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

Characteristics of Bacteria in Urine and Stones from Patients Treated with Percutaneous Nephrolithotomy and Association with Postoperative Infection

Background

The purpose of this study was to identify bacterial differences between urine cultures (UC) and stone cultures (SC) in patients with complex kidney stones and to determine any correlation with post-percutaneous nephrolithotomy Systemic Inflammatory Response Syndrome (SIRS).

Methods

Perioperative data of 1055 patients with complex kidney stones treated with first-stage Percutaneous Nephrolithotomy (PCNL) from September 2016 until September 2021 were included. Preoperative mid-stream urine samples and surgically obtained stone material were subjected to bacterial culture and antibiotic sensitivity tests. Preoperatively, antibiotic usage was determined by the UC or local bacterial resistance patterns. After PCNL treatment, antibiotic selection was guided by stone bacterial culture result and clinical symptoms. The effect of different preoperative antibiotic regimens based on urine cultures and postoperative antibiotic treatment based on stone cultures were assessed.

Results

Positive stone cultures (SC+) were significantly more common than positive urine cultures (UC+) (31.9% vs 20.9%, p < 0.05). Escherichia coli (E. coli) was the most common uropathogen in both urine (54.3%) and stones (43.9%). The difference was statistically significant (p < 0.05). Moreover, UC+SC-, UC-SC+, UC+SC+, and preoperative serum creatinine were independent risk factors of postoperative SIRS. The incidence of SIRS in the UC+SC+ patients with different bacteria in stones and urine (51.6%) was higher than that in other culture groups. The antibiotic resistance of E. coli inside the stone was increased when prolonged preoperative antibiotics were administered to UC+ patients.

Conclusion

The bacterial spectrum and positive outcome of culture in urine and stones were significantly different. The incidence of postoperative SIRS was highest in patients with UC+SC+ but with different bacteria strains. Prolonged pre-surgical antibiotic treatment apparently induced higher drug resistance for bacteria inside the stone.

The Significance of Stone Culture in the Incidence of Sepsis: Results from a Prospective, Multicenter Study on Infections Post Flexible UreteroreNescopy (I-FUN) and Laser Lithotripsy for Renal Stones

Objective: Sepsis is the most serious complication of flexible ureteroscopy (F-URS) and laser lithotripsy. We assessed the influence of positive stone culture (SC) on major infectious complications (sepsis, septic shock). Methods: This prospective study enrolled adult patients deemed suitable for F-URS and laser lithotripsy from nine centers (January 2022-August 2023). Inclusion criteria were as follows: kidney stone(s), preoperative midstream urine culture (MSUC), stone(s) assessed at computed tomography scan, and SC. Exclusion criteria were as follows: bilateral procedures, ureteral stones, and children. Group 1 included patients with sterile SC. Group 2 included patients with positive SC. Data are presented as median (interquartile range). A multivariable logistic regression analysis was performed to evaluate factors associated with having a positive SC. Results: In total, 293 patients were included. Median age was 51.0 (24) years. There were 167 (57.0%) males. Group 2 included 32 (2.5%) patients. Group 2 patients were significantly older [75.0 (14) vs 51.0 (23) years, p = 0.02]. Stone features were similar. Major infectious complications were higher in Group 2 (15.6% vs 0.4%). One patient died because of sepsis in Group 2. Two out of 6 (33.3%) patients with major infectious complications had the same pathogen in MSUC and SC. In the multivariable regression analysis, diabetes (OR 3.23), symptomatic urinary infections within 3 months before operation (OR 4.82) and preoperative stent/nephrostomy (OR 2.92) were factors significantly associated with higher odds of positive SC. Conclusions: Patients with positive SC have a higher incidence of major infectious complications after F-URS lithotripsy. SC should be performed whenever feasible because there is a poor correlation between MSUC and SC.

