JOURNAL OF ENDOUROLOGY Volume 28, Number 12, December 2014 ª Mary Ann Liebert, Inc. Pp. 1439–1443 DOI: 10.1089/end.2014.0343
Clinical Outcomes After Ureteroscopic Lithotripsy in Patients Who Initially Presented with Urosepsis: Matched Pair Comparison with Elective Ureteroscopy Ramy F. Youssef, MD, Andreas Neisius, MD, Zachariah G. Goldsmith, MD, Momin Ghaffar, BS, Matvey Tsivian, MD, Richard H. Shin, MD, Fernando Cabrera, MD, Michael N. Ferrandino, MD, Charles D. Scales, MD, Glenn M. Preminger, MD, and Michael E. Lipkin, MD
Abstract
Background and Purpose: The outcomes of ureteroscopy (URS) after urgent decompression and antibiotics for patients who initially present with urosepsis because of obstructive urolithiasis have not been previously evaluated. The aim of this study was to compare the outcomes and complications of URS in patients with a recent history of sepsis with those without sepsis. Methods: The study included 138 patients who underwent URS for stone removal from January 2004 to September 2011 at a university medical center. A matched-pair analysis was performed using three parameters (age, sex, and race) to compare outcomes and complications between 69 patients who had sepsis vs a matched cohort who did not have sepsis before URS. Results: The study included 138 patients, 88 (64%) females and 50 (36%) males with a median age of 57.5 years (range 18–88 years). Patients with previous sepsis had similar patient characteristics and stone-free rates (81% vs 77%) compared with patients without previous sepsis (P > 0.05). Patients with previous sepsis, however, had a significantly higher complications rate (20% vs 7%), longer hospital length of stay (LOS), and longer courses of postoperative antibiotics after URS (P < 0.05). Sepsis developed postoperatively in two patients with diabetes (one with and one without previous sepsis), and postoperative fever developed in five patients with previous sepsis. Conclusions: URS after decompression for urolithiasis-related sepsis has similar success but higher complication rates, greater LOS, and longer course of postoperative antibiotics. This is important in counseling patients who present for definitive URS after urgent decompression for urolithiasis-related sepsis. Introduction
U
rosepsis is defined as sepsis caused by a urogenital tract infection. Urosepsis in adults accounts for approximately 25% of all sepsis cases.1 Severe sepsis and septic shock is a critical condition, with a reported mortality rate ranging from 20% to 40%.1,2 Urosepsis is mainly caused by urinary obstruction, with urolithiasis being the most common cause.1,2 An early diagnosis is imperative for better clinical outcome. Emergent decompression of the collecting system is the standard of care for the initial management of urosepsis from obstructive urolithiasis. Both retrograde internal ureteral stent placement and percutaneous nephrostomy (PCN) drainage appear equally effective.3–6 After adequate decompression of the collecting system and proper treatment with antibiotics, definitive management of the stone is needed. Patients with ureteral stones or smaller
intrarenal stone burden are likely to be amenable to definitive treatment with ureteroscopy (URS). There have been a number of reports in the literature demonstrating the high success rates and low complication rates of patients undergoing URS for treatment of stones.5,7–10 The outcomes of URS after urgent decompression and an appropriate course of antibiotics for patients who initially present with urosepsis from obstructive urolithiasis have not been previously evaluated, however. The aim of this study is to compare the outcomes and complications of URS in patients who initially presented with sepsis in comparison with those who had elective URS without a history of sepsis. Methods
After obtaining Institutional Review Board approval, we performed a retrospective review of 854 patients who
Division of Urology, Comprehensive Kidney Stone Center, Duke University Medical Center, Durham, North Carolina.
