Prevention and treatment of septic shock following mini-percutaneous nephrolithotomy: a single-center retrospective study of 834 cases

Impacts of urinary tract anomalies or history of upper urinary tract surgery on outcome of mini-ECIRS (endoscopic combined intrarenal surgery)

This study assessed the impact of urinary tract anomalies or a history of upper urinary tract surgery (UTAS) on the minimally invasive endoscopic combined intrarenal surgery (mini-ECIRS) outcomes. Data from 1432 patients undergoing ECIRS for urolithiasis at three Japanese tertiary institutions between 2015 and 2021 were analyzed, with patients categorized into those with normal urinary tracts (non-UTAS) and those with UTAS (UTAS). We retrospectively examined the association between the UTAS and perioperative outcomes in mini-ECIRS. Of the 1096 cases in the final analysis, 1035 and 61 were identified as non-UTAS and UTAS, respectively. Stone-free rate (residual fragments > 2 mm, 62.8% vs. 62.7%), operation time (110.5 vs. 115.0 min), and hospital stay duration (5.6 vs. 5.7 days) showed no significant differences between non-UTAS and UTAS. The UTAS group demonstrated significantly higher rates of preoperative pyuria (86.2% vs. 71.1%), preoperative urinary tract infection (32.8% vs. 15.5%), preoperative stenting (52.5% vs. 31.0%), and preoperative nephrostomy (24.6% vs. 9.2%). However, the postoperative fever (26.3% vs. 25.0%) or septic shock (1.9% vs. 0%) were comparable between non-UTAS and UTAS. Stone burden and the number of calyces involved were significantly associated with a low stone-free rate (P < 0.001). Younger age, female sex, solitary stones, number of calyces involved, preoperative urinary tract infection, and absence of preoperative nephrostomy were identified as risk factors for perioperative complications. The UTAS was not associated with stone-free outcomes or perioperative complications. Mini-ECIRS demonstrated comparable stone-free outcomes and safety in patients with UTAS and those with normal urinary tracts.

A novel post-percutaneous nephrolithotomy sepsis prediction model using machine learning

OBJECTIVES

To establish a predictive model for sepsis after percutaneous nephrolithotomy (PCNL) using machine learning to identify high-risk patients and enable early diagnosis and intervention by urologists.

METHODS

A retrospective study including 694 patients who underwent PCNL was performed. A predictive model for sepsis using machine learning was constructed based on 22 preoperative and intraoperative parameters.

RESULTS

Sepsis occurred in 45 of 694 patients, including 16 males (35.6%) and 29 females (64.4%). Data were randomly segregated into an 80% training set and a 20% validation set via 100-fold Monte Carlo cross-validation. The variables included in this study were highly independent. The model achieved good predictive power for postoperative sepsis (AUC = 0.89, 87.8% sensitivity, 86.9% specificity, and 87.4% accuracy). The top 10 variables that contributed to the model prediction were preoperative midstream urine bacterial culture, sex, days of preoperative antibiotic use, urinary nitrite, preoperative blood white blood cell (WBC), renal pyogenesis, staghorn stones, history of ipsilateral urologic surgery, cumulative stone diameters, and renal anatomic malformation.

CONCLUSION

Our predictive model is suitable for sepsis estimation after PCNL and could effectively reduce the incidence of sepsis through early intervention.

A Novel Nomogram for Predicting Post-Operative Sepsis for Patients With Solitary, Unilateral and Proximal Ureteral Stones After Treatment Using Percutaneous Nephrolithotomy or Flexible Ureteroscopy

Background

The postoperative sepsis is a latent fatal complication for both flexible ureteroscopy (fURS) and percutaneous nephrolithotomy (PNL). An effective predictive model constructed by readily available clinical markers is urgently needed to reduce postoperative adverse events caused by infection. This study aims to determine the pre-operative predictors of sepsis in patients with unilateral, solitary, and proximal ureteral stones after fURS and PNL.

Methods

We retrospectively enrolled 910 patients with solitary proximal ureteral stone with stone size 10–20 mm who underwent fURS or PNL from Tongji Hospital's database, including 412 fURS cases and 498 PNL cases. We used the least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression analysis to identify the risk factors for sepsis. Finally, a nomogram was assembled utilizing these risk factors.

