Predictors of Postoperative Sepsis after Percutaneous Nephrostomy for Stone-related Urinary Tract Obstruction: A Tertiary Referral Center Experience

Ramazan Ugur; Emin Taha Keskin; Ahmet Eren Sagir; Abdullah Zilan; Direnc Ozboru; Halil Lutfi Canat

doi:10.4274/haseki.galenos.2026.64936

Abstract

Aim

Percutaneous nephrostomy (PN) is a well-established method for urgent decompression in stone-related urinary obstruction; however, post-procedural sepsis remains a significant concern. This study aimed to determine the incidence and risk factors for sepsis following PN in patients with stone-related urinary tract obstruction who did not have pre-existing sepsis.

Methods

This retrospective observational cohort included patients who underwent PN for stone-related urinary tract obstruction. Patients were classified as non-septic (n=290) or septic (n=18) based on postoperative (post-op) sepsis. Demographic, clinical, laboratory, microbiological, and radiological parameters were analyzed. Univariate and multivariable logistic regression analyses were performed to identify independent predictors of post-op sepsis. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the discriminative performance of the prediction model.

Results

Three hundred and eight patients were included; 18 (5.9%) developed post-op sepsis. Patients with post-op sepsis had significantly higher preoperative (pre-op) body temperature, white blood cell count and neutrophil count, C-reactive protein (CRP) levels, neutrophil-to-lymphocyte ratio, and systemic immune-inflammation index. Bacterial growth in nephrostomy catheter cultures and perirenal fat stranding were more frequent in the sepsis group. Multivariable analysis identified elevated body temperature, higher pre-op neutrophil count, increased pre-op CRP, and bacterial growth in nephrostomy catheter cultures as independent predictors of post-op sepsis. ROC curve analysis showed an area under the curve (AUC) of 0.925 for the prediction model, while body temperature, pre-op CRP, and neutrophil count had AUCs of 0.777, 0.750, and 0.746, respectively.

Conclusion

Percutaneous nephrostomy relieves urinary tract obstruction but may also lead to serious complications such as sepsis. An increased body temperature, a high pre-op neutrophil count, a high pre-op CRP level, and bacterial growth in nephrostomy catheter cultures were all independent predictors, and the prediction model showed excellent discrimination.

Keywords:

Percutaneous nephrostomy, sepsis, urinary tract obstruction, risk factors, urolithiasis

Introduction

Drainage of upper urinary tract obstruction caused by benign or malignant conditions is achieved by percutaneous nephrostomy (PN) or double J stent placement (1-3). Percutaneous nephrostomy is frequently performed for urinary diversion in conditions such as urolithiasis, pregnancy, ureteral strictures, obstruction-related sepsis, retroperitoneal fibrosis, pelvic malignancies, and trauma-associated urinary extravasation (4-6). Despite being a commonly performed urological intervention, PN is not free of complications and may be associated with bleeding, urinary tract perforation, urinoma formation due to extravasation, injury to adjacent organs such as the spleen, liver, bowel, or pleura, infection, and nephrocutaneous fistula formation (4, 5, 7, 8).

Stone-related urinary tract obstruction represents a urological emergency requiring prompt decompression of the collecting system (4, 9). In this situation, PN is frequently preferred due to its rapid effectiveness and wide availability (10). However, despite its effectiveness, manipulation of an infected and obstructed urinary system may lead to bacteremia, endotoxin release, and pyelovenous reflux, potentially resulting in sepsis and even mortality (3, 6, 11).

We hypothesized that postoperative (post-op) sepsis following PN in patients with stone-related urinary tract obstruction could be anticipated through accessible clinical, laboratory, microbiological, and radiological indicators. Therefore, this study aimed to determine the incidence of post-op sepsis and to identify its independent predictors in patients devoid of pre-existing sepsis.

Materials and Methods

Compliance with Ethical Standards

Ethical approval was obtained from the University of Health Sciences Türkiye Basaksehir Cam and Sakura City Hospital Institutional Ethics Committee at our center (approval no.: E-96317027-514.10-295318989/KAEK/19.11.2025.412, date: 24.11.2025), and the study was conducted in accordance with the Declaration of Helsinki. Prior to the procedures, written informed consent was obtained from all patients.

Study Design

This retrospective observational cohort study was conducted at a tertiary care center and included patients who underwent PN placement for urinary drainage due to stone-related urinary tract obstruction. Patients were excluded if they had evidence of sepsis at the time of PN placement. Patients with malignancy-related external compression, retroperitoneal fibrosis, or bladder, prostate, or gynecological malignancies were also excluded. Additionally, patients with congenital or acquired anatomical strictures, pediatric and pregnant patients, and those with incomplete clinical data were excluded. Patients were divided into two groups based on the development of post-op sepsis: (non-sepsis) and (sepsis) (Figure 1).

