University of Manitoba
Nephrostomy tube vs. ureteral stent for obstructing septic calculi: A nationwide propensity score matched analysis
Rachel Wong1, Sylvain Lother2,3, Premal Patel1, Barret Rush2.
1Section of Urology, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada; 2Section of Critical Care Medicine, Department of Medicine , University of Manitoba, Winnipeg, MB, Canada; 3Section of Infectious Diseases, Department of Medicine , University of Manitoba, Winnipeg, MB, Canada
Sepsis secondary to obstructive uropathy is a Urological emergency associated with significant mortality and morbidity. Decompression with retrograde placement of a ureteric stent (US) or a percutaneous nephrostomy tube (PCN) remains the gold standard of treatment in conjunction with fluid resuscitation and antibiotics. Prior literature suggests that advantages to PCN include higher insertion success rate as well as a shorter procedural time, which may account for the benefit in mortality. However, scant data exists regarding the optimal method of decompression.
Utilizing the National Inpatient Sample (NIS) database from 2006-2014 we included patients ≥18 years of age with a diagnosis of sepsis and a ureteral/renal calculi that underwent US or PCN. A multivariate logistic regression model predicting in-hospital mortality was created incorporating the 29 Elixhauser comorbidities, hemodialysis, shock, and mechanical ventilation. Additionally, a propensity score matched cohort was created based on the propensity to receive each treatment.
Of these, 9,828 (28.9%) patients underwent ureteral stenting and 24,181 (71.1%) underwent PCN. The unadjusted mortality rate for US patients was 2.8% compared to 5.3% in the PCN group (p<0.01). Patients who received US were more likely to be female (61.7% vs 53.8%, p<0.01) and White (69.3% vs 64.5%, p<0.01,Table 1). After adjustment for baseline characteristics, US compared to PCN was associated with a lower risk of mortality (OR 0.72, 95% CI 0.63-0.83, p<0.01). After matching patients based on propensity score, the mortality rate for patients who received a US was 3.5% compared to 3.9% in the PCN group (p=0.26).
This large national analysis demonstrates that US placement in septic obstructive uropathy is associated with lower mortality compared to PCN. After propensity score matching this finding was no longer statistically significant. Further prospective randomized trials are needed to address this important clinical question.
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