Development and validation of a predictive model for post-percutaneous nephrolithotomy urinary sepsis: a multicenter retrospective study

BACKGROUND

The objective of this retrospective, multicenter study was to analyze the factors associated with the development of urogenital sepsis after percutaneous nephrolithotomy (PCNL) and to establish a nomogram prediction model of urogenital sepsis after PCNL.

METHODS

A total of 2066 postoperative PCNL patients were included from three medical institutions: Zunyi Medical University Hospital, Beijing Jishuitan Hospital Guizhou Hospital, and Fenggang County People's Hospital. Clinical data of 1623 patients from the Department of Urology of Zunyi Medical University Hospital were randomized into a training cohort (Zunyi training cohort, N.=1139) and an internal validation cohort (Zunyi internal validation cohort, N.=484) using computer generated random numbers in a 7:3 ratio. Univariate and multivariate logistic regression analyses were performed on the compliance training cohort to identify risk factors for urogenital sepsis after PCNL and to develop a column line graph prediction model based on these risk factors. Finally, Zunyi internal validation cohort and two external validation cohorts (Guiyang external cohort, N.=306; Fenggang external cohort, N.=137) were used to validate the prognostic accuracy of the nomogram prediction model. R4.2.2 statistical software was used for all statistical data analyses.

RESULTS

Multifactorial logistic regression analysis of the Zuiyi training cohort (N.=1139) identified five independent risk factors associated with urogenital sepsis after PCNL, including urine culture positivity (odds ratio [OR]=5.29, P<0.001), urine nitrite positivity (OR=5.97, P<0.001), operation time ≥60 min (OR=4.4, P=0.0037), residual stone (OR=5.18, P<0.001), and size ≥30 mm (OR=3.22, P=0.0086). Nomogram were constructed based on these independent risk factors. The area under the curve (AUC) of the nomogram model was 0.907 in the in-progress sample and 0.948 after internal validation. The AUC of the model was 0.855 and 0.804 after external validation of the Guiyang external validation cohort and the Fenggang validation cohort, respectively, indicating good discrimination ability. The calibration curves of the nomogram showed good agreement, and the decision curve analysis demonstrated high clinical utility.

CONCLUSIONS

Based on the clinical independent risk factors such as positive urine culture, positive urine nitrite, operation time ≥60min, stone residue, stone size ≥30mm, nomogram prediction model of urogenital sepsis after PCNL was established, which can provide reference for urologists to develop preoperative evaluation and treatment strategies for patients with percutaneous nephrolithotomy.

Risk of Systemic Inflammatory Response Syndrome Following Preoperative Glucocorticoids Administration in Patients After Percutaneous Nephrolithotomy: A Retrospective Cohort Study

INTRODUCTION

Systemic inflammatory response syndrome (SIRS) is one of the most serious complications in patients undergoing percutaneous nephrolithotomy (PCNL). Although glucocorticoids are increasingly used during PCNL, few studies have been concerned about the association between glucocorticoids and postoperative SIRS. The study aims to explore whether preoperative use of glucocorticoids is associated with SIRS after PCNL.

METHODS

A total of 1259 patients who underwent PCNL between January 2015 and April 2021 were enrolled in the retrospective cohort study. Risk factors for post-PCNL SIRS were identified by univariate and multivariate regression analysis. To further explore the association between preoperative administration of glucocorticoids and SIRS, 113 pairs of patients were matched for the confounding factors using propensity score matching (PSM) analysis. The odds ratios (OR) and 95 % confidence intervals (CI) for the above variables were analyzed.

RESULTS

The incidence of SIRS after PCNL was 9.6 % (121/1259) and the patients who suffered from postoperative SIRS had longer hospital stays and higher hospital costs (all p < 0.05). Multivariate logistic regression analysis indicated that female, preoperative leukocyte count, insertion of central vein catheter, serum albumin, preoperative high-sensitive C-reactive protein/albumin ratio, preoperative transfusion, preoperative administration of glucocorticoids were independent risk factors for SIRS (all p < 0.05). After minimization, the effects of confounding factors by PSM, preoperative administration of glucocorticoids was significantly correlated with SIRS in patients after PCNL (OR=2.44, 95 %CI: 1.31-4.55, p = 0.005).

