Severe sepsis following percutaneous or endoscopic procedures for urinary tract stones

Neutrophil to lymphocyte ratio in urolithiasis: a systematic review

BACKGROUND

Urolithiasis is among the most prevalent and possibly devastating diseases. It affects millions worldwide, and a cheap or rapid biomarker is required to diagnose it. Previous investigations revealed that inflammation has a role in the progression of urolithiasis patients, and an elevated neutrophil-to-lymphocyte ratio (NLR) value can be a valuable biomarker to ensure inflammation and, consequently, renal stones. This study was conducted to summarize the results of studies investigating the role of NLR in urolithiasis.

METHODS

We systematically searched three main databases (Scopus, PubMed, and Web of Science) up to January 1, 2023. Our study was registered in PROSPERO (CRD42024500756).

RESULTS

Ultimately, 33 studies were selected for this review article. Patients in either acute or subacute phase exhibited higher NLR levels than healthy controls. Also, patients in acute and subacute phases significantly differed regarding NLR levels. In addition, studies showed that NLR could predict sepsis and systemic inflammatory response syndrome (SIRS) among urolithiasis patients. In addition, evidence reported that NLR was helpful in the prediction of spontaneous stone passage among these patients.

CONCLUSION

Our results support a reliable biomarker that is easily added into clinical settings to help predict urolithiasis patients' condition.

Constructing a machine learning model for systemic infection after kidney stone surgery based on CT values

This study aims to develop a machine learning model utilizing Computed Tomography (CT) values to predict systemic inflammatory response syndrome (SIRS) after endoscopic surgery for kidney stones. The goal is to identify high-risk patients early and provide valuable guidance for urologists in the early diagnosis and intervention of post-operative urosepsis. This study included 833 patients who underwent retrograde intrarenal surgery (RIRS) or percutaneous nephrolithotomy (PCNL) for kidney stones. Five machine learning algorithms and ten preoperative or intraoperative variables were used to develop a predictive model for SIRS. The SHapley Additive exPlanations (SHAP) method was used to explain the distribution of feature importance in the model's predictions. Among the 833 patients, 126 (15.1%) developed SIRS postoperatively. All five machine learning models demonstrated strong discrimination on the validation set (AUC: 0.690-0.858). The eXtreme Gradient Boosting (XGBoost) model was the best performer [AUC: 0.858; sensitivity: 0.877; specificity: 0.981; accuracy: 0.841; positive predictive value: 0.629; negative predictive value: 0.851]. The characteristic importance of the Machine Learning model (ML model) and SHAP results indicated Hounsfield Unit (HU), Urinary protein, Stone burden, and Serum uric acid as important predictors for the model. A machine learning model utilizing CT values was developed to predict postoperative SIRS in endoscopic kidney stone surgery. The model demonstrates strong predictive performance and can assist in assessing the risk of urosepsis in postoperative patients.

Predicting and Avoiding Complications in Percutaneous Nephrolithotomy in the Era of Personalized Medicine: A Scoping Review

BACKGROUND

Percutaneous nephrolithotomy (PCNL) is associated with a wide range of complications. This review aims to explore how recent technological advancements and personalized medicine can help prevent or predict these complications.

METHODS

A scoping review was conducted according to the PRISMA-SCR guidelines and registered on the Open Science Framework in April 2024. A literature search was performed on PUBMED, Web of Science, and Scopus databases. This review focused on predictive AI models, 3D surgical models, intrasurgical image guidance, and biomarkers. Articles meeting the following criteria were included: publication between 2019 and 2024, written in English, involving human participants, and discussing technological advancements or personalized medicine in the context of complications in PCNL.

RESULTS

Of the 11,098 articles searched, 35 new studies were included. We identified a few articles on predictive AI models. Several studies demonstrated that 3D presurgical models and virtual models could enhance surgical planning and reduce complications. New intrasurgical image and guidance systems showed the potential in reducing bleeding and radiation exposure. Finally, several biomarkers were identified as predictors of sepsis and other complications.

CONCLUSION

This scoping review highlights the potential of emerging technologies in reducing and predicting PCNL complications. However, larger prospective studies are required for validation.

Prospective Randomized Trial of Antibiotic Prophylaxis Duration for Percutaneous Nephrolithotomy in Low-Risk Patients

Introduction and Objective: Postoperative infection and sepsis account for the most common complications following percutaneous nephrolithotomy (PCNL), as high as 14% in low-risk patients. Although the American Urological Association (AUA) recommends perioperative antibiotics for 24 hours or less for PCNL, practice patterns vary regarding duration of antibiotic therapy. We aimed to compare the efficacy of 24-hour antibiotic coverage vs short-course protocol of antibiotic prophylaxis for PCNL. Materials and Methods: Low-risk patients with a sterile preoperative urine culture undergoing PCNL were prospectively randomized to antibiotics for up to 24 hours after procedure (24Hr) or continued until external urinary catheters were removed (CR) study groups. Patients were given a first generation cephalosporin, or ciprofloxacin in patients with penicillin allergy. Exclusion criteria included age <18 years, receiving antibiotics immediately before the procedure, history of urosepsis, presence of indwelling catheter >1 week, multistage procedure, immunosuppression, pregnancy, multiple antibiotic allergies, and patients who are breastfeeding. Results: Ninety-eight patients were randomized to either 24Hr (n = 49) or CR (n = 49). Mean duration of antibiotic administration was 20.6 and 34.0 hours in the 24Hr and CR groups (p = 0.04), respectively. Age, comorbidities, stone size, operative time, number of punctures, dilations, and proportion of "tubeless" procedures were similar between groups. There were no differences in febrile episodes, rates of systemic inflammatory response syndrome, bacteremia, or culture-proven postoperative urinary tract infection between the 24Hr and CR groups. Overall complication rates were similar between groups. In a subgroup analysis which excluded "tubeless" patients (24 and 29 patients in 24Hr and CR groups, respectively), no differences were seen in postoperative outcomes. Conclusions: In a randomized, prospective study, we found that a 24-hour protocol for antibiotic prophylaxis is not associated with increased risk of infection-related events compared to giving antibiotics until external catheters are removed in patients with low infectious risk undergoing PCNL. Clinicaltrials.gov: NCT02579161.