1439
1440
YOUSSEF ET AL.
underwent URS at our University Hospital from January 2004 to September 2011, using Current Procedural Terminology code 52353. We used a combination search approach to screen patients who initially presented with obstructive urolithiasis-related sepsis. Adult patients with an International Classification of Diseases (ICD)-9 diagnostic codes for urolithiasis (592.1, 592.0, and 592.9) were first identified and then cross-referenced for a diagnostic code for infection (995.91, 599.0, 590, and 780.6). This pool of patients was then filtered for concomitant procedural codes for either ureteral stent placement (52332, 59.8) or PCN (50390, 50392, 74425, 74475, 55.03, and 55.92). Patients who had obstructive urolithiasis based on CT diagnosis and sepsis identified by systemic inflammatory response syndrome defined by presence of ‡ 2 of the features mentioned in Table 1 were included and were age- and sexmatched with similar patients who did not present with sepsis. We identified 69 patients who presented initially with obstructive urolithiasis-related sepsis and were treated with urgent decompression and antibiotics followed by definitive URS. Matched-pair analysis was performed to compare outcomes and complications between these 69 patients who had sepsis at initial presentation vs a matched 69 patients who presented for elective URS and did not have a history of a septic episode. Stone characteristics such as stone size, number, and location were not included in the matching criteria because this would have limited the number of patients included in the study. The impact of stone characteristics on clinical outcomes and complication rates, however, were evaluated in univariable and multivariable models. The matching was specified 1:1 using three patients’ characteristics (age, sex, and race), and the closest match was chosen from patients who had URS without previous sepsis. The matching was performed using the R software v2.13 (The R Foundation for Statistical Computing, Vienna, Austria) with the MatchIt library. Primary outcomes included stone-free and complications rates. The stone-free rate was defined as the absence of any residual stones or fragments of any size on postoperative imaging performed 4 to 8 weeks after URS. Patients were evaluated 4 to 8 weeks after URS by kidneys, ureters, and bladder (KUB) radiography and tomography and renal ultrasonography or intravenous urography (IVU) or CT based on the discretion of the treating urologist. Postoperative complications were recorded and graded according to the Clavien system.11 Secondary outcomes included hospital length of stay (LOS), postoperative admission to the intensive care unit (ICU), duration of postoperative antibiotics, and duration of postoperative internal ureteral stent. Comparative outcomes between the treatment groups were assessed using a chi-square or Fisher exact test for categorical variables, and a Mann-Whitney U test for continuous variables.
Table 1. Features of Systemic Inflammatory Response Temperature Heart rate Respiratory rate White blood cells Immature band forms
< 36C or > 38C > 90 beats/minute > 20 breaths/minute > 12,000 or < 4000 cells/mm3 ‡ 10%
Multivariable linear regression model was used to evaluate independent predictors for residual fragments or complications. Statistical analysis was performed using SPSS version 21 (SPSS, Chicago, IL) with level of significance set at 0.05. Results Patient characteristics
The study included 138 adult patients who underwent URS for stone removal from January 2004 to September 2011–88 (64%) females and 50 (36%) males with a median age of 57.5 years (range 18–88 years). Table 2 describes patient and stone characteristics in those with and without previous sepsis. The stone size was larger in patients with previous sepsis with median stone diameter 8 mm (interquartile range [IQR] 5.5–11.5) compared with 6 mm (IQR 3–9) in patients without previous sepsis. Pretreatment stone diameter > 5 mm was found in 52 (75.4%) patients with initial sepsis vs 39 (56.5%) patients without previous sepsis. Outcomes
Patients who presented with sepsis were treated initially with decompression (63 with internal ureteral stents and 6 with PCN) and antibiotics. Intravenous (IV) antibiotics were used for a median period of 2 days (range 1–11 days) followed by oral antibiotics for 1 to 3 weeks after initial decompression. Of these 69 patients who presented with initial sepsis, 22 (32%) had to be admitted to the ICU for a mean 1.3 days (range 1–11 days), and 3 (4.3%) patients needed vasopressors. Patients were treated definitively by URS after a median duration of 32 days after initial presentation with sepsis and decompression of obstructive urolithiasis (range 5–126 days). Patients were evaluated 4 to 8 weeks after URS by KUB radiography and tomography and renal ultrasonography (61 patients; 44%) or IVU (48 patients; 35%) or noncontrast CT
Table 2. Patient and Treatment Characteristics No sepsis, n (%)
Sepsis, n (%)
Age, years 58 (47–67) 57 (44–66) (median, IQR) Sex, female/male 42/27 (61/39) 46/23 (67/33) Body mass index 28 (25–34) 27.5 (24–33) (median, IQR) Diabetes 13 (19) 18 (26) Stone size, mm 6 (3–9) 8 (5.5–11.5) (median and IQR) Stone side, 40/28 (58/42) 33/36 (48/52) right/left Stone location Kidney 27 (39) 19 (28) Ureter 36 (52) 39 (56) Kidney and ureter 6 (9) 11 (16) Stone number Single 49 (71) 48 (70) Multiple 20 (29) 21 (30) IQR = interquartile range.