CONCLUSION

Preoperative administration of glucocorticoids is an independent risk factor for SIRS in patients undergoing PCNL.

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.

Regulatory effect of Pseudomonas aeruginosa mannose-sensitive hemagglutinin on inflammation and immune function in percutaneous nephrolithotomy patients with upper urinary tract calculi complicated with infection

Objective

To study the effect of an injection of Pseudomonas aeruginosa mannose-sensitive hemagglutinin (PA-MSHA) on inflammation and immune function in patients with upper urinary tract calculi complicated by infection who have undergone percutaneous nephrolithotomy.

Methods

We retrospectively recorded the clinical data of patients with upper urinary tract calculi complicated by infection who have undergone Percutaneous nephrolithotomy(PCNL) in the Department of Urology, 2nd Affiliation Hospital of Kunming Medical University, from March to December 2021. Clinical data include general condition, laboratory index, CT, postoperative body temperature, heart rate, respiration, SIRS, sepsis, etc. Patients were divided into treated and control groups according to whether they had received a preoperative PA-MSHA injection. The two groups were compared for indices of inflammation and complications of infection after PCNL. Pre- and post-operative lymphocyte subsets and immunoglobulin changes were compared.

Results

115 patients were included in the study, including 43 in the treatment group and 72 in the control group. After Propensity Score Matching, 90 patients were divided into treatment (n=35) and control (n=55) groups. The postoperative inflammation index was higher in the treatment group than in the control group (P<0.05). The incidence of postoperative SIRS was higher in the treatment group than control (P<0.05). There were no cases of sepsis in either group. The double-positive T cells lymphocyte subsets were higher in the treatment group than in the control group ((P<0.05). Pre- and post-operative changes in immune function: total T lymphocyte count reduced, NK and NKT cell count increased in the control group, double-positive T cell count increased in the treatment group, IgG, IgA, IgM, complement C3 and C4 count reduced in both groups post-operatively.

Conclusion

This study found that patients with upper urinary tract calculi and infection treated with antibiotic-based PA-MSHA before percutaneous nephrolithotomy had an increased inflammatory response after surgery, which may play a role in the prevention and treatment of sepsis. The percentage of double-positive T cells in the peripheral blood was increased after PA-MSHA treatment, which may have an immunomodulatory and protective effect in PCNL patients with stones complicated by infection.

A nomogram for predicting postoperative urosepsis following retrograde intrarenal surgery in upper urinary calculi patients with negative preoperative urine culture

Retrograde intrarenal surgery (RIRS) is one of the main surgical methods for upper urinary calculi, but severe complications of infection may occur after surgery. This study aimed to establish and validate a preoperative nomogram for predicting postoperative urosepsis following retrograde intrarenal surgery to treat upper urinary calculus in patients with a negative preoperative urine culture. We retrospectively recruited 1767 patients with negative preoperative urine cultures who underwent retrograde intrarenal surgery to treat upper urinary calculi from January 2017 to April 2022. The independent risk factors for urosepsis include a solitary kidney, positive urine nitrite, operative time ≥ 75 min, history of recurrent urinary tract infections, and history of diabetes were identified by univariate analysis and multivariate binary logistic regression analysis, which construct a nomogram. The receiver operating characteristic curve of the nomogram for predicting urosepsis was 0.887 in the training cohort and 0.864 in the validation cohort, respectively. The calibration curve and decision curve analysis demonstrated great consistency and clinical utility of the nomogram. Therefore, the nomogram combining preoperative independent risk factors can predict the probability of a postoperative urosepsis following retrograde intrarenal surgery in patients with a negative preoperative urine culture, which could help urologists take preventive measures in advance after surgery to avoid more serious complications of infection.

