Neuromuscular Disorders Predisopose Patients to Urosepsis after PCNL: Efficacy of Staged PCNL
Jairam R. Eswara, MD, Dianne Sacco, MD.
Massachusetts General Hospital, Boston, MA, USA.
Title: Neuromuscular Disorders Predisopose Patients to Urosepsis after PCNL: Efficacy of Staged PCNL
Background: Neuromuscular disorders (ND) have been shown to predispose patients to stone formation and higher rates of complications from percutaneous nephrolithotomy (PCNL). We looked at the rates of urosepsis as well as the difference in hospital cost at our institution in patients who have ND compared with those who did not. We also determined whether delaying PCNL 24 hours or more from percutaneous access (staged PCNL) reduced these rates.
Methods: We identified 253 patients who underwent PCNL at our institution from 2003-2008. The primary endpoint was urosepsis defined as 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 urosepsis (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 33 patients with ND who underwent PCNL, 6 developed sepsis or bacteremia, leading to ICU admission in 3 patients. Of the 220 patients who had no ND, 5 developed sepsis or bacteremia, leading to ICU admission in 2 patients. The rate of urosepsis was significantly higher in the ND group (p=0.0009) with an odds ratio of 9.56. The median LOS for those with ND was 4 days (range 0-50 days), and the median LOS for those without ND was 2 days (range 0-10 days) (p=0.005). The median cost of hospitalization for patients with ND was $4289 (range $1072-50611), which was significantly higher than the median cost of PCNL in those without ND of $2144 (range $1072-17662) (p=0.004). 33% (6/18) of ND patients who underwent a non-staged PCNL developed bacteremia/sepsis compared to 0% (0/15) in the staged PCNL group (p=0.02).
Conclusions: We found that the rate of urosepsis was significantly higher for patients who had ND compared to those who did not. The median LOS and cost of hospitalization was also significantly higher for the ND group. Performing a staged PCNL reduced the rate of urosepsis in ND patients. These results suggest that additional measures to prevent urosepsis must be taken in performing PCNL in patients with ND, and that staged PCNL is a cost-effective means for reducing rates of urosepsis in ND patients.