The efficacy and safety of one-stage transurethral ureteroscopic lithotripsy for the management of ureteral calculi with secondary silent obstructive pyonephrosis / 中华泌尿外科杂志

ABSTRACT

Objective:To explore the efficacy and safety of one-stage transurethral ureteroscopic lithotripsy for the management of ureteral calculi with secondary silent obstructive pyonephrosis.Methods:Retrospective analysis was performed on the clinical data of 32 cases who had ureteral calculi with secondary silent obstructive pyonephrosis and underwent one-stage transurethral ureteroscopic lithotripsy in Peking University International Hospital from January 2018 to May 2020. Of all the 32 patients, 27 were males and 5 were females, with median age of 39.5 years, ranged from 18 years to 76 years.The distribution of stone location included left side in 23 cases and right side in 9 cases.The median stone volume was 138.84 mm 3, ranged from 33.28 mm 3 to 866.32 mm 3.All patients had no fever before surgery, and no obvious infection was indicated by preoperative blood routine, urine routine and urine bacterial culture.All patients underwent one-stage transurethral ureteroscopic lithotripsy and the dignosis of pyonephrosis was made intraoperatively.Purulent urine was collected during the operation for urine routine and bacterial culture test.We first suck out the pus at low pressure through an aspirator, and then turned down the perfusion pressure and flow to the lowest value of the pump.Intermittent low pressure and low flow perfusion combined with negative pressure suction were maintained during the subsequent lithotriptic operation.The double J stent must be indwelt routinely at the end of the operation, and anti-infective drug therapy was started postoperatively.We evaluated the stone free rate by rechecking KUB on the second day after the operation, and urinary CT scan or color ultrasound examination 4-6 weeks after the double J stent was removed.Postoperative infection was evaluated according to the incidence of systemic inflammatory response syndrome(SIRS) and the score of sequential organ failure assessment (SOFA) scale.Complications were graded by a Clavein-Dindo system to evaluate the safety of surgery. Results:All 32 patients underwent one-stage ureteroscopic lithotripsy, and 28 of them completed successfully, with a single-stage stone free rate of 87.5%. The operation time was 11 to 66 minutes, with a median of 28 minutes.During the operation, there were two patients calculi returned to the kidney, one patient had a too narrow ureter, and one patient had a unclear intraoperative visual field to continue the operation.Double J stents were indwelt in all of them at the end of the first stage surgery, and secondary ureteroscopic lithotripsy or flexible ureteroscopic lithotripsy was performed several weeks later. Calculi were cleared in all of them, with a second-stage stone free rate of 100%.Urine routine tests of pyuria collected during the operations showed that the bacterial count was 46-2 488/μl with a median of 295/μl and white blood cell count 57-7 863/μl with a median of 160.5/μl.The bacterial culture results of the pus showed that 22 cases had no bacterial growth and 10 cases had bacterial growth. One patient had fever on the first day after surgery, but the blood culture was negative. The temperature returned to normal after antibiotic treatment and symptomatic treatment for 1 day.There were 6 cases developed to SIRS but no sepsis occurred.No Clavein-Dindo Ⅲ or Ⅳ grade of operative complications occured.Conclusions:Transurethral ureteroscopic lithotripsy is clinically feasible with high stone free rate and no serious postoperative complications for one-stage treatment of ureteral calculi with secondary silent obstructive pyonephrosis for selected cases.Operation time should be shortened and the perfusion pressure and flow should be turned down as low as possible.