Factors associated with urosepsis following percutaneous nephrolithotomy

Objective: To evaluate factors associated with urosepsis after percutaneous nephrolithotomy (PCNL). Materials and Methods: Seventy-six upper tract urinary calculi patients underwent PCNL at Loei Hospital between July 2014 to January 2019, all were enrolled onto the study. The following data were collected: demographics, type and size of stone, intraoperative data, pelvic urine culture and urosepsis complications after the procedure. Association of factors with urosepsis after PNCL were identified using a binary logistic regression model with a bootstrap estimation. Results: Urosepsis complications occurred in 7 patients (9.2%). Mean (SD) of age was 54.4 (10.3) years. Of all patients, 2% with staghorn stone and 22% positive urine culture. Multivariable analysis indicated that staghorn stone (a OR =6.75; 95%CI: 1.59-28.63, p=0.01) and positive pelvic urine culture (a OR =7.51; 95%CI: 1.35-41.77, p=0.02) were associated with urosepsis after PCNL. Conclusion: There was no mortality after PCNL in this study. Staghorn stone and positive pelvic urine culture may be associated with an increased risk of urosepsis complication.

Should renal pelvic urine culture be obtained routinely in flexible ureterorenoscopy?

Background: Preoperative bladder urine culture (PBUC) analysis has become a standard application before any stone surgery. When growth is detected in PBUC, it is contraindicated to perform flexible ureterorenoscopy (f-URS). The results of the PBUC susceptibility test do not correlate well with those of the renal pelvic urine culture (RPUC) analysis. Previous studies have demonstrated the positivity of RPUC as an important marker for the development of infections after endoscopic operations. In the current study, we aimed to evaluate the consistency between PBUC and RPUC and to identify preoperative markers associated with a positive RPUC. Methods: Data from 129 patients who underwent f-URS on renal and proximal ureteral stones in two centers between 2015 and 2020 were prospectively recorded in a database and retrospectively analyzed. PBUC was obtained from all the patients preoperatively, and RPUC was taken at the beginning of the f-URS operation. The results of the two cultures were compared. Results: There was growth in PBUC in 25 (19.4%) patients and RPUC in 35 (27.1%) patients. Possible predictive markers in predicting a positive RPUC were evaluated using multivariate logistic regression analysis. Preoperative urine density at the renal pelvis [odds ratio (OR): 0.848, p<0.001],grade≥2 hydronephrosis (OR:18.970,p=0.001), and lower calyceal stone localization (OR:0.033,p=0.017) were determined as independent predictive factors for a positive RPUC. The ability of pelvis urine density to predict positive RPUC positivity was evaluated using the receiver operating characteristic analysis, in which the area under the curve value was determined to be 0.858 (0.780-0.936). The cut-off value of pelvis urine density in the prediction of RPUC positivity was 4.5, at which it had 80% sensitivity and 77.7% specificity. Conclusions: PBUC may not represent true colonization. Although bladder urine culture is negative before the operation, patients with preoperative hydronephrosis and low pelvis urine density may have RPUC growth.

Association of Preoperative mid-stream urine culture, Renal pelvic urine culture and Renal stone culture in the detection of Systemic inflammatory response syndrome/urosepsis post Percutaneous Nephrolithotomy

Introduction: Urosepsis post Percutaneous Nephrolithotomy (PCNL) is a dreaded complication with high mortality rate. Objective: To find the association of preoperative midstream urine culture (PMUC), renal pelvic urine culture (RPUC) and renal stone culture (RSC) in the post-operative development of Systemic Inflammatory Response Syndrome (SIRS) and urosepsis. Methods: It was a prospective cross-sectional observational study. The study included all symptomatic patients meeting the inclusion criteria who underwent Percutaneous Nephrolithotomy from 18th August, 2019 to 28th March, 2020. PMUC, RPUC and RSC were done and analyzed accordingly. Results: A total of 140 (73 males, 67 females) patients underwent PCNL. PMUC was positive in 15% (21/140) as compared to RPUC and RSC which were 7.9 % (11/140) and 4.3% (6/140) of total cases. None of the patients had simultaneous culture positivity in all the three types of specimens. Only two (1.42%) patients had simultaneous positivity in pelvic urine culture and stone culture. The organisms obtained in pelvic urine culture and stone culture were same i.e. Klebsiella and Escherichia coli respectively. Only two (1.42%) patients developed SIRS post PCNL, where in both the cases stone culture were positive but PMUC and RPUC were negative. Urosepsis was found in none of the patients. In the Fischer Exact test PMUC and RPUC were not statistically significant in the detection of SIRS post PCNL. Whereas only RSC showed statistical significance in the detection of SIRS. Conclusion: Stone culture has high prediction for SIRS and it might be considered for patients undergoing PCNL in order to prevent stone related infective complications.

