Prediction of Septicemia Following Endourological Manipulation for Stones in the Upper Urinary Tract

Abstract

We investigated 117 patients undergoing percutaneous nephrolithotomy, percutaneous nephrostomy, ureterorenoscopy, the push-back or push-bang procedure for ureteral stones, Double-J* ureteral stenting plus extracorporeal shock wave lithotripsy (ESWL), ESWL alone or cystoscopy. Blood samples obtained before, during and 1 hour after the procedure were cultured and assayed for endotoxin and tumor necrosis factor. Also, culture was done of the urine preoperatively and postoperatively, and the stones when they could be retrieved. There was a temporal relationship among bacteremia, endotoxemia and elevation of tumor necrosis factor. An unexpected finding was peroperative endotoxemia in a significant number of patients with stones. Risk factors noted for postoperative bacteremia, endotoxemia and/or elevation of tumor necrosis factor included preoperative endotoxin level, type of procedure, presence of preoperative bacteriuria and pyuria. With respect to the procedure the risk was greatest after the push-back method and least after cystoscopy (push-back method greater than percutaneous nephrolithotomy/percutaneous nephrostomy greater than Double-J stenting plus ESWL greater than ureterorenoscopy greater than ESWL greater than cystoscopy). If the risk factors are measured preoperatively it may be possible to identify the risk of postoperative bacteremia/endotoxemia and, therefore, septic shock postoperatively. Our patients appear to be a good clinical model to investigate the problems related to septicemia.

Contemporary Practice of Percutaneous Nephrolithotomy: Review of Practice in a Single Region of the UK

“…In addition, a much higher rate of postoperative pyrexia (temperature >37.5°C) was observed in patients following PCNL surgery (74% of cases). Moreover, although the study by Rao et al 7 confirmed a statistically significant association between pre-operative bacteriuria and the development of postoperative bacteraemia (bacteraemia in 37% of patients with a positive MSSU compared to 8% in those with a negative urine culture pre-operatively), this was not observed in our analysis. The postoperative sepsis (temperature >38.5°C) rates were similar in those patients without pre-operative confirmed UTI.…”

Infected Urinary Stones, Endotoxins and Urosepsis

“…An incidence of sepsis associated with obstructed uropathy and urinary stones treated surgically has also been reported in 1.28 % of cases (O'Keeffe et al, 1993). Rao et al (1991) found an incidence of septic shock after endoscopic manipulation for urinary stone in about 1% of treated patients. Sepsis is an advanced stage of uncontrolled systemic inflammatory response syndrome that may turn toward irreversible multiple organ failure and death.…”

“…Septic shock following urinary stone manipulation was reported with an incidence of 1 % and mortality up to 80 % (Rao et al, 1991). In an effort to predict septicemia following endourological manipulation for stones in the upper urinary tract, 117 patients were studied and classified according to the procedure performed (Rao et al, 1991): Percutaneous nephrolithotomy, push-back/push-bang procedure, double-J and extracorporeal shock wave lithotripsy (SWL), ureteroscopy, SWL alone and only cystoscopy. Blood samples for bacterial culture, endotoxin and tumor necrosis factor assay were collected before, at onset, at the end and one hour after completing the procedure.…”

“…No patient suffered septic shock; however, this complication developed in a female patient one week after percutaneous nephrolithotomy. Serum endotoxin and tumor necrosis factor levels after admission of this patient to the intensive care unit were 67.7 pg/mL and 3,827.5 pg/mL, respectively (Rao et al, 1991). Measurements of LPS were done in 34 renal stones, stored for several months and classified as infection stones (16), i.e., struvite and calcium apatite, and non-infection stones (18) composed of 50 % calcium oxalate monohydrate (McALeer et al, 2003).…”

“…Bacteria and likely endotoxins may emerge from several kinds of urinary stones and not exclusively from struvite stones (Hugosson et al, 1990;McALeer et al, 2003). In post-surgical stage, the most critical evidences of SIRS are during the first 6 hours post-procedure and seem to correlate with cytokines release into the bloodstream after endotoxin stimulus (Dandona et al, 1994;O'Keeffe et al, 1993;Rao et al, 1991;Taudorf et al, 2007). It has been suggested that if other causes of SIRS different than infection (i.e.…”