Development and Validation of the Prediction Model of Sepsis in Patients After Percutaneous Nephrolithotomy and Sepsis Progresses to Septic Shock

Background: To study the predictors of sepsis and the progression of sepsis to septic shock in patients after percutaneous nephrolithotomy (PCNL) and to establish and validate predictive models. Methods: The patients were assigned to either the development cohort or the validation cohort depending on their hospital. In the development cohort, univariate and multivariate logistic regression analyses were used to screen independent risk factors for sepsis after PCNL and sepsis progression to septic shock. Nomogram prediction models were established according to the related independent risk factors. Areas under the receiver operating characteristic curves, calibration plots, and decision curve analysis (DCA) were used to estimate the discrimination, calibration, and clinical usefulness of the prediction models, respectively. The two sets of models were further validated on the validation cohort. Results: In the development cohort, the risk factors for sepsis after PCNL were diabetes, urine nitrite, staghorn calculi, HU value, albumin-globulin ratio, and high-sensitivity C-reactive protein/albumin ratio. The pre- and postoperative white blood cell counts were risk factors for the progression of sepsis to septic shock. The area under the ROC curve value for predicting sepsis risk was 0.891 and that for predicting septic shock risk was 0.981 in the development cohort; in the validation cohort, these values were 0.893 and 0.996, respectively. In the development cohort, the calibration test p values in the sepsis and septic shock cohorts were 0.946 and 0.634, respectively; in the validation cohort, these values were 0.739 and 0.208, respectively. DCA of the model in the sepsis and septic shock cohorts showed threshold probabilities of 10%-90% in the development cohort; in the validation cohort, these values were 10%-90%. Conclusion: The individualized nomogram prediction models can help improve the early identification of patients who are at higher risk of developing sepsis after PCNL and the progression of sepsis to septic shock to avoid further damage.

Development and validation of a patient-specific model to predict postoperative SIRS in older patients: A two-center study

Introduction

Postoperative systemic inflammatory response syndrome (SIRS) is common in surgical patients especially in older patients, and the geriatric population with SIRS is more susceptible to sepsis, MODS, and even death. We aimed to develop and validate a model for predicting postoperative SIRS in older patients.

Methods

Patients aged ≥65 years who underwent general anesthesia in two centers of Third Affiliated Hospital of Sun Yat-sen University from January 2015 to September 2020 were included. The cohort was divided into training and validation cohorts. A simple nomogram was developed to predict the postoperative SIRS in the training cohort using two logistic regression models and the brute force algorithm. The discriminative performance of this model was determined by area under the receiver operating characteristics curve (AUC). The external validity of the nomogram was assessed in the validation cohort.

Results

A total of 5,904 patients spanning from January 2015 to December 2019 were enrolled in the training cohort and 1,105 patients from January 2020 to September 2020 comprised the temporal validation cohort, in which incidence rates of postoperative SIRS were 24.6 and 20.2%, respectively. Six feature variables were identified as valuable predictors to construct the nomogram, with high AUCs (0.800 [0.787, 0.813] and 0.822 [0.790, 0.854]) and relatively balanced sensitivity (0.718 and 0.739) as well as specificity (0.718 and 0.729) in both training and validation cohorts. An online risk calculator was established for clinical application.

Conclusion

We developed a patient-specific model that may assist in predicting postoperative SIRS among the aged patients.

Risk factors for moderate-to-severe postoperative pain after percutaneous nephrolithotomy: a retrospective cohort study