Post-operative sepsis was defined according to the Sepsis-3 criteria and recorded if it occurred within 72 hours of PN placement. Sepsis was considered present in patients with suspected or documented infection accompanied by organ dysfunction, defined as an acute increase of ≥2 points in the Sequential Organ Failure Assessment score (12). The primary outcome of the study was the development of post-op sepsis within 72 hours after PN placement.

Demographic, clinical, laboratory, microbiological, and radiological data were obtained from electronic medical records and patient files. The parameters included gender, age, body mass index, diabetes mellitus, history of a solitary kidney, and previous kidney surgery. Vital signs at admission were also recorded, including body temperature, heart rate, respiratory rate, and systolic and diastolic blood pressure. Data on the need for intensive care unit (ICU) admission, bleeding requiring angiographic embolization, and survival status were also included (Table 1). Laboratory parameters consisted of serum creatinine, white blood cell (WBC), neutrophil, lymphocyte, and platelet counts, C-reactive protein (CRP), and procalcitonin. Preoperative (pre-op) urine nitrite positivity and pyuria, arterial blood gas pH, alanine aminotransferase, aspartate aminotransferase (AST), gamma-glutamyl transferase, amylase, and lipase were also recorded.

Postoperative laboratory values were recorded from the initial measurements obtained after nephrostomy placement. Inflammatory indices, including the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio, and systemic immune-inflammation index (SII), were evaluated using both pre-op and post-op laboratory values. Midstream urine cultures were obtained before PN placement, and additional urine samples were collected from the nephrostomy catheter at the time of insertion. Empirical intravenous third-generation cephalosporin therapy was initiated perioperatively in all patients and subsequently adjusted according to culture and antimicrobial susceptibility results.

Radiological findings were assessed using pre-op computed tomography scans. Evaluated parameters included stone location, perirenal fat stranding, laterality, and hydronephrosis grade. The laterality of nephrostomy placement was also recorded.

Statistical Analysis

Statistical analysis was performed using SPSS version 27.0 software (IBM Corp., Armonk, NY, USA). Categorical variables were summarized as frequencies and percentages, while continuous variables were presented as mean ± standard deviation for normally distributed data or as median and interquartile range for non-normally distributed data. The normality of the distribution of continuous variables was assessed using the Kolmogorov-Smirnov and Shapiro-Wilk tests, along with visual methods (histograms and Q-Q plots) and analytical methods (skewness and kurtosis values). For comparisons between two independent groups, the Independent Samples t-test was used when the data were normally distributed, while the Mann-Whitney U test was applied for non-normally distributed data. Associations between categorical variables were analyzed using the Pearson chi-square or Fisher’s exact test as appropriate. To identify factors associated with post-op sepsis, univariate logistic regression analysis was first performed. Variables with statistical significance in univariate analysis were subsequently included in a multivariable logistic regression analysis to determine independent predictors of post-op sepsis. Variables with a p-value <0.05 in univariate analysis were included in the multivariable analysis. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive performance of the developed model and selected pre-op parameters for post-op sepsis following PN. Discriminative ability was assessed using the area under the curve (AUC). Optimal cutoff values were determined using the Youden index derived from the ROC curve. The goodness-of-fit of the model was evaluated using the Hosmer-Lemeshow test. For all statistical analyses, a p-value <0.05 was considered statistically significant.

Results

Among 923 patients assessed for eligibility, 308 met the inclusion criteria and were included in the final analysis. Of these, 290 patients (94.1%) were classified into the non-sepsis group and 18 (5.9%) into the sepsis group. The cohort consisted of 169 male (54.9%) and 139 female (45.1%) patients, and sex distribution did not differ significantly between the groups. Mean age was also similar between the non-sepsis and sepsis groups (52.0±17.0 vs. 55.8±18.0 years, p=0.409) (Table 1).

Patients in Group 2 (sepsis) presented with a significantly higher body temperature than patients in Group 1 (non-sepsis) (37.05 °C vs. 36.5 °C, p<0.001; Table 1).

Compared with the non-sepsis group, patients who developed sepsis had significantly higher pre-op WBC counts, neutrophil counts, CRP levels, NLR, and SII values and lower lymphocyte counts (all p<0.05). Postoperatively, CRP and procalcitonin levels were also significantly higher in the sepsis group. In microbiological analyses, both the rate of nephrostomy catheter culture sampling and the rate of bacterial growth in nephrostomy catheter cultures were significantly higher among patients with sepsis (all p<0.05) (Table 1).

Radiological assessments indicated that perirenal fat stranding was significantly more prevalent in Group 2 (sepsis) (94.4% vs. 39%, p=0.011). No significant differences were observed between the groups in stone location, stone laterality, grade of hydronephrosis, or laterality of nephrostomy tube placement (all p>0.05, Table 2).

