AUA 2018: Do Patients Undergoing Primary Ureteroscopy for Ureteral Stones Have a Lower Post-Operative Sepsis Rate Compared to Those Previously Stented?

San Francisco, CA USA ( Nina Mikkilineni, a clinical urologist from the Irving Medical Center at Columbia University, discussed her findings on the rates of sepsis following pre-stenting of patients versus primary ureteroscopy (P-URS). To begin, Dr. Mikkilineni advocated that P-URS is preferred over preoperative stenting due to fewer procedures for the patient, lower short-term costs, shorter duration of irritative stent symptoms, and a possible decreased infection risk. However, no prior studies have determined the prevalence of these infections within patients who have been pre-stented versus P-URS. Dr. Mikkilineni and her team hypothesized that preoperative stenting has a higher risk of postoperative sepsis due to the possibility of stent colonization.

To test this hypothesis, the researchers conducted a retrospective review of all patients treated at 12 medical centers with the ICD9/ICD10 codes for ureteral stones and corresponding procedure codes for ureteroscopic lithotripsy (patients undergoing shock wave lithotripsy and percutaneous nephrolithotomy were excluded). These patients were then categorized as pre-stented for suspected infection, pre-stented for non-infection, stented following P-URS in preparation for 2nd stage URS, or P-URS. All patients received culture specific antibiotics prior to surgery. Outcomes were defined as postoperative sepsis during postoperative hospital stay.

At the completion of the study, 420 patients were identified to the experimental cohort. Of these patients, 191 (45%) were presented, 41 (10%) were stented for 2nd stage URS, and 188 (45%) underwent P-URS. Interestingly, Dr. Mikkilineni described how patients were less likely to use a ureteral access sheath intraoperatively and less likely to receive a postoperative stent in the pre-stent groups versus the P-URS group. In regard to sepsis rates, a total of 7 cases of sepsis were experienced (1.7%): 5 cases were following a pre-stent case and 2 followed a P-URS case. There were no significant differences between any of the pre-stent groups and the P-URS group, however, P-URS patients do have a clinically meaningful decrease in sepsis rates. Through multivariate analysis, pre-stenting, P-URS, access sheath use, postoperative stent placement, or postoperative stent duration were factors predictive of postoperative sepsis.

In conclusion, Dr. Mikkilineni urged the audience to treat urinary calculi at first without subjecting the patient to extra surgeries. Though her results from this study were inconsequential, the slight improvement in sepsis rates following P-URS were large enough for urologists at Columbia University to rethink their surgical plan for future ureteroscopic stone treatment.

Presented by: Nina Mikkilineni, MD

Written by: Zachary Valley, Department of Urology, University of California-Irvine at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA