Re: “Safety and Efficacy of Emergency Ureteroscopy with Intracorporeal Lithotripsy in Patients Presented with Urinary Tract Infection with Mild Sepsis” by Bakr and Abdelhalim

Dear Editor:

We read with interest the article by Bakr and Abdelhalim, who conducted this rather bold study of evaluating the safety and efficacy of emergency ureteroscopy in patients presenting with mild sepsis. ¹ Although the authors report good results in this clinical setting, we have some reservations to the basic concept of this study and feel that ureteroscopy should not be performed in the setting of urinary infection and surely not in presence of sepsis.

First, the authors have used the term “mild sepsis” in their title and throughout the article. It appears they have used the 1992 definition of sepsis for their study. ² This landmark article of 1992 defined the entities “sepsis” and “severe sepsis.” Nowhere in that document the term “mild” was used. In fact, as clinicians, we would all agree that there can be nothing “mild” about the clinical condition of sepsis. The use of this term in the article tends to dilute the severity of the clinical condition. Second, the definition of sepsis was revised in 2016. Today, sepsis is defined as “a life-threatening organ dysfunction caused by a dysregulated host response to infection” and is identified using the SOFA (Sequential Organ Failure Assessment) score. ³ This was done with the intent of elimination of the concept of sepsis without organ dysfunction. As mentioned in the methods section of the article by Bakr, none of the patients included in the study had any organ dysfunction and hence, none of them should be classified as patients with sepsis.

Although we agree to the idea of pushing our boundaries and constantly aiming to refine the way we treat our patients, the concept of upfront definitive intervention in a patient with urosepsis seems unacceptable at present attributable to the well-known risk of septic shock and even death. Youssef and colleagues, in 2014, showed that performing ureterorenoscopy even in patients who had undergone previous decompression for urosepsis was associated with a higher complication rate. ⁴ Thus, the idea of upfront ureteroscopy in urosepsis seems farfetched. In our own experience, we had the unfortunate experience of all four-limb gangrene caused by gram-negative septicemia in a young fit woman/girl who was referred to us after having undergone upfront ureteroscopy in the presence of urosepsis. ⁵

In medical practice we go by the principle “primum non nocere:” first, do no harm. There are some basic principles, guidelines, and framework we need to work within. The results of this study should not lead the reader to conclude that upfront ureteroscopy is safe in patients presenting with sepsis, simply because the study actually does not include patients with sepsis. These patients can be classified as patients with associated infection and not sepsis. The current guidelines in 2020 for managing such patients remain urgent decompression with either a ureteral stent or a percutaneous nephrostomy and definitive treatment should be delayed until sepsis is resolved. ⁶