11. Postoperative Care of the Ureteroscopy Patient
KeywordsΑntibioticsComplicationsEndourologyFollow-up of the ureteroscopyInfectionsObstructionPain managementPostoperative care of the ureteroscopy patientRetrograde intrarenal surgerySepsisUpper urinary tract drainageUreteroscopy
Medical expulsive therapy
Nonsteroidal anti-inflammatory drugs
Shock wave lithotripsy
Ureteroscopy (URS) is the first-line therapy for ureteral and renal stones. Stone-free status may be as high as 90–100%. Stone procedures are even performed in various centers all over the world in the ambulatory setting at hospital outpatient facilities [1, 2].
In parallel to high stone-free rates and the use of miniaturized flexible instruments, the postoperative complication rates still remain a major issue. The incidence of unplanned admissions owing to post-URS complications ranges from 1.5% to 14.3% in Western countries, with the postoperative pain being the leading one [3, 4].
Important factors in postoperative care after ureterorenoscopy are also the infections and the septic complications. During endoscopic procedures, fluids infused to the collecting system elevate the intrarenal pressure. This fact in conjunction with the treatment of infectious stones plays the key role in possible postoperative septic, life-threatening events. Careful perioperative antibiotic prophylaxis and proper upper tract drainage are mandatory and discussed in this chapter .
Emergencies in Immediate Postoperative Period
The advances in the equipment and the technology have allowed endourologists to perform increasingly complex procedures to treat upper urinary tract stones. Larger diameter stones are now treated with URS with acceptable complication profiles. URS is reported to have a high stone clearance, and its observed complication rate is relatively low. The recent Clinical Research of the Endourological Society (CROES) of 11,885 patients found a URS complication rate of 7.4%. The most common complications after URS were bleeding, fever, and urinary tract infections (UTIs) .
SIRS and Sepsis
Understanding the Risk Factors
Urosepsis is defined as sepsis caused by a urogenital tract infection. Urosepsis in adults accounts for approximately 25% of all sepsis cases. Severe sepsis/septic shock is a critical condition, with a reported mortality rate ranging from 20% to 40%. Main risk factors are urinary obstruction, with urolithiasis being the most common cause . Treatment of urosepsis has four major aspects: (1) early diagnosis, (2) early goal-oriented therapy including optimal antimicrobials with high concentrations both in the plasma and in the urinary tract, (3) identification and control of the complicating factor in the urinary tract, and (4) specific sepsis therapy. Early adequate tissue oxygenation, adequate initial antibiotic therapy, and rapid identification and control of the septic focus in the urinary tract are critical steps in the successful management of a patient with urosepsis, which includes early imaging and an optimal interdisciplinary approach encompassing emergency unit and urological and intensive care medicine specialists. An early diagnosis is crucial for survival and better clinical outcome. Emergent decompression of the collecting system is the standard of care for the initial management of urosepsis from obstructive urolithiasis or edema secondary to URS. Both retrograde ureteral stent placement and percutaneous nephrostomy (PCN) drainage were shown equally effective in alleviation of the clinical course . After initiation of the proper antibiotic treatment, initial diagnosis and decision for the need of decompression of the collecting system are made. If obstruction is present, diversion is mandatory by stent or nephrostomy tube.
Various risk factors for postoperative fever, sepsis, or SIRS after URS have been identified. Without doubt, a positive preoperative urine culture and also a positive intraoperative upper collecting system urine and stone cultures consist main risk factors. Female sex, preoperative drainage, hydroureteronephrosis , large or complex stone burden, volume of irrigation fluids, increased operative time, age, and immune status have all been associated with an increased risk of postoperative infection sequela. Patients with previous urosepsis are more likely to be admitted and may need postoperative use of antibiotics compared with those undergoing elective URS .
First signs of urosepsis after endourologic procedures are tachycardia, flank pain, and fever. Later on, if unrecognized or untreated, septic shock followed by cardiovascular events may develop. NPO is advised at these steps together with anticipation of invasive procedure if initial diagnostic work-up shows signs of obstruction. A Foley urethral catheter is considered necessary to be inserted for reducing the pressure. Intravenous fluids and broad spectrum antibiotics are introduced as soon as possible. Complete laboratory tests including thorough urine and blood cultures are performed. Monitoring of vital signs and fluid balance is mandatory.
