Unplanned Hospital Return for Infection following Ureteroscopy-Can We Identify Modifiable Risk Factors?

Ureteroscopy for urolithiasis in bedridden patients: it is feasible and acceptable

PURPOSE

To investigate the safety of transurethral ureteroscopy (URS) for urolithiasis in bedridden patients and to identify bedridden patient-specific risk factors for postoperative complications.

METHODS

The patients who underwent URS for urolithiasis were divided into bedridden patients and good performance status (PS) patients, and the groups were compared regarding their clinical characteristics and postoperative complications. A multivariable logistic regression analysis was performed to evaluate independent predictors of postoperative febrile urinary tract infection (fUTI).

RESULTS

A total of 1626 patients were included, 276 in the bedridden patient group, and 1350 in the good PS patient group. The bedridden patient group had a significantly higher age and higher proportion of females and had multiple comorbidities. In 77 patients (27.9%), 88 postoperative complications developed for the bedridden patient group. Clavien-Dindo grade III or IV complications were observed in only 8 patients. No grade V complications were observed. The most common complication was fUTI. The frequency of fUTI with grade III or IV for the bedridden patient group (2.2%) was higher compared with the good PS patient group (0.5%), but the difference was not statistically significant (p = 0.13). Bedridden patient-specific risk factors for fUTI included female sex, diabetes mellitus, cerebrovascular comorbidities, lower extremity contracture, and prolonged operative time.

CONCLUSION

URS for urolithiasis is a feasible and acceptable procedure in bedridden patients, despite the moderate rate of postoperative complications. The identified risk factors provide a framework for risk stratification and individualized care in this unique patient population.

Urinary tract infection after flexible ureterorenoscopy for urolithiasis in patients with positive treated preoperative urinalysis

Prevalence of kidney stones is increasing worldwide, flexible ureterorenoscopy (f-URS) is the most common surgical treatment. Postoperative urinary tract infection (PUTI) is the primary complication. Some risk factors are classically associated with PUTI, especially preoperative positive urinalysis (POPU). We aimed to identify risk factors for PUTI after f-URS for urolithiasis in patients with treated POPU, and to identify the different pre and postoperative pathogens. Retrospective, single-center study of all f-URS for urolithiasis between January 2004 and December 2020. Procedures with treated POPU were categorized as PUTI or no PUTI (NPUTI). We examined demographics, preoperative, perioperative and postoperative characteristics in each group. Among 1934 procedures analyzed, 401 (20.7%) had POPU; these were categorized into NPUTI (n = 352, 87.8%) and PUTI (n = 49, 12.2%). By univariate analysis, only preoperative stenting duration (76.3 in NPUTI group vs 107.7 days in PUTI group, p = 0.001) was significantly associated with a higher risk of PUTI in univariate analysis. Germ distribution was similar in both groups. We compared pre- and postoperative microbiological data for interventions with PUTI, and found that only 8.7% of pathogens were identical between pre and postoperative urinalysis. Our study shows that the rate of PUTI is higher for patients with a POPU and that preoperative stent duration is the sole risk factor in patients with POPU. The low concordance rate (8.7%) between POPU and post-operative pathogens highlights the need for further research on obtaining sterile preoperative urinalysis, or performing intraoperative culture (urines, stent or stone), to treat PUTI early with an adapted antibiotic therapy.

Comparative Effectiveness Randomized Clinical Trial Using Next-generation Microbial Sequencing to Direct Prophylactic Antibiotic Choice Before Urologic Stone Lithotripsy Using an Interprofessional Model

Background

Next-generation sequencing (NGS) methods for microbial profiling have increased sensitivity to detect urinary pathogens.

Objective

To determine whether NGS microbial profiling can be used to guide antibiotic prophylaxis and reduce infection compared with the standard of care.

Design setting and participants

A prospective randomized controlled clinical trial of patients undergoing urologic stone interventions at an academic health center from December 2019 to January 2022 was conducted. Urine was collected at the preoperative visit for standard culture and intervention NGS diagnostics. Evaluable patients were culture negative, met 2-wk follow-up, and did not cancel surgery. Of 240 individuals (control = 121, intervention = 119), 83 control and 74 intervention patients were evaluable.

Intervention

Microbial findings (paired quantitative polymerase chain reaction and NGS) were sent to an infectious disease pharmacist to recommend prophylactic antimicrobial regimen.

Outcome measurements and statistical analysis

The primary outcome was postoperative urinary infection within the follow-up period (Fisher's exact test). The primary outcome was analyzed by modified intent-to-treat (mITT) and per-protocol analyses. Secondary endpoints considered included positive culture concordance, antibiotic use, and adverse events. Additional post hoc analyses investigated factors contributing to infection (univariate logistic regression).

Results and limitations

The intervention significantly reduced postsurgical urinary infection risk by 7.1% (-0.73%, 15%) compared with the standard of care in the mITT analysis (1.4% vs 8.4%, p = 0.045) or by 8.5% (0.88%, 16%) compared with the per-protocol analysis (0% vs 8.5%, p = 0.032). NGS-guided treatment altered the distribution of antibiotics used (p = 0.025), and antibiotics poorly matched with NGS findings were associated with increased infection odds (odds ratio [OR] = 5.9, p = 0.046). Women were at greater odds to develop infection (OR = 10, p = 0.03) and possessed differentiated microbial profiles (p < 0.001).