The requirement for post-op ICU was significantly more frequent in sepsis group (94.4% vs. 0.7%, p<0.001). Higher rates of post-op bleeding requiring angiographic embolization and in-hospital mortality were observed in sepsis group; these differences did not reach statistical significance (Table 1).

After univariate and multivariable logistic regression analyses, elevated body temperature, bacterial growth in nephrostomy catheter cultures, higher pre-op CRP, and higher pre-op neutrophil count were identified as independent predictors of post-op sepsis (Table 3).

ROC curve analysis demonstrated that the prediction model had an AUC of 0.925. The AUC values for individual parameters were 0.777 for body temperature, 0.750 for pre-op CRP, and 0.746 for pre-op neutrophil count (Figure 2). Based on the Youden index, the optimal cut-off values were 37.05 °C for body temperature (sensitivity 50.0%, specificity 94.7%), 98.5 mg/L for pre-op CRP (sensitivity 77.8%, specificity 67.1%), and 9.41×10³/µL for pre-op neutrophil count (sensitivity 77.8%, specificity 72.5%). The Hosmer-Lemeshow goodness-of-fit test indicated an adequate model fit (p=0.443).

Discussion

In cases of upper urinary tract obstruction, emergency drainage is recommended (2, 13). It has been reported that there is no definitive superiority between double J stenting and PN (14). The choice of drainage method has a decisive influence not only on providing mechanical decompression but also on systemic inflammatory response, sepsis, and procedure-related complications (4, 10). While PN is an effective and rapid drainage method, it can lead to systemic and local complications, particularly in infected systems, due to the direct involvement of the renal parenchyma and pelvicalyceal system (3, 4, 15). From a pathophysiological perspective, this intervention, by resembling a high-grade (grade IV) renal injury, may facilitate the translocation of infected urine into the systemic circulation via pyelovenous and pyelolymphatic pathways (16, 17). Considering that the kidneys receive approximately 20-25% of the cardiac output, have a blood flow of about 1.0-1.2 L per minute, and have a daily glomerular filtration volume of approximately 180 L, infected content may rapidly enter the systemic circulation via pyelovenous and pyelolymphatic pathways, potentially contributing to the development of a systemic inflammatory response (18-20). In our study, the identification of growth in nephrostomy catheter cultures as an independent predictor of post-op sepsis is consistent with the concept that PN may facilitate systemic dissemination of infected urinary contents through pyelovenous and pyelolymphatic pathways. Conversely, the absence of a significant association between post-op sepsis and pre-op urinalysis findings (pyuria and nitrite positivity), as well as a positive urine culture, suggests that sepsis risk may be more closely related to infected material in the upper urinary tract. Accordingly, the selection of the drainage method should be individualized based on the patient’s clinical condition, anatomical characteristics, hemodynamic stability, and the technical feasibility of the procedure.

Elevated body temperature, increased WBC count—particularly the neutrophil count—and high CRP levels are early, readily available indicators of active systemic inflammation, and their association with sepsis risk has been reported previously (21-23). Fever is a systemic response that occurs as a result of the effects of pyrogenic cytokines (interleukin-1, tumor necrosis factor-α, interleukin-6, and interferons) on the hypothalamic thermoregulatory center and represents an early indicator of systemic inflammatory activation (24). In the presence of an obstructed upper urinary system, elevated body temperature, which was identified as an independent predictor in our study, should be regarded as a clinical warning sign indicating potential development of sepsis. C-reactive protein, an acute-phase reactant, is stimulated in the liver via the interleukin-6 pathway and is a sensitive biomarker reflecting the severity of infection and the magnitude of the inflammatory response (25). In the literature, high CRP levels have been reported to be associated with bacteremia and sepsis (9). Similarly, neutrophils are key effector cells of the immune response in sepsis, with increased neutrophil counts reflecting an early and intense inflammatory response to infection. However, it has been shown that excessive neutrophil activation and associated cytotoxic mediator release can contribute to sepsis pathogenesis through tissue damage and microvascular dysfunction (26). The development of post-op sepsis is associated with increased pre-op CRP levels and pre-op neutrophil counts, which can be considered a pathophysiological reflection of the systemic inflammatory response in obstructed and infected systems.

In obstructed upper urinary tracts, the need for ICU after PN is a crucial indicator reflecting the clinical severity of sepsis and is associated with increased morbidity, prolonged hospital stay, and increased healthcare costs (3, 10, 27). Sepsis developed in 89% (17/19) of patients who required the ICU after PN in our study, supporting the clinical significance of this relationship.

