Department of Urology, National University Hospital, Singapore.
Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
Int J Urol. 2022 Dec;29(12):1488-1496. doi: 10.1111/iju.15023. Epub 2022 Sep 7.
To identify predictive factors for the development of sepsis/septic shock postdecompression of calculi-related ureteric obstruction using the Sequential Organ Failure Assessment (SOFA) score and to compare clinical outcomes and odd risk ratios of patients developing sepsis/septic shock following the insertion of percutaneous nephrostomy (PCN) versus insertion of retrograde ureteral stenting (RUS).
Clinico-epidemiological data of patients who underwent PCN and/or RUS in two institutions for calculi-related ureteric obstruction were retrospectively collected from January 2014 to December 2020.
537 patients (244 patients in PCN group, 293 patients in RUS group) from both institutions were eligible for analysis based on inclusion and exclusion criteria. Patients with PCN were generally older, had poorer Eastern Cooperative Oncology Group status, and larger obstructive ureteral calculi compared to patients with RUS. Patients with PCN had longer durations of fever, the persistence of elevated total white cell and creatinine, and longer hospitalization stays compared with patients who had undergone RUS. RUS up-front has more unsuccessful interventions compared with PCN. There were no significant differences in the change in SOFA score postintervention between the two interventions. In multivariate analysis, the higher temperature just prior to the intervention (adjusted odds ratio [OR]: 2.039, p = 0.003) and Cardiovascular SOFA score of 1 (adjusted OR:4.037, p = 0.012) were significant independent prognostic factors for the development of septic shock postdecompression of ureteral obstruction.
Our study reveals that both interventions have similar overall risk of urosepsis, septic shock and mortality rate. Despite a marginally higher risk of failure, RUS should be considered in patients with lower procedural risk. Patients going for PCN should be counseled for a longer stay. Post-HDU/-ICU monitoring, inotrope support postdecompression should be considered for patients with elevated temperature within 1 h preintervention and cardiovascular SOFA score of 1.
使用序贯器官衰竭评估（SOFA）评分确定结石相关输尿管梗阻减压后发生脓毒症/脓毒性休克的预测因素，并比较经皮肾造瘘术（PCN）与逆行输尿管支架置入术（RUS）后发生脓毒症/脓毒性休克的患者的临床结局和比值比。
回顾性收集 2014 年 1 月至 2020 年 12 月在两家机构因结石相关输尿管梗阻而行 PCN 和/或 RUS 的患者的临床流行病学数据。
根据纳入和排除标准，来自这两家机构的 537 名患者（PCN 组 244 名，RUS 组 293 名）符合分析条件。与 RUS 组相比，行 PCN 的患者年龄较大，东部合作肿瘤学组（ECOG）状态较差，梗阻性输尿管结石较大。与接受 RUS 的患者相比，行 PCN 的患者发热时间较长，白细胞和肌酐持续升高，住院时间较长。与 PCN 相比，RUS 首次介入的成功率较低。两种干预措施后 SOFA 评分的变化无显著差异。多变量分析显示，干预前较高的体温（调整后的优势比[OR]：2.039，p=0.003）和心血管 SOFA 评分 1（调整后的 OR：4.037，p=0.012）是梗阻性输尿管减压后发生脓毒性休克的独立预测因素。
本研究表明，两种干预措施发生尿脓毒症、脓毒性休克和死亡率的总体风险相似。尽管失败的风险略高，但对于低手术风险的患者，应考虑 RUS。对于行 PCN 的患者，应告知其住院时间较长。在 HDU/-ICU 监测后，对于干预前 1 小时内体温升高和心血管 SOFA 评分 1 的患者，应考虑在减压后使用血管活性药物支持。