Conclusions

Urinary microbial NGS-guided antibiotic prophylaxis before endoscopic urologic stone lithotripsy improves antibiotic selection to reduce healthcare-associated urinary infections; however, treatment efficacy may be limited by the ability to adhere to the recommended protocol.

Patient summary

We investigated whether microbial DNA sequencing could improve the selection of antibiotics before kidney stone surgery in patients not known to have any bacteria in the urine on standard culture. We found that using microbe DNA to guide antibiotic choices decreased postoperative infection rate and may encourage individualized use of available antibiotics.

Understanding the Role of Ureteral Access Sheath in Preventing Post-Operative Infectious Complications in Stone Patients Treated with Ureteroscopy and Ho:YAG Laser Lithotripsy: Results from a Tertiary Care Referral Center

INTRODUCTION AND OBJECTIVES

The use of ureteral access sheaths (UAS) limits the irrigation-induced increase in intrarenal pressure during ureteroscopy (URS). We investigated the relationship between UAS and rates of postoperative infectious complications in stone patients treated with URS.

MATERIALS AND METHODS

Data from 369 stone patients treated with URS from September 2016 to December 2021 at a single institution were analyzed. UAS (10/12 Fr) placement was attempted in case of intrarenal surgery. The chi-square test was used to assess the relationship between the use of UAS and fever, sepsis, and septic shock. Univariable and multivariable logistic regression analyses tested the association of patients' characteristics and operative data and the rate of postoperative infectious complications.

RESULTS

Full data collection of 451 URS procedures was available. Overall, UAS was used in 220 (48.8%) procedures. As for postoperative infectious sequalae, we recorded fever (n = 52; 11.5%), sepsis (n = 10; 2.2%), and septic shock (n = 6; 1.3%). Of those, UAS was not used in 29 (55.8%), 7 (70%), and 5 (83.3%) cases, respectively (all p > 0.05). At multivariable logistic regression analysis, performing URS without UAS was not associated with the risk of having fever and sepsis, but it increased the risk of septic shock (OR = 14.6; 95% CI = 1.08-197.1). Moreover, age-adjusted CCI score (for fever-OR = 1.23; 95% CI = 1.07-1.42, sepsis-OR = 1.47; 95% CI = 1.09-1.99, and septic shock-OR = 1.61; 95% CI = 1.08-2.42, respectively), history of fever secondary to stones (for fever-OR = 2.23; 95% CI = 1.02-4.90) and preoperative positive urine culture (for sepsis-OR = 4.87; 95% CI = 1.12-21.25) did emerge as further associated risk factors.

CONCLUSIONS

The use of UAS emerged to prevent the onset of septic shock in patients treated with URS, with no clear benefit in terms of fever and sepsis. Further studies may help clarify whether the reduction in fluid reabsorption load mediated by UAS is protective against life-threatening conditions in case of infectious complications. The patients' baseline characteristics remain the main predictors of infectious sequelae in a clinical setting.

Safety and efficacy of ureteroscopy for urolithiasis in octogenarians

OBJECTIVE

To examine the safety and efficacy of ureteroscopy (URS) for urolithiasis in octogenarians, and identify preoperative risk factors for the incidence of postoperative complications.

METHODS

The patients who underwent URS for urolithiasis were divided into octogenarians and younger patients (age: <80 years), and the groups were compared regarding their clinical characteristics, intraoperative and postoperative complications, and stone-free rate. The predictors of postoperative complications were evaluated using logistic regression models.

RESULTS

A total of 1207 patients were included, 166 in the octogenarian patient group and 1041 in the younger patient group. The proportion of female patients (p < 0.001), American Society of Anesthesiologists (ASA) score (p < 0.001), rate of preoperative pyelonephritis (p < 0.001), and diabetes mellitus (p = 0.003) were higher in the octogenarian group. No statistically significant differences were found between the two groups regarding stone size, location, and intraoperative complications. Postoperative complications, which reached a significant difference, were observed in 34 (20.5%) octogenarians and 117 (11.2%) younger patients (p = 0.002). However, age itself was not significantly associated with postoperative fever, the most frequent postoperative complication, in multivariate analysis. Female sex, ASA score of ≥3, history of diabetes mellitus, and prolonged operative time (≥120 min) were the significant predictors of fever. The stone-free rate in the octogenarian group was superior to that in the younger patient group (80.1% vs. 70.6%, respectively; p = 0.035).

CONCLUSION

Our results suggest that URS for urolithiasis can be safely and effectively applied to octogenarians in selected cases.

Infection after ureteroscopy for ureteric stones: analysis of 71 305 cases in the Hospital Episode Statistics database

OBJECTIVES

To investigate the burden of infectious complications following ureteroscopy (URS) for ureteric stones on a national level in England using data from the Hospital Episodes Statistics (HES) data warehouse.

