Current opinion amongst radiologists and urologists in the UK on percutaneous nephrostomy and ureteric stent insertion for acute renal unobstruction: Results of a postal survey

The efficacy and safety of retrograde ureteral stenting in the management of complicated cases of ureteral obstruction caused by urolithiasis

PURPOSE

To investigate the efficacy and safety of retrograde double J stent (RDJS) placement in the management of complicated obstructive uropathy caused by urolithiasis.

PATIENTS AND METHODS

An observational study done at a tertiary center was implemented in which a total of 27 patients (10 males, 17 females) with average age of 48.74 years (range: 15-88) who underwent RDJS or percutaneous nephrostomy (PCN) between 2017 and 2021 due to complicated obstruction caused by urolithiasis were included.

RESULTS

A total of 27 patients (10 males, 17 females) with average age of 48.74 years (range: 15-88) who underwent kidney decompression between 2017 and 2021 due to complicated unilateral or bilateral kidney obstruction caused by ureteral stones were included. Twenty-two patients (81.48%) underwent successful RDJS placement, two patients had RDJS placement then PCN was also placed, and two patients underwent PCN placement. Three patients needed an intensive care unit "ICU" after intervention, two of them were in the ICU before intervention. All septic parameters were normalized within a short period postoperatively. Two patients with failed previous ureteroscopy had a successful RDJS placement.

CONCLUSION

Retrograde DJS placement is a feasible option in the management of complicated cases of obstructive uropathy caused by urolithiasis. Short hospitalization period, low rate of complications and better quality of life are the most prominent advantages of RDJS placement. In the hands of experienced surgeons, RDJS should be offered as the first choice of decompression for obstructive uropathy caused by urolithiasis.

National consensus survey on management approaches for upper urinary tract obstruction: A comparative analysis of retrograde ureteric stent and percutaneous nephrostomy

To the Editor, Upper urinary tract obstruction (UUTO) is a common scenario in clinical practice, and it is caused by a variety of diseases. Lithiasis, tumours and strictures are some of the principal aetiologies. Multiple factors may influence both the need for decompression of the obstructed collecting system and the urgency of procedure...

Surgical Emergencies in the ICU

Surgical emergencies are common in the critical care setting and require prompt diagnosis and management. Here, we discuss some of the surgical emergencies involving the gastrointestinal, hepatobiliary, and genitourinary sites. In addition, foreign body aspiration and necrotizing soft-tissue infections have been elaborated. Clinicians should be aware of the risk factors, keys examination findings, diagnostic modalities, and medical as well as surgical treatment options for these potentially fatal illnesses.

Optimal duration of preoperative antibiotic treatment prior to ureteroscopic lithotripsy to prevent postoperative systemic inflammatory response syndrome in patients presenting with urolithiasis-induced obstructive acute pyelonephritis

PURPOSE

There is no consensus on the optimal duration of preoperative antibiotic treatment prior to ureteroscopic lithotripsy in patients presenting with urolithiasis-induced obstructive acute pyelonephritis (APN). We aimed to identify surgeon-modifiable, preoperative risk factors associated with postoperative systemic inflammatory response syndrome (SIRS) in these patients.

MATERIALS AND METHODS

This multicenter retrospective study evaluated 115 patients who presented with urolithiasis-induced obstructive APN between January 2008 and December 2019. All patients were administered intravenous third-generation cephalosporin until culture sensitivity confirmation or until ureteroscopic lithotripsy. Data were collected for age, sex, diabetes mellitus, performance status, stone features, hydronephrosis grade, preoperative renal collecting system drainage, laboratory data, operative time, and duration of preoperative antibiotic treatment. Sensitivity analysis using Youden's index and logistic regression analysis were used to assess risk factors of postoperative SIRS.

RESULTS

Postoperative SIRS was identified in 32 (27.8%) patients. The incidence of postoperative SIRS was higher in patients who received preoperative antibiotic treatment for fewer than 14 days (38.8% vs. 12.5%; p=0.001). Backward variable selection logistic regression analysis revealed maximal stone diameter ≥15 mm, duration of preoperative antibiotic treatment <14 days, and preoperative C-reactive protein (CRP) level ≥6.0 mg/L to be associated with higher risk of postoperative SIRS.

CONCLUSIONS

Patients with urolithiasis-induced obstructive APN planned for ureteroscopic lithotripsy should be administered at least 14 days of preoperative antibiotic administration and achieve a serum CRP level ≤6.0 mg/L to minimize the risk of postoperative SIRS.

