Can children with urinary tract infections and obstructing calculi be managed non-operatively? A challenge to the guidelines
Laura B. Cornwell, MD1, Paul C. Campbell, MD2, Sarah Marietti-Shepherd, MD1.
1Rady Children's Hospital, San Diego, CA, USA, 2Naval Center San Diego, San Diegto, CA, USA.
BACKGROUND: In adults, the combination of suspected infection and obstructing ureteral calculi is a urological emergency, with guidelines giving strong recommendation to intervene. In children, the understanding of stone management is rudimentary due to sparse literature. We sought to define the surgical decompression rate for children admitted to the hospital with infection and ureteral calculi. We assessed whether a benefit was associated with surgical decompression, in the form of mortality, intensive care unit (ICU) admission, and/or length of stay (LOS).
METHODS: Patient demographics, clinical history, and admission details were extracted from the Pediatric Health Information System (PHIS) for the years 2004-2020. We identified 1085 patients with ureteral calculi and urinary tract infection and/or sepsis. Patients who underwent an initial procedure with ureteroscopic intervention were excluded, leaving 906 patients in the cohort. Statistical analyses were performed to determine any associations between surgical decompression and mortality, ICU admission, or LOS.
RESULTS: The mean age was 13.1 (±6.5) years, 55.8% had a complex or chronic condition, and 18.4% were admitted to an ICU during hospitalization. 56% underwent surgical decompression, with 74% of those being performed on hospital day (HD) 0-1. Six mortalities were identified, all associated with a chronic or complex condition, and they were not associated with surgical decompression (1.0 vs 0.8%, p=1.000). Of 167 patients with an ICU admission, surgical decompression was more common than the full cohort at a rate of 65% (p=0.006), but performed later in the hospital admission at a mean 4.4 days vs 1.3 for those without ICU admission (p=0.002). 84% of patients admitted to the ICU were admitted on HD 0-1, 32% were decompressed on the day of ICU admission, and 28% were intervened at a median 4 days after ICU admission. ICU LOS was not significantly associated with surgical decompression (9.4 vs 17.7 days, p=0.142). Overall LOS, both for those with and without ICU stay, was also not significantly associated with surgical decompression (all: 8.5 vs 9.7 days, p=0.384; non-ICU: 5.6 vs 6.1 days, p=0.589).
CONCLUSIONS: Mortality is rare in pediatric patients presenting with ureteral calculi and infection. ICU admission is associated with higher likelihood of surgical decompression; however decompression was not associated with a difference in ICU LOS or overall LOS. Unlike the adult population, the role of surgical decompression in children with ureteral calculi and infection is unclear.
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