MATERIALS AND METHODS

A retrospective cohort was identified and followed up in HES during the period April 2013 to March 2020 for all procedure codes relating to ureteroscopic stone treatment (M27.1, M27.2, M27.3). Treatment episodes relating to the first URS ('index ureteroscopy') for each patient were further analysed. All subsequent admissions within 30 days were also captured. The primary outcome was diagnosis of urinary tract infection (UTI; including all codes relating to a UTI/sepsis within the first 30 days of index URS). Secondary outcomes were critical care attendance, attendance at the accident and emergency department (A&E) within 30 days, and mortality.

RESULTS

A total of 71 305 index ureteroscopies were eligible for analysis. The median age was 55 years, and 81% of procedures were elective and 45% were undertaken as day-cases. At the time of index URS, 16% of patients had diabetes, 0.5% had coexisting neurological disease and 40% had an existing stent/nephrostomy. Overall, 6.8% of the cohort (n = 4822) had a diagnosis of UTI within 30 days of index URS (3.9% immediately after surgery). A total of 339 patients (0.5%) required an unplanned stay in critical care during their index URS admission; 8833 patients (12%) attended A&E within 30 days. Overall mortality was 0.18% (60 in-hospital, 65 within 30 days); 40 deaths (0.056%) included infection as a contributing cause of death.

CONCLUSION

We present the largest series evaluating infectious complications after ureteroscopic stone treatment. The procedure is safe, with low inpatient infective complication and critical care admission rates.

QSOFA and SOFA scores are valuable tools for predicting postoperative sepsis resulting from ureteroscopic lithotripsy (URSL)

The sequential organ failure assessment (SOFA) and quick sequential organ failure assessment (qSOFA) scores are new tools which are used to assess sepsis based on the Third International Consensus Definitions for Sepsis and Septic Shock Task Force. This study aimed to evaluate the feasibility of using the SOFA and qSOFA to predict post-ureteroscopic lithotripsy (URSL) sepsis. Patients who underwent URSL due to ureteral stone obstruction were retrospectively reviewed using SOFA and qSOFA scores. Patient characteristics including age, gender, comorbidities, American Society of Anesthesiologists Classification, stone burden, stone location, hydronephrosis status, infectious status, preoperative SOFA and qSOFA score were collected. Preoperative factors were analyzed to determine if they were correlated with postoperative sepsis. A total of 830 patients were included in this study, of whom 32 (3.9%) had postoperative sepsis. Multivariate analysis revealed that older age, proximal ureteral stones, severe hydronephrosis, and high preoperative qSOFA or SOFA score were significantly associated with postoperative sepsis. The areas under the curves of a qSOFA score ≥ 1 and SOFA score ≥ 2 for predicting postoperative sepsis were 0.754 and 0.823, respectively. Preoperative qSOFA and SOFA scores are convenient and effective for predicting post-URSL sepsis. Further preventive strategies should be performed in these high-risk patients.

Risk of Sepsis in Retrograde Intrarenal Surgery: A Systematic Review of the Literature

Context

Objective

Evidence acquisition

Evidence synthesis

Conclusions

Patient summary

Primary versus delayed ureteroscopy for ureteric stones: A systematic review and meta-analysis

Background:

Ureteric colic is a major clinical and economic burden on the National Health Service. There has been a recent paradigm shift to consider definitive surgery as the primary intervention at the time of initial presentation.

Objective:

To systematically evaluate the outcomes of primary/emergency ureteroscopy versus delayed/elective ureteroscopy.

Methods:

We performed a critical review of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials–CENTRAL, CINAHL, Clinicaltrials.gov, Google Scholar and individual urological journals in April 2020. A robust database search was performed using a combination of the terms ‘primary ureteroscopy’, ‘immediate ureteroscopy’, ‘delayed ureteroscopy’ and ‘emergency ureteroscopy’. Adult patients (> 16 years) with ureteric stones presenting as an emergency were included.

Results:

Twelve studies met the inclusion criteria, with 4 studies directly comparing primary/emergency to delayed/elective ureteroscopy for an acute presentation of ureteric colic. Across the studies, 1708 patients underwent primary/emergency ureteroscopy for ureteric calculi and 990 underwent delayed ureteroscopy. No significant differences in stone-free rates were found between both groups with primary/emergency achieving 85% and delayed/elective 91% ( p = 0.68). The majority of stones treated were located in the distal ureter in both groups. Overall, there were no differences in complications between the groups ( p = 0.42) or major complications (0.17). However, there were fewer minor complications in the primary URS group ( p = 0.02). Ureteral catheter or double-J stent insertion was used in 71% of delayed/elective ureteroscopy cases, compared to 46.8% of primary/emergency cases (p = 0.001). For patients undergoing primary/emergency ureteroscopy, 6.4% patients required auxiliary procedures. In the delayed/elective group, 7.6% required further definitive treatment (NS).

