Urolithiasis DOI 10.1007/s00240-014-0730-8
ORIGINAL PAPER
Risk factors for postoperative infectious complications following percutaneous nephrolithotomy: a prospective clinical study Omer Koras · Ibrahim Halil Bozkurt · Tarik Yonguc · Tansu Degirmenci · Burak Arslan · Bulent Gunlusoy · Ozgu Aydogdu · Suleyman Minareci
Received: 7 August 2014 / Accepted: 23 September 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract The aim of the study was to assess the preoperative and intraoperative potential risk factors for infectious complications after percutaneous nephrolithotomy (PCNL). A total of 303 patients who underwent PCNL for renal stones were included in the recent study. A detailed history including past renal surgery, nephrostomy insertion and recurrent urinary infection were obtained from all patients. Preoperative urine culture, renal pelvic urine culture and stone culture were obtained from all patients. The intraoperative data were prospectively noted. All patients were followed up postoperatively for signs of systemic inflammatory response syndrome (SIRS) and sepsis. In 83 (27.4 %) of the patients, SIRS was observed and of these patients 23 (7.6 %) were diagnosed as sepsis. Escherichia coli was the most common organism detected in cultures, followed by Pseudomonas aeruginosa, Enterococcus and Klebsiella spp. in all patients. By multivariate logistic regression analysis, presence of infection stone, stone burden and recurrent urinary tract infection were associated with both SIRS and sepsis development. Presence of infection stone, stone burden ≥800 mm2 and recurrent urinary tract infection can be identified as independent predictors for the development of SIRS and sepsis. Keywords Percutaneous nephrolthotomy · Systemic inflammatory response syndrome · Sepsis O. Koras · I. H. Bozkurt (*) · T. Yonguc · T. Degirmenci · B. Gunlusoy · O. Aydogdu · S. Minareci Department of Urology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey e-mail: [email protected] B. Arslan Department of Urology, Istanbul Haseki Training and Research Hospital, Istanbul, Turkey
Introduction Since its introduction in 1976, percutaneous nephrolithotomy (PCNL) has become the standard treatment method for large renal stones [1]. Postoperative infectious complications requiring additional antibiotic treatment and prolonged hospitalization can potentially be observed after PCNL. Patients with complicated stones may develop systemic inflammatory response syndrome (SIRS) up to 35 %, with a small percent progressing to sepsis [2]. Sepsis was reported to be the most common cause of perioperative mortality after PCNL in large series [3, 4]. Thus, it is important to assess the risk factors associated with the occurence of postoperative infectious complications in patients who underwent PCNL. Formerly a diagnosis of sepsis often required evidence of positive blood cultures, but at the present day, it is known that the blood cultures are often negative in patients with sepsis [5]. Instead of relying on empirical antibiotic regimens it was offered to take the renal pelvic urine and stone cultures to guide the treatment [2, 6, 7]. Besides these culture profiles, there are also some other factors related to stone and patient characteristics that may influence the outcome of this surgery. In this study, we prospectively analyzed the preoperative and intraoperative potential risk factors for infectious complications after PCNL.
Materials and methods After obtaining institutional review board approval, a total of 303 patients who underwent PCNL for renal stones were included in the recent study. A detailed history including past renal surgery, nephrostomy insertion and recurrent urinary infection were obtained from all patients. Laboratory
13
Urolithiasis
investigations included urine analysis, midstream urine culture, complete blood count and renal function tests. The stones were evaluated with low-dose computed tomography (CT) and/or excretory urogram preoperatively. If the culture was negative, the patient was given a single dose of intravenous broad spectrum antibiotic at anesthesia induction and continued until the time of nephrostomy removal. Patients who had positive cultures (greater than 100,000 cfu/ml) were treated with appropriate antibiotics based on sensitivity profile at least 7 days, prior to surgical intervention. Also the same antibiotic was continued until nephrostomy removal. The stones located at the upper ureter, single calyx or renal pelvis only were defined as simple where as coraliform stones were defined as complex. The stone burden was calculated by multiplying the longest diameter by the perpendicular diameter of the stone and in cases of multiple stones the total stone burden was calculated as the sum of the burden of each stone.