Results

In this study, 49 patients (5.4%) developed sepsis after fURS or PNL surgery. Lasso regression showed postoperative sepsis was associated with gender (female), pre-operative fever, serum albumin (<35 g/L), positive urine culture, serum WBC (≥10,000 cells/ml), serum neutrophil, positive urine nitrite and operation type (fURS). The multivariate logistic analysis indicated that positive urine culture (odds ratio [OR] = 5.9092, 95% CI [2.6425–13.2140], p < 0.0001) and fURS (OR = 1.9348, 95% CI [1.0219–3.6631], p = 0.0427) were independent risk factors of sepsis and albumin ≥ 35g/L (OR = 0.4321, 95% CI [0.2054–0.9089], p = 0.0270) was independent protective factor of sepsis. A nomogram was constructed and exhibited favorable discrimination (area under receiver operating characteristic curve was 0.78), calibration [Hosmer–Lemeshow (HL) test p = 0.904], and net benefits displayed by decision curve analysis (DCA).

Conclusions

Patients who underwent fURS compared to PNL or have certain pre-operative characteristics, such as albumin <35 g/L and positive urine culture, are more likely to develop postoperative sepsis. Cautious preoperative evaluation and appropriate operation type are crucial to reducing serious infectious events after surgery, especially for patients with solitary, unilateral, and proximal ureteral stones sized 10–20 mm.

Neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and lymphocyte-monocyte ratio (LMR) in predicting systemic inflammatory response syndrome (SIRS) and sepsis after percutaneous nephrolithotomy (PNL)

The objective of this prospective observational study was to assess the clinical significance of neutrophil–lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR) and lymphocyte–monocyte ratio (LMR) as potential biomarkers to identify post-PNL SIRS or sepsis. Demographic data and laboratory data including hemoglobin (Hb), total leucocyte count (TLC), serum creatinine, urine microscopy and culture were collected. The NLR, LMR and PLR were calculated by the mathematical division of their absolute values derived from routine complete blood counts from peripheral blood samples. Stone factors were assessed by non-contrast computerized tomography of kidneys, ureter and bladder (NCCT KUB) and included stone burden (Volume = L × W × D × π × 0.167), location and Hounsfield value and laterality. Intraoperative factors assessed were puncture site, tract size, tract number, operative time, the need for blood transfusion and stone clearance. Of 517 patients evaluated, 56 (10.8%) developed SIRS and 8 (1.5%) developed sepsis. Patients developing SIRS had significantly higher TLC (10.4 ± 3.5 vs 8.6 ± 2.6, OR 1.19, 95% CI 1.09–1.3, p = 0.000002), higher NLR (3.6 ± 2.4 vs 2.5 ± 1.04, OR 1.3, 95% CI = 1.09–1.5, p = 0.0000001), higher PLR (129.3 ± 53.8 vs 115.4 ± 68.9, OR 1.005, 95% CI 1.001–1.008, p = 0.005) and lower LMR (2.5 ± 1.7 vs 3.2 ± 1.8, OR 1.18, 95% CI 1.04–1.34, p = 0.006). Staghorn stones (12.8 vs 3.24%, OR 4.361, 95% CI 1.605–11.846, p = 0.008) and long operative times (59.6 ± 14.01 vs 55.2 ± 16.02, OR 1.01, 95% CI 1.00–1.03, p = 0.05) had significant association with postoperative SIRS. In conclusion, NLR, PLR and LMR can be useful independent, easily accessible and cost-effective predictors for early identification of post-PNL SIRS/sepsis.

Predictive accuracy of the modified SOFA score, SIRS criteria, and qSOFA score for uroseptic shock after mini-percutaneous nephrolithotomy

The purpose of this study was to determine the plausibility and utility of utilizing a modified SOFA (mSOFA) score for predicting uroseptic shock after mini-percutaneous nephrolithotomy. A cohort of 707 patients who received mini-PCNL from August 2019 to December 2020 was retrospectively evaluated. The area under receiver operating characteristic curve (AUROC) was used to compare the predictive value of septic shock between mSOFA, systemic inflammatory response syndrome (SIRS) and qSOFA. Among 707 patients, 24 patients experienced uroseptic shock after mini-PCNL. Compared with the no uroseptic shock group, the proportion of females and rates of preoperative urine culture, renal pelvis urine culture and stone culture positivity were higher in the uroseptic shock group, with high levels of preoperative C-reactive protein (CRP) and postoperative procalcitonin (PCT). In the uroseptic shock group, the mSOFA score increased by two or more points in 83.3%; 79.2% had at least two SIRS criteria, and 100% had a qSOFA score of at least one point. mSOFA score (AUROC = 0.866, 95% CI: 0.779-0.954) exhibited greater discrimination for uroseptic shock after PCNL than SIRS (AUROC = 0.838, 95% CI: 0.742-0.943) and qSOFA (AUROC = 0.851, 95% CI: 0.811-0.892). In conclusion, the predictive value of the modified SOFA score for uroseptic shock after mini-PCNL was greater than that of the qSOFA score or SIRS.

