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Dr. Ayad Abdulkhaleq Ismael*


The prevalence of urolithiasis has increased over the past three decades and now affects approximately 9% of the American adult population, with comparable increases in prevalence in other developed countries.[1–10] Accordingly, complications associated with stone disease have increased over time as well. Obstructive pyelonephritis, the occurrence of urinary infection proximal to a site of ureteral obstruction, is considered a urologic emergency that requires prompt drainage of the kidney to prevent lifethreatening sepsis. According to data obtained from the Nationwide Inpatient Sample, hospital discharges associated with a diagnosis of renal or ureteral calculi and urinary tract infection/pyelonephritis increased by 96% between 1999 and 2009. Taking into account the increase in population, this represents a 12% increase in incidence per 100,000 U.S. adults.[11] Interestingly, despite a higher prevalence of nephrolithiasis in men than women, women were more than twice as likely to have infected urolithiasis than men (22.3 per 100,000 versus 10.2 per 100,000, respectively). There are no randomized trials comparing surgical decompression with conservative management in patients with obstructive pyelonephritis. Only one older retrospective trial evaluated the outcome of 14 febrile patients with ureteral calculi in whom conservative therapy with fluid and antibiotics was initiated.[12] All patients became apyrexial and 11 patients required no further intervention. However, concern for pyonephrosis, the most feared and extreme form of obstructive pyelonephritis, which carries a high mortality rate and risk of renal loss, leads most practitioners to recommend prompt drainage of the collecting system in the setting of obstruction and infection. Indeed, data from the Nationwide Inpatient Sample from 2007 to 2009 revealed a higher mortality rate in patients with ureteral calculi and sepsis treated conservatively than with surgical decompression (19.2% versus 8.8%, respectively, p < 0.001).[13] Furthermore, this disparity in mortality rates is likely an underestimate because of selection bias, by which only less sick patients were likely selected for conservative management.

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