Abstract
Background
People living with HIV (PLWH) are increasingly undergoing endourological procedures, including mini-percutaneous nephrolithotomy (mini-PCNL) and retrograde intrarenal surgery (RIRS), but comparative evidence on postoperative infectious outcomes is limited.
Objectives
This study aims to compare short-term postoperative outcomes between PLWH and HIV-negative patients undergoing mini-PCNL or RIRS, focusing on postoperative urosepsis and exploring factors associated with urosepsis among PLWH.
Design
A single-center, retrospective cohort study.
Methods
Consecutive adult patients who underwent mini-PCNL or RIRS between July 2023 and January 2025 were grouped by HIV status. The primary outcome was postoperative urosepsis during the index hospitalization. Secondary outcomes included stone-free status and length of stay.
Results
A total of 708 patients were included (70 PLWH and 638 HIV-negative). Postoperative urosepsis occurred in 8/70 (11.4%) PLWH and 45/638 (7.1%) HIV-negative patients, with no significant difference between groups (p=0.13). Stone-free status was achieved in 66/70 (94.3%) PLWH and 586/638 (91.8%) HIV-negative patients (p=0.48). Other outcomes, including total hospitalization time, postoperative hospital stay, and preoperative antibiotic exposure, did not differ significantly between groups (all p>0.05). Among PLWH, exploratory univariable analyses showed that female sex, positive preoperative urine culture, and clinically higher-risk HIV disease group (acute HIV infection or AIDS) were associated with higher odds of postoperative urosepsis. CD4+ T-cell count <400 cells/µL showed a higher but statistically non-significant estimated odds.
Conclusion
Short-term postoperative outcomes following mini-PCNL or RIRS did not differ significantly between PLWH and HIV-negative patients. Exploratory univariable analyses suggested that female sex, positive preoperative urine culture, and clinically higher-risk HIV disease group were associated with postoperative urosepsis among PLWH. These findings should be interpreted cautiously because of the limited number of PLWH and urosepsis events.
Keywords: urolithiasis, HIV, mini-percutaneous nephrolithotomy, retrograde intrarenal surgery, postoperative urosepsis, urine culture
Plain Language Summary
Why was this study done? People living with HIV may develop kidney stones, but doctors have limited information about whether kidney stone surgery is safe for these patients. What did we do? We reviewed medical records of patients who underwent minimally invasive kidney stone surgery at our hospital. We compared patients living with HIV with patients without HIV. What did we find? Among 708 patients, including 70 people living with HIV, the risk of serious infection after surgery was not significantly different between the two groups. Most patients achieved successful stone removal. What does this mean? Our findings suggest that kidney stone surgery can be safely performed in many people living with HIV when patients are carefully evaluated before surgery. Patients with active infection or more advanced HIV-related conditions may need closer monitoring.
Introduction
Urolithiasis, the formation of stones in the urinary tract, poses unique challenges in people living with HIV (PLWH). The occurrence of urolithiasis in this group is strongly influenced by factors such as the use of antiretroviral drugs, notably protease inhibitors like indinavir, which can serve as a foundation for the formation of more clinically significant stones, such as those made of calcium oxalate or phosphate.1,2 On the other hand, the occurrence of ammonium acid urate stones seems to be more common among PLWH, likely due to malnutrition and chronic diarrhea, which lead to dehydration, urinary acidification, concentrated urine, and hypocitraturia.2,3 Medication-related renal stones can severely impact kidney function and quality of life. 4
The introduction of HAART in 1995 improved HIV management and increased life expectancy.5,6 A s a result, PLWH are now living longer, which increases their risk of developing age-related conditions, such as benign and malignant colon and rectal pathologies,7,8 as well as urolithiasis, a condition often influenced by long-term drug therapy and the metabolic disturbances common among PLWH. 9 It is estimated that 20 to 25% of PLWH will need elective or emergency surgery during their illness, often unrelated to their HIV/AIDS diagnosis. 10 Studies on HIV and AIDS in surgical patients, as well as their postoperative outcomes, have yielded conflicting results.11–14 However, most studies indicate that postoperative outcomes in HIV patients are comparable to those in the general population, while those with AIDS face a higher risk of mortality and certain complications. 7
Against this background, the surgical management of urolithiasis in PLWH remains clinically demanding. Decisions regarding operative intervention must take into account immune status, comorbid conditions, and the potential risk of postoperative infectious complications. With the aging of the PLWH, the need for safe and effective surgical strategies for stone disease has become increasingly relevant. Using a relatively large single-center cohort of PLWH undergoing minimally invasive kidney stone surgery, the present study aims to evaluate postoperative outcomes after routine lithotripsy and to explore clinical and disease-related factors associated with postoperative urosepsis in this population.