Combination laparoscopy and nephrolithotomy technique in the same session in patients with complete staghorn stones and poor performance status: case series in a single center with long-term follow-up

BACKGROUND

The management of complete staghorn stones remains a challenge for urologists, owing to the high stone burden, low stone free rate, and high rate of complications. Hence, we aimed to evaluate the outcomes of a technique involving combination laparoscopy and nephrolithotomy in the same session in patient with complete staghorn stones and poor performance status.

METHODS

We retrospectively evaluated seven patients with complete staghorn stones who underwent a combination of laparoscopy and nephrolithotomy in the same session in our center between December 2016 and October 2019. The surgical technique was as follows. Through a four-port transperitoneal laparoscopic approach, the kidney was mobilized after complete dissection of the renal pedicle. The renal pelvis was then incised with a cold scalpel. A nephroscope was inserted into the renal collecting system through both a laparoscopic port and the renal pelvis incision. This method enabled visualization of and access to almost all calyces for clearing the stones from the affected kidneys in a hand-assisted manner which a hand was inserted in the peritoneal cavity. The outcome data included the stone-free rate, short-term and long-term complication rates, and stone recurrence rate.

RESULTS

The stone free rate was 85.70% (6/7). No patients had sepsis or required blood transfusion perioperatively, and no major short-term complications occurred. After 24.00 (15.00, 48.00) months' follow-up, no patients had long-term complications, and only one patient had stone recurrence.

CONCLUSION

The technique of combining laparoscopy and nephrolithotomy in the same session was an effective and safe treatment for patients with complete staghorn stones and poor performance status. The method was scarcely affected by the stone burden and morphology, had a satisfactory stone free rate, and resulted in no major complications, particularly life-threatening sepsis. It might be an option for such patients.

The value of procalcitonin for predicting urosepsis after mini-percutaneous nephrolithotomy or flexible ureteroscopy based on different organisms

PURPOSE

To assess the value of procalcitonin (PCT) as an early biomarker for predicting urosepsis caused by Gram-negative (GN) bacteria, Gram-positive (GP) bacteria and fungi following mini-percutaneous nephrolithotomy (mPCNL) and flexible ureteroscopy (FURS).

METHODS

A total number of 356 patients with positive preoperative UC (urine cultures) who underwent mPCNL and FURS between June 2017 and January 2021 were retrospectively analyzed. Univariable analysis and multivariable logistic regression analysis were conducted to compare the predictors for urosepsis caused by different organisms. Furthermore, the nomogram was established as a predicted model for urosepsis.

RESULTS

Among 356 positive UC, 265 (74.4%) were positive for GN bacteria, 77 (21.4%) for GP bacteria and 14 (3.9%) for fungal pathogens. Escherichia coli (48.9%) were the predominant pathogens and Enterococcus (54/77) were the most common GP bacteria. Multivariate logistic regression analysis showed that positive nitrite (OR 3.31, 95% CI 1.20-9.14; P = 0.021), operative time > 90 min (OR 3.10, 95% CI 1.10-8.75, P = 0.033) and postoperative PCT > 0.1 ng/mL (OR 56.18, 95% CI 15.20-207.64, P < 0.001) were associated with postoperative urosepsis originated in GN infections, while urosepsis caused by GP bacteria and fungi was not associated with PCT > 0.1 ng/mL (P = 0.198), only stone burden > 800 mm² (OR 3.69, 95% CI 1.01-13.53, P = 0.049) was an independent risk factor.

CONCLUSIONS

For patients with positive preoperative UC, postoperative PCT > 0.1 ng/mL was an independent risk factor of post-PCNL and post-FURS urosepsis caused by GN bacteria rather than GP bacteria and fungi.

