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Predicting Sepsis in Patients with Ureteral Stones in the Emergency Department

Margolin, Ezra Joseph; Wallace, Brendan K; Movassaghi, Miyad; Miles, Caleb; Shaish, Hiram; Golan, Ron; Katz, Matthew J; Anderson, Christopher B; Shah, Ojas
BACKGROUND:In the absence of overt infectious signs, clinical criteria for early intervention in patients with ureteral stones are poorly defined. We aimed to develop a model that can identify patients who are at risk for developing sepsis if discharged home from the emergency department (ED). MATERIALS AND METHODS/METHODS:We retrospectively reviewed patients between January 2010 and December 2019 who were discharged from the ED after diagnosis of ureteral stones. The primary outcome was sepsis requiring urgent surgical decompression. We used multivariable logistic regression to identify predictors of sepsis. We refined the model using backwards stepwise regression with a threshold p-value 0.05. RESULTS:We identified 1,331 patients who were discharged from the ED with ureteral stones. Of these patients, 22 (2%) subsequently developed sepsis requiring urgent decompression. In the initial multivariable model, female gender (OR 2.82, p=0.039) and urine white blood cells (WBC) (OR 1.02 per cell count, p<0.001) were predictive of sepsis. After performing backwards stepwise regression, female gender, urine WBC, and leukocytosis (WBC > 15,000/mm3) met criteria for inclusion in the model. A logistic model including these variables predicted sepsis with an internally cross-validated area under the curve of 0.79. Among patients with urine cultures completed in the ED, rates of sepsis were 9% in patients with positive cultures and 1% in patients with negative cultures (p<0.001). Antibiotic usage was not protective against developing sepsis. CONCLUSIONS:Sepsis is a rare complication among patients with ureteral stones selected for conservative management. The presence of elevated urine WBC and female gender can help identify patients who are at risk of developing sepsis. Patients with risk factors should be managed with an increased index of suspicion for infection and may benefit from early intervention to reduce the risk of sepsis. Sepsis is more common in patients with positive urine cultures.
PMID: 35156856
ISSN: 1557-900x
CID: 5175572

Implementation of a Hospital-Wide Protocol Reduces Time to Decompression and Length of Stay in Patients with Stone-Related Obstructive Pyelonephritis with Sepsis

Haas, Christopher R; Smigelski, Michael; Sebesta, Elisabeth M; Mobley, David; Shah, Ojas
PMID: 32668984
ISSN: 1557-900x
CID: 5122052

High Response Rates to Neoadjuvant Chemotherapy in High Grade Upper Tract Urothelial Carcinoma

Meng, Xiaosong; Chao, Brian; Vijay, Varun; Silver, Hayley; Margolin, Ezra J; Balar, Arjun; Taneja, Samir S; Shah, Ojas; Bjurlin, Marc A; Anderson, Christopher B; Huang, William C
OBJECTIVES/OBJECTIVE:To evaluate the impact of cisplatin-based neoadjuvant chemotherapy (NAC) in patients who underwent nephroureterectomy for high grade (HG) upper tract urothelial carcinoma (UTUC). METHODS:Retrospective review was conducted of patients with HG UTUC from 2011 to 2017 who underwent nephroureterectomy at two institutions. Patients with eGFR > 50 mL/min/1.73m2 were considered eligible for NAC and were referred for evaluation of NAC prior to nephroureterectomy. Patient demographics, kidney function, clinical and pathologic response rates and outcomes were analyzed. RESULTS:Of 95 patients with HG UTUC meeting inclusion criteria (mean age 72.3 years, mean pre-op eGFR 57.0 mL/min/1.73m2), 61 patients were considered eligible for NAC with eGFR > 50 mL/min/1.73m2, of which 25 (41%) received NAC. Of the patients who received NAC, 80% (20/25) of patients had clinical response on imaging and 80% (20/25) had pathologic response (<pT2N0 disease) on nephroureterectomy. On final pathology, only 20% of the NAC group had ≥pT2 disease compared to 64% of patients who proceeded directly to surgery (p = 0.001). Patients who received NAC had significantly longer progression free survival (p=0.051) and overall survival (p=0.052) compared to patients who proceeded directly to surgery. No patients progressed or were deemed ineligible for surgery due to NAC. CONCLUSIONS:Cisplatin-based NAC demonstrated a high clinical and pathologic response rate in patients with HG UTUC without compromising definitive surgical treatment. Since nephroureterectomy significantly reduces kidney function and eligibility for cisplatin-based chemotherapy after surgery, patients with HG UTUC should be considered for NAC.
PMID: 30930207
ISSN: 1527-9995
CID: 3783792

