Effect of body mass index on operative time, hospital stay, stone clearance, postoperative complications, and postoperative analgesic requirement in patients undergoing percutaneous nephrolithotomy

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.

Effect of Body Mass Index on Outcomes of Percutaneous Nephrolithotomy: A Systematic Review and Meta-Analysis

Objective

The current study aimed to assess the efficacy and safety of percutaneous nephrolithotomy (PCNL) in obese and overweight individuals based on body mass index (BMI).

Methods

We electronically explored the databases of PubMed, CENTRAL, ScienceDirect, Embase, and Google Scholar databases for all types of comparative studies investigating the role of BMI on PCNL outcomes. Only studies defining obesity as >30 kg/m² were included. Efficacy outcomes were stone-free rates and operating time while safety outcomes were complications and length of hospital stay (LOS).

Results

Eighteen studies with 101,363 patients were included. We noted no difference in the stone-free rates after PCNL for morbid obese vs normal BMI patients (OR: 0.78 95% CI, 0.57, 1.08 I²= 7% p = 0.13), overweight vs normal (OR: 1.01 95% CI, 0.89, 1.15 I²= 1% p = 0.83) and obese vs normal patients (OR: 1.00 95% CI, 0.87, 1.16 I²= 0% p = 0.95). PCNL operative time was significantly increased in morbid obese (MD: 9.36 95% CI, 2.85, 15.88 I²= 76% p = 0.005) and obese patients as compared with normal patients (MD: 2.15 95% CI, 1.20, 3.10 I²= 0% p < 0.00001), but not for overweight patients. There was no difference in the odds of complications between morbid obese vs normal (OR: 1.26 95% CI, 0.93, 1.72 I²= 0% p = 0.13), overweight vs normal (OR: 1.11 95% CI, 0.96, 1.28 I²= 0% p = 0.15), and obese vs normal patients (OR: 1.07 95% CI, 0.91, 1.27 I²= 0% p = 0.40). LOS was significantly reduced in obese patients (MD: −0.12 95% CI, −0.20, −0.04 I²= 0% p = 0.004) as compared to normal patients, but not for morbid obese or overweight patients.

Conclusion

PCNL has similar efficacy and safety in morbidly obese, obese, and overweight patients as compared to normal BMI patients with no difference in the stone-free and complication rates. Evidence suggests that operating time is increased in morbidly obese and obese patients and the latter may have shorter LOS.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/, identifier: CRD42022313599.

Evaluating outcomes of complete supine percutaneous nephrolithotomy for staghorn vs multiple non-staghorn renal stones: a 10-year study

PURPOSE

To evaluate the outcomes of complete supine percutaneous nephrolithotomy (csPCNL) for staghorn stones and multiple large non-staghorn stones.

METHODS

The records of 886 patients who underwent csPCNL from September 2009 to October 2019 were considered. Out of them, 201 cases met the eligibility criteria and they were divided into three groups: 63 cases of staghorn, 68 cases of multiple medium (20 mm < diameter ≤ 30 mm) non-staghorn and 70 cases of multiple large non-staghorn (> 30 mm) stones. Almost all outcomes and stone-related factors were analyzed.

RESULTS

There was not any significant difference regarding age, body mass index, history of urinary tract infection, transfusion rate, complication rate, pre and post-surgery serum creatinine, hemoglobin drop and total hospital stay between the three groups. Stone free rate was 98.5% in multiple medium group, 97.1% in multiple large group and 84.1% in staghorn group (P = 0.001). The operation duration was significantly shorter for the multiple medium group (P < 0.001) but it was not significantly different between the multiple large non-staghorn and staghorn group.

CONCLUSION

The results demonstrated that almost all outcomes were not significantly different between the three groups (especially between staghorn and larger non-staghorn ones). These findings reveal that surgeons could choose csPCNL for treatment of staghorn stones and multiple large non-staghorn stones and consider staghorn stones as challenging as multiple large (especially diameter > 30 mm) non-staghorn stones.

Postoperative Pain Control and Opioid Usage Patterns among Patients Undergoing Thyroidectomy and Parathyroidectomy

OBJECTIVES

To examine opioid-prescribing patterns after endocrine surgery. To evaluate factors associated with postoperative pain and opioid use.

STUDY DESIGN

Cross-sectional.

SETTING

Academic university health system.

SUBJECTS AND METHODS

The study sample included 209 patients who underwent total thyroidectomy, hemithyroidectomy, or parathyroidectomy by 4 surgeons between August 2015 and November 2017. Eighty-nine patients completed a phone survey about postoperative pain and opioid use. Prescription, demographic, and comorbidity data were collected retrospectively. Patient characteristics associated with opioid use, use of ≥10 opioid pills, and pain score were identified via chi-square, t test, analysis of variance, or Pearson correlation. Identified factors were further assessed with multivariable logistic and linear regression modeling.