Outcome of Mini-Percutaneous Nephrolithotomy in Patients Under the Age of 18: An Experience With 112 Cases

Purpose: Renal calculi are becoming more common among children. Although, extracorporeal shock wave lithotripsy (ESWL) is the first choice in this age group, minimal invasive surgeries, such as percutaneous nephrolithotomy (PCNL), are indicated for some patients. Recently, PCNL devices have become smaller in size with acceptable efficacy and lower complications. We evaluated the outcomes and complications of mini-PCNL (MPCNL) surgery in our referral training centers.

Materials and Methods: Between September 2012 and January 2020, a total of 112 children under the age of 18, who had shown failure of ESWL, and/or their parents refused to do it, underwent MPCNL (15 Fr). The patients' profiles were reviewed for data collection including preoperative and stone data, operation information, and postoperative complications.

Results: Of 112 patients, 69 were boys, and 43 were girls. Their mean age was 8.6 years (14 months to 18 years). Mean stone size was 20 mm (14–34 mm). Seventy-four cases had renal pelvic stone, 22 had pelvis and lower pole, and 16 had staghorn. The mean operation time was 65 min (35–100 min), and mean radiation time was 0.6 min (0.2–1.4 min). Low-grade fever was detected in 14 patients (12.5%). Four patients needed blood transfusion and two had increased creatinine, which improved with conservative management. One patient developed urosepsis that resolved with antibiotic therapy. None of the patients had kidney perforation or other organ injury or death. Early stone-free rate (SFR) after operation was 90.2% (101 patients). Six patients had residual fragment <5 mm, which passed spontaneously in 2 weeks after operation (total SFR 95.3%). Three patients underwent second-look nephroscopy, and ureteroscopy was done for two patients due to migrated stone fragments to the distal ureter.

Conclusion: MPCNL is recommended as a safe alternative option for treatment of the nephrolithiasis in children with good outcome and acceptable complications.

Value of preoperative urine white blood cell and nitrite in predicting postoperative infection following percutaneous nephrolithotomy: a meta-analysis

BACKGROUND

To evaluate to what degree preoperative urine white blood cell (WBC) and urine nitrite (NIT) values are predictive of postoperative infections following percutaneous nephrolithotomy (PCNL).

METHODS

A systematic literature search was performed of the PubMed, Embase, Cochrane Library, Wanfang Data, National Knowledge Infrastructure (CNKI), and China Science and Technology Journal Database (CSTJ or VIP) online databases to identify relevant studies that examined the predictive value of urine WBC or NIT as risk factors for post-PCNL infection, and the search was finished on February 28, 2020. Two independent reviewers screened the relevant studies, extracted necessary data from the eligible case-control studies (CCS), and assessed the quality of included studies through the Newcastle-Ottawa scale (NOS). RevMan 5.3 software and the Stata 16.0 software were used to complete the statistical analysis of data. Results are expressed as odds ratio (OR) with 95% confidence intervals (CIs).

RESULTS

According to the statistical analysis of 12 eligible studies involving 6113 patients, positive urine WBC (WBC+: OR =3.86, 95% CI: 3.03-4.91, P<0.001) and positive NIT (NIT+: OR =7.81, 95% CI: 5.44-11.21, P<0.001) in preoperative tests were identified as independent risk factors for postoperative infections following PCNL.

CONCLUSIONS

In summary, as risk factors for postoperative infections, the presence of preoperative urine WBC+ and NIT+ should be evaluated as part of clinical procedure, in order to reduce infections of PCNL.

Study on risk factors, bacterial species, and drug resistance of acute pyelonephritis associated with ureteral stent after percutaneous nephrolithotomy

The purpose of this study is to explore the risk factors, bacterial species, and drug resistance of acute pyelonephritis (AP) associated with ureteral stent after percutaneous nephrolithotomy (PCNL) and to provide reference for clinical intervention. The clinical data of 415 patients with indwelling ureteral stent after PCNL from December 2016 to May 2019 were analyzed retrospectively. The patients were divided into infection group (n = 54) and non-infection group (n = 361) according to whether patients had AP. Patients' clinical data, blood and urine bacterial culture, and drug sensitivity were collected and analyzed. The incidence of AP associated with ureteral stent after PCNL was 13.01% and diabetes mellitus (P = 0.001), postoperative stone residue (P = 0.002), urinary leucocytes ≥ 100/HP (P = 0.018), positive urine culture results (P = 0.001), ureteral stent retention time ≥ 8 weeks (P = 0.004), and high S.T.O.N.E. score (P = 0.014) are independent risk factors for it. Escherichia coli (40.54%, 47.82%), Klebsiella pneumoniae (16.21%, 15.21%), Pseudomonas aeruginosa (10.81%, 4.34%), Enterococcus faecalis (21.6%, 19.56%), and epidermis Staphylococci (10.81%, 13.33%) are the main pathogens in blood and urine. The main sensitive drugs of pathogenic bacteria are imipenem, meropenem, tigecycline, piperacillin/tazobactam, ceftazidime, linezolid, teicoplanin, levofloxacin, vancomycin, tigecycline, etc., while levofloxacin, norfloxacin, penicillin G, first, and second-generation cephalosporins showed a strong drug resistance rate (> 70%). This study found that diabetes, postoperative stone residuals, urinary leukocytes ≧ 100 cells/HP, positive urine culture results, ureteral stent indwelling time ≧ 8 weeks, and high S.T.O.N.E. score were independent of AP associated with ureteral stent after PCNL risk factors and Escherichia coli is the main pathogenic bacteria and shows drug resistance.