Acess to the ureter - flexible ureteroscopy

Chapter by: Shah, Ojas; Silva, Mark
in: Smith's textbook of endourology by Smith, Arthur D; Badlani, Gopal H; Preminger, Glenn M; Kavoussi, Louis R; Rastinehad, Ardeshir R (Eds)
Hoboken, NJ : Wiley-Blackwell, 2019
pp. ?-?
ISBN: 1119241359
CID: 3212002

Discordance Between Ureteroscopic Biopsy and Final Pathology for Upper Tract Urothelial Carcinoma

Margolin, Ezra J; Matulay, Justin T; Li, Gen; Meng, Xiaosong; Chao, Brian; Vijay, Varun; Silver, Hayley; Clinton, Timothy N; Krabbe, Laura-Maria; Woldu, Solomon L; Singla, Nirmish; Bagrodia, Aditya; Margulis, Vitaly; Huang, William C; Bjurlin, Marc A; Shah, Ojas; Anderson, Christopher B
INTRODUCTION/BACKGROUND:We sought to evaluate the discordance between ureteroscopic biopsy and surgical pathology for grading and staging of upper tract urothelial carcinoma (UTUC) and to establish preoperative predictors of aggressive tumors. METHODS:We performed a retrospective review of 314 patients who underwent ureteroscopic biopsy followed by surgical management for UTUC from 2000-2016 at three institutions. Our primary outcomes were muscle-invasive (≥pT2) disease at surgical pathology and upgrading of clinical low-grade (cLG) tumors to pathologic high-grade (pHG). RESULTS:At biopsy, 61% of patients had high-grade (cHG) tumors, and 21% had subepithelial connective tissue invasion (cT1+). On final pathology, 79% had pHG tumors, and 45% had stage ≥pT2. On multivariate analysis, advanced age, cHG, and cT1+ were independently associated with ≥pT2. The combined presence of cHG and cT1+ had a PPV of 86% for muscle invasion, and the combined absence of cHG and cT1+ had a NPV of 80%. The likelihood of missing invasion on biopsy in patients with muscle-invasive disease was increased when biopsy fragments were limited to ≤1mm. Among patients with cLG disease on biopsy, 51% were upgraded at surgery. The presence of positive urine cytology was associated with an increased risk of upgrading; however, this was not statistically significant. CONCLUSIONS:cHG, cT1+ on biopsy, and advanced patient age are independent risk factors for muscle-invasive UTUC. There is a significant risk of upgrading among patients with cLG tumors on biopsy, especially when urine cytology is positive. The predictive value of biopsy can likely be improved by more extensive ureteroscopic sampling.
PMID: 29427584
ISSN: 1527-3792
CID: 2948402

Complications of ureteroscopy for stone disease

Volkin, Dmitry; Shah, Ojas
Ureteroscopy is one of the most commonly performed surgeries for kidney stones and one of the most commonly performed surgeries by urologists overall. Although generally safe, recognizing and understanding the potential complications of ureteroscopy is paramount. Intraoperative complications discussed in this review include difficult access, bleeding, ureteral false passage, perforation, and avulsion. Postoperative considerations discussed include extravasation, infection, postoperative imaging for silent obstruction, and ureteral stricture. We place special emphasis on the management of ureteral stricture, which can be associated with significant morbidity.
PMID: 27441595
ISSN: 0393-2249
CID: 2185522

Evaluation of dusting versus basketing - can new technologies improve stone-free rates?