P value 0.545 0.479 0.455 0.308 0.008 0.233 0.225
0.852
URS AFTER SEPSIS TREATMENT VS ELECTIVE URS
1441
Table 3. Clinical Outcomes
Stone-free rate Overall complications High-grade complications Hospital length of stay, days (mean and range) Postoperative admission to ICU Duration for antibiotics, days (mean and range) Duration of stent, days (mean and range)
No sepsis n (%)
Sepsis n (%)
P value
53/69 (77) 5/69 (7) 3/69 (4) 0.6 (0–4) 0 0.4 (0–20) 7.4 (2–67)
56/69 (81) 14/69 (20) 5/69 (7) 2.5 (0–33) 2 (3) 1.7 (0–29) 9.8 (1–76)
0.531 0.007 0.466 < 0.001 0.154 0.023 0.149
ICU = intensive care unit.
(29 patients; 21%) based on the discretion of the treating urologist, with no significant difference between modality of follow-up imaging in sepsis and elective groups (p > 0.05). Table 3 describes the clinical outcomes including stone-free rates, complications, hospital LOS, postoperative admission to the ICU, duration of antibiotics use, and duration of stent after URS. Patients with previous sepsis had similar stonefree rates (81% vs 77%) compared with patients without previous sepsis (P > 0.05). Table 4 describes the stone-free rates in relation to stone characteristics. In patients who presented initially with sepsis, the stone-free rates dropped significantly from 90% in patients with single stones to 62% in patients with multiple stones (P = 0.007) and from >85% in patients who had stones either in the kidney or ureter to 54.5% in patients with stones located in both kidney and ureter (P = 0.044). These differences were not significant in patients who underwent elective URS with no previous sepsis (P > 0.05). The stone size did not have a significant impact on stone-free rates in both groups (P > 0.05). Patients with previous sepsis had significantly higher complications rate (20% vs 7%, P = 0.007), longer LOS, and longer courses of postoperative antibiotics (P < 0.05). Sepsis developed postoperatively in two patients with diabetes (one with and one without previous sepsis), and postoperative fever developed in five patients with previous sepsis. Table 5 describes the complications and their Clavien grading. Patients with previous sepsis had significantly higher overall complications; however, there was no statistically significant difference between high-grade complications in patients with and without previous sepsis (7% vs 4%, P = 0.466). In multivariable models, location, size, multiplicity of the stones and initial presentation with sepsis were not inde-
pendent predictors of developing complications or having residual stones after URS. Discussion
URS can be used to treat most patients with renal and ureteral stones without specific contraindications. URS outcomes have been well reported in the literature.5,7–10 The outcomes of URS after urgent decompression for patients who initially present with urosepsis from obstructive urolithiasis have not been well studied, however. In this study, URS after decompression for urolithiasis-related sepsis had similar stone-free but higher overall complication rates. The stone-free rate for patients with previous sepsis was 81% and was not significantly different from those patients without previous sepsis. Stone-free rates after URS were reported between 78% and 98% for management of ureteral stones depending on stone location, size, multiplicity, as well as definition of stone-free status.5,7,9 In our study, stone-free rates were significantly lower in patients with multiple stones and stones located in both the kidney and ureter, particularly in patients with previous sepsis (Table 4). The relatively small number of patients included in this study precluded detection of independent predictors of leaving residual fragments or having complications related to URS. We could not find an association between pretreatment stone diameter or sepsis with stonefree rates after URS. A recent study included 667 URS to evaluate the predictors of residual fragments >2 mm on postoperative CT. Pretreatment stone size, stone location, the presence of multiple stones, longer operative time, and exclusive use of flexible URS were
Table 4. Stone-Free Rates Stratified by Stone Characteristics Stone-free rates Stone characteristics Size £ 10 mm > 10 mm Multiplicity Single Multiple Location Ureter Kidney Kidney and ureter
All patients
P value
No sepsis
P value
Sepsis
P value
79 80
0.891
76 83
0.692
82 79
.772
84.5 66
0.014
79 85
0.493
90 62
0.007
80 85 59
0.076
75 81.5 67
0.689
85 89.5 54.5
0.044
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YOUSSEF ET AL.