Timing of midstream urine culture before endourological procedure-can we do better?-A comparative study

Endourological procedures are the mainstay of treatment for stone disease in the upper urinary system. Infection is a common complication, and urine cultures (UC) are often obtained preoperatively. In this study, we sought to investigate the role of positive UC in the 90 days prior to surgery (90PreOp) in predicting postoperative infectious complications in comparison to a single positive preoperative UC (PreOP). We compared the correlation between positive PreOp UCs and positive 90PreOp UCs with postoperative urosepsis, and a positive UC obtain proximal to obstruction (Prox UC) during percutaneous nephrolithotomy, ureteroscopy and a placement of nephrostomy tube or ureteral stent. Data from 140 consecutive patients were collected. PreOp UCs were positive in 15 (11%) of patients versus 31 of 140 (22%) positive 90PreOp UCs. All six sepsis events had a positive 90PreOp UC, and five had a positive PreOp UC. Fourteen (93.3%) out of 15 positive Prox UC had a positive 90PreOp UC, whereas only 7 (38.9%) had a positive 90PreOp UC. Positive 90PreOp UC outperformed PreOp UC in predicting positive Prox UC, OR = 12.8 (95% CI 3.70-44.30, p < 0.001), versus OR of 88.9 (95% CI 11.0-720.7, p < 0.001); sensitivity 93%(95% CI 68-100%) versus 47%(95% CI 21-73%); as well as area under the ROC curve(AUC), 0.90 (CI 0.80-0.95) for 90PreOp versus 0.70 (CI 0.56-0.82) for positive Prox UC. Uropathogen persistence was better identified when using 90PreOp UC (27%) than using PreOp UC (12%). We suggest reviewing UCs taken within 90 days preoperatively as this was found superior to a single preoperative midstream UCs in predicting postoperative infectious sequela after stone procedure.

Factors predicting infective complications following percutaneous nephrolithotomy and retrograde intrarenal surgery according to systemic inflammatory response syndrome and quick sequential organ failure assessment: A prospective study

Purpose

Myriad operative factors and characteristics of patients may influence the risk of infection in a patient undergoing stone surgery. We prospectively determined the risk factors for systemic inflammatory response syndrome (SIRS) and quick sequential organ failure assessment (qSOFA) in patients undergoing percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS).

Materials and Methods

Patients who underwent PCNL and RIRS from March 2018 to January 2020 satisfying our selection criteria were enrolled. Samples of urine from the renal pelvis, bladder, and retrieved stones were sent for culture testing. Postoperatively patients were keenly supervised for any indications of SIRS and qSOFA. The association between stone and urine cultures across various sites was examined. Regression analysis was performed to ascertain clinical variables affiliated with SIRS and qSOFA.

Results

The study included a total of 150 patients including both PCNL and RIRS, of which 23% post-PCNL and 20% post-RIRS met the criteria of SIRS and qSOFA. On univariate analysis in PCNL-Dilated pelvicalyceal system (PCS), renal pelvic urine culture (RPUC), stone culture (SC), and operative time >124 min among others were identified as risk factors whereas, in RIRS-residual calculus, RPUC, SC and operative time >62 min were risk factors. Multivariate analysis identified dilated PCS and SC for PCNL and only intraoperative RPUC for RIRS as independent risk factors. Only a significantly strong correlation among culture analysis was found between RPUC and SC in both the procedures.

Conclusion

Intraoperative RPUC and SCs are better predictors of post-PCNL SIRS while Intraoperative RPUC and duration of surgery are better predictors of post-RIRS sepsis. We, therefore, recommend that both these cultures must routinely be obtained in the above procedures to identify the offending organisms and amend antibiotic therapy during treatment and surgical duration should be kept <62 min in RIRS. SIRS serves as a sensitive review tool which is specifically useful for initial care and on the contrary qSOFA is well suited for patients at greater risk of demise, thereby guiding clinicians to decide future care and course of treatment of patients.

Surgical Parameters Related to Excessive Intrarenal Pressure during Minimally Invasive Percutaneous Nephrolithotomy in the Supine Position: A Prospective Observational Clinical Study

Objective

Excessive intrarenal pressure (IRP) during surgery for renal stones is related to postoperative complications due to systemic absorption of bacteria and endotoxins. This study is aimed at evaluating factors that induce excessive IRP in minimally invasive percutaneous lithotripsy (mini-PCNL) in the supine position.

Methods

27 patients underwent mini-PCNL for intrarenal stones under supine position and were analyzed in this study. The IRP changes were measured at the phases of “baseline,” “table tilting,” “upper-pole navigation,” “stone fragmentation,” and “vacuum cleaning effect.” The relationship between the mean IRP and cumulative time of IRP ≥ 30 cmH₂O was analyzed by according to the surgical parameters. Multiple regression analysis showed the effect of the surgical parameters on postoperative fever-related IRP elevation.

Results

Mean age was 59.3 ± 14.6 years. The mean stone burden was 24.6 ± 8.1 mm³. IRP was higher than baseline (31.6 ± 12.1) during upper-pole navigation (60.0 ± 22.9, p = 0.003) and stone fragmentation (46.2 ± 9.9, p < 0.001). The subgroup's IRP baseline < 20 cmH₂O significantly increased during the upper-pole navigation. Changes in IRP at each stage were affected by baseline IRP (p < 0.001), operation methods (p = 0.021), number of calyces with stones (p = 0.034), and laser energy of Joules (p = 0.041) and frequency (p = 0.038).

Conclusion

In supine mini-PCNL, the IRP was higher during laser fragmentation and upper-pole navigation. The table tilting procedure can be helpful in selected patients. The vacuum cleaner effect did not affect IRP.

The controversial association of gut and urinary microbiota with kidney stone formation

Nephrolithiasis (kidney stones) is one of the most common chronic kidney diseases that are typically more common among adult men comparing to adult women. The prevalence of this disease is increasing which is influenced by genetic and environmental factors. Kidney stones are mainly composed of calcium oxalate and urinary oxalate which is considered a dangerous factor in their formation. Besides diverse leading reasons in the progression of nephrolithiasis, the gut and urinary microbiome has been recognized as a major player in the development or prevention of it. These microbes produce metabolites that have diverse effects on host biological functions. Therefore, Changes in the composition and structure of the microbiome (dysbiosis) have been implicated in various diseases. The present review focuses on the roles of gut and urinary in kidney stone formation.

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.

