Predictive factors of infectious complications in the postoperative of percutaneous nephrolithotomy

The modified 5-item frailty index as a predictor of perioperative risk in patients undergoing percutaneous nephrolithotomy

INTRODUCTION

The modified 5-item frailty index is a relatively new tool to assess the post-operative complication risks. In urology, there is limited literature on the impact of frailty on percutaneous nephrolithotomy (PCNL) outcomes. We aimed to compare the predictive value of the modified 5-item frailty index (mFI-5) to identify high risk patients prior to PCNL.

METHODS

A database of patients undergoing PCNL, between 2015 and 2022, was analyzed. Patient frailty was assessed using the mFI-5 index. The mFI-5 index was calculated based on the presence of the five co-morbidities: congestive heart failure within 30 days prior to surgery, diabetes mellitus, chronic obstructive pulmonary disease, partially dependent or totally dependent functional health status at time of surgery, and hypertension requiring medication. Patients were grouped as not frail (mFI-5 = 0), intermediate (mFI-5 = 1), and severely frail (mFI-5 ≥ 2). Primary outcomes were 30-day postoperative complications. Secondary outcomes were hospitalization: total hospital length of stay, reoperation, and unplanned readmission.

RESULTS

From a total of 320 PCNL patients included for analysis, 54.06% (n = 173) were not frail, 17.81% (n = 57) were intermediate, and 28.12% (n = 90) were severely frail. Frail patients were likely to be older (p = 0.002) and have a higher American Society of Anesthesiologists score (p = 0.001), chronic kidney disease (p < 0.001). Patients of intermediate or severe frailty were more likely to exhibit postoperative sepsis (p = 0.042), significant blood loss (p = 0.036) and require intensive care units admissions (p = 0.0015). Frail patients had a longer hospital length of stay (p < 0.001) and tended to require reoperation (p = 0.001), and unplanned readmission (p = 0.02).

CONCLUSION

Frailty assessment appears useful in stratifying those at risk of extended hospitalization, septic and hemorrhagic complications, readmission, or reoperation after PCNL. Preoperative assessment of frailty phenotype may give insight into treatment decisions and assist surgeons in counselling patients on expected course and hospital stay following PCNL.

A nomogram model based on SII, AFR, and NLR to predict infectious complications of laparoscopic hysterectomy for cervical cancer

BACKGROUND

This study aimed to investigate the potential risk factors associated with postoperative infectious complications following laparoscopic hysterectomy for cervical cancer and to develop a prediction model based on these factors.

METHODS

This study enrolled patients who underwent selective laparoscopic hysterectomy for cervical cancer between 2019 and 2024. A multivariate regression analysis was performed to identify independent risk factors associated with postoperative infectious complications. A nomogram prediction model was subsequently constructed and evaluated using R software.

RESULTS

Out of 301 patients were enrolled and 38 patients (12.6%) experienced infectious complications within one month postoperatively. Six variables were independent risk factors for postoperative infectious complications: age ≥ 60 (OR: 3.06, 95% confidence interval (CI): 1.06-8.79, P = 0.038), body mass index (BMI) ≥ 24.0 (OR: 3.70, 95%CI: 1.4-9.26, P = 0.005), diabetes (OR: 2.91, 95% CI: 1.10-7.73, P = 0.032), systemic immune-inflammation index (SII) ≥ 830 (OR: 6.95, 95% CI: 2.53-19.07, P < 0.001), albumin-to-fibrinogen ratio (AFR) < 9.25 (OR: 4.94, 95% CI: 2.02-12.07, P < 0.001), and neutrophil-to-lymphocyte ratio (NLR) ≥ 3.45 (OR: 7.53, 95% CI: 3.04-18.62, P < 0.001). Receiver operator characteristic (ROC) curve analysis indicated an area under the curve (AUC) of this nomogram model of 0.928, a sensitivity of 81.0%, and a specificity of 92.1%.

CONCLUSIONS

The nomogram model, incorporating age, BMI, diabetes, SII, AFR, and NLR, demonstrated strong predictive capabilities for postoperative infectious complications following laparoscopic hysterectomy for cervical cancer.