Table 5. Complications Stratified by Clavien Grade Grade I II III
IV
Description Fever Ureteral injury Hematuria Atrial fibrillation Others Hematuria Ureteral perforation/ urinoma Migrated ureteral stent Reoperation for residual stones Sepsis
No sepsis (%) Sepsis (%) 0 0 1 (1.4) 1 (1.4) 0 0 1 (1.4)
5 (7.2) 1 (1.4) 0 2 (2.8) 1 (1.4) 1 (1.4) 1 (1.4)
0 1 (1.4)
1 (1.4) 1 (1.4)
1 (1.4)
1 (1.4)
associated with presence of residual fragments in follow-up CT. In a multivariable model, however, only pretreatment stone diameter was independently associated with residual fragments after URS. Of note, the stone-free rate after URS for ureteral stones was 78% vs 49% for kidney stones; 65% for stones located in the kidney or ureter alone vs 50% for stones located in both the kidney and ureter. Moreover, the stone-free rate dropped from 80% for stones £ 5 mm vs 44% for stones 6 to 10 mm, and from 69% for single stones vs 49% for multiple stones.10 A recent study from Japan12 addressed the safety and efficacy of URS after management of obstructive pyelonephritis. The study compared 48 URS to 40 shockwave lithotripsy (SWL) cases. The study found that URS had a higher success rate of 98% compared with SWL at 67.5%, P < 0.001. In that study, however, only ureteral stones were assessed, and the authors did not define the criteria for determining the stonefree rate. They evaluated patients with KUB radiography and renal ultrasonography 1 or 2 days after URS or SWL.12 URS for management of stones is generally a safe modality associated with a low rate of complications (
Clinical Outcomes After Ureteroscopic Lithotripsy in Patients Who Initially Presented with Urosepsis: Matched Pair Comparison with Elective Ureteroscopy Ramy F. Youssef, MD, Andreas Neisius, MD, Zachariah G. Goldsmith, MD, Momin Ghaffar, BS, Matvey Tsivian, MD, Richard H. Shin, MD, Fernando Cabrera, MD, Michael N. Ferrandino, MD, Charles D. Scales, MD, Glenn M. Preminger, MD, and Michael E. Lipkin, MD
Abstract
Background and Purpose: The outcomes of ureteroscopy (URS) after urgent decompression and antibiotics for patients who initially present with urosepsis because of obstructive urolithiasis have not been previously evaluated. The aim of this study was to compare the outcomes and complications of URS in patients with a recent history of sepsis with those without sepsis. Methods: The study included 138 patients who underwent URS for stone removal from January 2004 to September 2011 at a university medical center. A matched-pair analysis was performed using three parameters (age, sex, and race) to compare outcomes and complications between 69 patients who had sepsis vs a matched cohort who did not have sepsis before URS. Results: The study included 138 patients, 88 (64%) females and 50 (36%) males with a median age of 57.5 years (range 18–88 years). Patients with previous sepsis had similar patient characteristics and stone-free rates (81% vs 77%) compared with patients without previous sepsis (P > 0.05). Patients with previous sepsis, however, had a significantly higher complications rate (20% vs 7%), longer hospital length of stay (LOS), and longer courses of postoperative antibiotics after URS (P < 0.05). Sepsis developed postoperatively in two patients with diabetes (one with and one without previous sepsis), and postoperative fever developed in five patients with previous sepsis. Conclusions: URS after decompression for urolithiasis-related sepsis has similar success but higher complication rates, greater LOS, and longer course of postoperative antibiotics. This is important in counseling patients who present for definitive URS after urgent decompression for urolithiasis-related sepsis. Introduction
U
rosepsis is defined as sepsis caused by a urogenital tract infection. Urosepsis in adults accounts for approximately 25% of all sepsis cases.1 Severe sepsis and septic shock is a critical condition, with a reported mortality rate ranging from 20% to 40%.1,2 Urosepsis is mainly caused by urinary obstruction, with urolithiasis being the most common cause.1,2 An early diagnosis is imperative for better clinical outcome. Emergent decompression of the collecting system is the standard of care for the initial management of urosepsis from obstructive urolithiasis. Both retrograde internal ureteral stent placement and percutaneous nephrostomy (PCN) drainage appear equally effective.3–6 After adequate decompression of the collecting system and proper treatment with antibiotics, definitive management of the stone is needed. Patients with ureteral stones or smaller