The characteristics and influencing factors of fever in postoperative patients undergoing percutaneous nephrolithotomy: A retrospective analysis

Percutaneous nephrolithotomy (PCNL) is commonly used for the treatment of upper urinary calculi in clinical setting, and fever is a common complication after PCNL. It is necessary to evaluate the risk factors of fever in patients undergoing PCNL, to provide insights into the management of PCNL.Patients who underwent PCNL in our hospital from January 2018 to August 2020 were included. The clinical data of postoperative fever and no fever patients were collected and assessed. Logistic regression analyses were conducted to analyze the risk factors for fever in patients undergoing PCNL.A total of 276 patients undergoing PCNL were included, the incidence of postoperative fever for patients undergoing PCNL was 19.39%. No significant differences in the gender, body mass index, alcohol drinking, smoking, hypertension, hyperlipidemia, intraoperative blood infusion, length of hospital stay between fever patients, and no fever patients were found (all P > .05). There were significant differences in the age, diabetes, size of stones, duration of surgery between fever patients, and no fever patients (all P < .05). Age ≥60 years (odds ratio [OR] 2.143, 95% confidence interval [CI] 1.101∼3.264), diabetes (OR 2.218, 95% CI 1.176∼4.642), size of stone ≥2 cm (OR 1.428, 95%CI 1.104∼2.055), duration of surgery ≥100 minutes (OR 1.334, 95% CI 1.015∼1.923) were the risk factors for fever in patients with PCNL (all P < .05). Escherichia coli (48.44%), Staphylococcus aureus (18.75%), and Candida albicans (10.93%) were the top 3 pathogenic bacteria of urine culture.Fever is one of the common complications after PCNL. Patients with high-risk factors should be given full attentions and take corresponding preventive measures targeted on risks.

The effect of ideal urine culture time on urinary infections after flexible ureteroscopy: A match-pair case-control study

AIMS

To investigate the effect of the ideal period (Δ-day), which is a period between the sterile urine culture and initiation of flexible ureteroscopy (f-URS), on postoperative urinary tract infections (UTI) in our tertiary referral centre.

METHODS

After obtaining the approval of the local ethics committee, retrospective data were collected for all f-URS procedures performed between January 2017 and March 2019. Patients that developed UTI were matched in 1:1 proportion with patients that did not develop UTI based on their demographic and stone characteristics. The group of patients with postoperative UTI was compared with the control group.

RESULTS

A total of 916 f-URS cases that had all required data were analysed. Sixty-eight patients with postoperative UTI were determined and a total of 136 patients were included in the study after match-pair. We found that if the Δ-day is longer than 2 weeks, the possibility of postoperative urinary infection rates increases with statistical significance (P = .006). According to our subgroup analysis, postoperative UTI was more common if the Δ-day >14 days. ROC curve analysis provided a 14.5-day period as a cut-off value of Δ-day for postoperative UTI.

CONCLUSIONS

The present study is the first to examine the impact of the Δ-day for f-URS on postoperative UTIs. In brief, prolonging the Δ-day, especially if Δ-day >14 days, leads to an increase in the rates of postoperative UTI. We conclude that it is preferred to either perform the f-URS in the early period after the urine culture analysis or doing the urine culture analysis shortly before the surgery.

Does the duration between urine culture and percutaneous nephrolithotomy affect the rate of systemic inflammatory response syndrome postoperatively?

This study aimed to evaluate the preoperative and intraoperative factors that may cause systemic inflammatory response syndrome (SIRS) after percutaneous nephrolithotomy (PCNL) and to investigate the effect of the duration between urine culture (UC) and operation on postoperative SIRS. Three hundred and fifty-six patients who had PCNL between January 2015 and June 2019 were retrospectively included in the study. UC was obtained from all patients before the operation and during the puncture at the beginning of the operation. Postoperatively, patients were closely monitored for fever and other signs of SIRS. The post-PCNL SIRS incidence was 7%. In univariable and multivariable analyses, the rate of ipsilateral PCNL history, recurrent urinary tract infection (UTI) history, operation time and the length of hospital stay were significant predictive factors for SIRS. The duration between UC and PCNL was not a statistically significant variable in both univariable and multivariable analysis. Our study concluded that the duration between UC and PCNL is not an influential factor for post-PCNL SIRS. Clarifying this issue may be possible with prospective studies in which the effects of factors such as ipsilateral PCNL history and recurrent urinary tract infection history which has been proven to be risk factors for post-PCNL SIRS are restricted.

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.

Is the qSOFA more reliable than SIRS in detecting post-operative PCNL patients requiring escalation of care?

Aims

Percutaneous nephrolithotomy is known to have a significant risk of sepsis and traditionally the systemic inflammatory response score has been used to identify post-operative patients requiring higher levels of care. Recently, the quick Sepsis Related Organ Failure Assessment score has been developed as a rapid and easy tool to assess patients likely to deteriorate from sepsis. We aim to evaluate the quick Sepsis Related Organ Failure Assessment system against the established systemic inflammatory response score criteria in identifying patients at risk of intensive care unit admission following percutaneous nephrolithotomy.

Patients and Methods

A retrospective review of 157 patients undergoing percutaneous nephrolithotomy between May 2015 and November 2018 at our institution was performed. Patient demographics of age, sex and American Society of Anesthesiologists’ score were collected. Quick Sepsis Related Organ Failure Assessment and systemic inflammatory response scores were calculated at 24 hours and 7 days post-operatively. Primary outcome was admission to an intensive care unit. Specificity, sensitivity, positive and negative predictive values were calculated for the systemic inflammatory response and quick Sepsis Related Organ Failure Assessment scores.

Results

Of 157 patients undergoing percutaneous nephrolithotomy, eight (5.1%) and 52 (33.1%) scored positively for quick Sepsis Related Organ Failure Assessment and systemic inflammatory response score criteria within 24 hours. Quick Sepsis Related Organ Failure Assessment scoring had a higher specificity (98.7%: 95% confidence interval 98.6–98.7%) and positive predictive value (75.0: 95% confidence interval 74.0–75.0%) than systemic inflammatory response score criteria (69.5%: 95% confidence interval 69.3–69.7%), (11.5%; 95% confidence interval 1.2–11.8%) in predicting intensive care unit admission following percutaneous nephrolithotomy. Quick Sepsis Related Organ Failure Assessment correlated strongly with intensive care unit admission and overall length of stay, whereas systemic inflammatory response score correlated weakly with both parameters.