The initial imaging is by sonographic examination of the urogenital organs and can be performed in the emergency unit. As obstruction of the upper urinary tract is the predominant cause of postoperative urosepsis, sonographic examination of the kidneys for ruling out dilation of the renal pelvis is the first imaging study. Additional ultrasound of the bladder, ruling out urinary retention, is recommended in the cases without a urethral catheter. If the ultrasound investigations are inconsistent, further non-contrast CT scan is performed in order to recognize and to manage the cause of obstruction accordingly.
Upper tract drainage is indicated in cases of ongoing sepsis and radiographically proven upper urinary tract obstruction.
Perirenal Hematoma (PRH)
PRH formation is closely linked to perioperative bleeding which may be caused by a number of predisposing factors. Typically, PRH is known to occur after other stone procedures, such as PCNL or SWL, and its formation after retrograde procedure is not common. Patients under anticoagulation therapy are at increased risk. Post-URS PRH is rare, but its acute and dangerous clinical course should be recognized and managed properly to avoid long-term morbidity. Whitehurst et al. in their systematic review investigated the incidence and common predisposing factors and proposed the optimal preventative strategies and most appropriate management of PRH and its long-term sequelae. The incidence of PRH ranges between 0.15% and 8.9% worldwide . The predisposing factors include a moderate to severe degree of hydronephrosis, thin renal cortex, prolonged operation, hypertension, female gender, and UTIs. Other risk factors were higher perfusion pressures, larger stone size, existing chronic kidney disease (CKD), pre- and postoperative ureteral stent usage, ureteral sheath use, and previous renal operation or SWL. Patients with PRH had a larger stone size, with a mean stone size of 1.7 cm. Conflicting are the data for body mass index (BMI) as some authors claim that low BMI is a risk factor while others described opposite findings .
Initial conservative PRH management is proposed as the best approach and includes blood transfusion and antibiotic therapy. Intervention is required in 50% of the patients with PRH. Other cases were managed by percutaneous drainage, emergency angiography and open surgery for clot evacuation, and even nephrectomy in unstable patients. There was also one mortality reported . To summarize, controlling blood pressure, UTI prophylaxis, and treatment; maintaining a low collecting system pressure during the procedure; and reducing operative duration are the main preventive measures.
In patients with PRH formation despite these measures, conservative management may be recommended in most cases, while surgical intervention is indicated in a selected group of unstable patients . Bed rest during acute period is of course mandatory in these cases.
Postoperative pain is one of the main complicating factors necessitating direct management even in the recovery room. The cause may be multifactorial: renal colic due to stone fragments and obstruction of the upper urinary tract (either after tubeless or uneventful URS, either stent-related flank or lower abdominal pain). Nonsteroidal anti-inflammatory drugs (NSAIDs) (including metamizoledipyrone) and paracetamol are effective in patients with acute colic and have better analgesic efficacy than opioids . This is the first-line treatment for acute renal colic according to the European Urology Association guidelines. Patients receiving NSAIDs are less likely to require further analgesia for the management of the initial colic. In patients suffering from congestive heart failure, the use of diclofenac and ibuprofen may cause coronary events and increase preload [12, 13]. Additionally, another factor to count in is renal function. NSAIDs decrease renal blood flow with further increase of intrapelvic pressure. The risk increases with dose and duration of the treatment, and the lowest effective dose should be used for the shortest needed duration . In summary, for patients with ureteral residual fragments that are expected to pass spontaneously and normal renal function, NSAIDs (e.g., diclofenac sodium, 100–150 mg/day, 3–10 days) may help reduce inflammation and the risk of recurrent pain .
The addition of spasmolytics doesn’t result in better pain control and is not advised for renal colic treatment .
Opioids , particularly pethidine, are used widely for renal colic pain control. Their use may be associated with a high rate of nausea and vomiting compared to NSAIDs and unlikely to NSAIDs have a greater likelihood of pain recurrence and use of additional pain control medication .
Apart from the use of NSAIDs, corticosteroids, or opioids for immediate symptomatic control, passage of ureteral stones may be facilitated with the use of medical expulsive therapy (MET) . Although the ongoing discussion MET may contribute both to spontaneous passage and the control of pain. In case of post-URS residual fragments, obstruction, and pain, painkillers may not be enough, since the goal of the treatment is to avoid second intervention if possible. Hollingsworth et al. (2016) in a recent meta-analysis concluded that medical expulsive therapy seems efficacious in reducing pain episodes of patients with ureteral stones . Interestingly, regarding stone size, no benefit of MET for smaller ureteric stones was observed. Patients with larger stones, however, had a 57% higher possibility of stone passage compared with controls. More than that, there was a 9.8% increase in the risk ratio for stone passage for every 1 mm increase in stone size .
