and percentage mean operative time (77 vs 74 min, P = 0.728), with no (%) and compared with chi-squared or Fisher’s exact test. statistically significant difference. There was no need Independent predictors for SFR or complications were for second-look nephroscopy in any patient in either of evaluated using uni- and multivariate logistic regression the treatment groups; however, three patients (two in to control for baseline differences between the two Group A and one in Group B) required ESWL for com- groups. A P < 0.05 was considered statistically significant plete stone clearance. Patients in Group A had signifi - and all the analyses were performed using R software cantly higher overall complications rate (35% vs 10%, version 3.6.0. (R Core Team [2019]. R: A language and P = 0.03). Intraoperative complications included three environment for statistical computing. R Foundation for patients in Group A with significant bleeding necessi- Statistical Computing, Vienna, Austria. URL https://www. tating intraoperative blood transfusion, while no R-project.org/). patient in Group B needed blood transfusion. Subgroup analysis regarding methods of drainage revealed no significant difference between periopera- Results tive outcomes of those who had nephrostomy tube vs A total of 80 patients underwent PCNL (48 male and 32 those who had a JJ stent for relief of urosepsis in Group females) divided equally between both treatment A, including SFR (96.4% vs 83.3%, P = 0.76), operative groups, with a mean (interquartile range [IQR]) age of times (72.7 vs 79.2 min, P = 0.26), length of hospital 47 (19–75) years. Table 1 presents the demographic char- stay (2.8 vs 3.8 days, P = 0.1), and complications rate. acteristics of the studied patients in both groups.Table 2 Table 3 shows postoperative complications included fever (four patients in Group A and two in Group B), two patients developed sepsis postopera- Table 1. Patients’ characteristics. tively needing ICU admission in Group A. Mild gross Group Group haematuria in two patients (5%) in each group, which Characteristic A (N = 40) B (N = 40) P Age, years, median (IQR) 48 (19–76) 52 (19–80) 0.152 was managed conservatively by bed rest, intravenous Gender, male/female, n 22/18 26/14 0.751 fluids, and nephrostomy tube clamping. One patient BMI, kg/m , mean (SD) 28.49 (2.69) 27.13 (5.24) 0.503 presented by severe gross haematuria needed selec- Stone sizes, mm, mean (SD) 26.42 (4.54) 27.19 (6.25) 0.728 Stone side, left/right, n 13/27 15/25 0.320 tive angioembolisation for symptomatic arteriovenous Stone burden, mm , mean 376.68 (17) 412.46 (81) 0.654 fistula confirmed by CT angiography in Group (SD) Stone number, single/ 16/24 20/20 0.140 A. Persistent urinary leakage from the nephrostomy multiple site was noted in two patients in Group A, which was managed with endoscopic retrograde JJ stent Table 2. Clinical outcomes. Group Group Table 3. Perioperative complications (Clavien–Dindo grading). Outcome A (N = 40) B (N = 40) P Clavien–Dindo Group A, Group B, SFR, n/N (%) 37/40 (92.5) 39/40 (97.5) 0.212 Grade Description n (%) n (%) Operative time, min, mean 77 (44–116) 74 (48–110) 0.728 (range) I Fever 4 (10) 2 (5) Overall complications, n/N (%) 14/40 (35) 4/40 (10) 0.03* II Blood transfusion 3 (7.5) 0 High-grade complications, n (%) 5 (12.5) 0 0.001* Haematuria 2 (5) 2 (5) Length of hospital stay, days, 4.2 (1–9) 1.5 (1–3) 0.042* IIIA Angioembolisation 1 (2.5) 0 mean (range) IIIB Persistent urinary 2 (5) 0 Postoperative admission to 2 0 0.152 leakage ICU, n IV Sepsis 2 (5) 0 V Death 0 0 *Statistically significant at P < 0.05. ARAB JOURNAL OF UROLOGY 39 placement. There were no postoperative mortalities in The optimal duration of antibiotic treatment and our study and the mean length of hospital stay was waiting time before definitive treatment after urgent significantly longer in Group A patients compared to decompression for patients who initially present with group B (4.2 vs 1.5 days, P = 0.042). urosepsis have not been thoroughly investigated and Multivariate logistic regression analysis showed that determined [19]. In the present study, patients who stone size, side, burden, and number were not inde- presented with sepsis were treated initially with pendent predictors of stone-free status or developing decompression either by PCN or endoscopic JJ inser- complications after PCNL procedure. Initial presenta- tion, intravenous antibiotics were administrated for tion with urosepsis was statistically significantly related a median period of 7 days (up to 14 days) followed to the complication rate in multivariate models (odds by oral antibiotics for 1–2 weeks. ratio 3.251, 95% CI 1.829–8.654; P = 0.001). Patients were treated definitively by PCNL after a median (IQR) period of 37 (10–92) days from initial decompression of sepsis. This was influenced by multiple factors including the severity of initial pre- Discussion sentation, presence of comorbidities, clinical response to treatment after decompression and anti- Urosepsis due to an obstructing stone must be biotics, subsequent anaesthetic assessment of fit - managed by urgent decompression of the obstructed ness for their elective procedure, waiting list time, kidney, aggressive fluid resuscitation with haemody- and patient choice. The appropriate waiting time for namic support associated with controlling the source definitive management after initial decompression of the infection by an appropriate course of antibio- and its potential impact on success and complica- tics [8,9]. This should be followed by definitive man- tions rate could not be elucidated from our present agement of the stone, once the infection has resolved study due to the relatively small number of patients and the patient’s general conditions have and few complications. In addition, many of these improved [3,4,8]. cases were