Conclusion

Quick Sepsis Related Organ Failure Assessment demonstrated a statistically significant improvement in predicting intensive care unit admission and overall length of stay versus systemic inflammatory response score criteria following percutaneous nephrolithotomy. Further multi-centre studies are required to validate these findings, which are the first to be published in a urology-specific patient population.

Level of Evidence:

4

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.

Mini Versus Standard Percutaneous Nephrolithotomy: The Impact of Sheath Size on Intrarenal Pelvic Pressure and Infectious Complications in a Porcine Model

OBJECTIVE

To determine how sheath and endoscope size affect intrarenal pelvic pressures and risk of postoperative infectious complications comparing "Mini" vs "Standard" percutaneous nephrolithotomy (PCNL).

MATERIALS AND METHODS

Uropathogenic Escherichia coli were grown and 10⁹ of them were instilled into the porcine renal pelvis through retrograde access for 1 hour. Percutaneous access utilized a 14/16F 20 cm ureteral access sheath for the Mini arm and a 30F sheath for the Standard arm. Nephroscopy was simulated utilizing either an 8/9.8F semirigid ureteroscope or 26F nephroscope for 1 hour while intrarenal pelvic pressure was continuously monitored. Blood and tissue cultures of kidney, liver, and spleen biopsies were plated and incubated and positive cultures were confirmed with polymerase chain reaction.

RESULTS

Intrapelvic pressures were higher in the Mini group, 18.76 ± 5.82 mm Hg vs 13.56 ± 5.82 mm Hg (p < 0.0001). Time spent above 30 mm Hg was greater in the Mini arm, 117.0 seconds vs 66.1 seconds (p = 0.0452). All pigs had positive kidney tissue cultures whereas spleen cultures were positive in 100% and 60% of pigs in the Mini and Standard arms, respectively (p = 0.0253); 90% and 30% had positive liver tissue culture in the Mini and Standard arms, respectively (p = 0.0062). Blood cultures were positive in 30% of pigs in the Mini arm compared with none in the Standard arm (p = 0.0603).

CONCLUSION

Mini-PCNL was associated with higher intrarenal pressures and higher risk of end organ bacterial seeding in the setting of an infected collecting system. This suggests a higher potential for infectious complications in a clinical setting.

Efficacy of Intraoperative Renal Stone Culture in Predicting Postpercutaneous Nephrolithotomy Urosepsis/Systemic Inflammatory Response Syndrome: A Prospective Analytical Study with Review of Literature

AIM

To evaluate and study the efficacy of intraoperative renal stone culture (IOSC) in predicting postpercutaneous nephrolithotomy (PCNL) urosepsis (PPS) and systemic inflammatory response syndrome (SIRS). PPS is known to occur in patients despite negative preoperative midstream urine culture (MSUC).

METHODS

After obtaining institutional ethics committee approval and informed consent, 78 selected patients undergoing PCNL were evaluated as per protocol for risk factors for SIRS criteria with MSUC, intraoperative renal pelvic urine culture (RPUC), and IOSC.

RESULTS

MSUC was positive in six (7.7%) patients. The sensitivity, specificity, PPV, negative predictive value (NPV) and respiratory rate of MSUC for detecting SIRS were 20%, 93.15, 16.67%, 94.44%, and threefold, respectively. RPUC was positive in five (6.9%) patients with a specificity and NPV of 92.64% and 94.02%, respectively. IOSC positivity was seen in four (5.1%) patients with specificity and NPV of 94.5% and 3.2%, respectively. SIRS developed in five (6.4%) patients. MSUC, RPUC, and IOSC could not demonstrate any significant association with the occurrence of SIRS. Postoperative urine culture (POUC) was positive in 1/5 SIRS patients and no significant association (p < 0.182) could be demonstrated between the risk factors and PPS. Most complications were minor, while the mean hospital stay was significantly higher in SIRS patients.

CONCLUSIONS

While MSUC, RPUC, and IOSC were less sensitive in predicting the occurrence of SIRS/urosepsis in patients undergoing PCNL, nevertheless, we recommend routine IOSC for stone colonizing bacteria in at-risk select patients to predict potential PPS/SIRS. POUCs could be used in symptomatic SIRS to guide antimicrobial therapy in post-PCNL patients. Positive peri/intraoperative urine cultures may assist the urologist in directing appropriate antibiotics to prevent potential urosepsis in post-PCNL patients. Those with a higher blood transfusion rate and Clavien complications were at increased risk of PPS/SIRS. Escherichia coli was the most frequently isolated microbe followed by Klebsiella and Proteus, which were mostly sensitive to nitrofurantoin.

Does leaving residual fragments after percutaneous nephrolithotomy in patients with positive stone culture and/or renal pelvic urine culture increase the risk of infectious complications?

The residual fragments in patients with preoperative and intraoperative culture positivity may serve as an infection focus. The aim of this study was to assess the importance of residual fragments for developing SIRS in patients with stone culture and/or RPUC positivity. After obtaining institutional review board approval, a total of 729 patients who undergone PCNL for renal stones were included in this study. Residual fragments accepted to be positive if any fragment was detected irrespective of size. All patients were followed-up postoperatively for SIRS criteria. The patients were then followed-up for residual stone-related events and infectious complications. 94 of the 729 patients have developed SIRS postoperatively. SIRS positivity was more common among males and found to be associated with higher stone burden and presence of staghorn stone. Patients with residual fragments after PCNL also had higher rates of SIRS. In the subgroup analysis of 203 patients who had post-PCNL residual fragments, the peroperative stone and/or RPUC positivity was not found to be associated with the development of the SIRS. Although presence of residual fragments after PCNL is associated with SIRS development, stone culture and/or RPUC positivity has no additional risk for development of post-PCNL infectious complications in patients with residual fragments.

A Randomized Controlled Trial of Preoperative Prophylactic Antibiotics Prior to Percutaneous Nephrolithotomy in a Low Infectious Risk Population: A Report from the EDGE Consortium

PURPOSE

Single institution studies suggest a benefit of a week of preoperative antibiotics prior to percutaneous nephrolithotomy. These studies are limited by lower quality methodology, such as the inclusion of heterogeneous populations or nonstandard definitions of sepsis. The AUA (American Urological Association) Best Practice Statement recommends less than 24 hours of intravenous antibiotics but to our knowledge no other data exist on the duration or benefit of preoperative antibiotics. Using CONSORT (Consolidated Reporting of Trials) guidelines we sought to perform a rigorous multi-institutional trial to assess preoperative antibiotics in patients in whom percutaneous nephrolithotomy was planned and who were at low risk for infection.