Can we identify the risk factors for SIRS/sepsis after percutaneous nephrolithotomy? A meta‑analysis and literature review

With the increase in percutaneous interventions such as percutaneous nephrolithotomy (PCNL) for renal lithiasis, infectious complications are becoming more frequent. The present study performed a systematic Medline and Embase databases search, using the following words: 'PCNL' [MeSH Terms] AND ['sepsis' (All Fields) OR 'PCNL' (All Fields)] AND ['septic shock' (All Fields)] AND ['urosepsis' (MeSH Terms) OR 'Systemic inflammatory response syndrome (SIRS)' (All Fields)]. Because of the technological advances in endourology, articles published between 2012 and 2022 were searched. Of the 1,403 results of the search, only 18 articles, representing 7,507 patients in which PCNL was performed, met the criteria to be included in the analysis. All authors applied antibiotic prophylaxis to all patients and, in some cases, the infection was treated preoperatively in those with positive urine cultures. According to the analysis of the present study, the operative time has been significantly longer in patients who developed SIRS/sepsis post-operatively (P=0.0001) with the highest heterogeneity (I²=91%) compared with other factors. Patients with a positive preoperative urine culture had a significantly higher risk of developing SIRS/sepsis following PCNL (P=0.00001), OD=2.92 (1.82, 4.68) and there was also a high degree of heterogeneity (I²=80%). Performing a multi-tract PCNL also increased the incidence of postoperative SIRS/sepsis (P=0.00001), OD=2.64 (1.78, 3.93) and the heterogeneity was a little smaller (I²=67%). Diabetes mellitus (P=0.004), OD=1.50 (1.14, 1.98), I²=27% and preoperative pyuria (P=0.002), OD=1.75 (1.23, 2.49), I²=20%, were other factors that significantly influenced postoperative evolution. A total of two factors analyzed, body mass index and patient's age, did not influence the outcome, P=0.45, I²=58% and P=0.98, I²=63%.

[Urolithiasis-Therapy and recurrence prevention taking into account gender-specific aspects]

The prevalence of urolithiasis is steadily increasing worldwide in both genders. Diet and lifestyle, such as the rising prevalence of obesity and other metabolic syndrome traits, are considered key factors in this trend. Gender differences as a result of interventional therapy for urolithiasis have not been observed. However, iatrogenic injury to the male urethra is considered the most common reason for urethral strictures after endourologic (stone) therapy. In contrast, sepsis, as the major cause of urinary stone-related mortality, is more frequently reported in women after ureterorenoscopy and percutaneous nephrolithotomy. There are also differences in the frequency of various types of stones between men and women. Calcium oxalate and uric acid stones are more commonly observed in men, while carbonate apatite and struvite are diagnosed more often in women. Urinary stone analysis is therefore paramount for successful recurrence prevention. Diagnosis is based on the assignment of patients to the low-risk or high-risk group. The medical nutrition and pharmacological measures for the therapy of the respective type of stone are based on the risk factors in 24 h urine samples. A personalized approach that accounts for gender differences could further improve treatment, and recurrence prevention decisions for urinary stones.

A new safe and ergonomic manipulation tool for the flank free supine position: 'U-Pad'

INTRODUCTION

One of the most important problems in the supine percutaneous approach to the kidney is the narrow surgical surface area (SSA) in the lumbar region. Herein, the spatial and angular geometric advantages of the U-shaped lumbar pad (U-Pad) used as a new positioning tool for safety and ergonomics in the supine percutaneous approach have been revealed.

MATERIALS AND METHODS

Data of patients who underwent endoscopic combined intrarenal surgery (ECIRS) using the U-Pad for kidney stones between March and September 2021 were prospectively collected. The demographic, preoperative, operative, and postoperative data of patients have been saved. The patients were positioned first with the standard gel pad (Group 1) and then with the U-Pad (Group 2). Both SSA (X and X+Y, cm2) and angular degree (α and β,0) calculations were compared. Fluoroscopy images with the same settings (97 kV/3.00 mA) were visually compared. In geometric data, trapezoidal area formula ((upper base+lower base) X height/2) and goniometer were used to compare with Paired t-test.

