Systemic Inflammatory Response Syndrome after Percutaneou Nephrolithotomy A Randomized Single-Blind Clinical Trial Evaluating the Impact of Irrigation Pressure

Percutaneous nephrolithotomy is considered the golden standard for the management of 2 cm or greater renal calculi due to its superior outcomes and low morbidity rates. During a PCNL, it is common to pressurize the irrigation fluid; however irrigating fluid absorption may cause infective pyrexia after PCNL, leading patients to experience symptoms of urosepsis or septic shock. This study aims to look at optimal pressure needed for nephroscopy, and to evaluate the impact of intraoperative irrigation pressures on the risk of systemic inflammatory response after percutaneous nephrolithotimy.

90 patients with renal stones were enrolled between January 2014 and March 2015, and randomized into two groups: low (190mm Hg) or high (200mg Hg) irrigation pressure. Patient demographics, perioperative outcomes, and system inflammatory respondent incidence rates were compared using chi-square and Wilcoxon signed rank test.

The main findings of the study is that high pressure irrigation was associated with a higher risk of system inflammatory response syndrome (46%) compared to low pressure irrigation (11%, p=0.0002). On multivariate analysis, only high irrigation pressure, paraplegia or neurogenic bladder, and nonquinolone perioperative medication were predictive of postoperatives SIRS (systemic inflammatory response syndrome). Other factors such as gender, age, BMI, stone volume, stone composition, number of punctures, ASA score, negative preoperative urine culture, and degree of hydronephrosis did not impact the risk of SIRS (p>0.05).

Patients undergoing PCNL have a risk of SIRS, as SIRS occurs in 11%-35% of patients after PCNL, with progression to sepsis in 2.5% of patients. High pressure fluid irrigation increases the risk of post-operative systemic inflammatory response syndrome after PN. Some limitations that the authors acknowledge are that the stone culture or renal pelvis culture was not routinely sent except for patients with preoperative pyuria or a history of recurrent UTIs, and they did not measure intrarenal pressure. In conclusion, the results of this study shows that physicians should take into consideration minimizing irrigation pressures or using intermittent high pressure when doing a PCLN in patients, particularly patients with high risk for infectious complications.

Authors: Mohamed Omar, Mark Noble, Sri Sivalingam, Alaa El Mahdy, Ahmed Gamal, Mohamed Farag and Manoj Monga

Affiliations: Cleveland Clinic, Cleveland, Ohio

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