Perioperative outcomes and risk factors for major complications associated with nephrectomy for Xanthogranulomatous pyelonephritis: a multicenter study.

PURPOSE: To determine the risk factors associated with major complications in patients with histologically confirmed Xanthogranulomatous pyelonephritis (XGP) who underwent nephrectomy. METHODS: A multicenter retrospective study was performed including patients who underwent nephrectomy between 2018 and 2022 with histopathological diagnosis of XGP. Clinical and laboratory parameters at the initial presentation were evaluated. Data on extension of XGP was recorded as per the Malek clinical-radiological classification. Characteristics of nephrectomy and perioperative outcomes were obtained. The primary outcome was major complications, defined as a CD ≥ grade 3 and the need for intensive care unit (ICU) admission. Secondary outcomes included the comparison of complications evaluating the nephrectomy approach (transperitoneal, retroperitoneal, and laparoscopic). A sub-analysis stratifying patients who needed ICU admission and Malek classification was performed. RESULTS: A total of 403 patients from 10 centers were included. Major complications were reported in 98 cases (24.3%), and organ injuries were reported in 58 patients (14.4%), being vascular injuries the most frequent (6.2%). Mortality was reported in 5 cases (1.2%). A quick Sepsis-related Organ Failure Assessment (qSOFA) score ≥ 2, increased creatinine, paranephric extension of disease (Malek stage 3), a positive urine culture, and retroperitoneal approach were independent factors associated with major complications. CONCLUSION: Counseling patients on factors associated with higher surgical complications is quintessential when managing this disease. Clinical-radiological staging, such as the Malek classification may predict the risk of major complications in patients with XGP who will undergo nephrectomy. A transperitoneal open approach may be the next best option when laparoscopic approach is not feasible.

Clinical Presentation, Microbiological Characteristics, and Their Implications for Perioperative Outcomes in Xanthogranulomatous Pyelonephritis: Perspectives from a Real-World Multicenter Practice.

Xanthogranulomatous pyelonephritis (XGP) is an uncommon chronic granulomatous infection of renal parenchyma. XGP is often associated with long-term urinary tract obstruction due to stones and infection. We aimed to analyze the clinical, laboratory, and microbial culture profiles from bladder and kidney urine of patients who were diagnosed with XGP. Databases of patients with histopathological diagnosis of XGP from 10 centers across 5 countries were retrospectively reviewed between 2018 and 2022. Patients with incomplete medical records were excluded. A total of 365 patients were included. There were 228 (62.5%) women. The mean age was 45 ± 14.4 years. The most common comorbidity was chronic kidney disease (71%). Multiple stones were present in 34.5% of cases. Bladder urine culture results were positive in 53.2% of cases. Kidney urine culture was positive in 81.9% of patients. Sepsis and septic shock were present in 13.4% and 6.6% of patients, respectively. Three deaths were reported. Escherichia coli was the most common isolated pathogen in both urine (28.4%) and kidney cultures (42.4%), followed by Proteus mirabilis in bladder urine cultures (6.3%) and Klebsiella pneumoniae (7.6%) in kidney cultures. Extended-spectrum beta-lactamases producing bacteria were reported in 6% of the bladder urine cultures. On multivariable analysis, urosepsis, recurrent urinary tract infections, increased creatinine, and disease extension to perirenal and pararenal space were independent factors associated with positive bladder urine cultures. On multivariable analysis, only the presence of anemia was significantly more frequent in patients with positive kidney cultures. Our results can help urologists counsel XGP patients undergoing nephrectomy.

Retrograde Intrarenal Surgery Versus Miniaturized Percutaneous Nephrolithotomy for Kidney Stones >1cm: A Systematic Review and Meta-analysis of Randomized Trials.

