Predictors of systemic inflammatory response syndrome following percutaneous nephrolithotomy

Development and validation of the UCSS score, a novel method to predict septic shock after PCNL

OBJECTIVE

To develop an objective and easily recognizable model to predict septic shock following percutaneous nephrolithotomy (PCNL).

SUBJECTS AND METHODS

First, we identified differences between 431 patients who underwent PCNL with or without septic shock. These data were used to develop existing models and examine their improvement. Multivariate analysis was applied to identify risk factors of septic shock after PCNL based on the scores allocated to the PCNL postoperative test indicators. Finally, we developed a predictive nomogram using the selected factors and compared its performance with that of the existing nomograms SOFA, qSOFA, and SIRS.

RESULTS

Twelve (2.8%) of the patients met the criteria for postoperative septic shock after PCNL. Baseline data analysis revealed differences in sex, preoperative drainage, urinary culture, and urinary leukocyte between groups. After transforming patient data into measurement-level data, we investigated each index score in these conditions, and found that the incidence of septic shock generally increased with the score. Multivariate analysis and early optimization screening revealed that septic shock factors could be predicted using platelets, leukocytes, bilirubin, and procalcitonin levels. We further compared the prediction accuracy of urinary calculi-associated septic shock (UCSS), SOFA, qSOFA, and SIRS scores using the AUC of the ROC curve. As compared to SIRS [AUC 0.938 (95% CI 0.910-0.959)] and qSOFA [AUC 0.930 (95% CI 0.901-0.952)], UCSS [AUC 0.974 (95% Cl 0.954-0.987)] and SOFA [AUC 0.974 (95% CI 0.954-0.987)] scored better at discriminating septic shock after PCNL. We further compared the ROC curves of UCSS with SOFA (95% CI - 0.800 to 0.0808, P = 0.992), qSOFA (95% CI - 0.0611 to 0.0808, P = 0.409), and SIRS (95% CI - 0.0703 to 0.144, P = 0.502), finding that UCSS was non-inferior to these models.

CONCLUSIONS

UCSS, a new convenient and cost-effective model, can predict septic shock following PCNL and provide more accurate discriminative and corrective capability than existing models by including only objective data. The predictive value of UCSS for septic shock after PCNL was greater than that of qSOFA or SIRS scores.

Retrospective Analysis of the Risk Factors and Drug Resistance of Pathogenic Bacteria in Systemic Inflammatory Response Syndrome After Ureteroscopic Holmium Laser Lithotripsy for Impacted Ureteral Calculi

Objective

To investigate the risk factors, pathogen distribution, and drug resistance of systemic inflammatory response syndrome (SIRS) after holmium laser ureteroscopic lithotripsy for impacted ureteral calculi (HLULIUC).

Patients and Methods

The clinical data of 293 patients with HLULIUC in our hospital from October 2017 to February 2021 were retrospectively collected, including age, BMI, stone size, operation time, urine routine, urine culture, basic illness, complete blood count, liver and kidney function, etc. Patients were divided into SIRS and non-SIRS groups according to whether they had SIRS or not. Then the differences in clinical data, blood and urine bacterial culture results, and drug resistance between the two groups were analyzed.

Results

The incidence of SIRS after HLULIUC was 17.75%. Logistic regression analysis showed that the risk factors of SIRS after HLULIUC include ureteral calculi≥1cm (OR=2.839, 95% CI=1.341–5.647, P=0.021), long operation time (OR=4.534, 95% CI=2.597–12.751, P=0.017), diabetes mellitus (OR=3.137, 95% CI=1.142–7.319, P=0.012), increased preoperative C-reactive protein (OR=1.864, 95% CI=1.05–4.347, P=0.032), and positive urine leukocytes (OR=3.514, 95% CI=1.7237–9.734, P=0.007) and culture (OR=6.034, 95% CI=3.097–15.751, P<0.001) before operation. The main pathogens causing SIRS after HLULIUC were Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus, Enterococcus faecalis, and Pseudomonas aeruginosa. The pathogenic bacteria are sensitive to drugs including piperacillin/tazobactam, meropenem, tigecycline, teicoplanin, vancomycin, and imipenem. The resistance rates to quinolones (such as levofloxacin) and to the second- and third-generations of cephalosporins were as high as 52.94%–90.19%.

