Complications and treatment aspects of urological stone surgery

ConclusionsPaper I: Complications in Extracorporeal Shock Wave Lithotripsy (ESWL): A cohort study, conclusion: We conclude that there are few complications to modern ESWL treatment. 1 Hz should be used to reduce complications (p=0.025). As there is no indication that 1Hz is less effective than 1.5 Hz, this strongly implies that 1 Hz should normally be the frequency used.Success rate with ESWL alone was high 71.8% (n=1324). Our data indicate that diabetes and larger stone size increase the risk of complications. The need for antiemetics during ESWL is a factor that deserves special consideration and further study. Distal stones seem to have a lower risk of complications (p=0.017).Paper II: A study of clinical complications and possible risk factors for stone surgery - a population based study, conclusions: URS in a modern setting provides excellent results with high SFR and low morbidity. Preoperative stone size 4≤6 mm was 96.2 % (n=176), for stones >6≤10 mm 84.6 % (n=193), and for stones >10 mm was 68.2 % (n=30). Time of day, or the presence of a urological specialized operating nurse does not affect the risk of complications and we found no other significant risk factors for complications. Regarding bacteria, E. coli is the most common in preoperative cultures. In this study the risk of complications increases with age. We conclude that for patients >65 years this should be considered in preoperative counselling.Paper III: Percutaneous nephrolithotomy and modern aspects of complications and antibiotic treatment conclusions: Stone free rate was 65.6% (n=122) which is acceptable and comparable with other studies. This study has a total complication rate of 16%, with approximately 10% being severe. The most common complication of PCNL was infection at 60% (bleeding 5.4%, reoperation 1.6% and pain 0.5%). Our results regarding levels of E. faecalis in cultures, should be validated in a larger cohort, possibly with a higher rate of antibiotic resistance, before a change of guidelines regarding prophylactic antibiotics could be proposed. We conclude that the high prevalence of E. faecalis needs to be considered.Paper IV: Factors influencing stone free rate of Extracorporeal Shock Wave Lithotripsy (ESWL): A cohort study conclusions: We conclude that stone maximum size/stone volume and age have an impact on stone free rate after ESWL. We are puzzled by age being such a strong predictor for SFR, and this needs to be further investigated

Evaluation of the Forsvall biopsy needle in an ex vivo model of transrectal prostate biopsy - a novel needle design with the objective to reduce the risk of post-biopsy infection

Background Transrectal prostate biopsy (TRbx) transfers colonic bacteria into prostatic tissue, potentially causing infectious complications, including sepsis. Our objective was to determine whether biopsy needle shape, surface properties and sampling mechanism affect the number of bacteria transferred through the colon wall, and evaluate a novel needle with improved properties. Methods The standard Tru-Cut biopsy needle used today was evaluated for mechanisms of bacterial transfer in a pilot study. A novel Tru-Cut needle (Forsvall needle prototype) was developed. TRbx was simulated using human colons ex-vivo. Four subtypes of the prototype needle were compared with a standard Tru-Cut needle (BARD 18 G). Prototype and standard needles were used to puncture 4 different colon specimens in 10 randomized sites per colon. Needles were submerged into culture media to capture translocated bacteria. The media was cultured on blood agar and then the total amount of transferred bacteria was calculated for each needle. The primary outcome measure was the percent reduction of bacteria translocated by the prototype needles relative to the standard needle. Secondary outcome measures were the effects of tip design and coating on the percent reduction of translocated bacteria. Results Prototype needles reduced the number of translocated bacteria by, on average, 96.0% (95% confidence interval 93.0-97.7%; p < 0.001) relative to the standard needle. This percent reduction was not significantly affected by prototype needle tip style or surface coating. Conclusions The Forsvall needle significantly reduces colonic bacterial translocation, suggesting that it could reduce infectious complications in prostate biopsy. A clinical trial has been initiated

Perigenital necrotizing soft tissue infection caused by Aerococcus urinae

Aerococcus urinae can cause severe invasive infections emanating from the urinary tract especially in older males with comorbidities. Here we describe a case of an 80 year-old man with multiple comorbidities presenting with a peri-penile abscess and signs of severe infection. Upon incision A. urinae was isolated in pure culture and the infection was cured by a combination of drainage and antimicrobials. This case demonstrates the potential of A. urinae to cause severe soft tissue infections in predisposed individuals