Methods
The reporting of this retrospective cohort study conforms to the STROBE statement for cohort studies. 15
Study population
Between July 2023 and January 2025, a total of 780 patients underwent kidney stone surgery at the Department of Urology, First Hospital of Changsha, including 73 PLWH. Patients were assessed for eligibility based on predefined inclusion and exclusion criteria. Inclusion criteria were: age ≥18 years; diagnosis of kidney stones requiring surgical treatment; treatment with mini-PCNL or RIRS during the study period; documented HIV status; and available perioperative and postoperative outcome data. Exclusion criteria included: simultaneous bilateral kidney stone surgery; combined or additional procedures other than the index mini-PCNL or RIRS; conventional PCNL if not classified as mini-PCNL; maximal stone diameter >3 cm; and incomplete data for the primary outcome. After applying these criteria, 72 patients were excluded (Figure 1), leaving 708 patients for analysis. HIV-negative patients undergoing kidney stone surgery during the same period served as the comparison cohort. This study was approved by the Ethics Committee of the First Hospital of Changsha. All surgeries were performed by urologists specializing in the treatment of kidney stones.
Figure 1.
Study design flowchart.
Surgical procedure
Preoperative urine culture was obtained in all patients, and sensitive antibiotics were used based on the results of drug susceptibility in patients with positive urine culture. Besides, patients with negative urine culture also received antibiotic prophylaxis before surgery. For patients undergoing mini-percutaneous nephrolithotomy (mini-PCNL), under general anesthesia, an open-ended ureteral catheter was placed in the ipsilateral ureter using a nephroscope or cystoscope with the patient in the lithotomy position. After the patient is repositioned to the prone position, percutaneous access is established under ultrasound guidance, and the working channel is expanded with a guidewire and dilators. An 18F–20F surgical access sheath is inserted, and a 12F nephroscope with a 40W holmium laser is used to fragment the stones. After the procedure, a nephrostomy tube is placed in the lithotripsy channel, and a ureteral stent is inserted if stone fragments need to be expelled or if additional soft endoscopic lithotripsy is required. The nephrostomy tube is removed after 3-7 days if there are no complications such as active bleeding or infection, and no further surgery is needed. The ureteral stent is typically removed one month after mini-PCNL.
A flexible ureteroscope with an intelligent negative pressure suction system was used for flexible ureteroscopic lithotripsy with negative pressure suction (FANS). After the initial setup, a guidewire was passed through the ureter, followed by the insertion of the flexible ureteroscope into the urinary tract. The stones were located using the flexible-tip ureteroscope, and laser lithotripsy was employed to fragment them. Once the stones were sufficiently fragmented, the intelligent negative pressure suction system, along with a stone retrieval basket, was used to remove the stone fragments. If necessary, a ureteral stent was indwelled to facilitate the drainage of any remaining fragments. The ureteral stent is typically removed one month after the procedure unless further treatment is required.
Management of the PLWH
Perioperative management of PLWH focused on assessment of immune status and strict adherence to institutional infection-control protocols. Preoperative evaluation included documentation of the most recent HIV viral load, CD4+ T-cell count, antiretroviral treatment status, and HIV disease stage. Virological suppression and a CD4+ T-cell count above 200 cells/µL were preferred before surgery but were not absolute eligibility requirements. Surgery was deferred in patients with active uncontrolled systemic infection, untreated opportunistic infection, hemodynamic instability, or other conditions that made anesthesia or surgery unsafe. For patients who had not achieved the preferred immunological or virological targets, the decision to proceed was individualized after multidisciplinary assessment involving urologists, infectious disease physicians, and anesthesiologists. The assessment considered the potential consequences of delaying stone treatment, including urinary obstruction, recurrent urinary tract infection, persistent symptoms, progressive hydronephrosis, and risk of renal functional deterioration, together with HIV treatment status, viral load, CD4+ T-cell count, comorbidities, preoperative urine culture results, and anesthetic risk. HIV status or disease stage alone was not considered an absolute contraindication to surgery.