A prospective Comparative Clinical Study on Bladder Urine, Pelvic Urine and Renal Stone Culture & Sensitivity in Predicting Urosepsis Following Percutaneous Nephrolithotomy

Background: Urosepsis means a severe infection of urinary tract (UTI) and/or male genital tract (prostate) with features consistent with systemic inflammatory response syndrome. UTI may occur among all the age groups and produce a broad range of clinical syndromes ranging from asymptomatic bacteriuria to acute pyelonephritis with gram negative sepsis to septic shock. It is estimated that the mortality rate due to urosepsis ranges from 30 to 40 p.c respectively. Urosepsis may also cause multiple organ dysfunction, hypoperfusion or hypotension. Urosepsis due to percutaneous nephrolithotomy may be catastrophic despite prophylactic antibiotic coverage and negative midstream urine culture and sensitivity testing (C&S) and bacteria in the stone can be responsible for systemic infection. The aim of the study is to compare bladder urine (culture & sensitivity) and collecting system urine and stone (culture and sensitivity) in predicting urosepsis following percutaneous nephrolithotomy. Subjects and Methods: A hospital-based, analytical prospective clinical study was conducted among thirty cases who were present during the study period and had undergone percutaneous nephrolithotomy (PCNL). Cases were included irrespective of gender with renal calculi in whom percutaneous nephrolithotomy was about to be done at Narayana Medical College & Hospital, Chintareddypalem, Nellore, Andhra Pradesh during 1st February 2014 to 31st January 2015. Data collected was divided into three main groups Midstream urine (C&S); Pelvic urine (C&S); and Stone (C&S) respectively. Data obtained was entered in Microsoft Excel-2013 and analyzed in SPSS version-22 trial. Appropriate statistical tests were applied and p-value less than 0.05 was considered as significant. Results: Bladder urine (C&S) was positive in 3/30 (10.00%) patients, Pelvic urine (C&S) in 5/30 (16.66 %) patients and Stone (C&S) in 8/30 (26.66 %) patients. Most of the infected specimens grew Escherichia coli followed by pseudomonas, klebsiella, enterococcus. Systemic Inflammatory Response Syndrome (SIRS) was reported among 26.7 p.c (8) of the patients. In one patient (3.33%) septic shock developed but no deaths were reported. Conclusion: Stone (C&S) and Pelvic urine (C&S) are better predictors of urosepsis than Bladder urine (C&S).

Vanin-1 in Renal Pelvic Urine Reflects Kidney Injury in a Rat Model of Hydronephrosis

Urinary tract obstruction and the subsequent development of hydronephrosis can cause kidney injuries, which results in chronic kidney disease. Although it is important to detect kidney injuries at an early stage, new biomarkers of hydronephrosis have not been identified. In this study, we examined whether vanin-1 could be a potential biomarker for hydronephrosis. Male Sprague-Dawley rats were subjected to unilateral ureteral obstruction (UUO). On day 7 after UUO, when the histopathological renal tubular injuries became obvious, the vanin-1 level in the renal pelvic urine was significantly higher than that in voided urine from sham-operated rats. Furthermore, vanin-1 remained at the same level until day 14. There was no significant difference in the serum vanin-1 level between sham-operated rats and rats with UUO. In the kidney tissue, the mRNA and protein expressions of vanin-1 significantly decreased, whereas there was increased expression of transforming growth factor (TGF)-β1 and Snail-1, which plays a pivotal role in the pathogenesis of renal fibrosis via epithelial-to-mesenchymal transition (EMT). These results suggest that vanin-1 in the renal pelvic urine is released from the renal tubular cells of UUO rats and reflects renal tubular injuries at an early stage. Urinary vanin-1 may serve as a candidate biomarker of renal tubular injury due to hydronephrosis.