Complications in extracorporeal shockwave lithotripsy : a cohort study

Objective: The aim of this study was to evaluate clinically relevant complications within 14 days after extracorporeal shockwave lithotripsy (ESWL) in a modern setting. Materials and methods: Consecutive ESWL treatments between 2009 and 2015 in Ängelholm Hospital, Sweden, were analyzed retrospectively. The primary outcome was complications in patients seeking medical attention within 14 days after ESWL. Multivariable analysis was used to adjust for confounders such as diabetes, stone size and location, and presence of a urinary stent. Results: In total, 1838 stones were treated: 1185 (64.4%) localized in the renal pelvis, and 415 (22.5%) in the upper two-thirds and 205 (11.1%) in the lower third of the ureter. Overall, 116 out of 1838 cases (6.4%) needed medical attention within 14 days after ESWL and 75 (4%) crequired hospital care. Infection was found in 44 cases (2.4%), with a positive urine culture in 33 cases. Invasive/operative interventions were performed in 41 cases (2.2%). Distal stones had a lower risk of complications (p = 0.02) with ESWL. Diabetes (p = 0.02), larger stones (11–20 mm, p = 0.03; 21–30 mm, p = 0.009) and a need for antiemetics during treatment (p = 0.02) were significantly associated with an increased risk of complications. Conclusions: Few complications are associated with modern ESWL treatment. A frequency of 1 Hz should be used to reduce complications (p = 0.025). Diabetes and larger stone size increase the risk of complications. The need for antiemetics during ESWL requires special consideration and further study. Distal stones seem to carry a lower risk of complications (p = 0.017)

Finding the optimal candidate for shock wave lithotripsy : external validation and comparison of five prediction models

We aimed to externally validate five previously published predictive models (Ng score, Triple D score, S3HoCKwave score, Kim nomogram, Niwa nomogram) for shock wave lithotripsy (SWL) single-session outcomes in patients with a solitary stone in the upper ureter. The validation cohort included patients treated with SWL from September 2011 to December 2019 at our institution. Patient-related variables were retrospectively collected from the hospital records. Stone-related data including all measurements were retrieved from computed tomography prior to SWL. We estimated discrimination using area under the curve (AUC), calibration, and clinical net benefit based on decision curve analysis (DCA). A total of 384 patients with proximal ureter stones treated with SWL were included in the analysis. Median age was 55.5 years, and 282 (73%) of the sample were men. Median stone length was 8.0 mm. All models significantly predicted the SWL outcomes after one session. S3HoCKwave score, Niwa, and Kim nomograms had the highest accuracy in predicting outcomes, with AUC 0.716, 0.714 and 0.701, respectively. These three models outperformed both the Ng (AUC: 0.670) and Triple D (AUC: 0.667) scoring systems, approaching statistical significance (P = 0.05). Of all the models, the Niwa nomogram showed the strongest calibration and highest net benefit in DCA. To conclude, the models showed small differences in predictive power. The Niwa nomogram, however, demonstrated acceptable discrimination, the most accurate calibration, and the highest net benefit whilst having relatively simple design. Therefore, it could be useful for counselling patients with a solitary stone in the upper ureter

Rate and characteristics of infection after transrectal prostate biopsy : a retrospective observational study

Objectives: The aim of this study was to assess the incidence of infection after transrectal prostate biopsy (TRbx). Secondary objectives were to describe infection characteristics, antibiotic resistance patterns, ICD-10 coding, and costs. Methods: TRbx carried out at the hospitals of Ängelholm and Helsingborg, Scania, Sweden, between October 2017 and March 2019, were identified based on the NOMESCO Classification of Surgical Procedures code for TRbx, TKE00. All patients received per oral antibiotic prophylaxis, usually 750 mg ciprofloxacin at biopsy. Other preventative measures were not used. Medical care within 30 days of the biopsy was evaluated through a manual retrospective medical chart review. Data on patient and infection characteristics were collected. The costs of infections causing hospitalization were estimated. Results: After 36 (5.4%) of 670 biopsies, the patient developed post-biopsy infection within 30 days after TRbx. Twenty-six patients (3.9%) required hospitalization for an average of 6 days, at an estimated direct cost of USD 9174 (EUR 8031) per patient. Nine patients (1.3%) had a complicated infection leading to intensive care, multiple hospitalizations or emergency department visits. The inpatient care episodes for the 26 hospitalized patients were categorized with 15 different ICD-codes. In 6 episodes no ICD-code related to infection was used. Conclusions: In this study, we found an infection rate of 5.4% after TRbx; 3.9% of the patients were hospitalized for a post-TRbx infection and 1.3% had complicated infections. A specific ICD code for post-TRbx infections would facilitate evaluation and monitoring of this common, costly, and sometimes serious complication

Ureteroscopy : A population based study of clinical complications and possible risk factors for stone surgery

Introduction The aim of this study was to describe the complications of ureteroscopy (URS) and to investigate whether performing URS outside normal working hours leads to increased risk for clinically significant complications. Material and methods A cohort of 486 consecutive patients treated with URS, with a total of 567 sessions between 2009 and 2015 at Helsingborg/Ängelholm Hospital, Sweden, was analyzed. Outcome was complications within 14 days after URS treatment. Results We found no increased risk of complications related to URS performed outside normal working hours. Stone-free rate (SFR) in the distal third of the ureter was 95.2% (315/331), in the middle ureter 92.8% (90/97), in the proximal ureter 84.0% (63/75) and 69.0% (40/58) in renal pelvis. The overall complication rate was 10.6% (n = 60). None of the potential risk factors for complications showed any significance when adjusted for age and gender. We found an inverse relationship between stenting and SFR (p = 0.002). The most common preoperatively cultured bacteria was Escherichia coli. With adequate antibiotics, there was no increased risk of complications. There was an increased risk of complications after URS related to age, but not with gender. Conclusions URS in modern setting provides excellent results with adequate SFR and low morbidity. Time of day, the presence of urological specialized operating nurses did not affect the risk of complications and we found no other significant risk factors for complications. Escherichia coli was the most commonly found bacteria in preoperative cultures. The risk of complications increases with age. For patients >65 years old, this should be considered in preoperative counseling