CONTEXT: Although miniaturized percutaneous nephrolithotomy (mPCNL) and retrograde intrarenal surgery (RIRS) are both options for treating >1cm kidney stones, controversies exist on whether one is more effective and safer than the other. OBJECTIVE: To systematically appraise randomized trials comparing the effectiveness and safety of mPCNL and RIRS for treating >1cm kidney stones. EVIDENCE ACQUISITION: A systematic search on PubMed/Medline, Web of Science, Embase, and ClinicalTrials.gov was conducted in August 2020 following the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA). Randomized trials comparing mPCNL and RIRS for >1cm kidney stones, and reporting stone-free rate (SFR), hemoglobin drop, transfusion rate, length of hospital stay (LOS), and/or complications, were included. EVIDENCE SYNTHESIS: Eight studies compared mPCNL and RIRS, but one was not included due to its high risk of bias. SFR was higher for mPCNL (RR: 1.06 [95% coefficient interval {CI}, 1.01-1.10], p=0.008). Hemoglobin drop was higher for mPCNL (mean difference [MD]: 0.35 [95% CI, 0.05-0.65] g/dl, p=0.02); however, transfusion rates were similar (p=0.44). Complication rate was similar between mPCNL and RIRS (p=0.39), and the LOS was higher for mPCNL (MD: 1.11 [95% CI, 0.06-2.16] d, p=0.04). A subgroup analysis of lower pole stones showed that SFR was higher for mPCNL (RR: 1.09 [95% CI, 1.00-1.19], p=0.05). CONCLUSIONS: Both approaches are effective and safe. Among these approaches, mPCNL has a higher SFR than RIRS for overall >1cm renal and lower pole stones, but longer LOS, and a higher hemoglobin drop that does not translate into higher transfusion rates. Complications are comparable. PATIENT SUMMARY: Randomized trials have evaluated whether miniaturized percutaneous nephrolithotomy (mPCNL) or retrograde intrarenal surgery is more effective and safer for treating >1cm stones. After comparing the stone-free rate, hemoglobin drop, transfusion rate, length of hospital stay, and complications between both the approaches, mPCNL was found to be slightly more effective, but both were equally safe.

Laparoscopic nephrectomy in patients with renal exclusion secondary to urolithiasis. Which factors can predispose conversion to open surgery?

BACKGROUND: The prevalence of urolithiasis is 7-10% and has increased over the past years. Simple nephrectomy is, therefore, indicated when renal exclusion is associated with recurrent urinary tract infections and/or chronic pain. OBJECTIVE: The aim of the study was to describe the surgical experience of laparoscopic nephrectomy (LPN) due to urolithiasis in Mexican South-east and which factors can predispose conversion to open surgery. METHODS: This was a retrospective study including patients with renal exclusion secondary to urolithiasis, who underwent laparoscopic simple nephrectomy between 2016 and 2019. RESULTS: Forty simple LPN for renal exclusion due to urolithiasis was performed between 2016 and 2019. Mean age was 47 ± 10.8 and 82.5% were female. The mean BMI was 30.2 ± 5 kg/m2, mean operative time was 165.2 ± 64. Conversion rate was 12.5% (n = 5). Conversion was significantly associated with abnormal hilum vascular anatomy (p = 0.001), hilum adherences (p = 0.001), and hydronephrosis (p = 0.001). CONCLUSION: LPN is a safe surgical technique for renal exclusion due to urolithiasis. Hydronephrosis, abnormal vascular anatomy, and the adherences that involved de hilum are the factors that could predictive conversion to open surgery.

INTRODUCCIÓN: La prevalencia the urolitiasis es del 7-10% sin embargo a presentado un incremento del numero de casos en los ultimos años. La nefrectomia simple laparoscopica esta indicada en pacientes con exclusión renal asociado a cuadros repetitivos de infecciones en el tracto urinario y o dolor cronico a nivel fosa renal. OBJETIVO: Describir la experiencia de nefrectomia simple laparoscopica en pacientes con exclusion renal secundario litiasis en un hospital del sur de México, y que factores pueden predisponer la conversión a cirugia abierta. MATERIALS Y METODOS: Estudio restrospectivo que incluyo pacientes con exclusion renal secundario a urolitiasis durante el periodo comprendido entre 2016 y 2019. RESULTADOS: Se realizaron 40 nefrectomias simples laparoscopica durante el periodo comprendido 2016 y 2019 en paciente con exclusion renal asociada a litiasis. La media edad 47 ± 10.8 años, el 82.5% de los pacientes fueron del sexo femenino. La media de Indice de masa corporal fue de 30.2 ± 5 kg/m2, La tasa de conversion fue del 12.5% (n = 5), los factores que se asociaron a conversion a cirugia abierta fueron anormalidades dependientes del hilio vascular renal (p = 0.001)., adherencias dependientes del hilio renal (p = 0.001). e hidronefrosis (p = 0.001). CONCLUSIÓN: La nefrectomia simple laparocopica es un procedimiento seguro en pacienres con exclusion renal secundaria a urolitiasis. Hidronefrosis, anormalidades dependientes del hilio vascular renal y adherencias que involucren el hilio renal son factores que pueden predisponer conversion a cirugia abierta.