MATERIALS AND METHODS

This randomized controlled trial enrolled patients undergoing percutaneous nephrolithotomy who were at low risk, defined as negative preoperative urine cultures and no urinary drain. Of the subjects 43 were randomized to nitrofurantoin 100 mg twice daily for 7 days preoperatively while a control arm of 43 received no oral antibiotics. All subjects received perioperative doses of ampicillin and gentamicin. Prone percutaneous nephrolithotomy was performed by urologists blinded to randomization. The primary outcome was the development of sepsis.

RESULTS

A total of 86 subjects were enrolled. Preoperative patient characteristics were similar in the treatment and control cohorts with a stone size of 19 and 17 mm, respectively (p = 0.47). Intraoperative characteristics also did not differ. The sepsis rate was not statistically different between the treatment and control groups (12% and 14%, respectively, 95% CI -0.163-0.122, p = 1.0). Other infectious parameters and complications were similar, including intensive care admission, fever, hypotension and leukocytosis.

CONCLUSIONS

Our study demonstrated no advantage to providing 1 week of preoperative oral antibiotics in patients at low risk for infectious complications who undergo percutaneous nephrolithotomy. Perioperative antibiotics according to the AUA Best Practice Statement appear sufficient.

Predictors for uroseptic shock in patients who undergo minimally invasive percutaneous nephrolithotomy

To identify risk factors that can predict which patient is likely to progress from systemic inflammatory response syndrome (SIRS) to uroseptic shock after minimally invasive percutaneous nephrolithotomy (MPCNL) for the upper urinary tract stones. We retrospectively reviewed 156 patients who suffered infectious complications after MPCNL from March 2014 to February 2016. Perioperative risk factors that could potentially contribute to uroseptic shock were compared to those of patients with only SIRS. 135 of the 156 patients developed to SIRS only, the remaining 21 patients progressed to uroseptic shock. The rate of positive preoperative urine nitrite was significantly higher (p < 0.001), stone diameter was larger (p = 0.015) and operative time was longer (p < 0.001) in uroseptic shock group. Multivariable logistic analysis showed that preoperative urine nitrite (OR 10.570, p = 0.025), stone size (OR 11.512, p = 0.009) and postoperative blood leukopenia (OR 0.009, p < 0.001) were independently related to uroseptic shock. Moreover, ROC curve analysis showed that white blood count threshold within the first 3 h of uroseptic shock was 2.98 × 10⁹/L. The sensitivity and specificity of leukocyte count in predicting uroseptic shock were 90.5 and 92.6%, respectively. Preoperative urine nitrite, stone size and postoperative leukocyte count are statistically linked to uroseptic shock after MPCNL. Leukopenia of less than 2.98 × 10⁹/L within 3 h after MPCNL can be a predictor for uroseptic shock. For patients who have high risk factors for developing uroseptic shock, the white blood count should be measured within 3 h after MPCNL.

From Catheter to Kidney Stone: The Uropathogenic Lifestyle of Proteus mirabilis

Proteus mirabilis is a model organism for urease-producing uropathogens. These diverse bacteria cause infection stones in the urinary tract and form crystalline biofilms on indwelling urinary catheters, frequently leading to polymicrobial infection. Recent work has elucidated how P. mirabilis causes all of these disease states. Particularly exciting is the discovery that this bacterium forms large clusters in the bladder lumen that are sites for stone formation. These clusters, and other steps of infection, require two virulence factors in particular: urease and MR/P fimbriae. Highlighting the importance of MR/P fimbriae is the cotranscribed regulator, MrpJ, which globally controls virulence. Overall, P. mirabilis exhibits an extraordinary lifestyle, and further probing will answer exciting basic microbiological and clinically relevant questions.

Is extended preoperative antibiotic prophylaxis for high-risk patients necessary before percutaneous nephrolithotomy?

PURPOSE

The goal of this study was to compare the rate of systemic inflammatory response syndrome (SIRS) in high-risk patients undergoing percutaneous nephrolithotomy (PCNL) between patients who received 7, 2, or 0 days of preoperative antibiotics.

MATERIALS AND METHODS

We retrospectively reviewed a series of consecutive PCNLs performed at our institution. Patients with infected preoperative urine cultures were excluded. High-risk patients were defined as those with a history of previous urinary tract infection (UTI), hydronephrosis, or stone size ≥2 cm. Patients were treated with 7, 2, or 0 days of preoperative antibiotic prophylaxis prior to PCNL. All patients received a single preoperative dose of antibiotics within 60 minutes of the start of surgery. Fisher exact test was used to compare the rate of SIRS by preoperative antibiotic length.

RESULTS

Of the 292 patients identified, 138 (47.3%) had sterile urine and met high-risk criteria, of which 27 (19.6%), 39 (28.3%), and 72 (52.2%) received 7, 2, and 0 days of preoperative antibiotics, respectively. The 3 groups were similar in age, sex, and duration of surgery (p>0.05). There was no difference in the rate of SIRS between the groups, with 1 of 27 (3.7%), 2 of 39 (5.1%) and 3 of 72 patients (4.2%) meeting criteria in the 7, 2, and 0 days antibiotic groups (p=~1).

CONCLUSIONS

Extended preoperative antibiotic prophylaxis was not found to reduce the risk of SIRS after PCNL in our institutional experience of high-risk patients. For these patients, a single preoperative dose of antibiotics is sufficient.

Pre- and Postoperative Predictors of Infection-Related Complications in Patients Undergoing Percutaneous Nephrolithotomy

INTRODUCTION

We aim to describe pre- and postoperative predictors of infection-related complications in individuals undergoing percutaneous nephrolithotomy (PCNL).

PATIENTS AND METHODS

Patients treated with PCNL from 2009 to 2013 were reviewed. Patients with positive urine or stone cultures received extended antimicrobial treatment. All others received 7 days of empirical therapy preoperatively and postoperatively. Pre- and postoperative predictors of infectious complication were identified.