Percutaneous nephrolithotomy (PCNL) is a minimally invasive procedure for removing renal calculi, while a large number of patients experience acute moderate-to-severe pain despite the analgesia provided. This study aimed to explore the risk factors for postoperative pain after PCNL, which may provide a novel perspective to refine the enhanced recovery after surgery (ERAS) program and to improve clinical outcomes. The clinical data of 331 patients who underwent PCNL in our hospital from September 2020 to February 2021 were retrospectively analyzed. The pain intensity was assessed every 4 h until 24 h post-surgery. According to the visual analog scale (VAS) score, patients were divided into two groups: mild or no pain group (VAS score, 0–3) and moderate-to-severe pain group (VAS score, 4–10). The pre-, peri-, and post-operative data were collected and analyzed. The indicators with statistically significant differences were selected, and multivariate logistic regression analysis was employed to determine the risk factors for postoperative pain after PCNL. Among 331 patients, 221 patients had moderate-to-severe pain and the incidence rate was 66.77%. Multivariate logistic regression analysis showed that the independent risk factors for moderate-to-severe pain after PCNL were the diameter of the renal calculus (odds ratio (OR) = 6.23, 95% confidence interval (CI) 2.50–15.56, P = 0.001), the number of renal calculi (OR = 15.892, 95% CI 7.721–32.711, P < 0.01), the presence of residual calculi (OR = 1.780, 95% CI 0.897–3.533, P = 0.01), and operation time (OR = 1.033, 95% CI 1.020–1.046, P < 0.01). The diameter of the renal calculus, the number of renal calculi, the presence of residual calculi, and operation time were significant predictors of postoperative pain after PCNL.

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

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

The role of quantitative gray-scale ultrasound histogram in the differential diagnosis of infected and non-infected hydronephrosis

BACKGROUND

The early detection of infected hydronephrosis is critical before lithotripsy. A feasible and noninvasive diagnostic method is of considerable clinical attention.

OBJECTIVES

This retrospective study was performed to find some quantitative evaluation parameters of B-mode Gray-scale ultrasound histogram analysis that might assist the early diagnosis of infected hydronephrosis and test their diagnostic efficacy.

MATERIALS AND METHODS

The ultrasound images and clinical data of 245 patients with hydronephrosis were retrospectively analyzed. Image J software was applied to obtain the gray-scale maps and the analysis results of the signal strength. The difference in the data between the infected and non-infected groups and the diagnostic value of the parameters were calculated.

RESULTS

In this retrospective study, 70 patients with infected hydronephrosis and 175 patients with non-infected hydronephrosis were enrolled. The echogenicity of internal effusion and the echogenicity ratio of infected cases were significantly higher than those of non-infected cases (p < 0.05). The cutoff values were 23.82 (AUC = 0.859) of echogenicity of internal effusion, while 0.27 (AUC = 0.832) of echogenicity ratio.

CONCLUSION

The quantitative evaluation of gray-scale ultrasound histogram is an objective and reliable method in differentiating infected from non-infected hydronephrosis.

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.

Assessing the optimal urine culture for predicting systemic inflammatory response syndrome after percutaneous nephrolithotomy and retrograde intrarenal surgery: results from a systematic review and meta-analysis

Background Systemic inflammatory response syndrome (SIRS) is a dangerous complication after percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS). We aimed to review the diagnostic accuracy of mid steam urine culture (MSUC), pelvic urine culture (PUC) and stone culture (SC) derived from the same cases to predict SIRS after PCNL and/or RIRS. Materials and methods A comprehensive literature search was performed, using MEDLINE, EMBASE, and Cochrane Central Controlled Register of Trials. Sensitivity and specificity were calculated for MSUC, PUC, and SC. The diagnostic odds ratio (DOR) was estimated for each study with a random effect and hierarchical summary receiver operating characteristic (HSROC) model leading to a corresponding 95% Confidence Interval (CI). Overall test accuracy was measured by finding the area under the curve (AUC). An AUC value >0.70 stands for adequate overall accuracy Results The search retrieved 537 papers. After screening, 21 studies involving 5238 patients were included for the meta-analysis. The pooled sensitivity for MSUC was 0.322 (95% CI 0.2228-0.432), and pooled specificity 0.854 (95% CI 0.810-0.889). The DOR was low at 2.780 (95% CI 1.769-4.368), showing poor overall diagnostic accuracy. The pooled sensitivity for PUC was 0.323 (95% CI 0.224-0.440) and specificity 0.931 (95% CI 0.896-0.954). The DOR was 6.377 (95% CI 4.065-10.004), showing a mild overall diagnostic accuracy. The pooled sensitivity for SC was 0.552 (95% CI 0.441-0.658) and specificity 0.847 (95%CI 0.798-0.886). The DOR was 6.820 (95%CI 4.435-10.488), showing mild overall diagnostic accuracy. The AUC for HSROC for MSUC was 0.65, 0.73, and 0.75 for PUC and SC, respectively. Conclusion MSUC is a poor predictor for postoperative SIRS. PUC or SC should be collected during lithotripsy to better predict the possibility of developing postoperative SIRS after PCNL and RIRS.