Conclusion:

Primary ureteroscopy is a safe and feasible procedure, when performed in suitable patients in the acute setting. It is associated with significantly lower stent usage, equivalent stone clearance, no increase in overall or major complications including sepsis, and fewer minor complications when compared to delayed/elective ureteroscopy. Prospective studies will do well to explore this area further but on current evidence, primary ureteroscopy is the safe procedure.

Level of evidence:

Not applicable

Evaluation of the optimal duration for retrograde intrarenal stone surgery to prevent postoperative complications

OBJECTIVE

To evaluate retrograde intrarenal surgery (RIRS) outcomes and to determine the effect of operative time on complications of RIRS.

METHODS

Patients undergoing RIRS for renal stones were evaluated. These patients were divided into two groups according to the operation time (Group 1<60 minutes and Group 2>60 minutes). Peroperative outcomes such as fluoroscopy time, stone-free rates, complications and duration of hospitalization were compared.

RESULTS

Group 1 consisted of 264 patients and Group 2 consisted of 297 patients. SFR rates, duration of hospitalization, and postoperative urinary tract infection rates were similar in both groups. Fluoroscopy time was 7.8±7.3 (0-49) sec in group 1 and 13.1±9.8 (0-81) sec in group 2. Complications according to modified Clavien-Dindo classification system (MCDCS) were 13 and 32 patients (Grade 1), 31 and 63 patients (Grade 2), 1 and 1 patient (Grade 3) in group 1 and 2, respectively. There was statistical difference between the two groups in terms of duration of fluoroscopy time and the MCDCS. Although duration of hospitalization and UTI rates were higher in group 2, no statistical significance was observed among groups.

CONCLUSION

Limiting the operation time to 60 minutes in RIRS seems to be important in reducing postoperative complications.

Does time elapsed between urine culture and retrograde intrarenal surgery affect the rate of systemic inflammatory response syndrome?

OBJECTIVE

To identify the preoperative and intraoperative factors that might cause systemic inflammatory response syndrome (SIRS) after retrograde intrarenal surgery (RIRS), and to investigate the effect of time elapsed between the date of performing preoperative bladder urine culture (PBUC) and surgery date on postoperative SIRS.

MATERIALS AND METHODS

Four hundred sixty-seven patients who had RIRS between January 2013 and June 2020 constituted the target population of this study. PBUC were obtained from all patients before undergoing surgery. Postoperatively, patients were closely monitored for fever and other signs of SIRS. Univariate and multivariate logistic regression analysis were performed to reveal the predictive factors for SIRS after RIRS.

RESULTS

The entire study cohort consisted of 467 patients. The rate of SIRS was 5.6%. In univariate analysis, the rate of DM, recurrent urinary tract infection (UTI) history, surgical time, and stone burden were significant predictive factors for SIRS. In multivariate analysis, the rate of recurrent UTI history, surgical time and stone burden were observed to be statistically significant predictive factors. Time elapsed between the date of performing PBUC and surgery date was not different between the SIRS group and the normal group.

CONCLUSION

We conclude that the time between the date of performing PBUC and surgery date is not an influential factor for SIRS. Clarifying this issue with prospective studies may be useful, as endourologists frequently encounter this situation in daily practice.

The active guidewire technique versus standard technique as different way to approach ureteral endoscopic stone treatment

BACKGROUND

One of the greatest challenges in semi-rigid ureteroscopies, for both stones and tumors, is the control of endoscopic vision and the maintenance of low intracavitary liquid pressure. We present a comparison between two operative techniques: in the first method an ordinary guide wire (diameter 0.032'') is used for the procedure; in the second one a 5 Fr ureteral catheter replaces the guidewire (we called it "Active guidewire") Methods We compared 50 semirigid ureteroscopies (sURS) performed using the active guidewire with another 50 procedures conducted with a classic guidewire. We evaluated the difference in operating times, quality of endoscopic vision, periprocedural infections rate and stone-free rate.

RESULTS

The use of active guidewire has considerably reduced the standardized operating times per unit stone-volume by about 39%. Vision quality has improved considerably thanks to the continuous flow in-and-out. Consequently, periprocedural infections decreased (3% vs 30%) and the stone-free rate rose from 86% to 92%.

DISCUSSION AND CONCLUSIONS

Employing an "active guidewire" instead of the standard guidewire, the risk of complications related to high pressures and operating time is considerably lower, as well as better treatment quality thanks to the cleaner vision. This technique has proven to be safe as well as easy to apply, and in our belief is to be preferred whenever the ureter accepts without forcing, both the presence of the catheter and the semi-rigid 7 F ureteroscope.

Should ureteroscopy be performed for patients after ureteral reconstruction with autologous onlay flap/graft?

Background

To analyze the safety and clinical significance of performing ureteroscopy after ureteral reconstruction with autologous onlay/graft. To describe the ureteroscopic appearances of the appendiceal onlay flap and lingual mucosa graft.

Methods

Beginning in August 2018, we conducted a prospective cohort study of autologous onlay/graft techniques to repair ureteral strictures. The perioperative data of 42 patients who had undergone surgery more than 6 months prior were collected prospectively. During the postoperative follow-up, ureteroscopy was performed in 27 patients (64.3%) after surgery (group A), and ureteroscopy was not performed in the other 15 patients (35.7%) (group B). We carried out a comparative study of these two groups of patients. Analyses were conducted mainly on complications related to ureteroscopy and the success rate of ureteral reconstruction surgery.

