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Ureteral stent extraction strings in children: Stratifying the risk of post operative urinary tract infection
Shane F Batie1, Caitlin T Coco1, Shreedhar Reddy1
1Division of Pediatric Urology, Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, TX, USA.
Insights
Ureteral stents with extraction strings do not increase urinary tract infection (UTI) risk in children without a prior UTI history. However, those with a prior UTI, especially females, face a higher risk when using extraction strings.
Area of Science:
- Pediatric Urology
- Surgical Innovation
- Infection Control
Background:
- Ureteral stents are crucial in pediatric ureteral reconstruction, aiding recovery and eliminating external drains.
- Extraction strings offer a benefit by avoiding secondary cystoscopy and anesthesia for stent removal.
Purpose of the Study:
- To evaluate the association between ureteral stents with extraction strings and the risk of febrile urinary tract infections (UTIs) in pediatric patients undergoing ureteral reconstruction.
- To determine if a history of UTI influences the risk of infection when using extraction strings.
Main Methods:
- A retrospective review of pediatric patients who underwent pyeloplasty or ureteroureterostomy (UU) between 2014 and 2021.
- Incidences of UTI, fever, and hospitalization were recorded and analyzed, with a focus on comparing outcomes between stents with and without extraction strings, stratified by UTI history.
Main Results:
- While overall UTI risk was not increased in patients without a prior UTI history, those with a prior UTI, particularly females, showed a significantly higher risk of febrile UTI when using extraction strings (p < 0.01).
- Prophylaxis did not appear to mitigate this increased risk in patients with a history of UTI.
- Stent dislodgement occurred in 10% of cases with extraction strings, sometimes requiring further intervention.
Conclusions:
- Ureteral stents with extraction strings are safe for pediatric patients without a prior UTI history.
- Routine use of extraction strings is not recommended for children with a history of UTI due to an increased risk of febrile UTI.
- Further research may be needed to explore alternative strategies for managing ureteral drainage in high-risk pediatric populations.
Introduction:
Ureteral stents facilitate recovery and avoid external drains in pediatric ureteral reconstruction. Extraction strings avoid the need for a secondary cystoscopy and anesthetic. Due to concerns regarding febrile UTIs in children with extraction strings, we retrospectively assessed the relative risk of UTI in children with extraction strings.
Objective:
Our hypothesis was that stents with extraction strings do not increase the risk of UTI after pediatric ureteral reconstruction.
Methods:
Records of all children undergoing pyeloplasty and ureteroureterostomy (UU) from 2014 to 2021 were reviewed. The incidences of UTI, fever, and hospitalization were recorded.
Results:
245 patients mean age 6.4 years (163M:82F) underwent pyeloplasty (n = 221) or UU (n = 24). 42% (n = 103) received prophylaxis. Of these, 15% developed UTI versus 5% of those not receiving prophylaxis (p < 0.05). 42 females had prior history of UTI, compared to 20 males (p < 0.05). 49 patients had an extraction string. Stents with extraction strings were removed on average 0.6 months post-op while others underwent cystoscopic removal on average 1.26 months post-op (p < 0.05). 9 (18.4%) required hospitalization for febrile UTI while the stent with extraction string was in place, while only 13 (6.6%) of those without extraction string did (p < 0.02). Of the 9 children with a febrile UTI in the extraction string group, 6 had history of prior UTI (46.1%), compared to only 3 (8.3%) without a prior UTI (p < 0.05). With no prior UTI, there was no difference in UTI risk between those with (3, 8.3%) and without (8, 6.4%) extraction string (p = 0.71). Females with prior UTI and extraction string were more likely to develop UTI than those with prior UTI and no extraction string (p = 0.01). There were not enough males with history of UTI to analyze alone. There were 5 (10%) stent dislodgements in the extraction string group, 2 required further intervention with cystoscopy or percutaneous drainage.
Discussion:
Extraction strings provide the assurance of drainage while avoiding the need for a second general anesthetic procedure. There is not an increased risk of UTI with extraction string in those without prior history of UTI, but we no longer routinely leave extraction strings if there is history of UTI.
Conclusion:
Children, particularly females, with prior history of UTI have a significantly increased risk of febrile UTIs associated with the use of extraction strings. Prophylaxis does not seem to reduce this risk. Patients with no prior UTI had no higher risk of UTI with extraction string use for pyeloplasty or UU.
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