A preoperative nomogram for sepsis in percutaneous nephrolithotomy treating solitary, unilateral and proximal ureteral stones

Background

Postoperative sepsis is a lethal complication for percutaneous nephrolithotomy (PCNL). An early predictive model combined local and systemic conditions is urgently needed to predict infectious events. We aim to determine the preoperative predictors of sepsis after PCNL in patients with unilateral, solitary, and proximal ureteral stones.

Methods

A total of 745 patients who underwent PCNL between January 2012 and December 2018 were retrospectively enrolled. Sepsis was defined based on the International Sepsis Definitions in 2001, and the preoperative factors were compared between the non-sepsis and sepsis groups. Univariable analysis and multivariable logistic regression analysis were conducted to determine the predictors for sepsis after PCNL. A nomogram was generated using the predictors.

Results

In this study, 35 patients (4.7%) developed sepsis after PCNL. Univariate analysis showed that post-PCNL sepsis was associated with the female, lower albumin, higher globulin, lower albumin globulin ratio (AGR < 1.5), preoperative fever, leukocytosis (WBC ≥ 10,000 cells/μL), positive urine culture, leukocyturia (≥50 cells/μL) and positive urine nitrite. Multivariate logistic regression analysis suggested that AGR < 1.5 (odds ratio [OR] = 5.068, 95% confidence interval [CI] [1.135-22.624], P = 0.033), positive urine culture (OR = 3.243, 95% CI [1.162-9.047], P = 0.025), leukocytosis (OR = 3.706, 95% CI [1.444-9.512], P = 0.006) and female (OR = 2.529, 95% CI [1.127-5.672], P = 0.024) were independent risk factors for sepsis. A nomogram was generated and displayed favorable fitting (Hosmer-Lemeshow test P = 0.797), discrimination (area under receiver operating characteristic curve was 0.807), and clinical usefulness by decision curve analysis.

Conclusions

Patients with certain preoperative characteristics, such as female, lower AGR, positive urine culture, and leukocytosis, who undergo PCNL may have a higher risk of developing sepsis. A cautious preoperative evaluation and optimized treatment strategy should be considered in these patients to minimize infectious complications.

Percutaneous nephrolithotomy for staghorn calculi: Troubleshooting and managing complications

Staghorn calculi comprise a unique subset of complex kidney stone disease. Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for staghorn stones. Despite continuous refinements to the technique and instrumentation of PCNL, these stones remain a troublesome challenge for endourologists and are associated with a higher rate of perioperative complications than that for non-staghorn stones. Common and notable intraoperative complications include bleeding, renal collecting system injury, injury of visceral organs, pulmonary complications, thromboembolic complications, extrarenal stone migration, and misplacement of the nephrostomy tube. Postoperative complications include infection and urosepsis, bleeding, persistent nephrocutaneous urine leakage, infundibular stenosis, and death. In this review, we report recommendations regarding troubleshooting measures that can be used to identify and characterize these complications. Additionally, we include information regarding management strategies for complications associated with PCNL for staghorn calculi.

The evaluation of early predictive factors for urosepsis in patients with negative preoperative urine culture following mini-percutaneous nephrolithotomy

PURPOSE

To identify early predictive factors for urosepsis secondary to mini-percutaneous nephrolithotomy (MPCNL) in patients with negative preoperative urine culture (UC).

METHODS

A total of 786 patients with baseline negative UC who underwent MPCNL between January 2017 and June 2019 were retrospectively analyzed. Urosepsis was defined according to the Sepsis-3 definition. Subsequently, perioperative potential risk factors were compared between non-urosepsis and urosepsis groups.