Emergent urinary decompression in acute stone-related urinary obstruction: A systematic review and meta-analysis

Introduction:

Emergent urinary decompression through percutaneous nephrostomy (PCN) or ureteric stent (URS) remains a mainstay in the management of urethral calculi-related obstruction with associated signs of infection or renal injury. Available evidence has shown similar performance, and current guidelines endorse both treatment strategies.

Methods:

A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analysis criteria up until August 2020. Studies included data on stone size and location, operative time, complications, length of stay, analgesic consumption, quality of life (QoL), and clinical outcomes between URS and PCN.

Results:

Ten studies with a total population of 772, of which 420 were treated with URS and 352 with PCN, were included. No statistical difference in operative time between both techniques was found. Nevertheless, length of stay in PCN was longer than in USR, with a mean difference of −1.87 days ((95% CI −2.69 to −1.06), Z=4.50, p=0.00001). No differences were found in the time to normalization of temperature or white blood cell counts. There were no significant differences in success rates, with an overall odds ratio (OR) of 0.60 ((95% CI 0.26 to −1.40), Z=1.17, p=0.24), or spontaneous passage after emergent drainage between groups. Complication rates ranged from 5% to 25% in URS and from 0% to 38% in PCN. In the studied population, out of the 157 patients from four studies describing complications, only 5% of URS procedures presented complications compared to 2% in PCN, showing a relatively low complication rate for either group (OR=2.07 (95% CI 0.89–4.84), Z=1.68, p=0.09). Differences in QoL were not significant.

Conclusion:

Both methods are equally effective, with no clear advantage for PCN over URS.

Level of evidence:

IV

Predictors of antegrade ureteral stenting failure: a single-center experience in patients with malignant and benign ureteral obstruction

OBJECTIVE

To determine the potential predictors of antegrade ureteral stenting (AUS) failure in patients with malignant and benign ureteral obstruction.

METHOD

We retrospectively evaluated 116 AUS procedures performed in 80 patients for ureteral obstruction due to malignant and benign causes. Variables such as etiology for obstruction, ureter shape, previous treatment regimen, history of ileal loop diversion, and presence of percutaneous nephrostomy were recorded. Univariate and multivariate logistic regression methods were used between these variables and stent failure.

RESULTS

Antegrade ureteral stenting was performed as single stage in 24 procedures (n: 24/116, 21%) and performed as a two-step approach after percutaneous nephrostomy in 92 procedures (n: 92/116, 79%). Ureteral stent was successfully deployed in 112 AUS procedures (n: 112/116, 96.5%). In 35 of these successful procedures, the patients were referred to our department due to prior failed retrograde ureteral stenting (RUS). Subsequent stent failure occurred in 40 procedures after a median interval of 39 days. Pre-stenting percutaneous nephrostomy (PN) was a statistically significant risk factor for stent failure (p: 0.041), and age showed an inverse relationship with stent failure (p: 0.008). Complications in early (within the first 30 days after procedure) and late stage occurred in a total of 17 procedures. Early complications included urinary tract infection (n: 11), stent migration (n: 3), and malposition (n: 1). Late complications (after 30 days) were urinary tract infection (n: 1) and stent migration (n: 1).

CONCLUSION

This study suggests that AUS can be performed effectively in both benign and malignant ureteral obstructions including cases with prior failed RUS. Two-step AUS after percutaneous nephrostomy was found to be a significant risk factor for subsequent stent failure in our study cohort.

Percutaneous nephrostomy versus retrograde ureteral stenting for acute upper obstructive uropathy: a systematic review and meta-analysis

Acute obstructive uropathy is associated with significant morbidity among patients with any condition that leads to urinary tract obstruction. Immediate urinary diversion is necessary to prevent further damage to the kidneys. In many centres, the two main treatment options include percutaneous nephrostomy (PCN) and retrograde ureteral stenting (RUS). The purpose of this study if to compare the efficacy and safety of PCN and RUS for the treatment of acute obstructive uropathy. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL, EMBASE, the World Health Organisation International Clinical Trials Registry Platform and ClinicalTrials.gov. We also searched the reference lists of included studies to identify any additional trials. We included randomised controlled trials and controlled clinical trials comparing the outcomes of clinical improvement (septic parameters), hospitalisation duration, quality of life, urinary-related symptoms, failure rates, post-procedural pain [measured using a visual analogue scale (VAS)] and analgesics use. We conducted statistical analyses using random effects models and expressed the results as risk ratio (RR) and risk difference (RD) for dichotomous outcomes and mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs). Seven trials were identified that included 667 patients. Meta-analysis of the data revealed no difference in the two methods in improvement of septic parameters, quality of life, failure rates, post-procedural pain (VAS), or analgesics use. Patients receiving PCN had lower rates of haematuria and dysuria post-operatively and longer hospitalisation duration than those receiving RUS. PCN and RUS are effective for the decompression of an obstructed urinary system, with no significant difference in most outcomes. However, PCN is preferable to RUS because of its reduced impact on the patient's post-operative quality of life due to haematuria and dysuria, although it is associated with slightly longer hospitalisation duration.