Significance of preoperative systemic immune-inflammation (SII) in predicting postoperative systemic inflammatory response syndrome after percutaneous nephrolithotomy

There is evidence that inflammation response biomarkers are positivity associated with bacteremia and urosepsis. The objective of this study was to investigate the value of preoperative systemic immune-inflammation (SII) in predicting systemic inflammatory response syndrome (SIRS) after percutaneous nephrolithotomy (PCNL). Records from 365 consecutive patients who previously received standard PCNL for kidney stones were retrospectively reviewed. Exactly 108 (29.6%) of the 365 patients who underwent PCNL developed SIRS postoperatively. The association of SIRS with the preoperative risk factors of infectious complications was evaluated. Female gender, operating time, SII, neutrophil to lymphocyte ratio (NLR), and lymphocyte to monocyte ratio (LMR) were found to be independent predictors for post-PCNL SIRS. Female patients with SIRS were more likely to have positive urine culture, a higher level of serum leukocyte, and serum hs-CRP than male patients with SIRS. Receiver operating characteristic curve analysis indicated SII for predicting the occurrence of SIRS with a higher AUC (0.782) than other systemic inflammation biomarkers such as LMR (0.734), NLR (0.671), and PLR (0.617). As a novel integrated inflammation biomarker for predicting SIRS after PCNL, SII showed a better predictive value than other traditional inflammation indicators. To our knowledge, we present the first study to investigate the predictive value of the preoperative SII on post-PCNL SIRS.

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

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

The retrospective study of perioperative application of dexamethasone and furosemide for postoperative anti-inflammation in patients undergoing percutaneous nephrolithotomy

Objectives

To investigate whether the perioperatively combined application of dexamethasone and furosemide could alleviate the inflammation in patients undergoing percutaneous nephrolithotomy (PCNL).

Patients and methods

147 patients undergoing PCNL between November 2018 and October 2019 were enrolled in the study. 77 patients accepted a single dose of dexamethasone and furosemide administration (EXP group, n = 77), and 70 patients did not (CON group, n = 70). Demographic and perioperative data, inflammatory markers including interleukin-6 (IL-6) and procalcitonin (PCT), and clinical outcomes were compared between the two groups.

Results

Compared with the CON group, the incidence rate of urosepsis of the EXP group were significantly lower (11.69% vs. 24.29%, p = 0.046). 3 patients developed severe urosepsis in the EXP group, while 5 patients developed severe urosepsis in the CON group. Compared with those in the CON group, the patients with postoperative urosepsis in the EXP group showed lower serum levels of IL-6 at postoperative hour two (p = 0.045) and at postoperative day one (p = 0.031) and lower serum levels of PCT at postoperative day one (p = 0.015). There was a better clinical outcome of a shorter postoperative hospital stay (p = 0.015) in patients with postoperative urosepsis in the EXP group than in those in the CON group.

Conclusion

The perioperatively combined application of dexamethasone and furosemide was beneficial for alleviating postoperative inflammatory reaction and caused a better clinical outcome of a shorter postoperative hospital stay.