RESULTS

Despite negative UC in all patients, the rate of positive stone culture (SC) was 16.0%; the rate of pelvic urine culture (PUC) was 7.5%; 23 cases (2.9%) developed urosepsis after MPCNL. Univariate analysis showed that urosepsis was associated with the female gender, BMI, stone burden, diabetes mellitus and preoperative urine test. Multivariate logistic regression analysis suggested that urine test with positive nitrite and white blood cells and leukocyte esterase (N+WBC+LE+) (OR 17.51, 95% CI 6.75-45.38, P < 0.001) and operative time > 120 min (OR 3.53, 95% CI 1.41-8.85, P = 0.007) were independent risk factors for urosepsis. Additionally, receiver operating characteristic curve analysis of N+WBC+LE+ showed that the area under the curve was 0.785 for predicting the occurrence of urosepsis. Further analysis showed that N+WBC+LE+ provided an efficient prediction of SC+/PUC+ (SC+ or PUC+) with 61.7% sensitivity and 97.3% specificity.

CONCLUSIONS

In spite of the baseline negative preoperative UC, 2.9% of patients developed urosepsis after MPCNL. N+WBC+LE + was determined to be an early and efficient prediction of intraoperative bacterial status and urosepsis following MPCNL. Nevertheless, further studies are needed to confirm the results.

Risk factors and outcomes of urosepsis in patients with calculous pyonephrosis receiving surgical intervention: a single-center retrospective study

Background

Urosepsis is a catastrophic complication, which can easily develop into septic shock and lead to death if not diagnosed early and effectively treated in time. However, there is a lack of evidence on the risk factors and outcomes in calculous pyonephrosis patients. Therefore, this study was conducted to identify risk factors and outcomes of intra- and postoperative urosepsis in this particular population.

Methods

Clinical data of 287 patients with calculous pyonephrosis were collected. In the univariate and multivariate analysis, all patients were divided into urosepsis group and non-urosepsis group. The diagnosis of urosepsis was mainly on the basis of the criteria of American College of Chest Physicians (ACCP)/Society of Critical Care Medicine (SCCM). Patient characteristics and outcomes data were analyzed, and risk factors were assessed by binary logistic regression analysis.

Results

Of 287 patients, 41 (14.3%) acquired urosepsis. Univariate analysis showed that white blood cell (WBC > 10*10^9/L) before surgery (P = 0.027), surgery types (P = 0.009), hypotension during surgery (P < 0.001) and urgent surgery (P < 0.001) were associated with intra- and postoperative urosepsis for calculous pyonephrosis patients. In multivariate analysis, hypotension during surgery and urgent surgery were closely related to intra- and postoperative urosepsis. Outcome analysis suggested that patients developing urosepsis had a longer intensive care unit (ICU) stay and postoperative hospital stay and higher mortality.

Conclusions

Hypotension during surgery and urgent surgery were risk factors of intra- and postoperative urosepsis for calculous pyonephrosis patients, which may lead to a prolonged ICU stay, postoperative hospital stay and higher mortality.

Predictive factors of infectious complications in the postoperative of percutaneous nephrolithotomy

OBJECTIVE

Infectious complications (IC) following percutaneous nephrolithotomy surgery (PCNL) can be life-threatening. Our objective was to analyse preoperative predictors of IC in PCNL.

MATERIALS AND METHODS

A total of 203 patients who underwent PCNL were included in a prospective study between January 2013 and February 2016. A postoperative IC was defined as urinary infection/pyelonephritis, systemic inflammatory response syndrome or sepsis. The variables analysed were age, gender, number, size(cm) and side of stone; Hounsfield units,diabetes (insulin dependent or not), preoperative culture, isolated bacteria, multitract, bodymass index and surgical time (min). A multivariate forward stepwise (logistic regression) was performed.

RESULTS

IC occurred in 30 patients (14.8%): 9 (4.4%) had urinary infection, 14 (6.9%) systemic inflammatory response syndrome and 7 (3.5%) sepsis. In addition, 13 (43.3%) had negative preoperative urine culture, 15 (50%) positive and in 2 (6.7%) was not available. On the logistic regression analysis, stone size (cm), insulin dependent diabetes and female sex were independently associated with increased risk of IC (odds ratio [OR] 1.03, 14.6 and 7.8, respectively; P=.0001).

