Department of Urology and Columbia University Irving Medical Center/NewYork Presbyterian Hospital, New York, New York, USA.
Department of Radiology, Columbia University Irving Medical Center/NewYork Presbyterian Hospital, New York, New York, USA.
J Endourol. 2021 Jan;35(1):77-83. doi: 10.1089/end.2020.0626. Epub 2020 Sep 7.
Patients with obstructive pyelonephritis (OPN) require urgent decompression through retrograde ureteral stent (RUS) or percutaneous nephrostomy (PCN). In 2016, the urology and interventional radiology (IR) departments at our institution established a protocol for patients with OPN with sepsis. The primary objectives were to assess this protocol's impact on improving time to decompression and whether more expedient decompression decreased length of stay (LOS). Secondarily, we assessed the impact of the protocol and clinical factors on receipt of PCN over RUS. One hundred forty-seven patients at our institution who underwent PCN from 2012 to 2017 or stent from 2014 to 2017 for stone-related OPN meeting sepsis criteria were retrospectively reviewed. Univariate descriptive statistics compared patient characteristics and outcomes between RUS and PCN pre- and postprotocol implementation. Multivariable logistic regression assessed predictors of decompression with PCN ( RUS) and of prolonged LOS (pLOS; >5 days). Utilization of PCN increased after implementation of the protocol from 4 to 14 PCN/year with a decrease in the median time from urologic consultation to PCN from 9.2 to 4.3 hours ( = 0.001) with overall median time to decompression decreasing from 5.4 to 4.5 hours ( = 0.017). Predictors of undergoing PCN ( RUS) included increasing comorbidity and ≥1 cm obstructing stone. On multivariable analysis controlling for comorbidity, leukocytosis, and septic shock, increasing hours to decompression increased odds of pLOS (1.08, 95% confidence interval 1.02-1.15, = 0.014). After implementing our OPN with sepsis protocol, time to decompression decreased with dramatic improvement in time to PCN. Quicker decompression was independently associated with reduced odds of prolonged hospital stay. A well-designed protocol engages both urology and IR in the management of these acutely ill patients and improves outcomes.
患有梗阻性肾盂肾炎（OPN）的患者需要通过逆行输尿管支架（RUS）或经皮肾造口术（PCN）进行紧急减压。2016 年，我院泌尿科和介入放射科（IR）为患有败血症的 OPN 患者制定了一项方案。主要目标是评估该方案对改善减压时间的影响，以及更迅速的减压是否会缩短住院时间（LOS）。其次，我们评估了该方案和临床因素对接受 PCN 而不是 RUS 的影响。对我院 2012 年至 2017 年接受 PCN 或 2014 年至 2017 年接受支架治疗符合败血症标准的结石相关 OPN 患者进行回顾性分析。在方案实施前后，采用单变量描述性统计比较 RUS 和 PCN 患者的特征和结局。多变量逻辑回归评估接受 PCN（RUS）和 LOS 延长（pLOS；>5 天）的预测因素。该方案实施后，PCN 的使用率从每年 4 例增加到 14 例，泌尿科咨询至 PCN 的中位时间从 9.2 小时减少至 4.3 小时（=0.001），总体减压中位时间从 5.4 小时减少至 4.5 小时（=0.017）。接受 PCN（RUS）的预测因素包括合并症增加和≥1cm 梗阻性结石。多变量分析控制合并症、白细胞增多和感染性休克后，减压时间增加与 pLOS 的几率增加相关（1.08，95%置信区间 1.02-1.15，=0.014）。在实施 OPN 伴败血症方案后，减压时间缩短，PCN 时间明显改善。更快的减压与降低 LOS 延长的几率独立相关。精心设计的方案可使泌尿科和 IR 共同参与这些急危重症患者的管理，改善结局。