Weiss, Brian; Shah, Ojas
Over the past two decades, the management of upper-tract urinary stones has dramatically changed towards an increase in the use of ureteroscopic treatment. This change has been driven by technological advances such as the creation of flexible ureteroscopes with reduced calibre (which now have digital, disposable and dual flexion capability) and holmium lasers with increased power. Two basic principles exist when treating stones ureteroscopically: either creating stone dust and small fragments (<1-2 mm) to theoretically enable spontaneous passage of the small particles or stone fragmentation that enables safe extraction of the stone pieces with a basket or grasper in an efficient manner. Each method has unique advantages and disadvantages, but, ultimately, surgeon preference, stone size, composition, location and intrarenal and/or ureteral anatomy determine which technique is used. To date, clinical trials comparing these two techniques are lacking.
PMID: 27698400
ISSN: 1759-4820
CID: 2274012

Defining the Rate of Primary Ureteroscopic Failure in Unstented Patients: A Multi-Institutional Study

Fuller, Thomas W; Rycyna, Kevin J; Ayyash, Omar M; Ferroni, Matthew C; Mitchell, Christopher R; Ohmann, Erin; Wollin, Daniel A; Shah, Ojas; Miller, Nicole L; Semins, Michelle J
PURPOSE: Primary ureteroscopic intervention for kidney or ureteral stones occasionally encounters difficulty with passage of the ureteroscope in the initial procedure. These patients require a second procedure after stenting. We aim to define the contemporary failure rate of primary ureteroscopy (URS) and identify predictive factors that necessitate prestenting. This will assist in preoperative patient counseling, informed consent, and clinical decision-making. MATERIALS AND METHODS: We conducted a multi-institutional retrospective review of 535 unstented patients undergoing primary URS from August 2011 to August 2013. The primary outcome was gaining access to the unstented ureter. RESULTS: The failure rate for accessing the unstented ureter was 7.7% (41/535). The median age of females with primary ureteroscopic failure was significantly lower than in females who had successful ureteroscopic access (34 vs 52 years; p = 0.0041). There was no difference in the median age of males with access vs failure (58 vs 57 years; p = 0.3683). Proximal ureteral stones had the highest failure rate for ureteral access at 18.28% (p = 0.006). On multivariable logistic regression, proximal ureteral stone location remained a significant predictor of failure when compared to renal stones (odds ratio [OR] 3.14, p = 0.006). When including only ureteral stones in the multivariable analysis, stone location in the proximal ureter compared to the distal ureter remained the only significant predictor of access failure (OR 0.24, p = 0.015). CONCLUSIONS: A low overall rate of ureteral access failure in unstented patients is shown. Young female patients and proximal ureteral stones were less likely to be accessed primarily. This study provides information that will help urologists counsel their patients preoperatively regarding their likelihood of failing primary URS necessitating a second procedure. This will also help the patient to make an informed decision during the consent process and may guide urologists on selective prestenting in higher risk patients.
PMID: 27301268
ISSN: 1557-900x
CID: 2237872

Salvage Percutaneous Nephrolithotomy: Analysis of Outcomes Following Initial Treatment Failure

Borofsky, Michael S; Wollin, Daniel A; Reddy, Thanmaya; Shah, Ojas; Assimos, Dean G; Lingeman, James E
INTRODUCTION: Percutaneous Nephrolithotomy (PCNL) has high potential for morbidity or failure. There is limited data regarding risk factors for failure, and no published reports of surgical outcomes among patients with prior failed attempts at percutaneous stone removal. METHODS: Patients referred to three medical centers after prior failed attempts at PCNL were identified. Retrospective chart review was performed analyzing reasons for initial failure and outcomes of salvage PCNL. Outcomes were compared to a prospectively maintained database of over 1200 patients undergoing primary procedures. RESULTS: Thirty-one patients underwent salvage PCNL. Unsuitable access to the stone was the leading reason for failure (80%). Other reasons included infection, bleeding, and inadequate instrument availability (6.5% each). Compared to patients undergoing primary PCNL, those undergoing salvage were more likely have staghorn calculi (61.3% vs. 31.4%, p<0.01), larger maximum stone diameter (3.7 cm vs. 2.5 cm, P<0.01), and require secondary procedures (65.5% vs. 42.1%, p<0.01). There was no significant difference between cohorts for the remainder of demographics or perioperative outcomes. All patients were deemed completely stone free except one who elected to observe a 3 mm non-obstructing fragment. CONCLUSIONS: Despite the more challenging nature and prior unsuccessful attempts at treatment, outcomes of salvage PNL were no different from primary PNL when treated by experienced surgeons.
PMCID:5726404
PMID: 26555954
ISSN: 1527-3792
CID: 1834752

Editorial Comment [Editorial]

Shah, Ojas
PMID: 26577498
ISSN: 1527-9995
CID: 1848542