CONCLUSIONS

Patients with large stone burdens, insulin diabetes condition and female gender, should be counselled properly regarding postoperative infection risks and closely followed up to diagnose IC (specially sepsis) soon enough. Negative preoperative urine culture seems not reliable enough to exclude an infectious complication according to our results.

The Predictive Value of Preoperative High-Sensitive C-Reactive Protein/Albumin Ratio in Systemic Inflammatory Response Syndrome After Percutaneous Nephrolithotomy

OBJECTIVE

The aim of the study was to evaluate the predictive value of preoperative high-sensitive C-reactive protein/albumin (hs-CRP/Alb) ratio in systemic inflammatory response syndrome (SIRS) after percutaneous nephrolithotomy (PCNL).

MATERIALS AND METHODS

We retrospectively reviewed 556 patients who underwent PCNL at our institution between August 2015 and February 2018. The primary endpoint for the study was the development of SIRS after operation. A univariate and multivariate logistic regression analysis was used to identify the independent factors associated with the post-PCNL SIRS. Receiver operating characteristic (ROC) curves were constructed and the areas under the curve (AUC) were calculated to compare the discriminatory ability of systemic inflammation biomarkers.

RESULTS

Among the 556 patients who underwent PCNL, 123 patients (22.1%) developed SIRS. Multivariate analysis revealed that female gender (OR 1.691; 95% CI 1.045-2.735; p = 0.032), positive urine culture (OR 1.972; 95% CI 1.204-3.231; p < 0.01), hs-CRP/Alb ratio (OR 6.925; 95% CI 4.244-11.300; p < 0.01), neutrophil to lymphocyte ratio (NLR) (OR 2.476; 95% CI 1.471-4.167; p < 0.01), and prognostic nutritional index (PNI) (OR 0.559; 95% CI 0.338-0.924; p = 0.023) were independent predictors of post-PCNL SIRS. The optimal cutoff value of the hs-CRP/Alb ratio was 0.06 from the ROC analysis. The elevated hs-CRP/Alb ratio was significantly associated with female gender, positive urine culture, hs-CRP, albumin, leukocyte, neutrophil, monocyte, platelet, hemoglobin, creatinine, NLR, lymphocyte to monocyte ratio (LMR), platelet to lymphocyte ratio (PLR), PNI, high-sensitive modified Glasgow prognostic score (hs-mGPS), development of sepsis, ICU admission, and length of stay (all p < 0.05). In addition, the hs-CRP/Alb ratio had a higher AUC (0.791) with a sensitivity of 76.4% and a specificity of 73.2% than NLR (0.669), LMR (0.633), PLR (0.594), PNI (0.629), and hs-mGPS (0.739).

CONCLUSIONS

The preoperative hs-CRP/Alb ratio is independently predictive for the development of SIRS after PCNL. Moreover, compared with other systemic inflammation biomarkers, the preoperative hs-CRP/Alb ratio shows a better predictive value.

Mortality from kidney stone disease (KSD) as reported in the literature over the last two decades: a systematic review

INTRODUCTION

Current trends show a rising incidence of kidney stone disease (KSD) globally, with a lifetime risk of 10% and increasing hospital admissions. However, it is not perceived as a life-threatening condition and there are no publications examining its mortality rate. The aim of this review was to report on the number of KSD mortalities in the literature from the past two decades, identify risk factors, and to summarize their key learning points.

METHODS

A search was conducted for full-text English language articles that reported on KSD associated mortality, following intervention or conservative treatment, published between 1999 and 2017, using PubMed, MEDLINE, EMBASE, Scopus, CINAHL, Clinicaltrials.gov, Google Scholar and The Cochrane Library. Study quality and risk of bias assessment was undertaken using a validated critical appraisal tool from the Joanna Briggs Institute.

RESULTS

Of the 2786 articles identified, 34 were included. Of the total number of reported mortalities (2550), 21% were related to intervention. Sepsis was the leading cause of mortality. Risk factors identified were patients with multiple co-morbidities, spinal cord injury or neurogenic bladder and high stone burden. The main recommendations suggested were to treat pre-operative UTI or use prophylactic antibiotics and to reduce operative duration. The included studies were of moderate to good quality.

CONCLUSION

Pre-procedural optimization of the patients is the key to avoiding KSD mortality, and care should be taken in patients with multiple co-morbidities. Surgeons should meticulously plan for patients with high stone burden to reduce their operative time, as mortality can be procedural related.

