With the increase in percutaneous interventions such as percutaneous nephrolithotomy (PCNL) for renal lithiasis, infectious complications are becoming more frequent. The present study performed a systematic Medline and Embase databases search, using the following words: ‘PCNL’ [MeSH Terms] AND [‘sepsis’ (All Fields) OR ‘PCNL’ (All Fields)] AND [‘septic shock’ (All Fields)] AND [‘urosepsis’ (MeSH Terms) OR ‘Systemic inflammatory response syndrome (SIRS)’ (All Fields)]. Because of the technological advances in endourology, articles published between 2012 and 2022 were searched. Of the 1,403 results of the search, only 18 articles, representing 7,507 patients in which PCNL was performed, met the criteria to be included in the analysis. All authors applied antibiotic prophylaxis to all patients and, in some cases, the infection was treated preoperatively in those with positive urine cultures. According to the analysis of the present study, the operative time has been significantly longer in patients who developed SIRS/sepsis post-operatively (P=0.0001) with the highest heterogeneity (I2=91%) compared with other factors. Patients with a positive preoperative urine culture had a significantly higher risk of developing SIRS/sepsis following PCNL (P=0.00001), OD=2.92 (1.82, 4.68) and there was also a high degree of heterogeneity (I2=80%). Performing a multi-tract PCNL also increased the incidence of postoperative SIRS/sepsis (P=0.00001), OD=2.64 (1.78, 3.93) and the heterogeneity was a little smaller (I2=67%). Diabetes mellitus (P=0.004), OD=1.50 (1.14, 1.98), I2=27% and preoperative pyuria (P=0.002), OD=1.75 (1.23, 2.49), I2=20%, were other factors that significantly influenced postoperative evolution. A total of two factors analyzed, body mass index and patient's age, did not influence the outcome, P=0.45, I2=58% and P=0.98, I2=63%.
As the prevalence of kidney stone disease rises, a number of patients will need a minimally invasive procedure to remove kidney stones. In the 1970s, percutaneous nephrolithotomy (PCNL) was introduced as a less invasive option for kidney stone removal and it underwent additional development in the following years (
Technical advances have led to a significant reduction in the morbidity and mortality of this surgical technique. However, PCNL is not a risk-free intervention. According to Sharma
The present study performed this meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 reporting guidelines (
Due to the technological advances in endourology, the present study searched articles published between 2012 and 2022. Non-English language articles and those for which the full text was unavailable were excluded. The leading search, as well as screening for eligibility of titles, abstracts and full-text articles, was completed independently by two authors and any discrepancies were solved by consensus.
The present study selected studies with a control group (non-SIRS/sepsis) and analyzed elements that favored the appearance of sepsis after urological maneuvers. These have been patients' age, diabetes mellitus, preoperative pyuria, positive preoperative urine culture, operative time-minutes, multitract and body mass index (BMI).
Heterogeneity in PCNL's infectious complications outcome rate was assessed using I2 statistics. Review Manager (RevMan), Version 5.4.1, and The Cochrane Collaboration, 2020, (both Cochrane) were used to calculate the individual odds ratios (OR), P-value and personal and pooled mean differences with corresponding 95% confidence interval (CI). A P-value <0.05 has been considered statistically significant. The mean difference was used to compare the outcomes following PCNL from the infectious complications point of view. While random-effect models are considered less statistically powerful, they may produce more logical estimates if absolute heterogeneity exists. Furthermore, random-effects models may overestimate the extent of error variance, whereas fixed-effects models may underestimate it. Due to the heterogeneity of the included studies, a fixed effect size would be very implausible. Therefore, a standard random effect model was applied. Considering that all of the included studies were observational, the risk of bias was assessed using the Newcastle-Ottawa quality assessment scale.