New computed tomographic predictors of complicated perioperative course of 17.5F mini-percutaneous nephrolithotomy (mini-PNL)

PURPOSE

Radiological parameters predicting a postoperative stone-free status (SFS) or a complicated perioperative course of mini-PNL, are scarce. Our aim was to identify such factors for prone 17.5F mini-PNL.

METHODS

A monocentric cohort of 103 cases was retrospectively analysed for factors predicting SFS and relevant complications, i.e. Clavien-Dindo (CD) ≥ 2. Parameters measured on preoperative supine CT included maximal stone diameter, skin-to-stone distance (SSD), ideal tract length (ITL), access angle, minimal T12-Lower Kidney Pole distance (T12LP) and minimal Iliac Crest-Lower Kidney Pole distance (ICLP). Infundibulopelvic angle (IPA) was measured on intraoperative pyelography.

RESULTS

The median maximal stone diameter was lower in cases with postoperative SFS [16 mm (Min. 10; Max. 35) vs. 20 mm (Min. 6; Max. 85), p = 0.0052]. CD ≥ 2 was more frequent in cases with a bigger stone burden [19 mm (Min. 13; Max. 85) vs. 16 mm (Min. 6; Max. 49), p = 0.0056] and with the ribs in the access angle [7/23 (30.43%) vs. 8/76 (10.53%); p = 0.0454]. T12LP significantly differed in cases with and without CD ≥ 2 [80.48 mm (± 21.31) vs. 90.43 mm (± 19.42), p = 0.0397]; however, it had no influence on SFS (p > 0.05). SSD, ITL, IPA and ICLP were significant regarding neither SFS nor CD ≥ 2 prevalence (p > 0.05). Using multivariate logistic regression, T12LP was confirmed as an independent predictor on CD ≥ 2 prevalence.

CONCLUSIONS

Preoperative computed tomographic factors indicating elevated kidney position influence perioperative course of mini-PNL. T12LP and the presence of ribs in the access angle are, apart from stone diameter, the most useful indicators for cases at risk of CD ≥ 2.

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.

Risk Factors for Urosepsis after Minimally Invasive Percutaneous Nephrolithotomy in Patients with Preoperative Urinary Tract Infection

The purpose of this study was to assess risk factors of urosepsis after minimally invasive percutaneous nephrolithotomy (MPCNL) for the treatment of upper urinary tract stones in patients with preoperative urinary tract infection (UTI) and to explore preventive measures. Between 2008 and 2016, patients with preoperative UTI who underwent MPCNL for upper urinary tract stones were retrospectively collected. Patients were divided into nonurosepsis and urosepsis groups. Perioperative outcomes of all patients were evaluated and compared between the two groups. Risk factors for post-MPCNL urosepsis were investigated using univariate and multivariate regression analysis. A total of 843 patients including 22 patients with postoperative urosepsis (urosepsis group) and 821 patients without urosepsis (nonurosepsis group) were finally included in this study. All patients with postoperative urosepsis were cured and discharged after treatment. In univariate analysis it was demonstrated that the incidence of urosepsis after MPCNL was significantly correlated with channel size (P=0.001), surgical time (P=0.003), as well as the tear of the collection system and percutaneous renal channel crossing the renal papilla (P=0.004). Moreover, multivariate analysis showed that smaller channel size (OR = 11.192, 95% CI: 2.425-51.650, P=0.002), longer surgical time (OR = 6.762, 95% CI: 1.712-17.844, P=0.008), and tear of collection system and percutaneous renal channel crossing the renal papilla (OR = 5.531, 95% CI 1.228-14.469, P=0.012) were independent risk factors for urosepsis following MPCNL in patients with preoperative UTI. In conclusion, in patients with preoperative UTI undergoing MPCNL for upper urinary tract stones, smaller channel size, prolonged operation time, as well as tear of the collection system and percutaneous renal channel crossing the renal papilla are independent risk factors for postoperative urosepsis. Therefore, it is indicated that, in clinical practice, it is of great significance to choose appropriate channel size and avoid renal injury and control surgical time to prevent the urosepsis after MPCNL in patients with preoperative UTI.

