From the Research
In a patient with septic shock and an obstructing ureteral stone, a percutaneous nephrostomy is generally preferred over a ureteral stent. This recommendation is based on the most recent and highest quality study available, which compared the efficacy and safety of percutaneous nephrostomy and ureteroscopic management for sepsis associated with ureteral stone impaction 1. The study found that while both methods can be effective, percutaneous nephrostomy provides more rapid and reliable decompression of the collecting system, which is critical in life-threatening situations such as septic shock.
The advantages of percutaneous nephrostomy in this context include:
- Rapid and reliable decompression of the collecting system
- Can be performed quickly under local anesthesia at the bedside if necessary
- Avoids manipulation of the infected urinary tract below the obstruction, which could potentially worsen sepsis
- Creates a direct external drainage pathway for purulent urine, effectively removing the source of infection
In contrast, ureteral stents may not provide as immediate drainage in severe cases and require cystoscopy under anesthesia, which can be challenging in critically ill patients 2. Additionally, stent placement involves traversing the obstructed area, which can be technically challenging and potentially traumatic in the setting of impacted stones or severe inflammation.
While some studies suggest that ureteroscopic management can be safely and effectively performed in select clinical situations 3, 1, the most recent and highest quality study available supports the use of percutaneous nephrostomy as the preferred initial management strategy for patients with septic shock and obstructing ureteral stones 1. Following emergency drainage with nephrostomy, the patient can be stabilized, treated with appropriate antibiotics, and definitive stone management can be planned once the sepsis has resolved.