Preoperative urine cultures were obtained in all patients, and antimicrobial therapy was administered based on culture results. All PLWH underwent preoperative assessment by an infectious disease physician, including opportunistic infection history and status, symptoms and findings, CD4+ T-cell count, HIV RNA level, antiretroviral therapy, and any ongoing treatment or prophylaxis. Additional microbiological or imaging studies were obtained when indicated. Elective stone surgery was postponed in patients with active, untreated, or uncontrolled opportunistic infections until adequate treatment or control was achieved. Opportunistic infection prophylaxis was not routinely given to all PLWH or initiated solely for surgery. It was prescribed or continued according to immunological and virological status, prior infection history, relevant test results, and infectious disease assessment. When indicated, prophylactic or maintenance therapy was continued perioperatively with dose adjustment and drug–drug interaction review. HIV-negative patients did not undergo HIV-specific opportunistic infection assessment or prophylaxis. Both groups, however, received the same preoperative urine-culture evaluation and perioperative antimicrobial management under the institutional urological protocol.
All procedures were performed following standard precautions for blood-borne pathogens. Surgical staff used appropriate personal protective equipment, including impermeable gowns, double gloves, and eye or face protection when exposure to body fluids was anticipated. Sharps were handled using established safety techniques to minimize occupational exposure.
Intraoperative and postoperative body fluids, including urine, blood, and irrigation effluent, were handled as regulated medical waste. Stone fragments and related biological specimens were placed in sealed, clearly labeled biohazard containers for transport to the laboratory or pathology department. Reusable instruments were reprocessed using standard high-level disinfection and sterilization procedures.
Postoperatively, patients were closely monitored for early signs of infection, and antibiotic therapy was adjusted according to microbiological results and clinical response. Antiretroviral therapy was continued throughout the perioperative period whenever possible, with modifications made to account for potential drug–drug interactions. Follow-up assessment of immune parameters was performed as clinically indicated.
Data collection
Patient data, including baseline demographics, stone characteristics, and intraoperative details, were collected retrospectively. Preoperative antibacterial exposure was recorded as the number of days of systemic antibacterial therapy administered before the index procedure. This variable did not include prophylaxis or maintenance treatment for HIV-associated opportunistic infections. All patient-specific information was anonymized.
The primary endpoint was postoperative urosepsis during the index hospitalization. In this retrospective study, postoperative urosepsis was operationally defined as a presumed urinary tract source related to the kidney stone procedure plus at least two postoperative SIRS-type criteria: temperature above 38°C or below 36°C, heart rate over 90 beats per minute, respiratory rate greater than 20 breaths per minute, altered mental status, systolic blood pressure under 90 mmHg, mean arterial pressure below 70 mmHg or a decrease in systolic blood pressure of more than 40 mmHg, and WBC count greater than 12,000 or less than 4,000. 16 Fever, tachycardia, tachypnea, hypotension, and postoperative laboratory values were assessed during the index postoperative hospitalization. Secondary outcomes included the incidence of stone-free rate, and length of hospital stay.
Statistical analysis
Continuous variables are presented as mean ± standard deviation (SD) and categorical variables as n (%). Between-group comparisons used Welch’s t test for continuous variables and χ2 test or Fisher’s exact test for categorical variables, as appropriate. Given the small number of urosepsis events among PLWH (n=8), only exploratory univariable analyses were performed for selected clinically relevant predictors. Patients with acute HIV infection or AIDS were combined as a clinically higher-risk HIV disease group. Odds ratios with 95% confidence intervals were reported. No multivariable logistic regression model was fitted. Analyses were performed using SPSS version 24.0 (IBM Corp., Armonk, NY) and Stata version 12 (StataCorp, College Station, TX). A two-sided p value <0.05 was considered statistically significant. No formal a priori sample-size calculation was performed. This retrospective study included all consecutive eligible adult patients who underwent mini-PCNL or RIRS during the predefined study period. Therefore, the final sample size was determined by the number of eligible cases available in the institutional database. Because the number of PLWH and postoperative urosepsis events was limited, analyses of factors associated with urosepsis among PLWH were considered exploratory.