Risk factors for urinary tract infection in patients with urolithiasis-primary report of a single center cohort

Background

Urinary tract infection (UTI) is very common in patients with urolithiasis, which makes the treatment of urolithiasis complicated, even dangerous. The objective of this study was to determine the risk factors for UTI in patients with urolithiasis.

Methods

Eight hundred six patients with urolithiasis were retrospectively evaluated in the fourth affiliated hospital of China Medical University. All patients admitted to the study were divided into either a UTI infection group or a non-infection group. Sex, age, smoking, stone shape, alcohol consumption, position of stones, and presence of obstruction were used as exposure factors for the cross-sectional study.

Results

One hundred seventy-eight patients (22.0%) had UTI. Through a urine culture test, gram-negative bacilli were the most common pathogen, followed by gram-positive bacilli and fungi.

Conclusions

Sex, age, obstruction, stone shape, and multiple sites of stones could be considered the independent factors for UTI in patients with urolithiasis; smoking and drinking had no statistically significant correlation with the condition. Gram-negative bacilli are the most common pathogen in UTI in patients with urolithiasis.

Management of large renal stones: laparoscopic pyelolithotomy versus percutaneous nephrolithotomy

Background

Percutaneous nephrolithotomy (PCNL) remains the standard procedure for large (≥2 cm) renal calculi; however, laparoscopic pyelolithotomy (LPL) can be used as an alternative management procedure. The aim of present study was to compare LPL and PCNL in terms of efficacy and safety for the management of large renal pelvic stones.

Methods

A literature search was performed in Jan 2016 using electronic databases (Cochrane Central Register of Controlled Trials, Medline, and EMBASE) to identify relevant studies for the meta-analysis. Only comparative studies investigating LPL versus PCNL were included. Effect sizes were estimated by pooled odds ratio (ORs) and mean differences (MDs) with 95% confidence intervals (CIs).

Results

Five randomized and nine non-randomized studies were identified for analysis, involving a total of 901 patients. Compared with PCNL, LPL provided a significantly higher stone-free rate (OR 3.94, 95% CI 2.06–7.55, P < 0.001), lower blood transfusion rate (OR 0.28, 95% CI 0.13–0.61, P = 0.001), lower bleeding rate (OR 0.20, 95% CI 0.06–0.61, P = 0.005), fewer hemoglobin decrease(MD -0.80, 95% CI -0.97 to −0.63, P < 0.001), less postoperative fever (OR 0.38, 95% CI 0.21–0.68; P = 0.001), and lower auxiliary procedure rate (OR 0.24, 95% CI 0.12–0.46, P < 0.001) and re-treatment rate (OR 0.20, 95% CI 0.07–0.55, P = 0.002). However, LPL had a longer operative time and hospital stay. There were no significant differences in conversion to open surgery and prolonged urine leakage rates between LPL and PCNL.

Conclusions

Our present findings suggest that LPL is a safe and effective approach for management of patients with large renal stones. However, PCNL still suitable for most cases and LPL can be used as an alternative management procedure with good selection of cases.

Electronic supplementary material

The online version of this article (10.1186/s12894-017-0266-7) contains supplementary material, which is available to authorized users.

Mini percutaneous nephrolithotomy in the treatment of renal and upper ureteral stones: Lessons learned from a review of the literature

The aim of this review is to present the most recent data regarding the indications of mini percutaneous nephrolithotomy (PCNL), the results and the complications of the method. Medline was searched from 1997 to January 2014, restricted to English language. The Medline search used a strategy including medical subject headings and free-text protocols. PCNL is a well-established treatment option for patients with large and complex renal calculi. In order to decrease morbidity associated with larger instruments like blood loss, postoperative pain and potential renal damage, a modification of the technique of standard PCNL has been developed. This is performed with a miniature endoscope via a small percutaneous tract (11–20 F) and was named as minimally invasive or mini-PCNL. This method was initially described as an alternative percutaneous approach to large renal stones in a pediatric patient population. Furthermore, it has become a treatment option for adults as well, and it is used as a treatment for calculi of various sizes and locations. However, the terminology has not been standardized yet, and the procedure lacks a clear definition. Nevertheless, mini-PCNL can achieve comparable stone-free rates to the conventional method, even for large stones. It is a safe procedure, and no major complications are reported. Although less invasiveness has not been clearly demonstrated so far, mini-PCNL is usually related to less blood loss and shorter hospital stay than the standard method.