Results

There were no significant differences in patient demographic data or the length of ureteral reconstruction between the two groups (P>0.05). For the ureteroscopy group, the median time from repair surgery to ureteroscopy was 3 (range, 2-7) months, there was no poor healing of the anastomosis, and the ureteral lumen of all patients was unobstructed. Some expected observations can be found in the ureteral lumen, such as mucosa edema, stones, follicles and granulation tissue. Among the 27 patients, one patient (3.7%) developed bleeding intraoperatively and 7 patients (25.9%) were found to have low-grade (Clavien-Dindo I and II) postoperative complications, including 5 cases of fever and 2 cases of bleeding. The mean follow-up times of patients in group A and group B were 16.7±6.4 and 19.0±10.1 months, respectively. The objective success (imaging showed hydronephrosis ease) rate of the two groups was 100%. The subjective success (symptom relief) rates of group A and group B were 96.3% and 100%, respectively.

Conclusions

Patients after autologous onlay flap/graft ureteroplasty do not need to undergo routine ureteroscopy unless there is aggravation of hydronephrosis or other indications for ureteroscopy, such as stones.

Antimicrobial Selection for Transurethral Procedures Across the United States: A State-by-State Antibiogram Evaluation

OBJECTIVE

To evaluate optimal regimens for perioperative antimicrobial prophylaxis in transurethral procedures by examining antimicrobial susceptibility patterns in the United States.

MATERIALS AND METHODS

Through several methods, we attempted to attain an antibiogram for each state. We focused on microbes known to cause infections after transurethral surgeries and antibiotics referred to in current or prior recommendations and compared susceptibility rates across states using Kruskal Walis tests and the Dwass, Steel, Critchlow-Fligner tests. We also examined susceptibility to (non-ceftazidime) third generation cephalosporins.

RESULTS

Data is included from 40 states. For each microbe studied, there was significant variability in sensitivity to antibiotics studied. Current first line recommendations for antimicrobial prophylaxis include first generation cephalosporins with 82%, 80%, and 87% mean coverage for E coli, Proteus, and Klebsiella respectively and trimethoprim-sulfamethoxazole with 74%, 80%, and 93% coverage, respectively. Susceptibility to aminoglycosides is 91%, 92%, and 96%, respectively and to third generation cephalosporin, it is 92%, 99%, and 94%.

CONCLUSION

Current first line recommended antimicrobials for prophylaxis in transurethral procedures provide overall poor predicted coverage based on our database of antibiograms. Alternatives exist that have higher predicted susceptibility, though clinical significance of this and risk of resultant antimicrobial resistance is unknown. Urologists should consider local patterns when selecting antimicrobial prophylaxis for their patients.

Urine versus stent cultures and clinical UTIs

PURPOSE

Current American Urological Association guidelines recommend pre-operative antimicrobial therapy based on prior urine cultures (UC); however, the role of stent culture (SC) in urologic practice is unclear. We examined whether UC and SC differed at the time of stent removal, as well as the association, microbiology, and timing of subsequent UTIs as related to SC.

METHODS

This was a retrospective review of 159 patients with ureteral stents for indications of urolithiasis, benign stricture, malignant obstruction, and kidney transplant. UC and SC were analyzed at the time of stent removal. Patients were followed for 12 months after stent removal for development, concordance, and timing of clinical UTIs.

RESULTS

In 159 patients, 15% had positive UC and 45% had positive SC. Of patients who had positive SC, 66% had negative UC. All patients with positive UC had identical micro-organisms on SC; however, 33% of these had SC with additional micro-organisms. Relative to those with both negative UC and SC, patients with negative UC and positive SC had a 5.7 odds, and those with both positive UC and SC had a 13.6 odds of developing a clinical UTI within 12 months. Concordance of SC and future UTI was highest in those with post-operative sepsis, and those with Candida species on SC.

CONCLUSIONS

SC was a unique risk factor for development of UTI within 12 months of stent removal. Clinicians should consider SC results when empirically treating those with post-operative sepsis or those with UTI after Candida on SC.

Predictors of urosepsis in struvite stone patients after percutaneous nephrolithotomy

Purpose

This study aims to identify clinical factors that may predispose struvite stone patients to urosepsis following percutaneous nephrolithotomy (PCNL).

Materials and Methods

A retrospective review was conducted on patients who received PCNL for struvite stones. The Systemic Inflammatory Response Syndrome (SIRS) criteria and quick-Sepsis Related Organ Failure Assessment (q-SOFA) criteria were used to identify patients who were at an increased risk for urosepsis. Statistical analysis was performed using Fisher's exactness test, Wilcoxon rank test, and logistic regression.