Results
Study participants and clinical characteristics
Baseline characteristics and clinical data are summarized in Table 1. The mean age was 56.2 ± 13.3 years in PLWH and 51.9 ± 13.3 years in HIV-negative patients, and 65.7% and 68.0% were male, respectively. PLWH had a lower body mass index (22.0 ± 3.3 vs 23.5 ± 2.7 kg/m2, p<0.01) and a lower prevalence of prior stone history (10.0% vs 25.7%, p=0.03). Stone characteristics were otherwise similar, including axial stone diameter (length 16.4 ± 9.0 vs 13.1 ± 6.2 mm, p=0.28; width 10.1 ± 4.2 vs 11.3 ± 5.6 mm, p=0.56) and stone density. Detailed HIV-related clinical characteristics of the PLWH cohort are presented in Table S1. Among the 70 PLWH, 52 patients (74.3%) were in the asymptomatic phase, 10 (14.3%) had acute HIV infection, and 8 (11.4%) had AIDS. The median preoperative CD4+ T-cell count was 352.5 cells/µL (interquartile range [IQR], 262.0–441.2 cells/µL), and 7 patients (10.0%) had a CD4+ T-cell count <200 cells/µL.
Table 1.
Baseline characteristics of participants categorized by the presence or absence of HIV.
| | Non- HIV (n=638) | HIV (n=70) | P Value |
|---|---|---|---|
| Age (years) | 51.9 ± 13.3 | 56.2 ± 13.9 | 0.11 |
| Male (%) | 434 (68.0) | 46 (65.7) | 0.86 |
| Body Mass Index (kg/m2) | 23.5 ± 2.72 | 22.0 ± 3.3 | <0.01 |
| Dyslipidemia | 52 (8.2) | 4 (5.7) | 0.16 |
| History of diabetes (%) | 37 (5.9) | 2 (2.9) | 0.34 |
| History of hypertension (%) | 200 (31.3) | 15 (21.4) | 0.15 |
| History coronary artery disease (%) | 73 (11.4) | 5 (7.1) | 0.27 |
| History of kidney stones (%) | 164 (25.7) | 7 (10.0) | 0.03 |
| Positive urine WBC (%) | 246 (38.6) | 33 (47.1) | 0.39 |
| Positive urine culture (%) | 45 (7.1) | 12 (17.1) | 0.12 |
| Axial stone diameter (mm) | | | 0.64 |
| Length | 13.1 ± 6.2 | 16.4 ± 9.0 | 0.28 |
| Width | 11.3 ± 5.6 | 10.1 ± 4.2 | 0.56 |
| Hydronephrosis | 465 (72.9) | 48 (68.6) | 0.81 |
| Preop creatinine (umol/L) | 81.3 ± 31.4 | 86.6 ± 46.2 | 0.52 |
| Preop blood urea (mmol/L) | 6.1 ± 2.5 | 5.7 ± 3.1 | 0.71 |
| Preop CRP (mg/L) | 13.5 ± 37.8 | 19.4 ± 39.5 | 0.38 |
| Preop WBC (10 9 /L) | 6.72 ± 2.00 | 6.27 ± 2.43 | 0.24 |
| Preop hemoglobin (g/L) | 116 ± 52 | 134 ± 61 | 0.39 |
| CT value (Hu) | 1016.7 ± 393.7 | 1045.6 ± 403.7 | 0.67 |
Data are presented as mean ± SD for continuous variables and n (%) for categorical variables. P values were calculated using Student’s t test (or Mann–Whitney U test for non-normally distributed variables) for continuous variables and χ2 test or Fisher’s exact test for categorical variables, as appropriate. WBC+, positive urine white blood cell count; UC+, positive urine culture; HU, Hounsfield units.
Outcomes
Perioperative and postoperative variables were compared between PLWH and HIV-negative patients following kidney stone surgery. No statistically significant between-group differences were observed in postoperative fever, tachycardia, tachypnea, hypotension, or urosepsis during the index hospitalization (Table 2). Postoperative urosepsis occurred in 8 of 70 PLWH (11.4%) and 45 of 638 HIV-negative patients (7.1%; p=0.13). The stone-free rate was also similar between PLWH and HIV-negative patients (94.3% vs 91.8%, p=0.48). Positive preoperative urine cultures were numerically more frequent among PLWH than among HIV-negative patients (17.1% vs 7.1%, p=0.12). The duration of preoperative systemic antibacterial therapy was numerically longer in PLWH than in HIV-negative patients (5.70 ± 2.88 vs 2.51 ± 1.97 days, p=0.09), although this difference was not statistically significant. Additionally, there was no significant difference in hospitalization time, postoperative hospitalization days, surgical approach, or postoperative procalcitonin levels.
Table 2.
