Early Stone Manipulation in Urinary Tract Infection Associated with Obstructing Nephrolithiasis

Urolithiasis is a common urologic problem that can quickly turn into an emergency when sepsis occurs secondary to an obstructing stone. In these instances, urgent surgical decompression is required to avoid serious complications, including mortality. Following decompression, and initiation of antibiotic therapy, we typically wait at least 2 weeks and complete antibiotic course for complicated UTI before definitive management. In select patient populations with limited access to healthcare resources, this delay can easily turn an acute and manageable problem into a long-term health burden that only becomes more difficult to manage as time passes.

The problem of the “forgotten stent” is certainly not unique to our practice, and more timely management of an infected stone, potentially on the same admission, can avoid complications related to a stent that stays in too long. While we don’t necessarily advocate this approach on all patients, in those for whom ability to follow up may be in question, the potential benefit of expedited management may be worth any potential increased risk. This case series elucidates four instances where accelerated management of obstructing stones took place and saved the patient from the many potential complications from a retained and encrusted stent. We did not encounter any infection-related complications in this admittedly small number of cases.

Despite the absence of specific guidelines regarding the appropriate time for stone treatment after emergent stent placement in the context of an infected stone, both the AUA and EAU encourage physicians to take a delayed approach in treating the stone. However, delaying treatment for later outpatient management is not always practical. In these cases, a physician may be hesitant to deviate from current practice trends given the lack of evidence for outcomes associated with accelerated treatment. Our study attempts to fill this gap by providing data that suggests URS-LL can be performed within days of decompression and antibiotic administration without undue harm to patients.

In an era where the importance of health care utilization is becoming more and more paramount, future studies evaluating the cost as well as the safety of upfront accelerated stone treatment versus those associated with retained stents maybe beneficial and aid in future guideline recommendations.

Written by:
Joseph Sonstein, MD, Associate Professor of Urology, Urology Residency Program Director, Department of Surgery, Division of Urology, the University of Texas Medical Branch, Galveston, Texas
Elias J Farran, and Christopher D Kosarek, MD, the Division of Urology, Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States

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