Results

Chart review identified 99 struvite stone patients treated with PCNL. Post-operatively, 40 patients were SIRS positive (≥2 criteria) and/or q-SOFA positive (score ≥2). Using SIRS as an approximation for urosepsis, longer operative times (p<0.001), higher pre-operative white blood cell counts (p=0.01), greater total stone surface area (p<0.0001), and pre-operative stenting (OR, 5.75; p=0.01) were identified as independent risk factors for urosepsis. Multivariate analysis demonstrated pre-operative stenting (OR, 1.46; p=0.01) to be a risk factor. With q-SOFA, univariable analysis found that antibiotic use within 3 months prior to a PCNL (OR, 4.44; p=0.04), medical comorbidities (OR, 4.80; p=0.02), longer operative times (p<0.001), lengthier post-operative hospitalization (p<0.01), and greater total stone surface area (p<0.0001) were risk factors for urosepsis. Multivariate analysis revealed that bladder outlet obstruction (OR, 2.74; p<0.003) and pre-operative stenting (OR, 1.27; p=0.01) significantly increased odds of being q-SOFA positive.

Conclusions

Several risk factors for urosepsis following PCNL for struvite stones have been identified. These risk factors should be taken into consideration in peri-operative care to mitigate the risks of urosepsis.

Urosepsis and fever after laser lithotripsy procedures in a single Australian institution

Objective:

To identify predictive and modifiable risk factors associated with fever and urosepsis in the post-operative period of ureteropyeloscopy and laser lithotripsy procedures for urolithiasis.

Materials and methods:

Records from 284 consecutive adult patients undergoing laser lithotripsy at John Hunter Hospital, Australia (2013–2017) were retrospectively reviewed. A wide variety of demographics, results, anaesthetic and operative data were compared between those who developed infectious complications (defined as fever ⩾38 or sepsis from a urinary source) and those who did not.

Results:

In total, 372 cases of Holmium:YAG laser lithotripsy were included. Despite excellent antibiotic prophylaxis rates, 10.2% ( n=38) of patients developed infectious complications (81.6% within 24 hrs). Urosepsis cases were twice as likely to have a positive pre-operative urine culture ( p=0.0148) and nearly four times as likely to have mixed growth ( p=0.0001). The proportion of smokers was twice as high in the infectious complication group (42.1%, p=0.0017), as was incomplete stone clearance (31.6% compared to 12.3%, p=0.0013), and female patients were twice as likely to develop an infectious complication as men (16.7% of all female cases, 7.1% of all male cases).

Conclusion:

Infectious complications post laser lithotripsy remain common in the Australian setting. Positive pre-operative urine culture, current smoking status, incomplete stone clearance and female gender were identified as significant risk factors. We propose high-risk patients should be monitored in the post-operative period with a low threshold for extending antibiotic therapy and every opportunity taken for smoking cessation counselling.

Level of evidence:

3a (according to Oxford centre for evidence-based medicine)

Predictors of emergency department attendance following ureterorenoscopy for urolithiasis

BACKGROUND

We sought to determine the rate of emergency department (ED) attendance for complications after ureterorenoscopy (URS) for stone disease and to identify risk factors for ED attendance after URS.

METHODS

An analysis of all patients undergoing URS over 12 months at a single institution was performed. Patient demographics, preoperative and intraoperative variables associated with postoperative complications and subsequent ED attendance were collected. Logistic regression analyses were performed to determine predictors of URS complications presenting to ED.

RESULTS

In total, 202 ureteroscopies were performed on 142 patients for urolithiasis. The mean age was 50.73 ± 13.93 and 66% were male. The incidence of re-presentation to ED was 14.8% (n = 30). Patients presented with postoperative pain (n = 10; 4.95%), pyrexia (n = 9; 4.46%), urinary tract infection (UTI) (n = 7, 3.47%), haematuria (n = 3, 1.49%) and urosepsis (n = 1; 0.5%). Significant risk factors for ED attendance included preoperative stent dwell time > 30 days (P = 0.004), recently treated positive preoperative urine culture (P < 0.0001), stone size ≥ 13 mm (P = 0.043), stone location mid-ureter (P = 0.036) and female gender (P = 0.005). The following factors did not predict ED attendance, stent omission, access sheath utilization and operation duration.

CONCLUSION

Risk factors for ED attendance after URS include prolonged pre-stent dwell time, stone size ≥ 13 mm, treatment for a positive preoperative urine culture, mid-ureteric stone location and female gender. Urologists should be aware of these findings to decrease the risk of emergency re-presentation after elective URS surgery.

Correlation of Operative Time with Outcomes of Ureteroscopy and Stone Treatment: a Systematic Review of Literature

PURPOSE OF REVIEW

To present the latest evidence related to the impact of increased operative times in retrograde intrarenal surgery and identify possible important factors that can facilitate ureteroscopy procedures.

RECENT FINDINGS

Ureteroscopy constitutes the mainstay treatment of renal stones and is characterized by a huge variation in techniques and instrumentation. It has been suggested that increased operative times can mitigate the outcomes of the procedures by increasing complication rates. Nevertheless, little is known about the time limits, above which complications are likely to occur. Furthermore, complication rates in different procedure durations have not yet been assessed. Prolonged operative times are linked to increased complication rates in ureteroscopy. Stone complexity, patient risk factors, surgeon experience, bilateral surgery, and instrumentation constitute important factors that can hamper or facilitate a procedure and should be taken into account beforehand. Keeping procedural times below 90 min can dissuade potential predicaments and achieve improved stone-free rates.