RESULTS

Endoscopic combined intrarenal surgery was performed on 17 patients, 13 men and, 4 women, with a median age of 39 (range 32-47). The median body mass index (BMI) was 26.2 (23.5-29.1). Stone localization and features were recorded. The median SSA was calculated as 35.7 cm2 in group 1 and 97.3 cm2 in group 2, and it was calculated that the total SSA increased to 272.5% with a median of 61.6 cm2 extra surgical area. Similarly, the downward manipulation angle was 320 (α0) in group 1, while it was 60.60 (β0) in group 2, and the median extra motion angle was calculated as 28.60 (89.3%).

CONCLUSION

The U-Pad is a safe and rapid tool in the supine percutaneous approach to the kidney, providing at least 2 times the extra SSA and manipulation angle.

Nomogram for predicting risk factor of urosepsis in patients with diabetes after percutaneous nephrolithotomy

Background

Urosepsis is an infectious complication after percutaneous nephrolithotomy (PCNL). This study aimed to analyze the perioperative factors related to urosepsis after PCNL for upper urinary calculi and establish a nomogram to predict the probability of postoperative urosepsis based on the risk factors.

Methods

The Clinical data of one-stage PCNL for upper urinary stones in patients already diagnosed with type 2 diabetes between June 2010 and June 2020 were retrospectively analyzed. The patients were divided into two groups according to whether urosepsis occurred after surgery, and univariate and multivariate logistic regression analyses evaluated the risk factors for urosepsis. Moreover, the corresponding nomogram prediction model was determined by the regression coefficient.

Results

All 366 patients with diabetes underwent one-stage PCNL. Seventy-one (19.4%) patients had urosepsis after surgery, and their hospitalization time was longer than that of patients without urosepsis. Moreover, the incidence of non-infection-related complications was higher. Multivariate logistic regression analysis revealed four independent risk factors associated with postoperative urosepsis, including positive urine nitrite (odds ratio [OR] = 3.326, P = 0.007), positive urine culture (OR = 2.213, P = 0.023), intraoperative hypotension (OR = 8.968, P < 0.001), and staghorn calculi (OR = 3.180, P = 0.002). The above independent risk factors were used as variables to construct the nomogram. The nomogram model was internally validated. The calculated concordance index was 0.824. The Hosmer–Lemeshow goodness-of-fit test was performed (P = 0.972 > 0.05). The area under the curve of this model was 0.831, indicating that the nomogram model had good accuracy in predicting the probability of urosepsis in patients who underwent PCNL with diabetes and had good consistency with the actual risk.

Conclusion

Positive urine culture, positive urine nitrite, staghorn calculi, and intraoperative hypotension were independent risk factors for urosepsis in patients who underwent one-stage PCNL with diabetes. The new nomogram could accurately assess the risk of urosepsis after PCNL in patients with diabetes.

Gender Differences in Kidney Stone Disease (KSD): Findings from a Systematic Review

PURPOSE OF REVIEW

The prevalence of kidney stones is rising and historically carries a preponderance for males. However, recent evidence has questioned whether this gender gap is closing. The aim of this systematic review was to examine this further as well as evaluate possible underlying causes.

RECENT FINDINGS

Recent evidence confirms the disparity in kidney stone disease between genders is closing. In the modern era, the rise in prevalence among females has been greater, especially in adolescence. Quality of life is also more adversely affected by kidney stone events among females who are also more likely to develop sepsis after endourological surgery. Males, however, are more likely to present with stone events during periods of high ambient temperatures Recent literature demonstrates a temporal change in the disease burden of KSD among men and women. The latter, especially adolescent females, are more likely to develop KSD in their lifetime compared to previous eras. Determining causation is complex and continued research is warranted.

Preoperative Midstream Urine Cultures vs Renal Pelvic Urine Culture or Stone Culture in Predicting Systemic Inflammatory Response Syndrome and Urosepsis After Percutaneous Nephrolithotomy: A Systematic Review and Meta-Analysis

