Septic Shock Following Surgical Decompression of Obstructing Ureteral Stones: A Prospective Analysis

Impact of timing of urinary drainage on clinical outcomes in patients with obstructive pyelonephritis associated with upper urinary tract stones: a propensity score-matched analysis

OBJECTIVE

We aimed to assess the impact of the timing of urinary drainage on clinical outcomes in patients with obstructive pyelonephritis (OPN) associated with upper urinary tract (UUT) stones.

METHODS

We retrospectively evaluated the multicenter dataset of 240 patients with OPN associated with UUT stones who underwent urinary drainage. We divided the patients into two groups depending on the timing of urinary drainage; emergency drainage, defined as within 12 h from admission, and delayed drainage, defined as between 12 and 48 h from admission. The outcomes were the length of hospital stay, time to leukocyte normalization, and time to body temperature normalization. One-to-two propensity score matching (PSM) was applied to minimize the effect of confounders between the two groups. Subsequently, predictive patient factors for emergency drainage were analyzed using the logistic regression model.

RESULTS

Only the time from admission to normal body temperature was significantly shorter in the emergency drainage group when compared with the delayed drainage group (median: 2 vs. 3 days; p = 0.02), while there was no difference in time from drainage to body temperature normalization between the two groups. On multivariable analysis, high pretreatment C-reactive protein (CRP) was associated with implementing emergency drainage within 12 h.

CONCLUSIONS

The timing of urinary drainage was only associated with the duration of high fever, but it did not affect the postdrainage course. Emergency urinary drainage is more likely to be performed in severe patients, such as high pretreatment CRP.

Choosing the best way for urinary decompression and developing a novel predictive model for septic shock using SOFA in these patients

OBJECTIVES

To identify predictive factors for the development of sepsis/septic shock postdecompression of calculi-related ureteric obstruction using the Sequential Organ Failure Assessment (SOFA) score and to compare clinical outcomes and odd risk ratios of patients developing sepsis/septic shock following the insertion of percutaneous nephrostomy (PCN) versus insertion of retrograde ureteral stenting (RUS).

METHODS

Clinico-epidemiological data of patients who underwent PCN and/or RUS in two institutions for calculi-related ureteric obstruction were retrospectively collected from January 2014 to December 2020.

RESULTS

537 patients (244 patients in PCN group, 293 patients in RUS group) from both institutions were eligible for analysis based on inclusion and exclusion criteria. Patients with PCN were generally older, had poorer Eastern Cooperative Oncology Group status, and larger obstructive ureteral calculi compared to patients with RUS. Patients with PCN had longer durations of fever, the persistence of elevated total white cell and creatinine, and longer hospitalization stays compared with patients who had undergone RUS. RUS up-front has more unsuccessful interventions compared with PCN. There were no significant differences in the change in SOFA score postintervention between the two interventions. In multivariate analysis, the higher temperature just prior to the intervention (adjusted odds ratio [OR]: 2.039, p = 0.003) and Cardiovascular SOFA score of 1 (adjusted OR:4.037, p = 0.012) were significant independent prognostic factors for the development of septic shock postdecompression of ureteral obstruction.

CONCLUSIONS

Our study reveals that both interventions have similar overall risk of urosepsis, septic shock and mortality rate. Despite a marginally higher risk of failure, RUS should be considered in patients with lower procedural risk. Patients going for PCN should be counseled for a longer stay. Post-HDU/-ICU monitoring, inotrope support postdecompression should be considered for patients with elevated temperature within 1 h preintervention and cardiovascular SOFA score of 1.

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

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