Percutaneous nephrolithotomy and modern aspects of complications and antibiotic treatment

Objective: The incidence of urinary stones is increasing across the globe. Surgical treatment includes extracorporal shock-wave lithotripsy (ESWL), ureterolithotripsy (URS), percutaneous nephrolitotomy (PCNL) and rarely open surgery. This single center study describes complications to PCNL focusing on infections, bacterial growth/resistance and antibiotic prophylaxis/treatment. Materials and methods: All patients treated for kidney stones with PCNL at Ängelholm Hospital in north-western Scania, Sweden from January 2009 to December 2015 were included. A dipstick test and a bacterial culture was made on all patients. Kidney stones were analysed for composition and cultured for bacteria. Results: In total, 186 patients underwent PCNL, all receiving perioperative antibiotics. Thirty percent (56/186) had a positive urinary culture taken before surgery and 33.3% (62/186) had positive stone culture. The concordance between urinary and stone culture was 57.1%. Both positive stone and urinary culture increased the risk of complications after surgery (p = 0.002 and p = 0.017, respectively). Complications occurred in 16% (30/186). Eight patients (4.3%) developed sepsis. The most common bacteria in urine were Enterococcus faecalis and Escherichia coli, both 20%. The most common stone-bacteria reported was Enterococcus faecalis (26%). Conclusion: This study has a total complication rate of 16%, approximately 10% of those are severe. The most common complication to PCNL was infection (60%), followed by bleeding (5.4%), reoperation (1.6%) and pain (0.5%). The high prevalence of E. faecalis might need to be considered, however the results should be validated in a larger cohort, possibly with a higher rate of antibiotic resistance, before a change of guidelines regarding prophylactic antibiotics could be proposed

Prostate biopsy quality and patient experience with the novel Forsvall biopsy needle–a randomized controlled non-inferiority trial

Background: Transrectal prostate biopsy (TRbx) carries an increasing risk of infection. The Forsvall Needle Prototype (FNP) is a novel biopsy needle that reduces bacterial load brought across the rectum and may therefore reduce infection risk. The objective of this study was to compare biopsy length, quality and patient experience for the FNP Version 2 (FNP2) versus a standard Tru-Cut needle. Methods: We conducted a randomized, parallel-group, non-inferiority trial with twenty consecutive patients eligible for TRbx. Participants were randomized to undergo TRbx using either FNP2 or a standard Tru-Cut needle. The primary outcome was difference in mean biopsy lengths measured by the pathologist. FNP2 biopsy lengths ≤1.35 mm of the standard needle length were considered non-inferior. Secondary outcomes were biopsy length in the needle chamber and immediately after removal, biopsy quality, biopsy fragmentation, patient discomfort/pain, and complications (immediate and after 14 and 30 days). Results: Mean pathologist-measured FNP2 biopsy length was non-inferior compared to the standard Tru-Cut needle (0.02 mm longer, 95%CI–0.73 to 0.76 mm). Biopsy length in the needle chamber and immediately after removal were also non-inferior. Biopsy quality and patient discomfort were not significantly different for the FNP2 and the standard Tru-Cut needle. Biopsy fragmentation was more common in the FNP2 group. Conclusions: The FNP2 biopsy needle is non-inferior to the Tru-Cut needle in terms of biopsy length and not significantly different in terms of biopsy quality and patient experience. Future studies will evaluate the Forsvall needle design’s effect on post-biopsy infection risk

Factors influencing stone-free rate of Extracorporeal Shock Wave Lithotripsy (ESWL); a cohort study

Objective: To evaluate the success rate of Extracorporeal Shock Wave Lithotripsy (ESWL) therapy and identify relevant treatment-specific factors affecting stone-free rate (SFR) after ESWL. Materials and methods: All ESWL treatments in the years 2016–2019, in Ängelholm Hospital, Skåne, Sweden were analysed retrospectively. Primary outcome was stone-free rate (SFR) at 3 months. Univariate logistic regression was used followed by multivariable regression. Lasso analysis was made to adjust for treatment-specific factors such as age, stone size, skin-to-stone distance (SSD), stone attenuation, number of treatments, stone location and presence of a urinary stent. Results: Factors affecting successful ESWL treatment were lower age (p < 0.001), smaller stone size and volume (both p = 0.001). SSD, stone attenuation, sex, laterality and drainage did not have an effect on SFR in this study. After the first ESWL treatment session, 46.7% of the patients were stone-free. Conclusion: Results indicate that stone size and age are the most predictive factors for ESWL outcome. Based on this, we present a simple model for prediction of SFR after ESWL, to be used when counseling patients before ESWL treatment