Purpose: To compare preoperative midstream urine cultures (PMUC) and renal pelvic urine culture (RPUC) or stone culture (SC) in predicting systemic inflammatory response syndrome (SIRS) and urosepsis after percutaneous nephrolithotomy (PCNL). Methods: We searched the PubMed, Web of Science, and EMBASE databases up to September 1, 2020, for relevant published studies. Two authors independently confirmed whether the literatures met the inclusion criteria and collected the data from the selected literatures. A meta-analysis was performed with Review Manager Software 5.4.1. A total of 14 studies with 3540 patients were selected and analyzed in the meta-analysis. Results: Pooled data showed that SC was associated with a higher sensitivity (odds ratios [OR] 2.36, confidence interval [95% CI] 1.31-4.25; p < 0.00001), positive predictive value (PPV) (OR 1.54, 95% CI 1.18-2.01; p = 0.16) and negative predictive values (OR 1.17, 95% CI 1.01-1.37; p = 0.06) in the diagnosis of SIRS and urosepsis after PCNL, and RPUC provided a significantly higher specificity (OR 2.70, 95% CI 2.16-3.38; p = 0.07) and PPV (OR 2.17, 95% CI 1.49-3.15; p = 0.48) than PMUC in the diagnosis of SIRS and urosepsis after PCNL. Conclusion: Intraoperative SC and RPUC are more reliable than PMUC in predicting postoperative SIRS and urosepsis, identifying causative organisms, and directing antibiotic therapy for patients who underwent PCNL. PMUC, SC, and RPUC should be routinely collected for the diagnosis and management of SIRS and urosepsis after PCNL.

Risk factors and prediction model of urosepsis in patients with diabetes after percutaneous nephrolithotomy

Objective

To analyze the risk factors of patients with diabetes mellitus (DM) and urosepsis after percutaneous nephrolithotomy (PCNL) for upper urinary tract stones and to develop a nomogram to predict postoperative urosepsis according to the risk factors.

Methods

The data of patients with type 2 diabetes who underwent one-stage PCNL due to upper urinary tract stones were retrospectively analyzed. The risk factors of patients with postoperative urosepsis were evaluated by univariate and multivariate logistic regression analysis, and the nomogram prediction model was developed according to the regression coefficient.

Results

One-stage PCNL was successfully completed in 241 patients with DM, and urosepsis occurred in 41 (17.0%) patients after PCNL. Based on multivariate logistic regression analysis, the independent risk factors associated with postoperative urosepsis included preoperative leukocyte elevation (OR = 3.973, P = 0.005), positive urine nitrite (OR = 3.697, P = 0.010), and positive urine culture (OR = 3.562, P = 0.002). According to the results of the logistic regression analysis model, staghorn stones (OR = 2.049, P < 0.1) and complete intraoperative stone clearance (OR = 0.431, P < 0.1), were used to develop the nomogram. Internal validation of the nomogram showed that the concordance index (C-index) was 0.725. Additionally, the Hosmer–Lemeshow test was performed, P = 0.938 > 0.05.

Conclusion

Preoperative leukocyte elevation, positive urine nitrite, and positive urine culture are independent risk factors for urosepsis after one-stage PCNL for patients with DM with upper urinary tract stones. The nomogram, which is based on independent risk factors that combine stone morphology and intraoperative stone clearance, can help predict the risk of postoperative urosepsis.

Expression of Inflammatory Factors in Critically Ill Patients with Urosepticemia and the Imaging Analysis of the Severity of the Disease

Urine sepsis is a complex inflammatory response of the body to infection with a high fatality rate. It is one of the main causes of death in noncardiovascular intensive care units. Nevertheless, in daily clinical practice, early sepsis is often not detected. In this paper, discharged cases of urinary sepsis from the Department of Urology and Critical Care Medicine of a university hospital were collected as the observation group, and common urinary tract infection cases were selected as the control group. We sorted and summarized the discharged case information of the observation group and the control group. The results of the study showed that, after renal pelvis perfusion, the expression of HMGB1 protein and mRNA increased, and the expression of TLR4 increased; inhibiting HMGB1 can reduce the expression of inflammatory factors caused by perfusion and reduce the infiltration of neutrophils and macrophages caused by perfusion. In addition, r HMGB1 treatment can promote the expression of inflammatory factors caused by perfusion and aggravate the infiltration of neutrophils and macrophages caused by perfusion. We found that inhibition of HMGB1 can inhibit the expression of TLR4/My D88 signaling molecules and r HMGB1 treatment can enhance the expression of TLR4/My D88 signaling molecules.

