Abstract
The infected obstructing ureteral stone is one of the more common urologic emergencies and is likely to be encountered with greater frequency as rates of stone disease continue to rise. 1 Treatment guidelines mandate urgent renal decompression in such scenarios; yet, the term “urgent” has never been formally defined and has the potential to vary widely based on clinical scenarios, surgeon availability, as well as access to procedural suites where most such interventions occur. 2
Faw et al. seek to help address the question of whether time to decompression with ureteral stenting is associated with improved outcomes in the case of obstructing ureteral stones and infection. They utilized an institutional urology consult database to identify 48 patients presenting to the emergency department with CT confirmed ureteral stones and two or more Systemic Inflammatory Response Syndrome (SIRS) criteria who underwent stent placement. They found that patients stented more promptly (within 6 and 10 hours) had a significantly decreased length of stay relative to those who were stented at longer intervals.
The authors should be commended on raising awareness regarding the benefit of expeditious intervention in these cases. Ideally, this data could be used to help establish emergency department clinical care pathways to facilitate timely decompression for these patients. Such care pathways have become the clinical standard for more commonly encountered medical emergencies such as myocardial infarctions, strokes, and traumas. Decreasing the time to stenting would appear to benefit the patient and hospital alike in this situation.
Although the authors did not identify other apparent benefits to prompt ureteral stenting, it is possible that this may be the result of the small sample size and single institutional nature of the patient population where all patients received guideline concordant care. When analyzed on a wider scale it would appear as though a bigger question on a national level might be properly treating these patients in the first place. A 2013 study analyzing 1712 patients with ureteral stones and sepsis from the Nationwide Inpatient Sample found that 22% did not receive any decompression whether it is ureteral stent or nephrostomy tube placement. Those who did not undergo decompression had a higher mortality rate (19.2% vs 8.82%, p < 0.01). 3 In a continued effort to improve the quality of kidney stone care in our country, it is up to the urologists to be vocal in advocating and educating their colleagues that a ureteral stone and infection is an emergency and should be treated as such. Prompt recognition and treatment of this common and potentially fatal condition is in the interest of all.