Pakistan Journal of Surgery & MedicineE-ISSN: 2708-0285P-ISSN: 2708-0277 Vol 1 No 4 (Nov 2020 – Jan 2021) Title Author Study Type Identifier Read From the desk of Chief Editor Anwer A Editorial e230 HTMLPDF An Approach towards Integrated Healthcare System in Punjab, Pakistan Parvez A et al Guest Editorial e231 HTMLPDF Cytokine Storm Syndrome, a Read More ...
Muhammad Farhan Qureshi1, Imran Hussain1
- Assistant Professor, Urology Department, Sheikh Zayed Medical College, Rahim Yar Khan, Pakistan
Corresponding Author: Muhammad Farhan Qureshi, Assistant Professor, Urology Department, Sheikh Zayed Medical College, Hospital Road, Rahim Yar Khan 64200, Pakistan. Contact Author.
Submission: Aug 18, 2020
Acceptance: Mar 07, 2021
Publication: Sep 30, 2021
© Author(s) (or their employer(s) 2021. Re-use permitted under CC BY. No commercial re-use. Published by Pak J Surg Med.
Article Citation: Qureshi MF, Hussain I. Sepsis and stone clearance in ureteric stones managed with uretro-renoscope plus lithoclast with and without DJ stenting. Pak J Surg Med. 2021;2(1):e286. doi: 10.37978/pjsm.v2i1.286
Background: Ureteric Stone is a major health problem all over the world initially Ureteric Stones were managed by open surgery. With the passage of time endoscopy evolved for the treatment of the Ureteric stone. Today ureterorenoscopy + Lithoclast is the standard treatment of the Ureteric stone. In this modality, we have an option to put DJ Stent after ureterorenoscopy and Lithoclast for better clearance of stone but double DJ Stent has a risk of sepsis.
Objective: To determine the frequency of sepsis and stone clearance in ureteric stones managed with ureterorenoscopy + lithoclast with and without DJ stenting.
Study design: Retrospective cohort study
Setting: Department of Urology, Sheikh Zayed Hospital, Rahim Yar Khan.
Duration; January to December 2019.
Methodology: In this study, the cases of either gender with an age range of 15-60 years suffering from a ureteric stone of at least 8 to 15 mm or more assessed on USG KUB, IVP, or CT Pyelogram were included. Utreterorenoscopy was done followed by lithoclast and then DJ stent was placed in group A and no stent in group B of appropriate size. The cases were followed for sepsis based on fever and TLC count and successful stone clearance assessed on USG KUB and X-ray KUB outcome was assessed at the 7th day for infection and the end of four weeks for stone clearance.
Results: In this study, there were 30 cases in each group. The mean age in group A and B was 43.17±8.35 vs 42.89±9.14 years and the mean size of stones was 7.31±2.11 vs 8.07±3.05 mm. There were 18 (60%) vs 16 (53.33%) males and the most common site of stones was distal or lower ureter having 22 (73.34%) vs 19 (63.33%) cases in group A and B respectively. Infection was seen in 2 (6.67%) vs 1 (3.33%) cases in group A and B respectively with p= 0.67. The successful stone passage was observed in 29 (96.77%) cases in group A vs 25 (83.33%) cases in group B with p= 0.34.
Conclusion: Sepsis rate is slightly more in cases managed with DJ stenting as compared to no stenting and reverse is seen in terms of successful stone passage managed with ureterorenoscopy and lithotripsy; this difference of sepsis is statistically non-significant.
Keywords: Ureteric stone, Lithotripsy, DJ stent, Sepsis
Renal stones are a common entity and one of the important etiologies to seek medical or surgical attention. Their prevalence is variable across the globe and that difference can be due to variation in the genetics and distribution of the various risk factors in terms of purity of water and the number of different elements present in the water as well as the dietary habits.[1,2]
Renal stones can present from mild ache to severe pain, fever, and septic shock. The cardinal symptoms of urolithiasis are flank pain, fever, dysuria, acute urinary retention, vomiting or even the patient may present with anuria. In a severe setting due to continuous retrograde pressure, they can result in a permanent need for hemodialysis. Therefore, early diagnosis and prompt treatment is the key to success.
There are multiple invasive and non-invasive treatment modalities each carrying its benefits and side effect profiles. In the past, stones were managed with open surgery, but complications associated with this are immensely reduced with the advent of laparoscopic ureterolithotomy. Dormia baskets for stone removal were also an important tool and extracorporeal shock wave lithotripsy (ESWL) was used under limited circumstances. But now the data is supporting evidence that ureterorenoscopy (URS) and lithoclast is the best option for removal of stones from all sites of ureters with minimal to no side effect profiles. DJ stent is commonly inserted for successful stone passage, but sepsis is a dreadful complication. That’s why this study was planned to see the outcome in cases with or without DJ stents to see for sepsis rate and stone clearance.