intrarenal stone burden are likely to be amenable to definitive treatment with ureteroscopy (URS). There have been a number of reports in the literature demonstrating the high success rates and low complication rates of patients undergoing URS for treatment of stones.5,7–10 The outcomes of URS after urgent decompression and an appropriate course of antibiotics for patients who initially present with urosepsis from obstructive urolithiasis have not been previously evaluated, however. The aim of this study is to compare the outcomes and complications of URS in patients who initially presented with sepsis in comparison with those who had elective URS without a history of sepsis. Methods
After obtaining Institutional Review Board approval, we performed a retrospective review of 854 patients who
Division of Urology, Comprehensive Kidney Stone Center, Duke University Medical Center, Durham, North Carolina.
1439
1440
YOUSSEF ET AL.
underwent URS at our University Hospital from January 2004 to September 2011, using Current Procedural Terminology code 52353. We used a combination search approach to screen patients who initially presented with obstructive urolithiasis-related sepsis. Adult patients with an International Classification of Diseases (ICD)-9 diagnostic codes for urolithiasis (592.1, 592.0, and 592.9) were first identified and then cross-referenced for a diagnostic code for infection (995.91, 599.0, 590, and 780.6). This pool of patients was then filtered for concomitant procedural codes for either ureteral stent placement (52332, 59.8) or PCN (50390, 50392, 74425, 74475, 55.03, and 55.92). Patients who had obstructive urolithiasis based on CT diagnosis and sepsis identified by systemic inflammatory response syndrome defined by presence of ‡ 2 of the features mentioned in Table 1 were included and were age- and sexmatched with similar patients who did not present with sepsis. We identified 69 patients who presented initially with obstructive urolithiasis-related sepsis and were treated with urgent decompression and antibiotics followed by definitive URS. Matched-pair analysis was performed to compare outcomes and complications between these 69 patients who had sepsis at initial presentation vs a matched 69 patients who presented for elective URS and did not have a history of a septic episode. Stone characteristics such as stone size, number, and location were not included in the matching criteria because this would have limited the number of patients included in the study. The impact of stone characteristics on clinical outcomes and complication rates, however, were evaluated in univariable and multivariable models. The matching was specified 1:1 using three patients’ characteristics (age, sex, and race), and the closest match was chosen from patients who had URS without previous sepsis. The matching was performed using the R software v2.13 (The R Foundation for Statistical Computing, Vienna, Austria) with the MatchIt library. Primary outcomes included stone-free and complications rates. The stone-free rate was defined as the absence of any residual stones or fragments of any size on postoperative imaging performed 4 to 8 weeks after URS. Patients were evaluated 4 to 8 weeks after URS by kidneys, ureters, and bladder (KUB) radiography and tomography and renal ultrasonography or intravenous urography (IVU) or CT based on the discretion of the treating urologist. Postoperative complications were recorded and graded according to the Clavien system.11 Secondary outcomes included hospital length of stay (LOS), postoperative admission to the intensive care unit (ICU), duration of postoperative antibiotics, and duration of postoperative internal ureteral stent. Comparative outcomes between the treatment groups were assessed using a chi-square or Fisher exact test for categorical variables, and a Mann-Whitney U test for continuous variables.
