Early urinary decompression and mortality in septic obstructing ureteral stones: a nationwide comparative-effectiveness study.

backgroundSeptic obstructing ureteral stones are a time-critical urological emergency. Although urgent drainage is recommended, uncertainty persists regarding the comparative effectiveness of decompression strategies and the influence of timing in real-world practice.

methodsWe analyzed adults with sepsis or septic shock and obstructing ureteral stones (n = 9,172) from the U.S. HCUP National Inpatient Sample (2016-2022). Exposures included any decompression (ureteral stent or percutaneous nephrostomy [PCN]) versus conservative care, and decompression timing (same-day [day 0] vs. ≥ day 1; ≤ 24 h vs. > 24 h). The primary outcome was in-hospital mortality; secondary outcomes were acute kidney injury (AKI), mechanical ventilation, dialysis, and length of stay. Adjusted associations were estimated using propensity score matching, overlap weighting, instrumental variable (IV) analysis, and landmark/time-dependent survival models with a prespecified 12-variable adjustment set.

resultsOverall mortality was 2.5%. Decompression was associated with lower mortality than conservative care (1.6% vs. 4.0%; risk difference - 2.4% [95% CI - 3.2 to - 1.7]; number needed to treat ≈ 41). Late decompression (> 24 h) versus early (≤ 24 h) was associated with higher odds of mortality (OR 2.17 [1.38-3.41]), AKI, ventilation, and dialysis. In exploratory analyses among decompressed patients, PCN showed higher adjusted mortality than stenting (5.5% vs. 2.8%; OR 2.05 [1.31-3.09]); IV results were directionally consistent but likely reflect residual confounding by indication and feasibility.

conclusionUrgent decompression, particularly within 24 h, was associated with lower in-hospital mortality and fewer organ-failure outcomes. Modality differences should be interpreted as hypothesis-generating; PCN remains essential when retrograde stenting is not feasible.