RESULTS

We identified 227 patients who underwent primary PCNL with infectious complications occurring in 37 (16%): 11 (5%) urinary tract infection/pyelonephritis, 21 (9%) systemic inflammatory response syndrome (SIRS), and 2 (0.9%) sepsis. There were no significant differences between those with and without infectious complication with regard to age, gender, stone size, presence of diabetes, or procedure duration. Those with infectious complication were more likely to have a positive intraoperative stone culture (p = 0.01), struvite stone composition (p < 0.01), staghorn calculi (p < 0.001), and multiple stones (p = 0.02). Preoperatively, on multivariable analysis, only the presence of a staghorn calculus remained independently associated with increased risks of fever/SIRS/sepsis (odds ratio [OR] 3.14; p = 0.02) and total infectious complications (OR 2.53; p = 0.02) following PCNL. After controlling for pre- and post-PCNL risk factors, again, only staghorn calculi remained significantly associated with fever/SIRS/sepsis (OR 3.41; p = 0.01) and total infectious complications (OR 2.91; p = 0.01), with presence of multiple stones approaching significance (OR 4.2, confidence interval [CI]: 0.96, 18.6; p = 0.06).

CONCLUSIONS

In individuals undergoing PCNL on preoperative antibiotics, risk of SIRS/sepsis was low. The presence of a staghorn calculus confers a greater than threefold increased risk of postoperative infection with multiple stones approaching a significant risk. Patients with large stone burdens should be counseled appropriately regarding these risks.

Current Standard Technique for Modern Flexible Ureteroscopy: Tips and Tricks

BACKGROUND

Thanks to advancements in the endoscopic armamentarium, flexible ureteroscopy (fURS) has become a viable and attractive option for the treatment of renal stones because of its high stone-free rates (SFRs) and low morbidity.

OBJECTIVE

To describe our surgical technique for fURS, step-by-step, for the treatment of renal stones and to assess its effectiveness and safety.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective analysis of 316 consecutive patients who underwent fURS for renal stones at our institution between March 2014 and September 2015 was performed.

SURGICAL PROCEDURE

Ureteroscopy and laser lithotripsy using a standardized technique with last-generation flexible ureteroscopes.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Clinical data were collected in a dedicated database. Intraoperative and postoperative outcomes were assessed. A descriptive statistical analysis was performed.

RESULTS AND LIMITATIONS

The mean overall stone size was 16.5 ± 7.9mm. Ureteral access sheath placement was possible in 287 patients (90.8%). At 1-mo follow-up, the overall primary SFR was 79.1%; the secondary and tertiary SFRs were 89.5% and 91.5%, respectively. The mean operative time was 72.6 ± 27.5min. The mean number of procedures was 1.27. Complications were reported in 92 patients (29.1%) overall, with Clavien grade 1 in 55 patients (17.4%), grade 2 in 30 patients (9.5%), grade 3 in 6 patients (1.9%), grade 4 in 1 patient (0.3%), and grade 5 in none. The main limitation of the study was the retrospective nature.

CONCLUSIONS

The fURS procedure is safe and effective for the treatment of renal stones. A staged procedure is necessary to achieve stone-free status with large calculi.

PATIENT SUMMARY

Flexible ureteroscopy is an effective treatment with low complication rates for the majority of renal stones. Both the modern highly technological armamentarium and surgical know-how should be available.

Systemic Inflammatory Response Syndrome Following Percutaneous Nephrolithotomy: Assessment of Risk Factors and Their Impact on Patient Outcomes

OBJECTIVES

To identify perioperative risk factors for postoperative systemic inflammatory response syndrome (SIRS) and suggest possible modifications to reduce morbidity.

MATERIAL AND METHODS

We prospectively analysed perioperative data such as history of pervious stone surgery, number and configuration of stones, presence of stent or nephrostomy, any previous positive urine culture, intraoperative renal pelvic urine and stone culture, aspiration of turbid urine on initial puncture, number of tracts required and clearance of stones, operative time and intraoperative hypotension and tachycardia of all patients who underwent percutaneous nephrolithotomy over a period of 15 months.

RESULTS

A total of 182 patients were included, average stone size was 2.8 cm, 36.2% had staghorn stones and 15.9% had an indwelling stent or nephrostomy. Despite sterile preoperative urine culture, renal pelvic urine culture (RPUC) was positive in 14.8% (27 patients) and stone culture was positive in 21.9% (40 patients). SIRS developed in 17.5% (32 patients) and septic shock in 1.09% (2 patients). On analysis younger age, positive RPUC and stone culture, longer operative time and intraoperative tachycardia correlated significantly with the development of SIRS.

CONCLUSION

Intra-operative cultures are only therapy-guiding cultures during SIRS, as preoperative urine cultures seldom accurately depict bacteriological status of upper tracts and thus should be obtained in all patients.

Factors predicting infectious complications following percutaneous nephrolithotomy

Objective:

To determine the predictors of infectious complications following percutaneous nephrolithotomy (PCNL) in a prospective study.

Materials and Methods:

A total of 332 patients with renal or upper ureteric calculi who underwent PCNL between January 2013 and June 2014 were included in the study. Infectious complications included febrile urinary tract infection and septicemia. The patients were divided into Group A and B depending on whether they developed or did not develop infectious complications. Patient, stone, renal, and procedure-related factors were compared between the two groups.

Results:

There was no significant (P > 0.05) correlation among age (37.03 ± 16.24 vs. 36.72 ± 14.88), sex, and body mass index (21.00 ± 1.77 vs. 21.03 ± 2.25) between Group A and B. The patients in Group A were found to have significantly higher incidence of renal failure (39.5% vs. 9.2%,P= 0.0001), diabetes mellitus (12 [31.5%] vs. 33 [11.2%],P= 0.0001), previous percutaneous nephrostomy (PCN) tube placement (11 [28%] vs. 21 [7.1%]P= 0.0001), moderate to severe hydronephrosis (HDN), larger stone surface area (812.68 ± 402.07 vs. 564.92 ± 361.32,P= 0.0001), mean number of punctures (1.57 ± 0.50 vs. 1.20 ± 0.47,P= 0.002), and mean duration of surgery (94.28 ± 18.23 vs. 69.12 ± 21.23,P= 0.0001) than Group B.