min) and blood cultures were provided as indicated. SIRS was diagnosed in patients who met two or more criteria. The sepsis is defined as the presence of a source of infection together with SIRS [8]. In the statistical analysis, the student t test was used for comparison of the normally distributed variables between the groups (development of SIRS or sepsis), and the Mann– Whitney U test for non-normally distributed data. Proportions of patient characteristics, surgical history, preoperative nephrostomy condition, recurrent infection, access number, blood transfusion, residual stones, presence of infection stone, results of preoperative urine culture (UC), stone culture (SC) and renal pelvic urine culture (RPUC) data of the two groups were compared using the Chi-square test and Fisher’s exact test. Logistic regression method was used for multivariate analysis to determine which variables effect infectious complications. Values of p 38 or 90 per min., respiratory rate >20 per
13
Results A total of 303 patients included in this study. In 83 (27.4 %) of the patients SIRS was observed and of these patients 23 (7.6 %) were diagnosed as sepsis. Escherichia coli was the most common organism detected in cultures, followed by Pseudomonas aeruginosa, Enterococcus and Klebsiella spp. in all patients. Pseudomonas aeruginosa was the leading organism in patients with SIRS and mostly detected in stone cultures. The most common stone types were whewellite, weddellite, mixed and uric acid stones. The bacterial species detected at the preoperative BUC and SC of the patients according to stone types are shown in Table 1. The demographic characteristics and correlation of each factor and SIRS are shown in Table 2. At univariate analysis stone burden (p = 0,001), operation time (p
ORIGINAL PAPER
Risk factors for postoperative infectious complications following percutaneous nephrolithotomy: a prospective clinical study Omer Koras · Ibrahim Halil Bozkurt · Tarik Yonguc · Tansu Degirmenci · Burak Arslan · Bulent Gunlusoy · Ozgu Aydogdu · Suleyman Minareci
Received: 7 August 2014 / Accepted: 23 September 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract The aim of the study was to assess the preoperative and intraoperative potential risk factors for infectious complications after percutaneous nephrolithotomy (PCNL). A total of 303 patients who underwent PCNL for renal stones were included in the recent study. A detailed history including past renal surgery, nephrostomy insertion and recurrent urinary infection were obtained from all patients. Preoperative urine culture, renal pelvic urine culture and stone culture were obtained from all patients. The intraoperative data were prospectively noted. All patients were followed up postoperatively for signs of systemic inflammatory response syndrome (SIRS) and sepsis. In 83 (27.4 %) of the patients, SIRS was observed and of these patients 23 (7.6 %) were diagnosed as sepsis. Escherichia coli was the most common organism detected in cultures, followed by Pseudomonas aeruginosa, Enterococcus and Klebsiella spp. in all patients. By multivariate logistic regression analysis, presence of infection stone, stone burden and recurrent urinary tract infection were associated with both SIRS and sepsis development. Presence of infection stone, stone burden ≥800 mm2 and recurrent urinary tract infection can be identified as independent predictors for the development of SIRS and sepsis. Keywords Percutaneous nephrolthotomy · Systemic inflammatory response syndrome · Sepsis O. Koras · I. H. Bozkurt (*) · T. Yonguc · T. Degirmenci · B. Gunlusoy · O. Aydogdu · S. Minareci Department of Urology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey e-mail: [email protected] B. Arslan Department of Urology, Istanbul Haseki Training and Research Hospital, Istanbul, Turkey
Introduction Since its introduction in 1976, percutaneous nephrolithotomy (PCNL) has become the standard treatment method for large renal stones [1]. Postoperative infectious complications requiring additional antibiotic treatment and prolonged hospitalization can potentially be observed after PCNL. Patients with complicated stones may develop systemic inflammatory response syndrome (SIRS) up to 35 %, with a small percent progressing to sepsis [2]. Sepsis was reported to be the most common cause of perioperative mortality after PCNL in large series [3, 4]. Thus, it is important to assess the risk factors associated with the occurence of postoperative infectious complications in patients who underwent PCNL. Formerly a diagnosis of sepsis often required evidence of positive blood cultures, but at the present day, it is known that the blood cultures are often negative in patients with sepsis [5]. Instead of relying on empirical antibiotic regimens it was offered to take the renal pelvic urine and stone cultures to guide the treatment [2, 6, 7]. Besides these culture profiles, there are also some other factors related to stone and patient characteristics that may influence the outcome of this surgery. In this study, we prospectively analyzed the preoperative and intraoperative potential risk factors for infectious complications after PCNL.
Materials and methods After obtaining institutional review board approval, a total of 303 patients who underwent PCNL for renal stones were included in the recent study. A detailed history including past renal surgery, nephrostomy insertion and recurrent urinary infection were obtained from all patients. Laboratory
13
Urolithiasis
investigations included urine analysis, midstream urine culture, complete blood count and renal function tests. The stones were evaluated with low-dose computed tomography (CT) and/or excretory urogram preoperatively. If the culture was negative, the patient was given a single dose of intravenous broad spectrum antibiotic at anesthesia induction and continued until the time of nephrostomy removal. Patients who had positive cultures (greater than 100,000 cfu/ml) were treated with appropriate antibiotics based on sensitivity profile at least 7 days, prior to surgical intervention. Also the same antibiotic was continued until nephrostomy removal. The stones located at the upper ureter, single calyx or renal pelvis only were defined as simple where as coraliform stones were defined as complex. The stone burden was calculated by multiplying the longest diameter by the perpendicular diameter of the stone and in cases of multiple stones the total stone burden was calculated as the sum of the burden of each stone.
min) and blood cultures were provided as indicated. SIRS was diagnosed in patients who met two or more criteria. The sepsis is defined as the presence of a source of infection together with SIRS [8]. In the statistical analysis, the student t test was used for comparison of the normally distributed variables between the groups (development of SIRS or sepsis), and the Mann– Whitney U test for non-normally distributed data. Proportions of patient characteristics, surgical history, preoperative nephrostomy condition, recurrent infection, access number, blood transfusion, residual stones, presence of infection stone, results of preoperative urine culture (UC), stone culture (SC) and renal pelvic urine culture (RPUC) data of the two groups were compared using the Chi-square test and Fisher’s exact test. Logistic regression method was used for multivariate analysis to determine which variables effect infectious complications. Values of p 38 or 90 per min., respiratory rate >20 per
13
Results A total of 303 patients included in this study. In 83 (27.4 %) of the patients SIRS was observed and of these patients 23 (7.6 %) were diagnosed as sepsis. Escherichia coli was the most common organism detected in cultures, followed by Pseudomonas aeruginosa, Enterococcus and Klebsiella spp. in all patients. Pseudomonas aeruginosa was the leading organism in patients with SIRS and mostly detected in stone cultures. The most common stone types were whewellite, weddellite, mixed and uric acid stones. The bacterial species detected at the preoperative BUC and SC of the patients according to stone types are shown in Table 1. The demographic characteristics and correlation of each factor and SIRS are shown in Table 2. At univariate analysis stone burden (p = 0,001), operation time (p