Implementation of a Hospital-Wide Protocol Reduces Time to Decompression and Length of Stay in Patients with Stone-Related Obstructive Pyelonephritis with Sepsis

Introduction and Objectives: Patients with obstructive pyelonephritis (OPN) require urgent decompression through retrograde ureteral stent (RUS) or percutaneous nephrostomy (PCN). In 2016, the urology and interventional radiology (IR) departments at our institution established a protocol for patients with OPN with sepsis. The primary objectives were to assess this protocol's impact on improving time to decompression and whether more expedient decompression decreased length of stay (LOS). Secondarily, we assessed the impact of the protocol and clinical factors on receipt of PCN over RUS. Materials and Methods: One hundred forty-seven patients at our institution who underwent PCN from 2012 to 2017 or stent from 2014 to 2017 for stone-related OPN meeting sepsis criteria were retrospectively reviewed. Univariate descriptive statistics compared patient characteristics and outcomes between RUS and PCN pre- and postprotocol implementation. Multivariable logistic regression assessed predictors of decompression with PCN (vs RUS) and of prolonged LOS (pLOS; >5 days). Results: Utilization of PCN increased after implementation of the protocol from 4 to 14 PCN/year with a decrease in the median time from urologic consultation to PCN from 9.2 to 4.3 hours (p = 0.001) with overall median time to decompression decreasing from 5.4 to 4.5 hours (p = 0.017). Predictors of undergoing PCN (vs RUS) included increasing comorbidity and ≥1 cm obstructing stone. On multivariable analysis controlling for comorbidity, leukocytosis, and septic shock, increasing hours to decompression increased odds of pLOS (1.08, 95% confidence interval 1.02-1.15, p = 0.014). Conclusions: After implementing our OPN with sepsis protocol, time to decompression decreased with dramatic improvement in time to PCN. Quicker decompression was independently associated with reduced odds of prolonged hospital stay. A well-designed protocol engages both urology and IR in the management of these acutely ill patients and improves outcomes.

ACR Appropriateness Criteria® Radiologic Management of Urinary Tract Obstruction

Acute obstructive uropathy is a medical emergency, which often is accompanied by acute renal failure or sepsis. Treatment options to resolve the acute obstructive process include conservative medical management, retrograde ureteral stenting, or placement of percutaneous nephrostomy or nephroureteral catheters. It is important to understand the various treatment options in differing clinical scenarios in order to guide appropriate consultation. Prompt attention to the underlying obstructive process is often imperative to avoid further deterioration of the patient's clinical status. A summary of the data and most up-to-date clinical trials regarding treatment options for urinary tract obstruction is outlined in this publication. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Placement of double-J stent in patients with malignant ureteral obstruction: antegrade or retrograde approach?

AIM

To determine whether antegrade or retrograde methods should be preferred for double-J stent placement in patients with malignant ureteral obstruction (MUO).

MATERIAL AND METHODS

The medical records of patients treated for MUO in the Urology and Interventional Radiology Clinic, Konya Training and Research Hospital, were reviewed retrospectively. Patients with benign aetiology were excluded from the study. Reports of the procedures, ultrasonography findings, computed tomography (CT), angiography, and pyelography images and the follow-up records of patients with MUO were assessed. A total of 111 patients and 114 ureteral stenting treatments were included in the study; 63 (55.3%) were operated on using the antegrade ureteral stenting (AUS) method, whereas 51 (44.7%) were operated on using the retrograde ureteral stenting (RUS), method, and the characteristics of these groups were evaluated. The presence of hydroureteronephrosis and ureteral tortuosity were determined.

RESULTS

Overall success rates were found to be 95.2% using the AUS method and 47.1% using the RUS method. The technical success of the antegrade method was significantly higher in patients with or without tortuosity (respectively: p=0.005, Z shape p=0.001, pigtail shape p=0.035″). The technical success of the antegrade method was significantly higher in patients with hydroureteronephrosis (p=0.001).