Conclusion:

Post-PCNL infectious complications were found to be more common in patients with renal failure, diabetes mellitus, preoperative PCN placement, staghorn calculi, severe HDN, multiple punctures, and prolonged duration of surgery.

Predictive Value of Leukocytosis for Infectious Complications After Percutaneous Nephrolithotomy

OBJECTIVE

To investigate the natural history of white blood cell (WBC) values and incidence of leukocytosis after percutaneous nephrolithotomy (PCNL), factors associated with development of postoperative leukocytosis, and predictive value of WBC count for infection.

METHODS

A total of 303 patients who underwent PCNL for renal stones were included in the recent study. Electronic medical records of the patients were reviewed retrospectively to collect daily serum leukocyte counts and perioperative cultures. WBC count was followed daily for patients with positive urine culture and/or postoperative fever until leukocyte levels turned to normal limits.

RESULTS

Leukocytosis was detected in 133 of the 303 patients (43.9%). The mean preoperative and postoperative WBC counts were 7.73 ± 2.01 × 10(6) cells/μL and 11.9 ± 3.31 × 10(6) cells/μL, respectively. The average postoperative WBC count increased by 4.2 ± 2.99 × 10(6) cells/μL over the first 2 postoperative days. Receiver operating characteristic curve analysis resulted in an area under the curve of 0.87 and 0.80 for postoperative WBC count and absolute WBC count difference, respectively. The thresholds provided by the analysis were 14.05 × 10(6) cells/μL and an increase greater than 5.25 × 10(6) cells/μL, respectively.

CONCLUSION

Our data show postoperative leukocytosis is common after PCNL and represents a normal physiologic response to surgery. Our study demonstrated that 14.05 × 10(3) × 10(6) cells/μL WBC count and absolute difference in WBC count from baseline of 5.25 × 10(3) × 10(6) cells/μL were significantly associated with post-PCNL sepsis development. Further studies are needed to determine the significance of leukocytosis for infectious complications after PCNL.

Systemic inflammatory response syndrome after flexible ureteroscopic lithotripsy: a study of risk factors

OBJECTIVE

To evaluate the risk factors for systemic inflammatory response syndrome (SIRS) after flexible ureteroscopic lithotripsy (FUL).

MATERIALS AND METHODS

Patients who underwent FUL between October 2012 and November 2013 were studied. Complete data was available for 260 adult patients who met this criteria. Preoperative and intraoperative risk factors that potentially contribute to SIRS were compared in patients who developed postoperative SIRS and those who did not. Furthermore, multivariable logistic regression analysis was performed and the odds ratio (OR) and 95% confidence interval (CI) were calculated to identify the independent risk factors for SIRS after FUL.

RESULTS

The incidence of SIRS after FUL was 8.1%. In the univariate test analysis, significant correlation between SIRS and four factors was noted: sex of the patient (P<0.001), stone size (P=0.001), irrigation flow rate (P<0.001), and irrigation volume (P<0.001). Multivariable logistic regression analysis identified stone size (OR=1.691; 95% CI,0.879-3.255), small-caliber ureteral access sheath (UAS) (OR=2.293; 95% CI, 0.730-7.200), irrigation flow rate (OR=1.161; 95% CI, 1.096-1.230), and struvite calculi (OR=3.331; 95% CI, 0.971-11.426) as independent risk factors for SIRS after FUL.

CONCLUSIONS

We recommend that the length of lithotripsy be well controlled in patients with large stone burden and struvite calculi. Staging procedures are also required. Additionally, irrigating with a low flow rate and low pressure and using a large-caliber UAS for better drainage are required to keep a low renal pelvic pressure during FUL procedures.

Statin Use and Risk of Sepsis After Percutaneous Nephrolithotomy

PURPOSE

To examine the association between statin medication use and sepsis risk after percutaneous nephrolithotomy (PCNL).

MATERIALS AND METHODS

Using medical claims data, we identified working-age adults with urinary stone disease who were treated with PCNL. Among this cohort, we determined which patients had a prescription fill for a statin agent that encompassed their surgery date. We then fitted logistic regression models to examine for differences in rates of postoperative sepsis between statin users and nonusers. In addition, we evaluated the frequency of nonfebrile urinary tract infections (UTIs) and intensive care unit (ICU) services utilization and hospital length of stay (LOS) as a function of statin use.

RESULTS

During the study period, at total of 2046 patients underwent PCNL, 382 (18.7%) of whom had a prescription fill for a statin agent preceding their surgery. The overall rate of sepsis in this population was 3.8%. After adjusting for patient health status and sociodemographic factors, the rate of postoperative sepsis was comparable between statin users and nonusers (5.3% vs 3.5%, respectively; P=0.105). In addition, UTI and ICU utilization rates did not relate to statin use (P>0.05 for all associations). Adjusted hospital LOS was shorter among statin users, but the difference was clinically trivial (3.6 vs 4.1 days; P=0.007).

CONCLUSIONS

Statin use is not associated with reductions in postoperative sepsis, nonfebrile UTIs, ICU utilization, or hospital LOS after PCNL. To increase the safety of PCNL, urologists will have to consider other processes of care (e.g., clinical care pathways).

Percutaneous nephrolithotomy for infection stones: what is the risk for postoperative sepsis? A retrospective cohort study

The purpose of this study was to compare the postoperative course of patients with positive stone culture (SC) to patients with sterile SC, and to analyze the predictors for post percutaneous nephrolithotomy (PCNL) sepsis; and to describe the type and resistance patterns of bacteria responsible for post PCNL sepsis. From a cohort of 206 consecutive patients undergoing PCNL, we identified 45 patients with a positive SC (group A) and compared them to patients with a sterile SC (group B). Association between different groups was assessed using Chi square, two-tailed Student's t test and Mann-Whitney U test, as appropriate. Twenty-three patients had postoperative sepsis and regression analysis was performed to identify clinical variables associated with sepsis. Demographics, stone load and hospitalization time were similar in both groups. Postoperative sepsis developed in 31.1% of patients in group A compared to 5.9% in group B. In multivariate analysis, only positive SC was an independent risk factor for postoperative sepsis (OR 6.894, 95% CI 2.31-20.59, P = 0.001). All patients responded well to treatment with no septic complications. Enterococci were the prevalent organism (29.4%) in patients with a positive SC. Quinolone resistance was high in both gram negative and gram positive bacteria. Patients with an infected stone are at high risk to develop postoperative sepsis despite standard preoperative antibiotic preparation. SC is important to direct further treatment as almost half of patients with positive SC have a discordant or sterile urine culture. Determining the prevalent bacteria and resistance patterns in SC can aid the selection of empiric antibiotic therapy in high-risk patients.

