Update on the evaluation of repeated stone formers

The predictive and diagnostic ability of IL-6 for postoperative urosepsis in patients undergoing percutaneous nephrolithotomy

The aim of this study is to investigate the predictive and diagnostic ability of interleukin-6 (IL-6) for postoperative urosepsis in patients undergoing percutaneous nephrolithotomy (PCNL). 90 patients undergoing PCNL between April 2019 and September 2019 were studied. 16 patients progressed to urosepsis (EXP1 group, n = 16) and 74 patients did not (CON group, n = 74); demographic and perioperative data were compared between these two groups. 25 patients who progressed to postoperative urosepsis without receiving the test of IL-6 between March 2018 and March 2019 were enrolled (EXP2 group, n = 25); demographic and perioperative data were compared between EXP1 group and EXP2 group. Compared with CON group, EXP1 group showed higher serum levels of IL-6 (p < 0.001) and neutrophil (p < 0.001) at postoperative hour two; higher serum levels of IL-6 (p < 0.001), procalcitonin (PCT) (p < 0.05), white blood cell (WBC) (p < 0.05), and neutrophil (p < 0.001) on postoperative day one; higher serum levels of PCT (p < 0.05) and WBC (p < 0.05) on postoperative day three. ROC curves showed IL-6 (AUC = 1.000) at postoperative hour two and PCT (AUC = 0.954) on postoperative day three. Compared with EXP2 group, EXP1 group showed shorter time to intervene (p < 0.001), a shorter postoperative hospital stay (p < 0.001), and a lower incidence rate of severe urosepsis (p < 0.05). There were different diagnostic abilities of IL-6, PCT, WBC, and neutrophil for postoperative urosepsis at different time points, and IL-6 was greatly valuable as a predictive and early diagnosing biomarker for postoperative urosepsis in patients undergoing PCNL at postoperative hour two and on postoperative day one.

Long-term complications following bladder augmentations in patients with spina bifida: bladder calculi, perforation of the augmented bladder and upper tract deterioration

BACKGROUND

We desire to review our experience with bladder augmentation in spina bifida patients followed in a transitional and adult urologic practice. This paper will specifically focus on three major complications: bladder calculi, the most frequent complication found following bladder augmentation, perforation of the augmentation, its most lethal complication and finally we will address loss of renal function as a direct result of our surgical reconstructive procedures.

METHODS

We reviewed a prospective data base maintained on patients with spina bifida followed in our transitional and adult urology clinic from 1986 to date. Specific attention was given to patients who had developed bladder calculi, sustained a spontaneous perforation of the augmented bladder or had developed new onset of renal scarring or renal insufficiency (≥ stage 3 renal failure) during prolonged follow-up.

RESULTS

The development of renal stones (P<0.05) and symptomatic urinary tract infections (P<0.0001) were found to be significantly reduced by the use of high volume (≥240 mL) daily bladder wash outs. Individuals who still developed bladder calculi recalcitrant to high volume wash outs were not benefited by the correction of underlying metabolic abnormalities or mucolytic agents. Spontaneous bladder perforations in the adult patient population with spina bifida were found to be directly correlated to substance abuse and noncompliance with intermittent catheterization, P<0.005. Deterioration of the upper tracts as defined by the new onset of renal scars occurred in 40% (32/80) of the patients managed by a ileocystoplasty and simultaneous bladder neck outlet procedure during a median follow-up interval 14 years (range, 8-45 years). Development of ≥ stage 3 chronic renal failure occurred within 38% (12/32) of the patients with scarring i.e., 15% (12/80) of the total patient population. Prior to the development of the renal scarring, 69% (22/32) of the patients had been noncompliant with intermittent catheterization. The onset of upper tract deterioration (i.e., new scar formation, hydronephrosis, calculus development, decrease in renal function) was silent, that is, clinically asymptomatic in one third (10/32 pts).

CONCLUSIONS

This paper documents the need for high volume bladder irrigations to both prevent the most common complication following bladder augmentation, which is the development of bladder calculi and to reduce the incidence of symptomatic urinary tract infections. It provides a unique perspective regarding the impact of substance abuse and patient non-compliance with medical directives as being both the most common cause for both spontaneous bladder rupture following augmentation cystoplasty and for deterioration of the upper tracts. These findings should cause the surgeon to reflect on his/her assessment of a patient prior to performing a bladder augmentation procedure and stress the need for close follow-up.