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.

Predictive factors of infectious complications in the postoperative of percutaneous nephrolithotomy

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Perioperative application of dexmedetomidine for postoperative systemic inflammatory response syndrome in patients undergoing percutaneous nephrolithotomy lithotripsy: results of a randomised controlled trial

OBJECTIVE

Our previous retrospective study demonstrated that perioperative dexmedetomidine (Dex) administration was associated with low systemic inflammatory response syndrome (SIRS) incidence. The present study was designed to investigate whether perioperative administration of Dex decreases the incidence of postpercutaneous nephrolithotomy lithotripsy (PCNL) SIRS in patients who undergo PCNL.

DESIGN

A randomised controlled trial was designed.

PARTICIPANTS

A total of 190 patients were randomly assigned to receive Dex (DEX group, n=95) or saline control (CON group, n=95) and completed the study. In the DEX group, Dex was loaded (1 µg/kg) before anaesthesia induction and was infused (0.5 µg/kg/h) during surgery.

OUTCOMES

The incidences of postoperative SIRS were recorded. Serum interleukin-6 (IL-6) and tumour necrosis factor α(TNF-α) were measured.

RESULTS

The incidence rates of SIRS were significantly lower in the DEX group than in the CON group (35.8% vs 50.5%, p=0.04). No patients developed sepsis in either group. These results might be attributed to inhibition of inflammatory responses and the resulting lower serum levels of IL-6 and TNF-α, caused by Dex administration. However, compared with the CON group, the lower incidence rate of SIRS in the DEX group did not result in better outcomes, such as shorter postoperative hospitalisation stays and lower costs.

CONCLUSION

The present study showed that Dex administration during PCNL might be beneficial for decreasing the incidence of SIRS through inhibiting the release of inflammatory mediators, but not clinical consequences such as postoperative hospitalisation duration and costs. Further effects of Dex administration on SIRS in patients who are scheduled for PCNL should be explored in future studies.

TRIAL REGISTRATION NUMBER

ChiCTR-ICR-15006167.

Risk factors for systemic inflammatory response syndrome after percutaneous nephrolithotomy

OBJECTIVES

To explore the risk factors for systemic inflammatory response syndrome (SIRS) after percutaneous nephrolithotomy (PCNL).

METHODS

A retrospective chart review was performed to identify 1030 patients who had undergone PCNL from January 2014 to July 2016 in the Minimally Invasive Surgery Center. Multiple data, including age, sex, body mass index (BMI), operation time, Staghorn calculi, diabetes, Serun creatinine, preoperative urine culture and the urinary sediment microscopy white blood cell (WBC) were collected. These factors and postoperative SIRS were retrospectively analyzed.

RESULTS

There were 108 cases (10.49%) of SIRS among 1030 patients. The results of univariate analysis showed that sex (P=0.015), Staghorn calculi (P<0.001), preoperative urinary culture of Gram-negative bacteria (P<0.001) and preoperative urinary sediment microscopy WBC (+, ++, +++, ++++) (P<0.001, P<0.001, P=0.009, P=0.045) were correlated with postoperative SIRS (P<0.05). According to Multivariate analysis results, the likelihood of SIRS after PCNL increased with Staghorn calculi (P=0.01, OR=10.457, 95% CI=1.312-3.092), the urinary sediment microscopy WBC (+∼++++) (P<0.001, OR=2.591, 95% CI=1.661-4.042) and positive urine culture for Gram-negative bacteria (P<0.001, OR=3.550, 95% CI=2.205-5.715).

CONCLUSIONS

Staghorn calculi, the urinary sediment microscopy WBC and positive urine culture for Gram-negative bacteria are independent risk factors for SIRS. Patients affected by these risk factors should receive careful anti-infectious perioperative management for prevention of postoperative SIRS.

LEVEL OF INCIDENCE

4.

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.