Risk factors for postoperative infectious complications following percutaneous nephrolithotomy: a prospective clinical study

The aim of the study was to assess the preoperative and intraoperative potential risk factors for infectious complications after percutaneous nephrolithotomy (PCNL). A total of 303 patients who underwent PCNL for renal stones were included in the recent study. A detailed history including past renal surgery, nephrostomy insertion and recurrent urinary infection were obtained from all patients. Preoperative urine culture, renal pelvic urine culture and stone culture were obtained from all patients. The intraoperative data were prospectively noted. All patients were followed up postoperatively for signs of systemic inflammatory response syndrome (SIRS) and sepsis. In 83 (27.4%) of the patients, SIRS was observed and of these patients 23 (7.6%) were diagnosed as sepsis. Escherichia coli was the most common organism detected in cultures, followed by Pseudomonas aeruginosa, Enterococcus and Klebsiella spp. in all patients. By multivariate logistic regression analysis, presence of infection stone, stone burden and recurrent urinary tract infection were associated with both SIRS and sepsis development. Presence of infection stone, stone burden ≥800 mm(2) and recurrent urinary tract infection can be identified as independent predictors for the development of SIRS and sepsis.

Procalcitonin as an early diagnostic and monitoring tool in urosepsis following percutaneous nephrolithotomy

To evaluate the value of procalcitonin (PCT) as an early marker for diagnosis and differentiation of without urosepsis, urosepsis, severe urosepsis, and uroseptic shock following PCNL and the ability of PCT to assess the effectiveness of antibiotic therapy in patients with urosepsis. From June 2012 to August 2013, 267 patients undergoing PCNL for renal calculi, and who fulfilled selection criteria, were recruited into our study. The patients' medical records were reviewed retrospectively. One of selection criteria was the scores of PCT and WBC were collected at operative day, postoperative day one, day two, day three, day five and day seven. The area under the ROC curve for the prediction of urosepsis was 0.960 for PCT and 0.634 for WBC. PCT concentrations were higher in patients with uroseptic shock versus severe urosepsis versus urosepsis versus without urosepsis following PCNL. WBC values showed no significant difference between patients with urosepsis, severe urosepsis and uroseptic shock following PCNL. With time, in patients with successfully treated urosepsis following PCNL, the PCT concentrations significantly declined and kept decreasing from postoperative day two to postoperative day seven and the WBC scores showed no significant change over the first postoperative 2 days and were decreased only after postoperative day three. PCT appears to be a useful early marker to diagnosis and discriminate urosepsis, severe urosepsis and uroseptic shock following PCNL. Daily PCT measurements may be a valuable tool in monitoring the effectiveness of antibiotic therapy in urosepsis following PCNL.

Restrictive cardiomyopathy in a patient presented with fever, vomiting, and consciousness disorder

Restrictive cardiomyopathy (RCM) is an uncommon form of myocardial disorder characterized by diastolic dysfunction and increased myocardial stiffness. Endomyocardial fibrosis is one type of RCM hallmarked by formation of fibrous tissue on the endocardium. This report describes a case of RCM confirmed by autopsy in a young man who presented atypically with fever, vomiting, and delirium.

Risk factors for sepsis after percutaneous renal stone surgery

Since its introduction into the endourologist's armamentarium almost 40 years ago, percutaneous nephrolithotomy (PCNL) has become the standard of care for patients with large-volume nephrolithiasis. Postoperative infection is one of the most common complications of the procedure, and postoperative sepsis is one of the most detrimental. A number of factors have been found to increase the risk of postoperative sepsis. These include patient characteristics that are known preoperatively, such as urine culture obtained from the bladder or from the renal pelvis if percutaneous access to the renal pelvis is obtained in advance to the procedure. Neurogenic bladder dysfunction secondary to spinal cord injury and anatomical renal abnormalities, such as pelvicalyceal dilatation, have also been associated with increased incidence of fever and sepsis after the procedure. Several intraoperative factors, such as the average renal pressure sustained during PCNL and the operative time, also seem to increase the risk of sepsis. Finally, the contribution of postoperative factors, such as presence of a nephrostomy tube or a urethral catheter, has also been investigated. A short preoperative course of antibiotics has been found to significantly decrease the rate of postoperative fever and sepsis. Novel agents targeted at sepsis prevention and treatment, such as anti-endotoxin antibodies and cholesterol-lowering drugs statins, are currently under investigation.

Lithotrites and postoperative fever: does lithotrite type matter? Results from the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study

OBJECTIVE

To compare the risks of fever from different lithotrites after percutaneous nephrolithotomy (PNL).

MATERIALS AND METHODS

The Clinical Research Office of the Endourological Society (CROES) PNL database is a prospective, multi-institutional, international PNL registry. Of 5,803 total patients, 4,968 received preoperative antibiotics, were supplied with complete information and included in this analysis. The lithotrites assessed included no fragmentation, ultrasonic, laser, pneumatic and combination ultrasonic/pneumatic. Risk of fever was estimated using multivariate logistic regression with adjustment for diabetes, steroid use, a history of positive urine culture, the presence of staghorn calculi or preoperative nephrostomy, stone burden and lithotrite.

RESULTS

The overall fever rate was 10%. Pneumatic lithotrites were used in 43% of the cohort, followed by ultrasonic (24%), combination ultrasonic/pneumatic (17.3%), no fragmentation (8.4%) and laser (7.3%). Fever rates were no different between patients who underwent no or any fragmentation (p = 0.117), nor among patients when stratified by lithotrite (p = 0.429). On multivariate analysis, fragmentation was not significantly associated with fever [Odds Ratio (OR) 1.17, p = 0.413], while diabetes (OR 1.32, p = 0.048), positive urine culture (OR 2.08, p < 0.001), staghorn calculi (OR 1.80, p < 0.001) and nephrostomy (OR 1.65, p < 0.001) increased fever risk. Fever risk among lithotrites did not differ (p ≥ 0.128).

CONCLUSIONS

Risk of post-PNL fever was not significantly different among the various lithotrites used in the CROES PNL study.