Table 1. Features of Systemic Inflammatory Response Temperature Heart rate Respiratory rate White blood cells Immature band forms
< 36C or > 38C > 90 beats/minute > 20 breaths/minute > 12,000 or < 4000 cells/mm3 ‡ 10%
Multivariable linear regression model was used to evaluate independent predictors for residual fragments or complications. Statistical analysis was performed using SPSS version 21 (SPSS, Chicago, IL) with level of significance set at 0.05. Results Patient characteristics
The study included 138 adult patients who underwent URS for stone removal from January 2004 to September 2011–88 (64%) females and 50 (36%) males with a median age of 57.5 years (range 18–88 years). Table 2 describes patient and stone characteristics in those with and without previous sepsis. The stone size was larger in patients with previous sepsis with median stone diameter 8 mm (interquartile range [IQR] 5.5–11.5) compared with 6 mm (IQR 3–9) in patients without previous sepsis. Pretreatment stone diameter > 5 mm was found in 52 (75.4%) patients with initial sepsis vs 39 (56.5%) patients without previous sepsis. Outcomes
Patients who presented with sepsis were treated initially with decompression (63 with internal ureteral stents and 6 with PCN) and antibiotics. Intravenous (IV) antibiotics were used for a median period of 2 days (range 1–11 days) followed by oral antibiotics for 1 to 3 weeks after initial decompression. Of these 69 patients who presented with initial sepsis, 22 (32%) had to be admitted to the ICU for a mean 1.3 days (range 1–11 days), and 3 (4.3%) patients needed vasopressors. Patients were treated definitively by URS after a median duration of 32 days after initial presentation with sepsis and decompression of obstructive urolithiasis (range 5–126 days). Patients were evaluated 4 to 8 weeks after URS by KUB radiography and tomography and renal ultrasonography (61 patients; 44%) or IVU (48 patients; 35%) or noncontrast CT
Table 2. Patient and Treatment Characteristics No sepsis, n (%)
Sepsis, n (%)
Age, years 58 (47–67) 57 (44–66) (median, IQR) Sex, female/male 42/27 (61/39) 46/23 (67/33) Body mass index 28 (25–34) 27.5 (24–33) (median, IQR) Diabetes 13 (19) 18 (26) Stone size, mm 6 (3–9) 8 (5.5–11.5) (median and IQR) Stone side, 40/28 (58/42) 33/36 (48/52) right/left Stone location Kidney 27 (39) 19 (28) Ureter 36 (52) 39 (56) Kidney and ureter 6 (9) 11 (16) Stone number Single 49 (71) 48 (70) Multiple 20 (29) 21 (30) IQR = interquartile range.
P value 0.545 0.479 0.455 0.308 0.008 0.233 0.225
0.852
URS AFTER SEPSIS TREATMENT VS ELECTIVE URS
1441
Table 3. Clinical Outcomes
Stone-free rate Overall complications High-grade complications Hospital length of stay, days (mean and range) Postoperative admission to ICU Duration for antibiotics, days (mean and range) Duration of stent, days (mean and range)
No sepsis n (%)
Sepsis n (%)
P value
53/69 (77) 5/69 (7) 3/69 (4) 0.6 (0–4) 0 0.4 (0–20) 7.4 (2–67)
56/69 (81) 14/69 (20) 5/69 (7) 2.5 (0–33) 2 (3) 1.7 (0–29) 9.8 (1–76)
0.531 0.007 0.466 < 0.001 0.154 0.023 0.149
ICU = intensive care unit.
