Staged Percutaneous Nephrolithotomy Results in Lower Rates of Bacteremia/Sepsis and Lower Hospitalization Cost
Jairam R. Eswara, MD, Dianne Sacco, MD.
Massachusetts General Hospital, Boston, MA, USA.
Title: Staged Percutaneous Nephrolithotomy Results in Lower Rates of Bacteremia/Sepsis and Lower Hospitalization Cost
Background: Percutaneous nephrolithotomy (PCNL) is an endoscopic procedure used for the removal of large stones in the kidney through a percutaneous tract. The establishment of percutaneous access to the calyx or renal pelvis is typically performed at the time of the percutaneous surgery or more than 24 hours prior to the surgery (staged PCNL). We looked at the rates of sepsis as well as the difference in hospital cost in patients who had access on the day of PCNL vs. those who had access obtained more than 24 hours prior to surgery.
Methods: We identified 253 patients who underwent PCNL at our institution from 2003-2008. The primary endpoint was bacteremia (fever and positive blood culture) or sepsis (fever and hypotension requiring pressors). All patients had negative urine cultures preoperatively and were treated with antibiotics for 4-7 days prior to surgery. The length of hospital stay (LOS), including ICU stay, was obtained from the medical record. The total cost of hospitalization was estimated from average daily costs of non-ICU and ICU stays related to PCNL during this time period. The rates of bacteremia/sepsis between the two groups were compared by a Fisher’s exact test. A Wilcoxon rank sum test was used to compare LOS and actual total cost between the 2 groups.
Results: Of the 164 patients who had a non-staged PCNL, 11 developed sepsis or bacteremia, leading to ICU admission in 5 patients. Of the 89 patients in the staged PCNL group, none developed sepsis or bacteremia, which was significantly less than the non-staged group (p=0.009). The median LOS for a non-staged PCNL was 3 days (range 0-50 days), and the median LOS for a staged PCNL was 2 days (range 0-14 days) (p=0.008). The median cost of hospitalization for a non-staged PCNL was $3217 (range $1072-53610), which was significantly higher than the median cost of a staged PCNL of $2144 (range $1072-15011) (p=0.006).
Conclusions: We found that the rate of bacteremia and sepsis was significantly lower for patients that had a staged PCNL compared to non-staged PCNL. The median LOS and cost of hospitalization was also significantly lower for the staged PCNL group. These results suggest that staged PCNL is a cost-effective means for reducing rates of bacteremia and sepsis in selected patients.