Hamidi et al., in an interesting retrospective study of 397 patients who underwent unstented ureteroscopy, concluded that the administration of corticosteroids after uncomplicated unstented ureteroscopy may reduce early postoperative pain, renal colic episodes, and the need of the total analgesic consumption .
In summary, standardized postoperative pain control protocol should be developed in every endourologic department. If analgesia cannot be achieved by medications or there is evidence of obstruction of the upper urinary tract and/or renal function deterioration , drainage, using stenting, percutaneous nephrostomy, or stone removal with additional procedure are indicated .
Postoperative Upper Urinary Tract Drainage
Ιntraoperative upper urinary tract drainage may also affect the postoperative course. The main options of drainage are either the temporarily placed ureter catheter (UC) or a mono-J stent usually attached to the urethral catheter or a long-term-placed double-J stent (DJS) . According to EAU guidelines, routine stenting is not necessary before URS. However, pre-stenting may improve the stone-free rates (SFR) and reduce intraoperative complications . In general, randomized prospective trials have found that routine stenting after uncomplicated URS and complete stone removal is not necessary. Α stent might also be associated with higher postoperative morbidity . Stents should be inserted in patients who are at increased risk of complications: obvious intraoperative ureteral trauma, suspected residual fragments, bleeding, history of sepsis, and in all doubtful cases, to avoid stressful emergencies. The ideal duration of postoperative stenting is not known. The majority of urologists prefer to retain the stent for 1–2 weeks after URS, while others prefer to remove the stent only after abdominal computer tomography 4–6 weeks after the procedure confirming stone-free status. The different approaches, most probably, are due to different types of stone treatment: fragmentation or dusting. “Dusters” need to ensure stone fragments expulsion before removing the stent. Ureteral stents could be the source of significant long-term postoperative morbidity, including flank or suprapubic pain and lower urinary tract symptoms, and it demands additional invasive procedure for its extraction.
The proponents of tubeless approach after uncomplicated ureterorenoscopic lithotripsy state that patients without ureteral stenting tend to have similar renal function recovery and satisfactory pain reduction with less irritative symptoms compared to those treated with an ureteral stent. They suggest that it is not necessary to place a stent routinely especially after treatment of stones smaller than 1 cm . A suggestion is that a ureter catheter with a shorter indwelling time (1 day) may also be used, with similar results. Decision to place ureter catheter necessitates also the placement of a urethral catheter, which is not absolutely needed in tubeless or DJS approaches. This fact may prolong hospitalization period and cause symptoms that could be avoided, but on the other hand, the period of postoperative drainage is usually short, and lower urinary symptoms subside few days later.
The main goals of a postoperative double-J stent or UC are to avoid pain, facilitate stone fragments expulsion, and prevent infections and ureteral stricture formation . The prevention of upper urinary tract obstruction secondary to intramural ureteral edema due to the intraoperative manipulations is another advantage . Various studies suggested that there are significant disadvantages in the placement of stents in terms of LUTS and postoperative pain with no benefit in stone-free rates, infections rates, morbidity, and analgesia requirements. These studies conclude that there is no routine need for ureteral drainage after uncomplicated intracorporeal lithotripsy [22–24]. Decreasing instrumentation size and the stent-related symptoms in up to 50% of cases led to the conclusion that there is no need for routine upper tract drainage after uncomplicated procedures with efficient stone dusting . Avoiding postoperative drainage constitutes ureterorenoscopy a viable ambulatory option, and the discharge of the patient is possible at the same day without the need for further upper urinary tract manipulation. Additionally, there is no difference in the occurrence of urinary frequency, urgency, or dysuria between the stented and tubeless groups on postoperative day one, but all these symptoms are significantly reduced in the non-stented group further on. A recent meta-analysis of 22 randomized controlled trials (RCT) by Hai Wang et al. concluded that stenting failed to improve stone-free rates and, instead, resulted in additional complications . However, ureteral stents contributed in the prevention of re-hospitalization. In another study no significant differences in the visual analog scale (VAS) , stricture formation, fever, or hospital stay were found between stented and non-stented groups. Stenting was independent on the stone size and location . The decision for stenting and proper postoperative monitoring should be made on basis of each individual case . To summarize, the advances in stent technology, with a particular focus on identifying the nature and source of stent morbidity, should eventually minimize bothersome symptoms and improve surgical care in postoperative ureterorenoscopy period.