(29 patients; 21%) based on the discretion of the treating urologist, with no significant difference between modality of follow-up imaging in sepsis and elective groups (p > 0.05). Table 3 describes the clinical outcomes including stone-free rates, complications, hospital LOS, postoperative admission to the ICU, duration of antibiotics use, and duration of stent after URS. Patients with previous sepsis had similar stonefree rates (81% vs 77%) compared with patients without previous sepsis (P > 0.05). Table 4 describes the stone-free rates in relation to stone characteristics. In patients who presented initially with sepsis, the stone-free rates dropped significantly from 90% in patients with single stones to 62% in patients with multiple stones (P = 0.007) and from >85% in patients who had stones either in the kidney or ureter to 54.5% in patients with stones located in both kidney and ureter (P = 0.044). These differences were not significant in patients who underwent elective URS with no previous sepsis (P > 0.05). The stone size did not have a significant impact on stone-free rates in both groups (P > 0.05). Patients with previous sepsis had significantly higher complications rate (20% vs 7%, P = 0.007), longer LOS, and longer courses of postoperative antibiotics (P < 0.05). Sepsis developed postoperatively in two patients with diabetes (one with and one without previous sepsis), and postoperative fever developed in five patients with previous sepsis. Table 5 describes the complications and their Clavien grading. Patients with previous sepsis had significantly higher overall complications; however, there was no statistically significant difference between high-grade complications in patients with and without previous sepsis (7% vs 4%, P = 0.466). In multivariable models, location, size, multiplicity of the stones and initial presentation with sepsis were not inde-
pendent predictors of developing complications or having residual stones after URS. Discussion
URS can be used to treat most patients with renal and ureteral stones without specific contraindications. URS outcomes have been well reported in the literature.5,7–10 The outcomes of URS after urgent decompression for patients who initially present with urosepsis from obstructive urolithiasis have not been well studied, however. In this study, URS after decompression for urolithiasis-related sepsis had similar stone-free but higher overall complication rates. The stone-free rate for patients with previous sepsis was 81% and was not significantly different from those patients without previous sepsis. Stone-free rates after URS were reported between 78% and 98% for management of ureteral stones depending on stone location, size, multiplicity, as well as definition of stone-free status.5,7,9 In our study, stone-free rates were significantly lower in patients with multiple stones and stones located in both the kidney and ureter, particularly in patients with previous sepsis (Table 4). The relatively small number of patients included in this study precluded detection of independent predictors of leaving residual fragments or having complications related to URS. We could not find an association between pretreatment stone diameter or sepsis with stonefree rates after URS. A recent study included 667 URS to evaluate the predictors of residual fragments >2 mm on postoperative CT. Pretreatment stone size, stone location, the presence of multiple stones, longer operative time, and exclusive use of flexible URS were
Table 4. Stone-Free Rates Stratified by Stone Characteristics Stone-free rates Stone characteristics Size £ 10 mm > 10 mm Multiplicity Single Multiple Location Ureter Kidney Kidney and ureter
All patients
P value
No sepsis
P value
Sepsis
P value
79 80
0.891
76 83
0.692
82 79
.772
84.5 66
0.014
79 85
0.493
90 62
0.007
80 85 59
0.076
75 81.5 67
0.689
85 89.5 54.5
0.044
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YOUSSEF ET AL.
Table 5. Complications Stratified by Clavien Grade Grade I II III
IV
Description Fever Ureteral injury Hematuria Atrial fibrillation Others Hematuria Ureteral perforation/ urinoma Migrated ureteral stent Reoperation for residual stones Sepsis
No sepsis (%) Sepsis (%) 0 0 1 (1.4) 1 (1.4) 0 0 1 (1.4)
5 (7.2) 1 (1.4) 0 2 (2.8) 1 (1.4) 1 (1.4) 1 (1.4)
0 1 (1.4)
1 (1.4) 1 (1.4)
1 (1.4)
1 (1.4)
associated with presence of residual fragments in follow-up CT. In a multivariable model, however, only pretreatment stone diameter was independently associated with residual fragments after URS. Of note, the stone-free rate after URS for ureteral stones was 78% vs 49% for kidney stones; 65% for stones located in the kidney or ureter alone vs 50% for stones located in both the kidney and ureter. Moreover, the stone-free rate dropped from 80% for stones £ 5 mm vs 44% for stones 6 to 10 mm, and from 69% for single stones vs 49% for multiple stones.10 A recent study from Japan12 addressed the safety and efficacy of URS after management of obstructive pyelonephritis. The study compared 48 URS to 40 shockwave lithotripsy (SWL) cases. The study found that URS had a higher success rate of 98% compared with SWL at 67.5%, P < 0.001. In that study, however, only ureteral stones were assessed, and the authors did not define the criteria for determining the stonefree rate. They evaluated patients with KUB radiography and renal ultrasonography 1 or 2 days after URS or SWL.12 URS for management of stones is generally a safe modality associated with a low rate of complications (