initially managed outside our hospital by It was assumed that, patients undergoing planned renal decompression for urosepsis control and pre- endourological approaches after prior urosepsis sented to us later for definitive PCNL procedure. decompression were more likely to have more com- In the present study, the SFR was similar between plex procedure and a higher complication rate the two treatment groups. History of prior urosepsis [10,11]. Prolonged antibiotic administration, longer did not affect the SFR as long as the technical steps are postoperative hospital stay, and auxiliary procedures strictly followed, PCNL can still be performed with may also be needed. This suggests that patients with a comparable success rate. prior urosepsis, even those adequately managed in Patients in Group A had a higher overall complica- the emergency phase, are more prone to complica- tion rate (35% vs 10%) and severity of complications tions after the elective endourological treatment [12– compared to Group B. None of patients in Group 14]. A possible explanation for this may be attributed B developed a high-grade complication (Grade III–V); to the residual effect of inflammatory changes however, five patients in Group A had high-grade com- induced by urosepsis on renal parenchyma and plications. This substantial difference can be explained microvasculature [15]. In addition, patients’ frailty, to some extent by urosepsis induced effect on renal associated comorbidities in patients with prior uro- parenchyma including tissue inflammation, ischaemia, sepsis and the more prevalence of septic foci includ- vascular damage, and the presence of uncleared septic ing infection stones in the urinary tracts are other foci inside the urinary system resulting in an increase in potential causes among this group of patients the risk of intra- and postoperative complications. The [16,17]. mean postoperative hospital stay was 4.2 and 1.5 days Few publications have investigated the impact of in groups A and B, respectively (P = 0.042). prior urosepsis as an independent risk factor on surgi- Postoperative adverse events were more prevalent cal outcomes and complications after definitive among patients in Group A and the time needed for endourological approaches. A retrospective matched- their appropriate management may account for the pair comparison between elective ureteroscopy (URS) more prolonged postoperative hospital stay. and patients with prior urosepsis showed SFRs were In the present study, matching of patients was similar between the two groups, but patients with successfully performed based on age, gender, BMI, history of prior sepsis were more likely to have and ASA classification for better patient characteris- increased hospital stay, require prolonged antibiotic tics adjustment. Our results revealed that prior uro- use, and have prolonged stent duration [18]. Another sepsis is predictive of adverse perioperative study reported the outcomes of elective URS stone outcomes in patients requiring elective PCNL after treatment in 76 patients with prior sepsis and emer- urosepsis control and was associated with higher gency drainage, the SFR was 97% and there was only grades of complications. one high-grade complication [5]. 40 A. FAHMY ET AL. Considering the results of the present study, the [3] Goldsmith ZG, Oredein-McCoy O, Gerber L, et al. Emergent ureteric stent vs percutaneous nephrost- following limitations should be taken into account. omy for obstructive urolithiasis with sepsis: patterns The first limitation is its retrospective nature, repre- of use and outcomes from a 15-year experience. BJU senting a single centre experience, which implicates Int. 2013;112:E122–E128. potential confounding. To control for this, we matched [4] Pearle MS, Pierce HL, Miller GL, et al. Optimal method patients based on propensity scores. Second, the rela- of urgent decompression of the collecting system for obstruction and infection due to ureteral calculi. J Urol. tively small number of patients included, which pre- 1998;160:1260–1264. cluded the meaningful analysis of other independent [5] Pietropaolo A, Hendry J, Kyriakides R, et al. Outcomes predictors for clinical outcomes or complication rates, of elective ureteroscopy for ureteric stones in patients especially with the relatively small number of out- with prior urosepsis and emergency drainage: pro- comes. Finally, we were not able to study the differ - spective study over 5 yr from a tertiary endourology ence in clinical outcome and complications between centre. Eur Urol Focus. 2020;6:151–156. [6] Wagenlehner FM, Pilatz A, Weidner W. Urosepsis— both groups based on the type of stone composition, from the view of the urologist. Int J Antimicrob as stone analysis was not available in our data. It was Agents. 2011;38(Suppl):51–57. demonstrated that infection stone composition could [7] Dindo D, Demartines N, Clavien PA. Classification of negatively affect the overall complication rate with surgical complications: a new proposal with evalua- previous sepsis [17]. tion in a cohort of 6336 patients and results of a However, the advantage of the present study is its survey. Ann Surg. 2004;240:205–213. [8] Reyner K, Heffner AC, Karvetski CH. Urinary obstruction ability to demonstrate higher complication rates and is an important complicating factor in patients with longer postoperative hospital stay associated with elec- septic shock due to urinary infection. Am J Emerg Med. tive PCNL after treatment of urosepsis. This may help in 2016;34:694–696. counselling a selected group of patients with a higher risk [9] Miano R, Germani S, Vespasiani G. Stones and urinary of intra- and postoperative complications, thus could tract infections. Urol Int. 2007;79(Suppl. 1):32–36. [10] Tambo M, Okegawa T, Shishido T, et al. 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