Perioperative and postoperative variables of the patients.
| Postoperative variables | Non- HIV (n=638) | HIV (n=70) | P value |
|---|---|---|---|
| Fever (%) | 55 (8.6) | 9 (12.9) | 0.21 |
| Tachycardia (%) | 119 (18.7) | 11 (15.7) | 0.36 |
| Tachypnea (%) | 73 (11.4) | 10 (14.3) | 0.51 |
| Hypotension (%) | 64 (10.0) | 6 (8.6) | 0.87 |
| Postoperative WBC category (×10^9/L) (%) | |||
| <4.0 | 8 (1.3) | 2 (2.8) | 0.11 |
| >12 | 91 (14.3) | 12 (17.1) | 0.59 |
| Stone free status (%) | 586 (91.8) | 66 (94.3) | 0.48 |
| Hospitalization time | 9.4 ± 3.8 | 10.7 ± 2.3 | 0.71 |
| Postoperative hospitalization days | 4.5 ± 2.0 | 5.2 ± 2.5 | 0.43 |
| Urosepsis (%) | 45 (7.1) | 8 (11.4) | 0.13 |
| Days of preoperativeantibiotic use | 2.51 ± 1.97 | 5.70 ± 2.88 | 0.09 |
| Surgical method | | | 0.36 |
| PCNL | 109 (17.1) | 15 (21.4) | |
| RIRS | 529 (82.9) | 55 (78.6) | |
| PCT | 0.61 ± 0.23 | 0.87 ± 0.39 | 0.24 |
Outcomes were assessed during the index hospitalization unless otherwise specified. Data are presented as mean ± SD and n (%). P values were calculated using Student’s t test (or Mann–Whitney U test) for continuous variables and χ2 test or Fisher’s exact test for categorical variables, as appropriate. Mini-PCNL, mini-percutaneous nephrolithotomy; RIRS, retrograde intrarenal surgery.
Further analysis divided patients into two subgroups based on the surgical approach: PCNL and RIRS. When comparing outcomes within each subgroup, including stone-free rate, incidence of postoperative sepsis, and length of hospital stay, the results remained comparable between HIV and non-HIV patients (Tables 3 and 4).
Table 3.
Perioperative and postoperative variables among patients undergoing mini-PCNL.
| Postoperative variables | Non- HIV (n=109) | HIV (n=15) | P value |
|---|---|---|---|
| Fever (%) | 14 (12.8) | 3 (20.0) | 0.07 |
| Tachycardia (%) | 26 (23.9) | 5 (33.3) | 0.10 |
| Tachypnea (%) | 19 (17.4) | 4 (26.7) | 0.12 |
| Hypotension (%) | 17 (15.6) | 2 (13.3) | 0.25 |
| Postoperative WBC category (×10^9/L) (%) | |||
| <4.0 | 2 (1.8) | 0 (0) | - |
| >12 | 25 (22.9) | 4 (26.7) | 0.49 |
| Stone free status (%) | 101 (92.7) | 14 (93.3) | 0.28 |
| Hospitalization time | 10.5 ± 3.8 | 12.1 ± 3.7 | 0.16 |
| Postoperative hospitalization days | 5.3 ± 2.0 | 6.0 ± 2.3 | |
| Urosepsis (%) | 11 (10.1) | 2 (13.3) | 0.19 |
| Days of preoperative antibiotic use | 3.3 ± 1.8 | 6.8 ± 2.1 | 0.24 |
| PCT | 0.65 ± 0.34 | 0.90 ± 0.48 | 0.22 |
Table 4.
Perioperative and postoperative variables among patients undergoing RIRS.