Conclusion

Ureteral calculi≥1cm, long operation time, diabetes, increased C-reactive protein, and preoperative positive urine leukocytes and culture are independent risk factors of SIRS after HLULIUC. Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus, Enterococcus faecalis, and Pseudomonas aeruginosa are the main pathogenic bacteria for SIRS after HLULIUC. The pathogenic bacteria are sensitive to drugs, including piperacillin/tazobactam, meropenem, tigecycline, teicoplanin, vancomycin, and imipenem.

Renal pelvis urine Gram stain as a traditional, but new marker in predicting postoperative fever and stone culture positivity in percutaneous nephrolithotomy: an observational, prospective, non-randomized cohort study

PURPOSE

The aim of this study was to evaluate the diagnostic value of renal pelvis urine Gram staining (RPUGS) in predicting postoperative fever and renal stone culture (RSC) positivity in percutaneous nephrolithotomy (PCNL).

METHODS

Totally 141 consecutive patients undergoing PCNL for renal stone were included between January 2018 and December 2019. The RPUGS and renal pelvis urine culture (RPUC) were performed using urine sample from renal collecting system, while RSC was performed using stone fragments. Patients were divided into two groups as Group 1 (n = 119) without postoperative fever (< 38 °C) and Group 2 (n = 22) with postoperative fever (≥ 38 °C). Stone culture and Gram staining models were created for predicting postoperative fever using constant covariates of the presence of residual stone, hydronephrosis, and stone burden.

RESULTS

A significantly higher number of patients in Group 2 had RPUGS, RSC, and RPUC positivity (p < 0.001, for each). The sensitivity, specificity, positive predictive value, and negative predictive value of RPUGS in predicting postoperative fever were 72.7%, 89.9%, 57.1%, and 94.7%, respectively. It was observed that both models had similar predictive values and diagnostic performances. Although RSC and RPUGS had a similar diagnostic value in predicting postoperative fever in univariable analysis, both were found to be independent predictors in multivariable analysis (OR: 10.6, 95% CI 4.07-27.9, p < 0.001 and OR: 15.0, 95% CI 5.4-41.2, p < 0.001, respectively).

CONCLUSIONS

In conclusion, RPUGS is as effective as RSC in predicting fever after PCNL. We recommend RPUGS during PCNL to manage post-PCNL infectious complications.

Risk Factors for Systemic Inflammatory Response Syndrome Induced by Flexible Ureteroscope Combined with Holmium Laser Lithotripsy

Objective

To investigate the risk factors of systemic inflammatory response syndrome (SIRS) induced by flexible ureteroscope combined with Holmium laser lithotripsy. Patients and Methods. The clinical data from 216 consecutive patients who had undergone flexible ureteroscope combined with Holmium laser lithotripsy between August 2015 and May 2019 were retrospectively analyzed. To identify the risk factors of systemic inflammatory response syndrome induced by flexible ureteroscope combined with Holmium laser lithotripsy, the cases were divided into two groups according to whether they developed postoperative SIRS: SIRS group (21 cases) and non-SIRS group (195 cases). Age, gender, body mass index, stone size, surgery time, stone location, hydronephrosis, urine culture, hospital stay, stone-free rate, ureteral access sheath, and diabetes mellitus were collected. Univariate analysis was performed to calculate the potential factors. In order to determine the independence of the various factors, factors that potentially contributed to SIRS were compared between the SIRS group and the non-SIRS group. Furthermore, multivariate logistic regression analysis was used to identify the risk factors of systemic inflammatory response syndrome induced by flexible ureteroscopic lithotripsy.

Results

All patients were successfully treated with flexible ureteroscopic lithotripsy. The incidence of SIRS after flexible ureteroscopic lithotripsy was 9.7%. The univariate analysis demonstrated the potential risk factors of systemic inflammatory response syndrome induced by flexible ureteroscopic lithotripsy were stone size (p = 0.002), surgery time (p = 0.002), surgery time (p = 0.002), surgery time (p = 0.002), surgery time (p = 0.002), surgery time (p = 0.002), surgery time (p = 0.002), surgery time (p = 0.002), surgery time (.