CONCLUSION

The AUS technique should be the first choice for double-J stent placement in patients with MUO.

Ureteric stent versus percutaneous nephrostomy for acute ureteral obstruction - clinical outcome and quality of life: a bi-center prospective study

BACKGROUND

To compare quality of life (QoL) indices between ureteral stent (DJS) and nephrostomy tube (PCN) inserted in the setting of acute ureteral obstruction.

METHODS

Prospective bi-centered study. Over the span of 2 years, 45 DJS and 30 PCN patients were recruited. Quality of life was assessed by 2 questionnaires, EuroQol EQ-5D and 'Tube symptoms' questionnaire, at 2 time points (at discharge after drainage and before definitive treatment).

RESULTS

Patients' demographics and pre-drainage data were similar. There were no clinically significant differences in patient's recovery between the groups, including post procedural pain, defeverence, returning to baseline renal function, and septic shock complications. More DJS patients presented to the emergency room with complaints related to their procedure compared to PCN patients. At first, DJS patients complained more of urinary discomfort while PCN patients had worse symptoms relating to mobility and personal hygiene, with both groups achieving similar overall QoL score. At second time point, PCN patients' symptoms ameliorated while symptoms in the DJS group remained similar, translating to higher overall QoL score in the PCN group.

CONCLUSIONS

The two techniques had a distinct and significantly different impact on quality of life. Over time, PCN patients' symptoms relieve and their QoL improve, while DJS patients' symptoms persist. Specific tube related symptoms, and their dynamics over time, should be a major determinant in choosing the appropriate drainage method, especially when definitive treatment is not imminent.

The Role of Antegrade Irrigation via Percutaneous Nephrostomy on Surgical Outcomes in Semirigid Ureteroscopy among Patients with Upper Ureteral Stones

Objective

We aimed to investigate the role of antegrade irrigation via percutaneous nephrostomy on surgical outcomes in retrograde ureteroscopy in patients with upper ureter stones.

Materials and Methods

In this retrospective study, we analyzed 134 patients who underwent retrograde semirigid ureteroscopy for upper ureter stones between August 2012 and December 2017. Patients were divided into two groups: retrograde irrigation group (conventional URS) and antegrade irrigation group (using percutaneous nephrostomy). Operation time, postoperative hospital stay, complications, and stone-free rate were measured for each patient after ureteroscopy.

Results

The mean age in the retrograde irrigation and antegrade irrigation groups was 53.3 and 60.7 years, respectively (p=0.007). The operation time was 60.8 min vs. 43.0 min (p=0.002), and stone-free rate was 82.0 % vs. 95.5 % (p=0.033). Stone size, laterality, the proportion of male patients, and urinary tract infection prevalence were comparable between the groups. In the subgroup analysis of stone size >10 mm, the antegrade irrigation group had a shorter operation time and a higher stone-free rate. For stone size of 5-10 mm, operation time in the antegrade irrigation group was shorter and the stone-free rate between the two groups was comparable.

Conclusion

Antegrade irrigation via percutaneous nephrostomy during ureteroscopy has a higher stone-free rate with a shorter operation time without an increased urinary tract infection risk. Therefore, if percutaneous nephrostomy is necessary before ureteroscopy, antegrade irrigation of external fluid via percutaneous nephrostomy is strongly recommended.

Early Stone Manipulation in Urinary Tract Infection Associated with Obstructing Nephrolithiasis

A urinary tract infection (UTI) and sepsis secondary to an obstructing stone are one of the few true urological emergencies. The accepted management of infected ureteral stones includes emergent decompression of the collecting system as well as antibiotic therapy. Despite this, no consensus guidelines clarify the optimal time to undergo definitive stone management following decompression. Historically, our institution has performed ureteroscopy with laser lithotripsy (URS-LL) treatment at least 1 to 2 weeks after decompression to allow for clinical improvement and completion of an antibiotic course. In this case series, we retrospectively review four cases in which patients had a documented UTI secondary to an obstructive ureteral stone. The patients underwent urgent decompression and, based on labs and clinical improvement, were subsequently treated with URS-LL. The presented patients received URS-LL within 5 days of decompression and antibiotics. The patients had no sepsis related postoperative complications from the accelerated course of treatment, resulting in discharge within 2 days following URS-LL. We provide a detailed examination of each patient presentation to describe our institution's experience with treating infected kidney stones within days of urgent decompression in order to question the previous standard of treating an infected kidney stone with a more delayed intervention.