| Postoperative variables | Non- HIV (n=529) | HIV (n=55) | P value |
|---|---|---|---|
| Fever (%) | 41 (7.8) | 6 (10.9) | 0.11 |
| Tachycardia (%) | 93 (17.6) | 10 (14.3) | 0.76 |
| Tachypnea (%) | 54 (10.2) | 6 (10.9) | 0.82 |
| Hypotension (%) | 47 (8.9) | 4 (7.3) | 0.64 |
| Postoperative WBC category (×10^9/L) (%) | | | |
| <4.0 | 6 (1.1) | 2 (2.8) | 0.06 |
| >12 | 66 (12.5) | 8 (14.5) | 0.37 |
| Stone free status (%) | 485 (91.7) | 52 (94.5) | 0.65 |
| Hospitalization time | 8.2 ± 2.9 | 9.8 ± 3.4 | 0.42 |
| Postoperative hospitalization days | 4.5 ± 1.8 | 5.1 ± 2.5 | 0.56 |
| Urosepsis (%) | 34 (6.4) | 6 (10.9) | 0.10 |
| Days of preoperativeantibiotic use | 2.1 ± 1.4 | 3.7 ± 1.6 | 0.27 |
| PCT | 0.55 ± 0.2 | 0.75 ± 0.3 | 0.13 |
Risk factors for urosepsis in HIV patients
Exploratory univariable analyses among PLWH are presented in Table 5. Postoperative urosepsis occurred in 8 of 70 PLWH. Female sex was associated with higher odds of postoperative urosepsis compared with male sex (25.0% vs 4.3%; OR 7.33, 95% CI 1.35–39.81; p = 0.017). Positive preoperative urine culture was also associated with increased odds of postoperative urosepsis (33.3% vs 6.9%; OR 6.75, 95% CI 1.40–32.52; p = 0.025). Patients clinically higher-risk HIV disease group had higher odds of postoperative urosepsis than those in the asymptomatic stage (27.8% vs 5.8%; OR 6.28, 95% CI 1.32–29.79; p = 0.023). A CD4+ T-cell count <400 cells/µL showed a higher point estimate for urosepsis risk, although the association did not reach statistical significance (17.1% vs 3.4%; OR 5.76, 95% CI 0.67–49.70; p = 0.128). These findings should be interpreted as exploratory because of the limited number of events.
Table 5.
Exploratory univariable analysis of factors associated with postoperative urosepsis among PLWH (n = 70).
| Predictor | Urosepsis (n=8) | Non-urosepsis (n=62) | Unadjusted OR (95% CI) | P value |
|---|---|---|---|---|
| Age (years) | 59.8 ± 12.7 | 55.8 ± 11.0 | 1.03 (0.96–1.11) | 0.395 |
| BMI (kg/m2) | 23.1 ± 4.6 | 21.8 ± 3.0 | 1.14 (0.82–1.56) | 0.436 |
| Sex | Female vs Male (ref) | 6/24 (25.0) vs 2/46 (4.3) | 7.33 (1.35–39.81) | 0.017 |
| Preoperative urine culture | UC+ vs UC− (ref) | 4/12 (33.3) vs 4/58 (6.9) | 6.75 (1.40–32.52) | 0.025 |
| Lower CD4+ T-cell count | CD4 <400 vs ≥400 (ref) | 7/41 (17.1) vs 1/29 (3.4) | 5.76 (0.67–49.70) | 0.128 |
| HIV disease stage | Acute or AIDS vs Asymptomatic (ref) | 5/18 (27.8) vs 3/52 (5.8) | 6.28 (1.32–29.79) | 0.023 |
| Procedure type | mini-PCNL vs RIRS (ref) | 2/15 (13.3) vs 6/55 (10.9) | 1.26 (0.23–6.97) | 0.845 |
| Presence of hydronephrosis | 5/8 (62.5%) | 43/62 (69.4%) | 0.74 (0.16–3.40) | 0.702 |
| History of diabetes (%) | 1/8 (12.5%) | 1/62 (1.6%) | 8.71 (0.49–155.25) | 0.217 |
| History of hypertension (%) | 2/8 (25.0%) | 13/62 (21.0%) | 1.26 (0.23–6.97) | 0.924 |
| PCT | 0.71 ± 0.41 | 0.89 ± 0.34 | 0.86 (0.67–1.10) | 0.234 |
Data are presented as mean ± SD for continuous variables or n/N (%) for categorical variables. Odds ratios (ORs) are unadjusted. Binary categorical predictors were analyzed using 2 × 2 tables or univariable logistic regression, and p values were derived from Fisher’s exact tests or univariable logistic regression, as appropriate. Continuous predictors were analyzed as univariable effects per one-unit increase. PLWH, people living with HIV; OR, odds ratio; CI, confidence interval; UC+, positive preoperative urine culture; mini-PCNL, mini-percutaneous nephrolithotomy; RIRS, retrograde intrarenal surgery; PCT, procalcitonin.
Discussion
Evidence on minimally invasive kidney stone surgery in PLWH remains limited, and large-sample data are scarce. In particular, clinical outcomes of contemporary flexible ureteroscopy performed with intelligent pressure-control/negative-pressure suction systems have not been well described in PLWH, and factors associated with postoperative urosepsis in this population are not fully established. This study provides observational evidence that short-term postoperative outcomes after mini-PCNL or RIRS were comparable between PLWH and HIV-negative patients in a single-center retrospective cohort. However, these findings should not be interpreted as proof of equivalence because the PLWH cohort and the number of infectious events were limited.