Perioperative Antibiotic Treatment
Diagnostic and therapeutic upper urinary tract endoscopic procedures, especially stone treatment, have an increased risk of urinary tract infections and urosepsis. Risk factors are considered the trauma to the mucosa, bleeding, duration of the operation, increased intrarenal pressure, and manipulation or resection of infected material and stones. Knopf et al. described the use of antimicrobial prophylaxis by fluoroquinolone administration and showed that it significantly reduced post-procedural UTIs in healthy patients with ureteral stones and sterile preoperative urine . If an infection or infectious material is suspected, culture and a full perioperative treatment course of an appropriate antimicrobial agents are recommended before the procedure.
The risk of infectious endocarditis (IE) after urologic procedures is low. Previous guidelines from the American Heart Association (AHA) had recommended routine prophylaxis, but the current recommendation is that the use of prophylactic antibiotics solely to prevent IE is not recommended. However, instrumentation in the GU tract may result in transient enterococcal bacteremia . There is no data to demonstrate the link between bacteremia and IE or that administration of antimicrobial prophylaxis prevents IE. Regardless, the guidelines state that for patients with specific concomitant conditions (prosthetic cardiac valve, previous IE, congenital heart disease, cardiac transplantation) and an active infection or colonization that are planned to be submitted to GU tract manipulation, antibiotic therapy to sterilize the urine may be reasonable. In these patients amoxicillin or ampicillin is suggested as a first-line antibiotic for the management of enterococci or vancomycin in case of allergy or culture-directed agents as possible .
According to the guidelines, urinary tract infections should always be treated if stone removal is planned. In patients with clinically significant infection and obstruction, drainage should be performed for several days before stone removal. A urine culture should be performed before treatment .
For the prevention of infection following URS and percutaneous stone removal, no clear-cut evidence exists. In a review including a large number of patients submitted to PNL, it was reported that in patients with negative baseline urine culture, antibiotic prophylaxis significantly reduced the rate of postoperative fever and other complications .
The need for postoperative antibiotics is still a contradictory subject. There is a trend in various centers to continue prophylactic antibiotic treatment even in cases of sterile preoperative cultures. The suggested duration of such treatment may vary from 3 to 5 days postoperatively and depends on local microbiologic conditions. The commonly used antibiotics, acting effectively in urinary tract, are mostly quinolones, cephalosporins, and trimethoprim/sulfamethoxazole with or without penicillin (amoxicillin). These antibiotics have a compatible side effects profile and are potent suppressors of urinary bacteria. Despite that, a single preoperative dose should be sufficient according to current guidelines, and each endourologist may choose the appropriate antimicrobial prophylaxis strategy. Preoperative bacteriuria should be treated according to culture results and sensitivity test and should be initiated as soon as possible and continued at least 3 days after the procedure.
Postoperative sepsis must be treated aggressively, and initial work-up includes urine and blood cultures, renal function, CBC, CRP and maximal drainage of lower and upper urinary tracts, intravenous fluids, and antibiotics initiated with first sign of sepsis. Thorough cardiovascular monitoring, intravascular fluid balance, and possible ICU admission should be the next step in acute management.
Postoperative care of the patient submitted to a URS procedure is multifactorial. It depends on the type of instrumentation (rigid, flexible), on the size of the ureteroscope, on the type of the procedure (diagnostic, therapeutic for stone or tumor), on the anatomic location the procedure is focused (ureter or kidney), on the duration of the operation, on the use or not of upper urinary tract drainage, and finally on the occurrence of intraoperative complications. All these factors must be taken into consideration, and regardless the guidelines the postoperative follow-up of a patient submitted to a URS is individualized. Apart from the administration of antibiotics and perhaps the use of a stent, there are not specific guidelines for the postoperative care of the URS patient, and more studies are needed in order for a standardized protocol to be proposed. URS is a common but very important operation performed with delicate instruments requiring specialized endourologist maneuvers, and the postoperative care is also a crucial part of the procedure that can last till 4–6 weeks after the initial procedure where an inserted stent is planned to be removed or a second auxiliary procedure is to be performed.