Materials and Methods
This retrospective cohort study was conducted at the Department of Urology, Sheikh Zayed Hospital, Rahim Yar Khan after the approval from the ethical committee. The study was conducted to determine the frequency of sepsis and stone clearance in ureteric stones managed with ureterorenoscopy plus lithoclast with and without DJ stenting. Records of patients from January 2019 to December 2019 were accessed. Patients with Ureteric stone 8mm to 15mm diagnosed on ultrasound (USG) kidney-ureter-bladder (KUB), intravenous pyelography (IVP), and CT Pyelogram, age group 15 years to 60 years of either gender, operated on the elective list of urology operation theatre, were included. Patients having preoperative urinary tract infection detected on urine culture were excluded. The subjects were divided into 2 groups; group A consisted of patients of ureteric stones managed with ureterorenoscopy plus lithoclast and DJ Stent whereas patients of Ureteric stone managed with ureterorenoscopy plus lithoclast without DJ Stent were included in group B.
The frequency of sepsis in terms of temperature > 100 Fᵒ and total leukocyte count( TLC ) > 11000, stone clearance on post-operative USG KUB, and X-ray KUB in both groups during four weeks postoperative period were studied. The data was analyzed by using SPSS-version 23.0. Both the groups were compared by using an independent sample t-test for quantitative data and Chi-square tests for qualitative data taking p ≤ 0.05 as significant.
In this study, there were 30 cases in each group. The mean age in group A and B was 43.17±8.35 vs 42.89±9.14 years and the mean size of stones was 7.31±2.11 vs 8.07±3.05 mm respectively as in table I. There were 18 (60%) vs 16 (53.33%) males in groups A and B and the most common site of stones was distal or lower ureter having 22 (73.34%) vs 19 (63.33%) cases in group A and B respectively as in table II. Sepsis was seen in 2 (6.67%) vs 1 (3.33%) cases in group A and B respectively with p= 0.67 and successful stone passage was observed in 29 (96.77%) cases in group A vs 25 (83.33%) cases in group B with p= 0.34 as in table III.
Nephrolithiasis is a global concern and the numbers of cases with renal stones are increasing day by day and hence both primary and secondary preventions are required to avoid unwanted sequels of permanent renal damage. There are multiple modalities but the need for the tool with minimal to no side effect profile is always needed. Postoperative sepsis is one of the important concerns and needs to be addressed after interventions like DJ stenting.[6,7]
In the present study, there were 18 (60%) males in group A and 16 (53.33%) males in group B and showing male dominance with renal stones. This was comparable to the results of the previous studies where they have shown that males are also more affected and according to a study males vs females were seen as 62% vs 38 and in another study by Rasool et al males were seen in 74% cases and females as 26%.[8,9]
The most common site for the ureteric stone was the lower part of the ureter and this was also in line with the results of the previous studies. The study done by Y-El Harrech et al revealed that around 50% of the cases had a distal ureteral stone. They further described that mid-zone stones were the 2nd commonest as was seen in the present study.
In the present study, the infection was seen in 2 (6.67%) vs 1 (3.33%) cases in groups A and B managed with and without DJ stenting respectively with p= 0.67. The data regarding the exact grouping was lacking and it was seen that DJ insertion was negated by the study of Hosking DH and Netto NR, where they found that success of the procedure regarding stone passage is enough with ureterorenoscopy with lithotripsy and they claimed that there is no further need for DJ insertion as it increases the risk of infection.(11,12) The results from another study done by Akmal M et al revealed that post-procedure septic markers in the form of dysuria were observed in 20.40% in the cases without DJ stent and 33.36% with a stent and they also found fever in 7.60% vs 3.06% cases with DJ and without DJ stenting group.(13) The results of the study done by El Harrech et al also revealed that overall post-operative complications were more in the DJ stent group than in the non-DJ stent group, similar results were seen in most of the studies.[10,14–16]
In the present study, the successful stone passage was observed in 29 (96.77%) cases in group A vs 25 (83.33%) cases in group B with p= 0.34. these results were also in line with the study of Akmal et al where they evaluated vice versa and it was seen that failure to pass stone was observed in 5.10% of the cases without DJ stent and 2.17% with a stent with p= 0.28. similar results were noted by the study done by Subhani et al where the DJ stent group results in better stone clearance. The study done regarding the analysis of several RCTs by Wang H et al revealed that DJ stents improve stone clearance, but there is no statistically significant difference in success rate (p > 0.05).
