Readmission After Ureteroscopy for Patients Stented Due to Febrile UTI with Obstructing Stone
Alexander J. Bandin, MD, Benjamin Press, MD, Jeremy E. Green, BA, Adam E. Ludvigson, MD, Thomas V. Martin, MD, Piruz Motamedinia, MD.
Yale New Haven Hospital, New Haven, CT.
Background
Patients presenting with an obstructing ureteral stone and signs of infection represent a surgical emergency, requiring urgent decompression. Patients who have a ureteral stent placed in this setting often undergo ureteroscopy (URS) for definitive stone management following recovery. For these patients we postulated an increased risk for postoperative infectious complications and higher rates of readmission than those published in the literature for all-comers undergoing URS (2-7%).
Methods
A retrospective chart review was conducted at two hospitals associated with an academic medical center. After IRB approval, electronic medical records were reviewed from February 2012-June 2019. All patients who had a documented fever >100.4º F and underwent a ureteral stent (CPT 52332) for obstructing stone were reviewed. Exclusion criteria included age <18 years, lack of subsequent URS, time to URS > 6 months from stent placement, pregnancy, and non-stone indication for stent (UPJ obstruction, malignant obstruction, etc). Variables collected included Charlson Comorbidity Index (CCI), medical comorbidities, laboratory values, vital signs, and illness severity during initial presentation (QSOFA, ICU admission rates), as well as the use of access sheath, laser, and postoperative antibiotics at the time of definitive URS.
Results
135 patients were included in the study, of whom 18 patients (13.3%) required unplanned admission within 30 days after URS. 13 of those patients (9.6%) were admitted for symptomatic UTI. Of these 13 patients, 23% became septic in the PACU, 23% required ICU admission, and 15% required postoperative vasopressors. Average time to readmission was 5.4 days for patients who were discharged home after URS. Average length of readmission was 3.7 days. A documented history of UTIs aside from the event prompting initial stent placement was a significant predictor of readmission following URS (p = 0.009). Female gender (p = 0.055), systolic hypotension <100 mmHg during initial presentation (p = 0.085), and a return visit for symptomatic UTI (p = 0.085) did not achieve significance. Age, CCI, diabetes, stone size, initial illness severity (ICU admission, pressor requirement, QSOFA score, bacteremia), stent dwell time, postoperative antibiotics, and stone composition did not impact readmission rates.
Conclusions
Patients who exhibit signs of infection coincident with an obstructing ureteral stone are at high risk of unplanned admission following URS for stone clearance. This risk is significantly increased for patients who have a prior history of recurrent UTIs. Patients who are readmitted have a high rate of severe illness requiring ICU-level care. Consideration should be given to closer post-operative follow-up or overnight monitoring for these patients, and they should be counseled appropriately about their elevated risk.
| Unplanned admission <30 days for symptomatic UTI | No (122) | Yes (13) | Total Sample | P value |
| Age (years) at stent | 61.1 (15.9) | 59.8 (13.3) | 61 (15.6) | 0.786 |
| Male | 33.6% | 7.7% | 31.1% | 0.056 |
| CCI | 2.94 (2.68) | 2.77 (2.17) | 2.93 (2.63) | 0.822 |
| Diabetic | 29.5% | 46.2% | 31.1% | 0.221 |
| Prior UTI history | 21.3% | 53.8% | 24.4% | 0.009 |
| Size of stone (mm) | 7.27 (3.99) | 6.67 (3.09) | 7.22 (3.91) | 0.611 |
| ICU admission | 20.5% | 15.4% | 20.0% | 0.664 |
| Pressors | 10.7% | 15.4% | 11.1% | 0.609 |
| Bacteremic | 31.1% | 46.2% | 32.6% | 0.276 |
| Tmax (ºF) before stent | 102.0 (1.3) | 101.5 (1.1) | 102 (1.3) | 0.194 |
| Systolic BP <100 mmHg | 36.9% | 61.5% | 39.3% | 0.085 |
| QSOFA | 0.84 (1.00) | 1.31 (1.11) | 0.89 (1.02) | 0.12 |
| Return for UTI between stent and ureteroscopy | 8.2% | 23.1% | 9.6% | 0.085 |
| Sterile preop urine culture | 61.5% | 61.5% | 61.5% | 0.996 |
| Time since stent (days) | 42.8 (30.5) | 47.9 (27.7) | 43.3 (30.2) | 0.564 |
| Ureteral access sheath | 42.6% | 30.8% | 41.5% | 0.413 |
| Laser use | 63.1% | 69.2% | 63.7% | 0.666 |
| Operative time (min) | 49.8 (34.2) | 45.6 (27.0) | 49.4 (33.6) | 0.667 |
| Post-op antibiotics | 65.6% | 84.6% | 67.4% | 0.166 |
| Predominantly infectious stone (brushite, struvite) | 31.1% | 22.2% | 30.4% | 0.584 |
| Categorical variables tested using Pearson''s chi squared analysis listed as % | ||||
| Nominal variables tested using independent t-test listed as mean (SD) | ||||
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