Renal pelvis urine Gram stain as a traditional, but new marker in predicting postoperative fever and stone culture positivity in percutaneous nephrolithotomy: an observational, prospective, non-randomized cohort study

PURPOSE

The aim of this study was to evaluate the diagnostic value of renal pelvis urine Gram staining (RPUGS) in predicting postoperative fever and renal stone culture (RSC) positivity in percutaneous nephrolithotomy (PCNL).

METHODS

Totally 141 consecutive patients undergoing PCNL for renal stone were included between January 2018 and December 2019. The RPUGS and renal pelvis urine culture (RPUC) were performed using urine sample from renal collecting system, while RSC was performed using stone fragments. Patients were divided into two groups as Group 1 (n = 119) without postoperative fever (< 38 °C) and Group 2 (n = 22) with postoperative fever (≥ 38 °C). Stone culture and Gram staining models were created for predicting postoperative fever using constant covariates of the presence of residual stone, hydronephrosis, and stone burden.

RESULTS

A significantly higher number of patients in Group 2 had RPUGS, RSC, and RPUC positivity (p < 0.001, for each). The sensitivity, specificity, positive predictive value, and negative predictive value of RPUGS in predicting postoperative fever were 72.7%, 89.9%, 57.1%, and 94.7%, respectively. It was observed that both models had similar predictive values and diagnostic performances. Although RSC and RPUGS had a similar diagnostic value in predicting postoperative fever in univariable analysis, both were found to be independent predictors in multivariable analysis (OR: 10.6, 95% CI 4.07-27.9, p < 0.001 and OR: 15.0, 95% CI 5.4-41.2, p < 0.001, respectively).

CONCLUSIONS

In conclusion, RPUGS is as effective as RSC in predicting fever after PCNL. We recommend RPUGS during PCNL to manage post-PCNL infectious complications.

Predicting and comparing postoperative infections in different stratification following PCNL based on nomograms

To discuss the mechanisms of infection complications in different degrees after percutaneous nephrolithotomy (PCNL) through predicting and comparing post-PCNL infections based on nomograms, a retrospective cohort study was conducted among 969 cases who underwent PCNL from Dec 5, 2016 to Dec 25, 2017 in Kunming, Yunnan Province. We examined clinical features, urine routine, blood routine, blood biochemistry, imaging studies and operative information and recorded the examination results before surgery for univariate and multivariate logistic regression. We applied receiver operating characteristic curves, calibration curves, accuracy, specificity, sensitivity, positive predictive value and negative predictive value to evaluate and compare the models. Nomograms were used to visualize the different degrees of postoperative infection complications. The risk scores of the three groups were compared by diabetes mellitus distribution. Our results suggest that the more severe the infection is, the more accurate the model predicts and that the occurrence of severe infection mostly is related to the patients' homeostasis. Hence, we developed an online post-PCNL sepsis dynamic nomogram which can achieve visualization and dynamically predict the incidence of sepsis in postoperative patients.

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.

Evaluation of day-care versus inpatient mini-percutaneous nephrolithotomy: a propensity score-matching study

Day-care percutaneous nephrolithotomy (day-PCNL) is being performed more routinely, however, safety remains a concern. The purpose of this study was to compare the complication rate, readmission rate and medical cost saving between day-PCNL and inpatient-PCNL. A protocol for day-PCNL was applied. A retrospective review of 86 patients planned day-PCNL by one surgeon were conducted. Using propensity matching, 86 inpatients (minimum 2-day post-operative stay) treated with the same procedure were matched. For each cohort, 14-day occurrence of complications and unplanned readmissions were recorded and compared. More than 80% of patients had multiple or staghorn stones in both groups. There were no significant differences between stone-free rate, operative time, multiple-tracts use, hemoglobin drop (each p > 0.05). Day- PCNL has a higher tubeless rate (60.8% vs. 24.4%, p < 0.001) and were less costly (mean 2732 vs. 3828 dollars) compared with inpatient PCNL. Within 14 days post-operatively, 10 day-care patients (11.6%) and 13 inpatients (15.1%) experienced complications, with no difference in rate or severity. Four patients (4.6%) required full admission (longer than 24 h) and two patents needed readmission in day-PCNL group. Day-care PCNL was more cost-effective than in-patients PCNL, with no significant difference in complications along with very low unplanned readmission during the postoperative period of 14 days. Therefore, day-care PCNL is a cost-effective choice in selected patients.