Via Research Recognition Day Program VCOM-Carolinas 2025

Case Reports

Recurrent Urosepsis Following Stent Removal For Ureteral Stones: A Case Report Cesar Prugue, OMS III 1 , Parker Reber, OMS II 1 , Amanda Austin, DO 2

1. Edward Via College of Osteopathic Medicine, Spartanburg, SC 2. Gateway Family Medicine, Bon Secours, 406 N Poinsett Hwy, Travelers Rest, SC

Abstract

Case Presentation

Discussion

Patient Overview : ● Healthy 56-year-old female ● History of right kidney stones, hyperlipidemia

Introduction Urosepsis, a life-threatening infection originating from the urinary tract, is a serious complication of ureteral stent use. A 56-year-old female developed urosepsis twice within 15 days each time after stent removal. She initially underwent ureteroscopy and stent placement for a 12 mm distal left ureteral stone. Hospital imaging during both admissions revealed missed stone fragments and hydronephrosis, which were undetected during office evaluations. This case highlights the need for improved imaging techniques to reliably detect residual stones and calls for careful consideration of routine stent placement to minimize infection risk. ● Urosepsis, a severe urinary tract infection with high mortality, occurs in ~5% of patients after ureteroscopy. ● Risk factors include older age, diabetes, and heart disease. ● Double J stents, used to prevent obstruction from stone fragments, are placed in over 1.5 million patients annually. ● Stent placement varies widely and is often routine, even when omission criteria are met. ● This case questions the adequacy of imaging for detecting residual stones and the routine use of stents, even in low-risk patients.

Conclusions Improve Imaging : Focus on using more accurate imaging, like CT, to detect residual stones. Reevaluate Stent Practices : Assess the need for stent placement, especially in low-risk patients. Prevent Urosepsis : Investigate strategies to reduce recurrent urosepsis after ureteroscopy. Recurrent urosepsis is rare and typically seen in patients with significant comorbidities, though it can occur in healthier patients, as demonstrated in this case. Routine stent placement after URS is common but may contribute to sepsis risk. Further investigation is needed to evaluate stent efficacy and risk of complications. KUB and ultrasound may miss residual stones. CT imaging is more accurate for detecting fragments, which is crucial to prevent infections like urosepsis.

Initial Findings : ● Mildly elevated alkaline phosphatase levels (183 IU/L) on annual wellness visit. Abdominal US found left sided hydronephrosis

Imaging : ● CT scan: 12 mm stone in distal

left ureter with moderate hydronephrosis (Figure 1)

Initial Procedure : ● URS with laser lithotripsy and stent placement ● KUB (1 week post-procedure): No residual stones, stent removed. First Sepsis Episode : ● 3 days post-stent removal: Fever, chills, flank pain ● Lab results: WBC 19.2 K/uL, lactate 1.0 mmol/L, procalcitonin 5.36 ng/mL ● CT: Hydroureteronephrosis with residual stone fragments (Figure 2) ● Blood cultures positive for E. coli, diagnosed with UTI and obstructive pyelonephritis ● Repeat URS with stent placement and IV antibiotics Second Sepsis Episode : ● 12 days post-repeat URS: Stent removed, prescribed cefpodoxime ● 3 days later: Fever, tachycardia, chills ● Lab results: WBC 24.7 K/uL, lactate 2.7 mmol/L, procalcitonin 1.08 ng/mL ● CT: Severe hydronephrosis, residual 2 mm stone (Figure 3) ● Treated with IV antibiotics and supportive care Figure 1: Coronal section showing moderate left hydronephrosis secondary to a 12 mm stone in the distal left ureter.

References

1.The Urosepsis-A Literature Review. Medicina (Kaunas). 2021 Aug 25;57(9):872. doi: 10.3390/medicina57090872 2.Risk Factors for Urosepsis After Ureteroscopy for Stone Disease: A Systematic Review with Meta-Analysis. J Endourol. 2021 Jul;35(7):991-1000. doi: 10.1089/end.2020 3.Indications, Complications and Side Effects of Ureteral Stents. In: Soria, F., Rako, D., de Graaf, P. (eds) Urinary Stents. Springer, Cham. https://doi.org/10.1007/978-3-031-04484-7_2

Acknowledgements

We would like to thank the patient for allowing us to write and publish this case report.

Figure 2: Moderate hydroureteronephrosis and left perinephric stranding due to multiple stones measuring up to 3 mm in width within the distal left ureter.

Figure 3: Moderate to severe left-sided hydroureteronephrosis with interval decrease in stone burden.

2025 Research Recognition Day

80