Presented by: Ameer Nsair MD
Rambam Health Care Campus

Introduction

Urinary tract infections (UTIs) are a common complication of endourological procedures for stone fragmentation. In a recent meta-analysis, the risk of postoperative urosepsis after ureteroscopy for stone disease is 5%. Risk factors for postoperative urosepsis were older age, diabetes mellitus, ischemic heart disease, preoperative stent placement, a positive urine culture, and longer procedure time. 

Septic shock is a life-threatening subset of sepsis and It’s identified with a clinical construct of sepsis with persisting hypotension requiring vasopressors to maintain MAP ≥ 65 mmHg and having a serum lactate level > 2 mmol/L (18 mg/dL) despite adequate volume resuscitation. With these criteria, hospital mortality is more than 40%. 

The aim of this study is to identify clinical and surgical risk factors for the development of septic shock following ureteroscopy.

Materials

Between January 2010 to December 2021, 5000 patients underwent ureteroscopy in our academic medical center. 20 cases of postoperative septic shock were identified and evaluated retrospectively. A control group of 115 patients were identified that consecutively underwent ureteroscopy during 2021 at our academic medical center and did not develop septic shock. Septic shock was defined as those requiring vasopressors admission due to sepsis following the procedure.

Several preoperative and intraoperative factors have been collected: age, gender, medical history including presence of hypertension, diabetes, ischemic heart disease, malignancy, chronic kidney disease, baseline glomerular filtration rate, baseline creatinine levels and body mass index (BMI).  Presence and type of pre-operative and post-operative drainage, duration of pre-operative drainage, pre-operative culture status and operating time.

All patients completed preoperative workup including complete blood count, blood chemistry and urine culture. In addition, all patients underwent a preoperative non-contrast CT examination of the urinary tract. The stone numbers, location and size were identified.

Results

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The demographic and clinical factors of both groups are presented in Table 1. The septic shock group was significantly older, females comprising about 65% of the group which is about twice the females in the control group. In addition, they had significantly higher BMI, twice as much hypertension and far greater percentage of preoperative positive urine culture with 6 times that of the control group. In addition, the septic shock group had a higher percentage of preoperative drainage and their preoperative drainage duration was significantly higher than their controls. No pattern was identified in the other compared factors.

Multivariate analyses was applied on gender, age, BMI, history of diabetes, hypertension, ischemic heart disease, duration of preoperative drainage and positive urine culture. Multivariate analysis indicated that advanced age, higher BMI and positive preoperative urine culture were statistically significant. The data are presented in Table 2.

Conclusion

Risk factors for the occurrence of urinary septic shock following ureteroscopy include advanced age, higher BMI and previously positive culture. This information can assist in risk stratifying patients for developing this severe infectious complication following ureteroscopy and therefore diagnose septic shock more efficiently in order to provide prompt treatment. Further research preferably multi-centred with a larger cohort is needed to better characterise the risk factors for septic shock following ureteroscopy.

Funding

None

Co-Authors

Michael Mullerad, MD
Rambam Health Care Campus

Oleg Goldin, MD
Rambam Health Care Campus

Gilad Amiel, MD
Rambam Health Care Campus