Introduction: Patients with obstructive pyelonephritis (OPN) with sepsis require urgent decompression via retrograde ureteral stenting (RUS) or nephrostomy tube (NT). In 2016, the urology and IR departments at our institution enacted a protocol for the management of patients with OPN that enabled urologists to more swiftly engage IR for NT should the urologist decide to pursue NT (Fig. 1). Our objective was to assess this protocol's impact on outcomes including time to NT or RUS and length of stay (LOS).
Methods: We retrospectively reviewed all patients at our institution who underwent NT from 2012 – 2018 or RUS from 2014 - 2018 for stone related OPN meeting sepsis criteria. Univariate descriptive statistics (t-test or Mann-Whitney U test for continuous and chi-square for proportions) were used to compare patient characteristics and outcomes between RUS and NT and between NT pre- and post-protocol. Multivariable logistic regression assessed predictors of prolonged LOS (>6 days).
Results: Utilization of NT increased after implementation of the protocol from 4 NT/yr to 14 NT/yr with a decrease in the median time from urologic consultation to NT from 9.2 hrs to 4.3 hrs (p = 0.001). Patients receiving NT were older and more comorbid than those receiving RUS (table 1). Median length of stay was shorter for those undergoing NT after the protocol compared to before the protocol (3.9d vs 7.8d, p = 0.05). On multivariable analysis controlling for sex, Charlson Comorbidity Score, and septic shock, increased hours to decompression increased odds of prolonged LOS (OR 1.08, p = 0.016).
Conclusions: After implementing our OPN with sepsis protocol, NT utilization increased, time to decompression with NT decreased, and LOS decreased. Timely decompression reduced odds of prolonged hospital stay. A well-designed protocol engages both urology and IR in the management of these acutely ill patients expediting decompression and improving outcomes. Source of