Radiologically, the presence of perirenal fat stranding on computed tomography represents a marker of local inflammation and, in our study, was found to be significantly associated with post-op sepsis (28). However, the lack of independent predictive value of this variable in the multivariable logistic regression analysis suggests that local inflammation may increase the risk of sepsis in the presence of a concomitant systemic inflammatory response. Similarly, pre-op lymphocyte count, AST, pre-op NLR, pre-op SII, post-op CRP, and post-op procalcitonin were associated with sepsis in univariate analyses but were not independent predictors in the multivariable analysis. This finding indicates that these parameters may reflect indirect manifestations of systemic inflammation and overall disease severity rather than serving as stand-alone determinants of post-op sepsis risk, underscoring the need to interpret them within a comprehensive clinical context. From a clinical perspective, all these variables may help identify patients who require closer monitoring, earlier escalation of antimicrobial therapy, and heightened post-procedural surveillance.

Percutaneous nephrostomy is an invasive procedure that may be associated with a broad spectrum of complications, including bleeding and various local adverse events. In particular, the close anatomical proximity of structures such as the colon, liver, spleen, pleura, and lungs may increase the risk of injury to these organs, which, in turn, may adversely affect the clinical course. In addition, urinary extravasation and catheter-related problems can lead to limitations in daily activities and reduced quality of life, particularly for patients who may experience chronic pain or recurrent infections as a result of these complications (7, 29-31). In our study, bleeding requiring angioembolization was identified in 14 patients (4.5%). This complication is typically attributable to procedure-related segmental arterial injury, arteriovenous fistula formation, or pseudoaneurysm development (29, 32). Notably, in patients with coagulopathy and radiological evidence of perirenal fat stranding, increased tissue fragility is likely to increase the potential risks associated with PN (33). Therefore, procedure-related complications should be carefully considered when selecting a drainage strategy. In patients in whom retrograde access is feasible, retrograde double J stent placement may represent a less invasive option without direct trauma to the renal parenchyma; conversely, PN may be preferred when retrograde access is not feasible or has failed.

Study Limitations

This study has several limitations. The retrospective design and the absence of a comparative control group evaluating PN limit the ability to draw method-specific inferences from the observed findings. In addition, ICU requirement, which represents a clinical outcome resulting from sepsis, was not included in the logistic regression analysis to minimize potential bias and allow a more appropriate assessment of causal relationships. Another limitation is the relatively low number of sepsis events (n=18). Since only 18 instances of sepsis were recorded, the multivariable model may be susceptible to overfitting; consequently, the identified predictors should be regarded as preliminary until externally validated. Finally, the single-center nature of the study represents an additional limitation that may restrict the generalizability of the findings. Furthermore, the predictive model lacked internal bootstrapping and external validation; consequently, its discriminative efficacy may be overly optimistic and requires validation in independent cohorts.

Despite these limitations, this study includes a relatively large, well-characterized cohort of patients undergoing PN for stone-related urinary tract obstruction without pre-existing sepsis. Furthermore, it identifies independent predictors of post-op sepsis, allowing identification of higher-risk patients in this population.

Conclusion

This study underscores the potential prognostic significance of clinical and laboratory parameters in forecasting sepsis subsequent to PN in patients with obstructed upper urinary tracts. An elevated body temperature, higher pre-op neutrophil counts and pre-op CRP levels, and bacterial growth in nephrostomy catheter cultures were identified as independent predictors of post-op sepsis. These findings may help clinicians identify patients at increased risk of post-op sepsis and support more individualized peri-procedural monitoring and management. In high-risk patients, it may be clinically appropriate to consider less invasive drainage strategies before proceeding to more invasive approaches. Further prospective randomized controlled studies are needed to clarify the effects of different drainage strategies on sepsis development and clinical outcomes.

Ethics

Ethics Committee Approval: The study was approved by the University of Health Sciences Türkiye Basaksehir Cam and Sakura City Hospital institutional Ethics Committee at our center (approval no.: E-96317027-514.10-295318989/KAEK/19.11.2025.412, date: 24.11.2025).

Informed Consent: Informed consent was obtained from all patients involved in this study.

Authorship Contributions

Surgical and Medical Practices: R.U., E.T.K., A.E.S., A.Z., D.O., H.L.C., Concept: R.U., E.T.K., A.E.S.,A.Z., D.O., H.L.C., Design: R.U., E.T.K., A.E.S.,A.Z., D.O., H.L.C., Data Collection or Processing: R.U., E.T.K., A.E.S., A.Z., D.O., H.L.C., Analysis or Interpretation: R.U., E.T.K., A.E.S., A.Z., D.O., H.L.C., Literature Search: R.U., E.T.K., A.E.S., A.Z., D.O., H.L.C., Writing: R.U., E.T.K., A.E.S., A.Z., D.O., H.L.C.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.

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