Are there any predictive risk factors for failure of ureteric stent in patients with obstructive urolithiasis with sepsis?

Purpose

To compare patients with sepsis due to obstructive urolithiasis (Sep-OU) and underwent drainage by percutaneous nephrostomy (PCN) or a double-J (DJ)-ureteral stent and to identify predictive risk factors of DJ stent failure in these patients.

Materials and Methods

We reviewed our records from January 2013 to July 2018 and identified 286 adult patients with Sep-OU out of which 36 had bilateral involvement, thus total 322 renal units were studied. Urologic residents in training carried out both ureteral stenting and PCN tube placement. Demographic data and stone characteristics were recorded along with Charlson comorbidity index. For predicting risk factors of DJ stent failure, those variables that had a p-value <0.1 in univariate analysis were combined in a multinomial regression analysis model.

Results

The patients with PCN placement were significantly older than those with DJ stent placement (p=0.001) and also had significant number of units with multiple calculi (p=0.018). PCN was also placed more frequently in those patients with a upper ureteric calculi (p<0.05). On multinomial regression analysis multiple calculi (p=0.014; odds ratio [OR], 4.878; 95% confidence interval [CI], 1.377–17.276) and larger calculi size (p=0.040; OR, 0.974; 95% CI, 0.950–0.999) were the significant predictors of DJ stent failure.

Conclusions

In patients with sepsis from obstructive urolithiasis due to larger and multiple calculi a PCN placement might be better suited although this data requires further prospective randomized studies to be extrapolated.

Urological Management of Extramural Malignant Ureteric Obstruction: A Survey of Irish Urologists

Introduction

The absence of guidelines in the management of extramural malignant ureteric obstruction leads to confusion in decision making and in the interaction between urology and other clinical disciplines. In this study, we surveyed consultant urologists with the goal of achieving a better consensus on optimal management options.

Methods

A multiple choice survey was sent via the online survey tool "SurveyMonkey" to all consultant urologists practicing in the Republic of Ireland.

Results

There was a response rate of 57.5% (n = 23). Twenty-two (96%) consultants consider the use of percutaneous nephrostomy with placement of antegrade ureteric stent but only 22% (n = 5) would consider using a metallic stent. Eleven (48%) respondents favor retrograde stenting in the first instance with an equal proportion choosing an antegrade method. Nine (39%) consultants perform the initial stent change at 4-6 months, 8 (35%) at 2-4 months, and 1 at < 2 months and 6-10 months respectively. Total 59% (n = 13) of respondents felt that the duration of expected patient survival influenced their decision and agreement to stent with 42% (n = 8) saying this survival would need to be > 6 months and 82% (n = 18) were generally happy with the level of ongoing communication between urology and the primary service managing the patient.

Conclusion

There is a lack of consensus regarding the management of this challenging problem, particularly with regard to timing of first stent change and whether to initially use an antegrade or retrograde approach. This reflects the heterogeneous patient cohort and the important factors of life expectancy and patient co-morbidities.

[Management of ureteral obstruction : Value of percutaneous nephrostomy and ureteral stents]

Ureteral obstruction represents a heterogeneous disease pattern and is treated by ureteral stenting or percutaneous nephrostomy (PCN) depending on the necessity. The benefits of urinary diversion with ureteral stenting or PCN in malignant ureteral obstruction (MUO) for patient survival are only moderate. No differences have been found between ureteral stenting and PCN in MUO with regard to median patient survival and complication rates. In cases of MUO there is currently no evidence that urinary diversion improves the quality of life. Alternative concepts of ureteral stenting, such as tandem ureteral stents, metallic ureteral stents or metal mesh ureteral stents have not yet shown clear benefits. In benign ureteral obstruction, prospective randomized studies have demonstrated comparable quality of life after PCN or ureteral stenting. The method of choice for urinary diversion is influenced by the recommendations, personal experience of the clinician and the availability of the method.

Use of percutaneous nephrostomy and ureteral stenting in management of ureteral obstruction

The management options for ureteral obstruction are diverse, including retrograde ureteral stent insertion or antegrade nephrostomy placement, with or without eventual antegrade stent insertion. There is currently no consensus on the ideal treatment or treatment pathway for ureteral obstruction owing, in part, to the varied etiologies of obstruction and diversity of institutional practices. Additionally, different clinicians such as internists, urologists, oncologists and radiologists are often involved in the care of patients with ureteral obstruction and may have differing opinions concerning the best management strategy. The purpose of this manuscript was to review available literature that compares percutaneous nephrostomy placement vs ureteral stenting in the management of ureteral obstruction from both benign and malignant etiologies.