Of the 1,403 results of the search, only 18 articles were selected. The flowchart of selection is shown in
All authors applied antibiotic prophylaxis to all patients and in some cases, the infection was treated preoperatively in those with positive urine cultures. According to the analysis of the present study, the operative time has been significantly longer in patients who developed SIRS/sepsis post-operatively (P=0.0001) with the highest heterogeneity (I2=91%) compared with other factors. Patients with a positive preoperative urine culture have a significantly higher risk of developing SIRS/sepsis following PCNL (P=0.00001), OD=2.92 (1.82, 4.68) and there is also a high degree of heterogeneity (I2=80%). Performing a multi-tract PCNL also increases the incidence of postoperative SIRS/sepsis (P=0.00001), OD=2.64 (1.78, 3.93) and the heterogeneity was a little smaller (I2=67%). Diabetes mellitus (P=0.004), OD=1.50 (1.14, 1.98), I2=27% and preoperative pyuria (P=0.002), OD=1.75 [1.23, 2.49], I2=20%, as shown in
PCNL is an increasingly widespread intervention that increases the incidence of complications. According to Ghani
Aging brings changes that can influence patients' immunity. A low-grade inflammatory condition characterizes elderly patients. According to Aiello
A positive bladder urine culture before surgery will lead to better antibiotic prophylaxis, although a complete obstruction of the collecting system can lead to a sterile bladder urine culture. For this reason, some authors suggested that the renal pelvis urine culture could be more reliable for making preoperative prophylaxis. In a cohort of 138 patients, Dogan
On the other hand, to get the renal pelvis urine culture, placing a needle in the collecting system is necessary. After obtaining the urine, the urologist can perform the intervention simultaneously or place a drainage tube until the result is available after ~48 h. The presence of a nephrostomy tube before PCNL is a debatable factor. In a cohort of 217 patients, Aghdas
A complex relationship exists between elevated BMI, kidney stones and urinary tract infections (UTIs). We are witnessing a concomitant increase in the prevalence of kidney stone disease and obesity. According to Poore
Diabetes mellitus, obesity and arterial hypertension are essential elements of metabolic syndrome. Urinary abnormalities indicate a definite association between metabolic syndrome and kidney stones. According to Domingos
In patients with staghorn stones, surgical management can be complex. Performing multiple tracts, PCNL can increase the rate of complications and the period of hospitalization. In a cohort of 27 patients where multiple tract PCNL was performed, Liang
Given the risk of infectious complications, a logical strategy would be to use antibiotic prophylaxis. However, it remains a debatable topic related to the categories of patients who would benefit the most and the treatment regimen, a single preoperative dose or treatment for several days. In a meta-analysis by Yu
According to European Association of Urology recommendations, 2022 edition, the probability of infection during PCNL is high and antibiotic prophylaxis has been demonstrated to minimize the risk for infectious complications significantly with a single dosage being adequate (
From the data of the present study, between 2017-2021, of the 463 cases in which PCNL was performed, 5.18% (n=24) developed postoperative sepsis/SIRS. Of these, 54.2% (n=13) were men and 45.8% (n=11) were women. The stone-free rate was 75% and the overall stone-free rate was 69.11%. The bladder preoperative urine culture was positive in 58.33% (n=14) of patients compared with 25.20% in the non-sepsis group. Also, the preoperative presence of urinary stents was noted more frequently in the sepsis/SIRS group (62.5% vs. 17.71%). The majority (93.33%) had JJ ureteral stents. In all cases, developing sepsis/SIRS symptoms led to a change in the postoperative antibiotic regimen (
The present meta-analysis has some limitations: First, the studies are somewhat heterogenous; the authors came from different continents, the number of patients varied from 60 to 1,030 and renal pelvic urine culture was not available in all cases. Also, the dilatation technique, balloon compared with telescopic/serial dilation, was not known in all studies. Another drawback of the meta-analysis is the need to evaluate the type of kidney stones according to the various scoring systems. Only one of the included studies reported that a higher STONE (Stone size, Tract length, Obstruction, Number of involved calices and Essence or stone density) score correlates significantly with sepsis/SIRS (
Despite this, the present meta-analysis has some strong points. All patients in the included studies underwent the same type of intervention. The outcomes are well defined, SIRS respectively sepsis, or quantified such as WBC, preoperative urine culture, or BMI. Thus, some elements are easy to compare, such as the operative time, which depends on several factors. According to Akman
The present analysis showed that diabetes mellitus, multitract PCNL, pyuria, operative time and positive urine culture are factors that, if not controlled, favor the appearance of SIRS or urosepsis. In some high-risk patients, such as those with diabetes, a history of urinary tract infections, or positive urine cultures, antibiotic prophylaxis should be mandatory and performed for at least one week before surgery.
Not applicable.
Data sharing is not applicable to this article, as no data sets were generated or analyzed during the current study.