Predictors of Urinary Infections and Urosepsis After Ureteroscopy for Stone Disease: a Systematic Review from EAU Section of Urolithiasis (EULIS)

PURPOSE OF REVIEW

To present the latest evidence related to the predictors of urinary tract infections (UTIs) and urosepsis after ureteroscopy (URS) for stone disease.

RECENT FINDINGS

Our review suggests that almost half of all post-URS complications are related to infectious complications although reported rates of urosepsis were low. The use of antibiotic prophylaxis, treatment of pre-operative UTI, and low procedural time seem to reduce this risk. However, the risk is higher in patients with higher Charlson comorbidity index, elderly patients, female gender, long duration of pre-procedural indwelling ureteric stents and patients with a neurogenic bladder and with high BMI. Infectious complications following ureteroscopy can be a source of morbidity and potential mortality. Although majority of these are minor, efforts must be taken to minimise them especially in high-risk patients. This includes the use of prophylactic antibiotics, limiting stent dwell and procedural time, prompt identification and treatment of UTI and urosepsis, and careful planning in patients with large stone burden and multiple comorbidities.

Urinary sepsis after endourological ureterorenoscopy for the treatment of lithiasis

OBJECTIVE

To evaluate the incidence, clinical presentation and factors associated with the development of urinary sepsis after performing ureterorenoscopy.

MATERIAL AND METHODS

Retrospective study of patients undergoing ureterorenoscopy for the treatment of lithiasis between July 2015 and October 2017. Patients who developed urinary sepsis during the 30 days following the intervention were identified. Personal, clinical, surgical and microbiological backgrounds were collected. Statistical analysis was performed with the Chi squared test (or Fisher's exact test), Student's t (or U Mann-Whitney) or logistic regression as appropriate.

RESULTS

246 ureterorenoscopies were performed, 184 (74.8%) on ureteral stones and 62 (25.2%) on kidney stones, with a mean age of 52 (44.5-59.5) years. After procedure, 18 (7.3%) patients developed urinary sepsis, 10 of them (55.5%) occurred in the first 24h. The urine culture showed enterobacteria (61.1%) and enterococci (38.9%). The antibiogram showed greater sensitivity to nitrofurantoins (100%) and quinolones (72%). The statistical analysis showed that female sex, the clinical debut of urolithiasis as urinary sepsis, having received antibiotic or having required urinary diversion by a double J during debut, positive presurgical uroculture and the persistence of residual lithiasis after surgery were significantly associated (P<.05) with the development of urinary sepsis after ureterorenoscopy.

CONCLUSION

Urinary sepsis is a complication that appears after performing ureterorenoscopy, especially in female patients with a history of urinary sepsis, antibiotic therapy, double J, previous positive urine culture or residual lithiasis after the procedure.

Unplanned 30-Day Encounters After Ureterorenoscopy for Urolithiasis

OBJECTIVE

To identify avoidable predictors of postureteroscopy (URS) unplanned encounters and to minimize 30-day encounters.

MATERIALS AND METHODS

We performed retrospective chart review and telephone surveys on patients who underwent URS for urolithiasis between January and June 2016. Univariate and multivariable analyses evaluated for potential predictors of unplanned encounters.

RESULTS

Of 157 patients, there were 44 (28.0%) unplanned patient-initiated clinical phone calls, 23 (14.6%) emergency department (ED) visits, and 8 (5.1%) readmissions, with pain being the most common complaint during the encounters. Factors associated with a higher rate of phone calls include first-time stone procedure (36.6% vs 20.9%, p = 0.029), outpatient status (30.3% vs 0%, p = 0.021), intraoperative stent placement (31.2% vs 0%, p = 0.006), and stent removal at home (58.8% vs 28.8%, p = 0.014). Factors associated with increased rate of ED visits were first-time stone procedure (22.5% vs 8.1%, p = 0.011) and ureteral access sheath (UAS) usage (29.6% vs 11.8%, p = 0.018). Factors associated with a higher rate of readmissions were lower body mass index (23.9 vs 29.7, p = 0.013), bilateral procedure (20.0% vs 2.9%, p = 0.010), and UAS usage (14.8% vs 3.1%, p = 0.032). Stone burden, operative time, Charlson comorbidity index, and preoperative urinary tract infection were not significantly associated with postoperative encounters.

CONCLUSIONS

Pain, first-time stone treatment, presence of a ureteral stent, outpatient status, bilateral procedures, and UAS usage were common reasons for postoperative encounters after URS. Appropriate perioperative patient education and counseling and adequate pain management may minimize these encounters and improve treatment quality and patient satisfaction.