Conclusions

Stone size, surgery time, urine culture, and ureteral access sheath are independent risk factors for SIRS induced by flexible ureteroscopic lithotripsy. Patients with these high-risk factors should be carefully evaluated to reduce systemic inflammatory response syndrome.

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.

Research progress of percutaneous nephrolithotomy

Percutaneous nephrolithotomy (PCNL) is generally accepted as the gold standard treatment for the treatment of large kidney stones (> 2 cm). For nearly 40 years, with the continuous progress of technology and the constant updating of ideas, PCNL has made great progress. In this review, we discuss the current research progress, recent advancement and hot spot of the whole process of PCNL including anesthesia, position, puncture, dilation, lithotripsy approaches, perfusate, tube placement, hospitalization time, drug, treatment of residual stones, prognosis judgment and operation evaluation by summarizing the related research in this article.

Clinical importance of chemokines and inflammatory cytokines for patient care following percutaneous nephrolithotripsy

Chemokines are a class of proteins with low molecular weight that serve important roles in the progression of inflammation. Percutaneous nephrolithotripsy is a surgical technique in which lasers or ultrasound are utilized to break down and/or remove kidney stones. In order to ensure a full recovery following surgery, effective patient care and nursing are required. In the present study, a total of 348 patients with kidney stones were recruited and the clinical importance of chemokines and inflammatory cytokines for the nursing of patients during perioperative period was investigated. Plasma levels of inflammatory cytokines, as well as chemokines in the C, CC and CXC families, were analyzed in patients following percutaneous nephrolithotripsy. Correlations between chemokines and inflammatory cytokines and the urinary concentration of calcium oxalate were also investigated. The results indicated that plasma levels of C and CC chemokines were downregulated in patients following percutaneous nephrolithotripsy, whereas the plasma concentrations of CXC chemokines were upregulated. Plasma concentration levels of inflammatory cytokines interleukin (IL)-8, IL-1, IL-17 and tumor necrosis factor (TNF)-α were significantly downregulated in patients following percutaneous nephrolithotripsy; however, no significant differences were observed in plasma levels of IL-6 and IL-10 pre- and post-surgery. Regression analysis revealed that plasma concentration levels of chemokine C motif ligand, which is a C chemokine, chemokine ligand 2, which is a CC chemokine, and TNF-α were positively correlated with the urinary concentration of calcium oxalate during the perioperative period. The results of the present study indicate that plasma levels of chemokines and inflammatory cytokines are clinically important for nursing of patients who experienced percutaneous nephrolithotripsy.

Renal Pelvic Pressure in Percutaneous Nephrolithotomy: The Effect of Multiple Tracts

INTRODUCTION

During percutaneous nephrolithotomy (PCNL), elevated renal pelvic pressures (RPPs) may spread infection through pyelovenous backflow whereas decreased pressures can hinder observation and increase bleeding. The purpose of this study was to evaluate the effects of multiple access tracts and different sized endoscopic equipment on RPP in a porcine model.

MATERIALS AND METHODS

RPP was measured in one- vs two-tract access, rigid vs flexible nephroscopy, and suction vs no suction. Twenty trials were performed for each condition. An independent samples Mann-Whitney U-test was used to compare parameters, with p < 0.05 considered significant.

RESULTS

With one tract, rigid nephroscopy resulted in higher mean pressures (31.35 mm Hg) than flexible nephroscopy (11.1 mm Hg; p < 0.001). The RPP was higher with rigid nephroscopy in one tract (31.35 mm Hg) than when two tracts were present (9.35 mm Hg; p < 0.001). In contrast, there was no difference in pressure during the use of a flexible nephroscope in one (11.1 mm Hg) vs two tracts (10.7 mm Hg; p = 0.63). Use of suction with the rigid nephroscope resulted in significantly lower pressures with one (-1.3 mm Hg) than with two tracts (1.8 mm Hg; p = 0.004).

CONCLUSION

In PCNL, RPP is significantly affected by an additional tract during rigid nephroscopy and suctioning but not when using a flexible nephroscope. Understanding the effects of multiple tracts and equipment type on RPP may improve the safety of PCNL.