Sepsis and stone clearance in ureteric stones managed with uretro-renoscope plus lithoclast with and without DJ stenting

Muhammad Farhan Qureshi1, Imran Hussain1

  1. 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

Abstract

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

Introduction

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.[3]
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.[4] 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.[5] 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.

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 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.

Table I. Quantitative variables of the study (n= 30 each)
Table II. Qualitative variables of the study
Table III. Outcome comparison of both groups

Discussion

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.[10]
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.[17] 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).[15]
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.

Conclusion

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.

References

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Author CRediT

MFQ: Conceptualization, Project administration, Writing – original draft, Writing – review & editing
IH: Data curation, Investigation, Methodology, Formal Analysis, Writing – original draft

Ethical Consideration

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.

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