Assessment of Patient and Surgical Variables Including Residency Training Level on Adverse Events After Ureteroscopy for Ureteral Stones: A Multivariate Analysis

PURPOSE

With advances in technology, ureteroscopy (URS) is increasingly utilized for the management of urolithiasis. Previous studies have attempted to characterize the post-operative complication and readmission rates relative to the technical difficulty of the procedure. There is limited data exploring the resident level of training and its effect on adverse outcomes in these cases. We review our experience with URS to create a model to predict factors, including resident experience, that affect rates of post-operative complications.

MATERIALS AND METHODS

We reviewed ureteroscopies performed at our academic facility from January 2009 to December 2013. Ureteral-only stones were examined for demographics, stone characteristics, operative techniques, and resident training level. Post-operative adverse events requiring urology consultation, clinic or emergency department visits, hospital admission, prolonged post-operative hospitalization, or unplanned repeat surgery within 30 days of the procedure were identified and analyzed.

RESULTS

Four hundred seventeen cases of URS for ureteral-only stones were included for study. We identified 53 (12.7%) involving an unexpected post-operative course. Several logistic regression models were created to make a predictive model of adverse events. One model found only lack of stone clearance to be significant for increasing the likelihood of an adverse event. A second model determined that no residency year showed higher odds of adverse outcomes.

CONCLUSIONS

URS has increased in prevalence in recent years, but overall complication rates are low. Resident level of experience does not appear to impact adverse event rate. Stone clearance during initial surgery appears to be the most important in avoiding adverse events. Further expansion of the database over time will improve our ability to predict adverse outcomes in this common procedure.

To Dust or Not To Dust: a Systematic Review of Ureteroscopic Laser Lithotripsy Techniques

PURPOSE OF REVIEW

This review discusses factors affecting outcomes during ureteroscopy (URS) with laser lithotripsy (LL), explores specific clinical challenges to the efficacy of URS LL, and reviews the available literature comparing the dusting and basketing approaches to URS LL.

RECENT FINDINGS

Data show high stone-free rates with URS LL in all locations of the urinary tract and with all stone types and sizes. Recent data comparing LL with dusting versus basketing suggest higher rates of residual fragments with dusting but less utilization of ureteral access sheaths and potentially shorter operative times. Differences in postoperative complications, re-intervention rates, and other outcome parameters are not yet clear. Interpretation of published data is problematic due to variability in laser settings, follow-up intervals, and definitions for what constitutes stone-free status. URS has overtaken shock wave lithotripsy in the last decade as the most commonly utilized surgical approach for treating urolithiasis. Two primary strategies have emerged as the most common techniques for performing LL: dusting and basketing. There is a relative paucity of data examining the difference in these techniques as it pertains to peri-operative outcomes and overall success. We attempt to synthesize this data into evidence-based and experience-based recommendations.

Analysis of Factors' Association with Risk of Postoperative Urosepsis in Patients Undergoing Ureteroscopy for Treatment of Stone Disease

INTRODUCTION

To investigate which patient, stone, infective, and surgical factors were most likely to increase the risk of postoperative urosepsis within 28 days of ureteroscopy (URS) and laser stone fragmentation for ureteral or renal stones.

METHODS

Data were collected prospectively in a single National Health Service institution. A logistic regression model was used to assess the association of factors with postoperative urosepsis. Two matched-pair analyses were used to assess the risk of postoperative urosepsis in patients with (a) an emergency presentation to hospital with urosepsis in the 90 days preceding URS and (b) a positive midstream sample of urine (MSSU) identified, but who were asymptomatic at preoperative assessment, who then received an appropriate course of antibiotics.

RESULTS

Four hundred sixty-two consecutive patients were included in the study. Thirty-four patients (7.4%) had an episode of urosepsis within 28 days of their operation. A positive preoperative MSSU was significantly associated with postoperative urosepsis on multivariable analysis, despite appropriate treatment with a preoperative course of antibiotics: odds ratio (OR) 4.88, 95% confidence interval (CI) 2.11, 11.31, p < 0.001. The presence of diabetes mellitus, presence of ischemic heart disease, patient American Society of Anesthesiologists score, same-session bilateral URS, and stone volume were the other variables significantly associated with postoperative infection on univariable analysis, but these ceased to be significantly associated on multivariable analysis. Subgroup analysis found that a positive MSSU in both patients with a preoperative ureteral stent and those without was significantly associated with postoperative urosepsis, however, the OR was much lower for the stented group (OR 3.23 vs OR 16.67). On matched-pair analysis, patients with a positive preoperative MSSU were significantly more likely to have postoperative urosepsis compared to controls (OR 17.46, 95% CI 2.18, 139.80, p = 0.007). There was no significant difference in the OR of postoperative urosepsis in patients who had a preceding urine infection requiring hospital admission in the 90 days preceding URS (OR 0.60, 95% CI 0.19, 1.92, p = 0.39).

CONCLUSIONS

Positive preoperative MSSU was significantly associated with postoperative urosepsis by logistic regression and matched-pair analysis. These higher risk patients should be counseled appropriately before surgery, and should be the focus of vigilant postoperative monitoring. The study suggests particular caution in patients with a positive preoperative MSSU without a preoperative ureteral stent.