RESULTS

The median numbers of opioid pills prescribed were 20 for total thyroidectomy, 25 for hemithyroidectomy, and 20 for parathyroidectomy, and the median numbers of pills used were 1.5, 2, and 0, respectively. Of 1947 total prescribed pills, 19.7% were reported to be taken. The number of pills meeting the opioid needs of 80% of these patients was 10. In multivariable analyses, older age was associated with lower odds of opioid use (odds ratio, 0.97; 95% CI, 0.94-0.999; P = .04) and lower pain scores (Pearson correlation coefficient, -0.05; 95% CI, -0.10 to 0.001, P = .04). Charlson Comorbidity Index score >5 was associated with use of ≥10 pills (odds ratio, 6.62; 95% CI, 1.60-27.50; P = .01).

CONCLUSION

Excess opioids are often prescribed for endocrine surgery. By using an ideal pill number and understanding predictors of postoperative pain, surgeons can more adequately treat pain and limit excess opioid prescriptions.

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.

Obesity Does Not Increase Operative Time in Otologic Surgery: An Analysis of 5125 Cases

OBJECTIVES

A large shoulder can impact otologic surgical access. The physical obstruction of a large shoulder may force the surgeon to adjust his or her posture or hand position. We sought to assess the effect of body mass index (BMI) on operative time in tympanoplasties and tympanomastoidectomies.

STUDY DESIGN

Cross-sectional analysis.

SETTING

National surgical quality improvement program dataset (NSQIP) 2011 to 2014.

PATIENTS

Current procedural terminology (CPT) codes were used to identify patients undergoing tympanoplasties and tympanomastoidectomies.

INTERVENTIONS

Otologic surgery as indicated by CPT code.

MAIN OUTCOME MEASURES

Targeted variables included height, weight, and operative time. BMI was stratified to assess a range of body compositions (<25, 25-30, >30-35, >35-40, >40). Categorical variables were compared using χ tests and continuous variables were compared using Kruskal-Wallis tests. Correlation between operative time and BMI was assessed using Spearman's rho. A generalized linear model was used to analyze the variables affecting operative time. Surgical complications were assessed in binary logistic regression using the enter method. Two-tailed significance was set at α = 0.05.

RESULTS

Two surgical groups were identified: tympanoplasty (n = 3,508) and tympanomastoidectomy (n = 1,617). There was not a significant difference in mean operative time across the BMI subgroups for either surgical group (p = 0.617, 0.859, respectively). Multivariate analyses showed no significant difference in operative times based on BMI classification.

CONCLUSIONS

The body habitus of obese patients may force the otologic surgeon to adapt, but obese patients do not have a statistically significant longer mean operative time for tympanoplasties and tympanomastoidectomies than patients with a lower BMI.

Comparison of the outcomes of complete supine percutaneous nephrolithotomy in patients with radiopaque and radiolucent kidney stones

Objective

This study compared the stone opacity effect in patients who had radiopaque and radiolucent stones in percutaneous nephrolithotomy (PCNL) results.

Material and methods

The medical records of 171 complete supine PCNL procedures were gathered. Patients were categorized into two groups: those with radiopaque (n=141) and those with radiolucent (n=30) stones. Kidney, ureter and bladder x-ray was done a day after PCNL and Ultrasound imaging was done two weeks later to evaluate the stone free rate. A stone free result was defined as having less than 4 mm residual stone size. Outcome parameters were compared by univariate analysis and those which were significantly different between the two groups were assessed by multivariate binary logistic regression analysis.

Results

There were no significant differences in age, sex, body mass index, hypertension, diabetes mellitus, pre-surgery hemoglobin, pre-surgery serum creatinine, stone and also surgery-related parameters between the two groups. Stone free rate, surgery time, complication-related parameters, hemoglobin drop, serum creatinine and glomerular filtration rate (GFR) changes were similar in both groups based on univariate analysis. The radiopaque group had higher post-surgery GFR (p=0.04) and longer hospital stay (p=0.009). However, opacity had no effect on these outcomes after multivariate analysis. Higher post-surgery GFR was seen in patient with higher GFR before surgery (p<0.0001). Also, higher hemoglobin before surgery was correlated with less hospital stay (p=0.001).

Conclusion

The complete supine percutaneous nephrolithotomy outcomes are similar in patients with radiopaque and radiolucent stones.