Blackmur James P, Maitra Neil U, Marri Rajendar R, Housami Fadi, Malki Manar, McIlhenny Craig
1 Urology Department, Forth Valley Royal Hospital , Scotland, United Kingdom .
2 Urology Department, Monklands Hospital , Lanarkshire, Scotland, United Kingdom .
J Endourol. 2016 Sep;30(9):963-9. doi: 10.1089/end.2016.0300. Epub 2016 Jul 13.
To investigate which patient, stone, infective, and surgical factors were most likely to increase the risk of postoperative urosepsis within 28 days of ureteroscopy (URS) and laser stone fragmentation for ureteral or renal stones.
Data were collected prospectively in a single National Health Service institution. A logistic regression model was used to assess the association of factors with postoperative urosepsis. Two matched-pair analyses were used to assess the risk of postoperative urosepsis in patients with (a) an emergency presentation to hospital with urosepsis in the 90 days preceding URS and (b) a positive midstream sample of urine (MSSU) identified, but who were asymptomatic at preoperative assessment, who then received an appropriate course of antibiotics.
Four hundred sixty-two consecutive patients were included in the study. Thirty-four patients (7.4%) had an episode of urosepsis within 28 days of their operation. A positive preoperative MSSU was significantly associated with postoperative urosepsis on multivariable analysis, despite appropriate treatment with a preoperative course of antibiotics: odds ratio (OR) 4.88, 95% confidence interval (CI) 2.11, 11.31, p < 0.001. The presence of diabetes mellitus, presence of ischemic heart disease, patient American Society of Anesthesiologists score, same-session bilateral URS, and stone volume were the other variables significantly associated with postoperative infection on univariable analysis, but these ceased to be significantly associated on multivariable analysis. Subgroup analysis found that a positive MSSU in both patients with a preoperative ureteral stent and those without was significantly associated with postoperative urosepsis, however, the OR was much lower for the stented group (OR 3.23 vs OR 16.67). On matched-pair analysis, patients with a positive preoperative MSSU were significantly more likely to have postoperative urosepsis compared to controls (OR 17.46, 95% CI 2.18, 139.80, p = 0.007). There was no significant difference in the OR of postoperative urosepsis in patients who had a preceding urine infection requiring hospital admission in the 90 days preceding URS (OR 0.60, 95% CI 0.19, 1.92, p = 0.39).
Positive preoperative MSSU was significantly associated with postoperative urosepsis by logistic regression and matched-pair analysis. These higher risk patients should be counseled appropriately before surgery, and should be the focus of vigilant postoperative monitoring. The study suggests particular caution in patients with a positive preoperative MSSU without a preoperative ureteral stent.
探讨哪些患者因素、结石因素、感染因素和手术因素最有可能增加输尿管镜检查（URS）及输尿管或肾结石激光碎石术后28天内发生尿脓毒症的风险。
在一家单一的国民医疗服务机构中前瞻性收集数据。采用逻辑回归模型评估各因素与术后尿脓毒症的关联。采用两种配对分析来评估以下两类患者术后发生尿脓毒症的风险：（a）在URS前90天因尿脓毒症紧急入院的患者；（b）术前中段尿样本（MSSU）检测呈阳性，但术前评估无症状，随后接受了适当疗程抗生素治疗的患者。
该研究纳入了462例连续患者。34例患者（7.4%）在术后28天内发生了尿脓毒症。多变量分析显示，尽管术前进行了适当疗程的抗生素治疗，但术前MSSU检测呈阳性与术后尿脓毒症显著相关：比值比（OR）为4.88，95%置信区间（CI）为2.11至11.31，p < 0.001。单变量分析中，糖尿病的存在、缺血性心脏病的存在、患者美国麻醉医师协会评分、同期双侧URS以及结石体积是与术后感染显著相关的其他变量，但在多变量分析中这些变量不再显著相关。亚组分析发现，术前放置输尿管支架和未放置输尿管支架的患者中，MSSU检测呈阳性均与术后尿脓毒症显著相关，然而，放置支架组的OR值要低得多（OR为3.23，而未放置支架组为16.67）。配对分析显示，术前MSSU检测呈阳性的患者与对照组相比，术后发生尿脓毒症的可能性显著更高（OR为17.46，95% CI为2.18至139.80，p = 0.007）。在URS前90天因尿感染需入院治疗的患者中，术后尿脓毒症的OR值无显著差异（OR为0.60，95% CI为0.19至1.92，p = 0.39）。
通过逻辑回归和配对分析，术前MSSU检测呈阳性与术后尿脓毒症显著相关。对于这些高风险患者，术前应给予适当的咨询，并且应作为术后密切监测的重点。该研究表明，对于术前MSSU检测呈阳性且未放置术前输尿管支架的患者应格外谨慎。