In exploratory analyses restricted to PLWH, female sex, positive preoperative urine culture, and clinically higher-risk HIV disease group were associated with increased odds of postoperative urosepsis. A lower CD4+ T-cell count (<400 cells/µL) showed a higher but statistically non-significant estimated odds. These findings may help inform perioperative risk stratification and support closer monitoring and tailored antimicrobial strategies for higher-risk subgroups.
Previous studies on HIV/AIDS patients have yielded conflicting results on outcomes. While operative mortality for both emergency and elective surgeries in AIDS patients is high, elective procedures tend to have better outcomes than emergency ones. 17 General anesthesia can suppress immunity and accelerate AIDS progression. 18 Thus, HIV-positive patients without AIDS have no increased risk of wound issues, while those with AIDS are more likely to experience delayed wound healing. 19 Additionally, AIDS patients with renal cell carcinoma had lower survival rates compared to HIV-negative individuals. 20 However, adjuvant therapy with HAART has improved resistance to infections and nutritional status. 6 Studies also suggest that HIV-positive patients undergoing robot-assisted laparoscopic prostatectomy (RALRP) face no higher risk of severe postoperative complications.21,22 These findings suggest that sex, preoperative urinary infection status, and HIV disease stage may help identify higher-risk PLWH for closer perioperative monitoring or tailored prophylactic strategies, while CD4 count, despite showing a non-significant trend, should be interpreted cautiously given the limited number of events. It should be emphasized that these analyses are exploratory, and the limited sample size and number of urosepsis events preclude definitive conclusions regarding causality or the generalizability of these associations.
The risk of postoperative urosepsis among PLWH appeared to be influenced by HIV disease stage. In our exploratory univariable analyses, clinically higher-risk HIV disease group was associated with higher estimated odds of urosepsis (OR 6.28, 95% CI 1.32–29.79; p=0.023). HIV-positive individuals with lower viral loads experience fewer postoperative complications. HIV/AIDS patients are not a homogeneous group. Those with only HIV infection generally have a lower surgical risk and pose a lower risk of transmission compared to those with AIDS.8,23 This finding aligns with research by Yang et al., who observed varying postoperative complication rates based on HIV viral load. Reducing perioperative viral load can improve surgical safety for both patients and surgeons. 24 Additionally, changes in immune-related indicators before and after surgery are crucial for postoperative tolerance and survival prognosis. A recent study found significant reductions in CD4+ T, CD8+ T, and CD3+ T cell counts following surgery, associated with a reduced survival rate. 25 In our cohort, although a lower CD4+ T-cell count (<400 cells/µL) was associated with an increased estimated odds of postoperative urosepsis (OR 5.76, 95% CI 0.67–49.70; p=0.128), this did not reach statistical significance. Taken together, these observations support careful perioperative immune monitoring in higher-risk PLWH, while recognizing that our analyses are exploratory due to the limited number of events.
Preoperative urine culture and culture-directed antibacterial treatment are important components of infection prevention in patients undergoing stone surgery. In our exploratory univariable analysis, a positive preoperative urine culture was associated with higher odds of postoperative urosepsis among PLWH (OR 6.75, 95% CI 1.40–32.52; p=0.025). Positive preoperative urine cultures were numerically more frequent among PLWH than among HIV-negative patients (17.1% vs 7.1%, p=0.12), although the between-group difference was not statistically significant. The duration of preoperative systemic antibacterial therapy was also numerically longer among PLWH than among HIV-negative patients (5.70 ± 2.88 vs 2.51 ± 1.97 days, p=0.09). This variable referred exclusively to systemic antibacterial therapy administered before the index stone procedure. Prophylaxis or maintenance treatment for HIV-associated opportunistic infections was recorded separately and was not included in the calculation of preoperative antibacterial-treatment days. The longer duration observed among PLWH likely reflected, at least in part, the numerically higher prevalence of positive urine cultures and individualized culture-directed treatment based on antimicrobial susceptibility results and clinical response.