DP and CP were responsible for conceiving the study and DP was responsible for the methodology, formal analysis and software. Validation was performed by DP, CP and SG and investigation by GR and SG. Data curation was by SG, GR and VJ. DP, GR and SG wrote the original draft of the manuscript, which was reviewed and edited by VJ and CP. CP and VJ were responsible for visualization and supervision. Data authentication is not applicable. All authors read and approved the final manuscript.
Not applicable.
Not applicable.
The authors declare that they have no competing interests.
PRISMA flowchart of the study selection. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PCNL, percutaneous nephrolithotomy.
Forest plot showing factors influencing the PCNL outcome (Diabetes mellitus, multitract PCNL, preoperative pyuria, operative time and positive preoperative urine culture). Black diamonds indicate study weight. Green squares indicate the overall result. Horizontal lines indicate the 95% confidence interval. CI, confidence interval; df, degrees of freedom; Random, random effects model; SD, standard deviation; PCNL, percutaneous nephrolithotomy; SIRS, Systemic inflammatory response syndrome.
Forest plot showing factors that did not influence the PCNL outcome (BMI and patient's age). Black diamonds indicate study weight. Green squares indicate the overall result. Horizontal lines indicate the 95% confidence interval. PCNL, percutaneous nephrolithotomy; BMI, body mass index; CI, confidence interval; df, degrees of freedom; Random, random effects model; SD, standard deviation; SIRS, Systemic inflammatory response syndrome.
Characteristics of included studies.
Author, year | Factor studied | Number of patients | Analyzed outcome | (Refs.) |
---|---|---|---|---|
Amier |
B,D,E,F | 171 | Sepsis | ( |
Chen |
A,B,C,D,E,F | 802 | Sepsis | ( |
Chhetri |
A,C,D,E,F | 97 | Sepsis | ( |
He |
A,B,C,D,E,G | 1,030 | SIRS | ( |
Koras |
A,D,E,F,G | 303 | SIRS | ( |
Kumar |
B,D,E,F | 320 | SIRS | ( |
Liu |
A,B,D,E,F | 303 | SIRS | ( |
Liu |
A,C,D,F,G | 241 | Sepsis | ( |
Lorenzo Soriano |
A,B,D,E,F,G | 203 | SIRS | ( |
Rashid and Fakhulddin, 2016 | A,D,E, | 60 | Sepsis | ( |
Tabei |
A,B,C,D,E,F,G | 370 | SIRS | ( |
Tang |
A,B,C,D,E,F,G | 758 | SIRS + Sepsis | ( |
Teh and Tham, 2021 | B,C,D,F | 425 | Sepsis | ( |
Wang |
A,D,E,F,G | 843 | Sepsis | ( |
Wei |
A,B,E,F,G | 411 | SIRS | ( |
Xu |
A,B,C,D,E,F,G | 220 | SIRS | ( |
Yang |
A,B,E | 164 | SIRS | ( |
Zhu |
A,B,C,D,E,F,G | 786 | Sepsis | ( |
A, age; B, diabetes mellitus; C, pyuria; D, positive preoperative urine culture; E, operative time-minutes; F, multitract; G, body mass index.
Newcastle-Ottawa scale of included studies.
Author, year | Selection | Comparability | Exposure | Total score | (Refs.) |
---|---|---|---|---|---|
Amier |
**** | *** | 7 | ( |
|
Chen |
*** | * | ** | 6 | ( |
Chhetri |
** | * | *** | 6 | ( |
He |
**** | ** | 6 | ( |
|
Koras |
*** | * | * | 5 | ( |
Kumar |
*** | ** | 5 | ( |
|
Liu |
*** | * | ** | 6 | ( |
Liu |
*** | * | * | 5 | ( |
Lorenzo Soriano |
*** | * | *** | 7 | ( |
Rashid and Fakhulddin, 2016 | **** | ** | 6 | ( |
|
Tabei |
*** | * | ** | 6 | ( |
Tang |
*** | *** | 6 | ( |
|
Teh and Tham, 2021 | *** | * | **** | 8 | ( |
Wang |
**** | * | ** | 7 | ( |
Wei |
*** | * | *** | 7 | ( |
Xu |
*** | ** | 5 | ( |
|
Yang |
*** | * | *** | 7 | ( |
Zhu |
**** | *** | 7 | ( |