Though infection rate is higher in cases with DJ stent group; but the benefits of increased stone clearance in this group lead to this intervention to compromise with infection rate, because retention stone can be another precursor for infection in situ.
Sepsis rate is more in cases managed with DJ stenting as compared to no stenting and reverse is seen in terms of successful stone passage managed with ureterorenoscopy and lithotripsy; though this difference is statistically non-significant.
- Marberger M. Ureterolithotomy. In: Graham JJ, Glenn J, editors. Glenn’s Urological Surgery. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1998. p. 63–8.
- Tracy CR, Raman JD, Cadeddu JA, Rane A. Laparoendoscopic single-site surgery in urology: where have we been and where are we heading? Nat Clin Pract Urol. 2008 Oct;5(10):561–8.
- Seitz C, Fajkovic H, Waldert M, Tanovic E, Remzi M, Kramer G, et al. Extracorporeal shock wave lithotripsy in the treatment of proximal ureteral stones: Does the presence and degree of hydronephrosis affect success? Eur Urol. 2006 Feb;49(2):378–83.
- Türk C, Petřík A, Sarica K, Seitz C, Skolarikos A, Straub M, et al. EAU Guidelines on Interventional Treatment for Urolithiasis. Eur Urol. 2016 Mar;69(3):475–82.
- Chew BH, Seitz C. Impact of ureteral stenting in ureteroscopy. Curr Opin Urol. 2016 Jan;26(1):76–80.
- Kumar S. Ureteroscopic lithotripsy-skip the stent and spare the patient. Indian J Urol. 2005;21(2):116.
- Duvdevani M, Chew BH, Denstedt JD. Minimizing symptoms in patients with ureteric stents. Curr Opin Urol. 2006 Mar;16(2):77–82.
- Zaki MR, Salman A, Chaudhary AH, Asif K, MUR I. DJ stenting still needed after uncomplicated ureteroscopic lithotripsy? A randomized controlled trial. Pak J Med Sci. 2011;5:121–4.
- Rasool M, Tabassum SA, Pansota MS, Mumtaz F, Saleem MS. Ureterorenoscopic Lithotripsy – Efficacy and Complications. Is Ureteric Stenting Necessary in Every Patient. Ann Pak Inst Med Sci. 2012;8(3):161–4.
- El Harrech Y, Abakka N, El Anzaoui J, Ghoundale O, Touiti D. Ureteral stenting after uncomplicated ureteroscopy for distal ureteral stones: a randomized, controlled trial. Minim Invasive Surg. 2014;2014.
- Hosking DH, McCOLM SE, Smith WE. Is stenting following ureteroscopy for removal of distal ureteral calculi necessary? J Urol. 1999;161(1):48–50.
- Netto NR, Ikonomidis J, Zillo C. Routine ureteral stenting after ureteroscopy for ureteral lithiasis: is it really necessary? J Urol. 2001;166(4):1252–4.
- Akmal M, Subhani GM, Munir MI, Anwar M, Javed SH. Ureterorenoscopy And Lithotripsy with and Without DJ Insertion – Experience at Allied Hospital, Faisalabad. Ann Punjab Med Coll. 2018;12(4).
- Ramsay JWA, Payne SR, Gosling PT, Whitfield HN, Wickham JEA, Levison DA. The effects of double J stenting on unobstructed ureters. An experimental and clinical study. Br J Urol. 1985;57(6):630–4.
- Wang H, Man L, Li G, Huang G, Liu N, Wang J. Meta-analysis of stenting versus non-stenting for the treatment of ureteral stones. PLoS One. 2017;12(1):e0167670.
- Ordonez M, Hwang EC, Borofsky M, Bakker CJ, Gandhi S, Dahm P. Ureteral stent versus no ureteral stent for ureteroscopy in the management of renal and ureteral calculi. Cochrane Database Syst Rev. 2019;(2).
- Subhani GM, Javed SH, Iqbal Z, Akmal M, Mehmood K, Jafari AA, et al. Outcome of Retrograde Ureteroscopy URS for the Management of Ureteric Calculi: Four Years Experience. Ann Punjab Med Coll. 2009;3(1):8–12.
MFQ: Conceptualization, Project administration, Writing – original draft, Writing – review & editing
IH: Data curation, Investigation, Methodology, Formal Analysis, Writing – original draft
This study was approved by the Institutional Review Board of Sheikh Zayed Medical College / Hospital Rahim Yar Khan, Pakistan on 30-03-2020 via letter no 37/IRB/SZMC/SZH.
Conflict of Interest
The author declared no conflict of interest.
This article has been subjected to extensive editing and double blind peer review process. The following editors were involved in editing of this article;
The views and opinion expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any other agency, organization, employer or company.