Because the indication and duration of preoperative antibacterial therapy were determined clinically rather than assigned according to a standardized research protocol, preoperative antibacterial exposure may have reduced postoperative infectious risk and attenuated the observed between-group difference in urosepsis. Therefore, residual confounding from preoperative antibacterial management cannot be excluded, and the absence of a statistically significant difference in postoperative urosepsis should not be interpreted as evidence of equivalence. Previous randomized and systematic-review evidence also supports the use of appropriately selected preoperative antibacterial strategies in patients at increased infectious risk undergoing stone surgerys.16,26
Female sex was identified as a significant risk factor for postoperative urosepsis in HIV patients with kidney stones (OR 1.45, p=0.03), consistent with findings from non-HIV patients.27–29 Studies suggest that the shorter female urethra is associated with urinary tract infections (UTIs), although their susceptibility has not been thoroughly explored.30,31 This study emphasizes the need for gender-specific management strategies, particularly in HIV patients undergoing urological stone surgery.
Future studies should incorporate multicenter designs with larger and more diverse populations, including patients with advanced AIDS or higher viral loads, to improve representativeness and confirm the reproducibility of these findings across different practice settings. In addition, prospective studies and randomized controlled trials are warranted to better define optimal perioperative antibiotic strategies and to clarify the role of antiretroviral therapy and immune status in shaping surgical outcomes among patients with HIV.
Limitations
This study has several limitations. First, it was a single-center retrospective cohort study, which may limit generalizability and introduce residual confounding. Second, no formal sample-size or power calculation was performed, and the number of PLWH and postoperative urosepsis events was limited; therefore, the absence of statistically significant between-group differences should not be interpreted as evidence of equivalence. Third, analyses of factors associated with postoperative urosepsis among PLWH were exploratory and unadjusted. Preoperative antibacterial treatment was clinically determined and was not standardized or randomized between groups. The numerically longer preoperative antibacterial exposure among PLWH may have modified postoperative infectious risk and represents a potential source of residual confounding. Fourth, postoperative urosepsis was defined using a retrospective SIRS-based operational definition, which may not be equivalent to contemporary organ dysfunction-based sepsis definitions. Fifth, outcomes were limited to the index hospitalization, and long-term recurrence, renal function, and 30-day postoperative infectious complications were not assessed.
Conclusion
In this single-center retrospective cohort, PLWH undergoing mini-PCNL or RIRS had short-term postoperative outcomes comparable to those of HIV-negative patients. Among PLWH, female sex, positive preoperative urine culture, and clinically higher-risk HIV disease group were associated with postoperative urosepsis in exploratory univariable analyses. These findings support careful perioperative risk assessment and culture-guided antimicrobial planning in selected PLWH, but should be interpreted cautiously because of the limited number of PLWH and infectious events.
Supplemental material
Supplemental material for Efficacy and postoperative outcomes of kidney stone surgery in HIV-positive patients: A retrospective cohort study by Nannan Li, Zhiwang Tang, Ke Yang, Yanlin Li, Jinbo Chen, Meng Gao, Liang Deng in Therapeutic Advances in Urology.
Acknowledgements
We would like to thank all the patients who participated in this study and the medical staff at the Department of Urology, First Hospital of Changsha, for their support and collaboration in data collection and patient care.
Author contributions: N.L. contributed to conceptualization, data curation, formal analysis, and writing of the original draft. Z.T., K.Y., Y.L., J.C., and M.G. contributed to formal analysis and critical review and editing of the manuscript. L.D. contributed to conceptualization, methodology, supervision, and critical review and editing of the manuscript. All authors have read and approved the final manuscript for submission.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Supplemental material: Supplemental material for this article is available online.
ORCID iD
Liang Deng https://orcid.org/0000-0002-0535-5412
Ethics considerations
This study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of the First Hospital of Changsha/The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University, Changsha, China (approval number: 2025-197; approval date:2025.06.30).
Consent to participate
Because this was a retrospective study using anonymized patient data, the requirement for informed consent was waived by the Ethics Committee of the First Hospital of Changsha.
Data Availability Statement
The datasets generated and/or analyzed during the current study are not publicly available because they contain patient-level clinical information, but are available from the corresponding author on reasonable request and subject to institutional approval.*
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental material for Efficacy and postoperative outcomes of kidney stone surgery in HIV-positive patients: A retrospective cohort study by Nannan Li, Zhiwang Tang, Ke Yang, Yanlin Li, Jinbo Chen, Meng Gao, Liang Deng in Therapeutic Advances in Urology.
Data Availability Statement
The datasets generated and/or analyzed during the current study are not publicly available because they contain patient-level clinical information, but are available from the corresponding author on reasonable request and subject to institutional approval.*