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Role of Relook Flexible Ureteroscopy in Post-Stenting Management of Acute Pyelonephritis: Where We Miss the Boat

S. Aravind¹, P. Rameshkumar¹, V. Palaniyandi¹, H. Sekar¹, S. Krishnamoorthy¹

¹Sri Ramachandra Institute of Higher Education, Department of Urology and Renal Transplantation, Chennai, India

Introduction:

Acute pyelonephritis (APN) with acute kidney injury is one of the common urological emergencies needing intensive care and monitoring. Initial evaluation regularly involves a non-enhanced computed tomography (NECT), followed by an emergency Double J (DJ) stenting to decompress the pelvicalyceal system and facilitate urinary drainage. Many a time, once renal function improves, due to financial constraints, these stents are most often removed under local anaesthesia in outpatient settings. Though most patients recover well after stent removal, a smaller subset of patients develop recurrent symptoms needing readmission. Necrosed papillae, which form infection-prone foci in the lower calyces, are frequently observed in such cases. Our study investigates the increasing incidence of these findings and emphasizes the growing need for a relook flexible ureteroscopy in preventing bacterial persistence and reinfections.

Material and methods:

This prospective study was performed on patients who were treated with cystoscopy and DJ stenting for APN from August 2023 to July 2024. A relook flexible ureteroscopy (Flexi URS) was performed 4–6 weeks after the initial DJ stenting. Experienced urologists with at least 3 years of experience in flexible ureteroscopy performed all procedures. Necrosed papillae, if present, were removed. The findings were documented and analyzed.

Results:

Among 303 enrolled patients, 229 underwent DJ stenting followed by relook Flexi URS. Of these, 127 were female and 102 males, with a mean age of 60.25 ± 12.92 years in males and 49.27 ± 11.46 years in females (p = 0.0001). The mean baseline serum creatinine was 2.57 mg/dL, and the mean eGFR was 32.8 mL/min/1.73 m². A total of 199 patients (65.6%) were in stage 3 or higher of chronic kidney disease. Hydroureteronephrosis (HUN) was noted in 160 patients (69.7%), 116 of whom (72.5%) exhibited necrosed renal papillae within the pelvicalyceal system (PCS). Among 69 patients (30.1%) without HUN, 28 (40.6%) also had necrosed papillae. Flexi URS successfully retrieved necrosed papillae in 97 patients. Significant improvements were observed in total leukocyte count, serum creatinine, and eGFR after DJ stenting (p < 0.05) and at 6 months post-relook Flexi URS. Serum creatinine reduced from 2.57 mg/dL to 1.4 ± 0.7 mg/dL (p < 0.05), indicating enhanced renal function and reduced reinfection risk.