CUA Guideline: Management of ureteral calculi

The focus of this guideline is the management of ureteral stones. Specifically, the topics covered include: conservative management, medical expulsive therapy, active intervention with either shockwave lithotripsy (SWL) or ureteroscopy (URS), factors affecting SWL treatment success, optimizing success, and special considerations (e.g., pregnancy, urinary diversion). By performing extensive literature reviews for each topic evaluated, we have generated an evidence-based consensus on the management of ureteral stones. The objective of this guideline is to help standardize the treatment of ureteral stones to optimize treatment outcomes.

Temporal trends, practice patterns, and treatment outcomes for infected upper urinary tract stones in the United States

BACKGROUND

The incidence of infected urolithiasis is unknown, and evidence describing the optimal management strategy for obstruction is equivocal.

OBJECTIVE

To examine the trends of infected urolithiasis in the United States, the practice patterns of competing treatment modalities, and to compare adverse outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A weighted estimate of 396385 adult patients hospitalized with infected urolithiasis was extracted from the Nationwide Inpatient Sample, 1999-2009.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Time trend analysis examined the incidence of infected urolithiasis and associated sepsis, as well as rates of retrograde ureteral catheterization and percutaneous nephrostomy (PCN) for urgent/emergent decompression. Propensity-score matching compared the rates of adverse outcomes between approaches.

RESULTS AND LIMITATIONS

Between 1999 and 2009, the incidence of infected urolithiasis in women increased from 15.5 (95% confidence interval [CI], 15.3-15.6) to 27.6 (27.4-27.8)/100 000); men increased from 7.8 (7.7-7.9) to 12.1 (12.0-12.3)/100000. Rates of associated sepsis increased from 6.9% to 8.5% (p=0.013), and severe sepsis increased from 1.7% to 3.2% (p<0.001); mortality rates remained stable at 0.25-0.20% (p=0.150). Among those undergoing immediate decompression, 113 459 (28.6%), PCN utilization decreased from 16.1% to 11.2% (p=0.001), with significant regional variability. In matched analysis, PCN showed higher rates of sepsis (odds ratio [OR]: 1.63; 95% CI, 1.52-1.74), severe sepsis (OR: 2.28; 95% CI, 2.06-2.52), prolonged length of stay (OR: 3.18; 95% CI, 3.01-3.34), elevated hospital charges (OR: 2.71; 95%CI, 2.57-2.85), and mortality (OR: 3.14; 95%CI, 13-4.63). However, observational data preclude the assessment of timing between outcome and intervention, and disease severity.

CONCLUSIONS

Between 1999 and 2009, women were twice as likely to have infected urolithiasis. Rates of associated sepsis and severe sepsis increased, but mortality rates remained stable. Analysis of competing treatment strategies for immediate decompression demonstrates decreasing utilization of PCN, which showed higher rates of adverse outcomes. These findings should be viewed as preliminary and hypothesis generating, demonstrating the pressing need for further study.

Percutaneous Nephrostomy and Ureteric Stent Insertion for Acute Renal Deobstruction Consensus Based Guidance

Objective:

Ureteric obstruction can be relieved by either percutaneous nephrostomy (PCN) or retrograde ureteric stenting (RUS). Both are associated with variable technical success, complication rates, availability and quality of life issues. Our aim was to generate guidelines for PCN, RUS and the general approach of renal deobstruction in the UK.

Materials and Methods:

Subsequent to a pilot study, a formal postal questionnaire regarding the indication and method of renal deobstruction was sent via the BAUS audit office to members of BAUS, BSIR, BSUR. Data from 227 radiologists and urologists were categorised into areas of “clear agreement” (>75% agreement), “broad agreement” (50–75% agreement) and “no broad consensus” (less than 50% agreement) for any particular method of management.

Results:

In septic patients with renal obstruction, there was “clear agreement” for urgent deobstruction by PCN. If uncorrectable coagulopathy exists then RUS was the preferred option. There was “clear agreement” that patients with acute or chronic renal failure should be deobstructed during working hours if not septic, with “broad agreement” that this should be performed with PCN. Patients with obstruction subsequent to pelvic malignancy and the pregnant patient are discussed.

Conclusion:

The authors hope that these results and recommendations will aid clinical decision-making and aid the development of local and regional PCN and RUS services.