Surgical antibiotic practices among pediatric urologists in the United States

A rare case of necrotizing soft tissue infection following circumcision of buried penis

Circumcision is generally a safe procedure with rare serious adverse events. We report the case of a 7-month-old male who developed necrotizing soft tissue infection following circumcision of his buried penis. A high index of suspicion must be present to diagnose necrotizing fasciitis, and treatment involves early, aggressive debridement, and broad spectrum antibiotics.

The diversity of hypospadias management in North America: a survey of pediatric urologists

PURPOSE

To determine trends in hypospadias management, including surgical techniques and perioperative care, by pediatric urologists in North America.

METHODS

An anonymous online survey was devised to assess approaches to hypospadias repair and management, including anesthetic considerations, catheter placement, choice of dressing, and postoperative antibiotic treatment. The survey was sent to all practicing members of the Societies for Pediatric Urology.

RESULTS

The survey was completed by 133 (34.5%) respondents. Hypospadias repair was overwhelmingly recommended between ages 6-12 months (89.5%). A local or regional anesthetic block (caudal, penile, pudendal, spinal) is performed nearly universally (96.2%). The majority of surgeons perform distal repairs outpatient (70.7%), while fewer perform outpatient staged repairs (47.4%) or redo surgery (33.8%). Nearly all respondents preferred either VicrylTM/DexonTM (50.4%) or MaxonTM/PDSTM (48.1%) for urethroplasty. All but one respondent leaves a stent for midshaft to proximal repairs whereas stenting for glanular repairs was split with 53.4% leaving a stent. Most surgeons (60.9-70.9%) prescribe postoperative antibiotics regardless of severity and the majority (72.9%) prescribe narcotics for analgesia.

CONCLUSIONS

Approaches to hypospadias repair are extremely varied such that there is a lack of consensus among pediatric urologists regarding most aspects of hypospadias management. Investigations comparing hypospadias practice patterns are necessary to develop a standard of care for this complex pediatric urologic entity.

The effect of the use of postoperative antibiotic prophylaxis compared with non-use for stented distal hypospadias repair wound: A meta-analysis

A meta-analysis investigation to measure the influence of the usage of postoperative antibiotic prophylaxis (POP) compared with non-usage for stented distal hypospadias repair (SDHR). A comprehensive literature inspection till February 2023 was applied and 1067 interrelated investigations were reviewed. The 10 chosen investigations enclosed 1398 individuals with SDHR in the chosen investigations starting point, 812 of them were using POP, and 586 were not using POP. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the effect of the usage of POP compared with non-usage for SDHR by the dichotomous and continuous approaches and a fixed or random model. No significant difference was found between individuals using POP and not using POP in posthypospadias repair problem (PRP) (OR, 0.99; 95% CI, 0.42-2.34, P = .97) with moderate heterogeneity (I2  = 69%), posthypospadias repair infection problem (PRIP) (OR, 0.56; 95% CI, 0.30-1.06, P = .08) with no heterogeneity (I2  = 15%), and overall composite posthypospadias repair wound healing associated problem (OCPRWHAP) (OR, 1.27; 95% CI, 0.61-2.63, P = .53) with moderate heterogeneity (I2  = 59%) for SDHR. No significant difference was found between individuals using POP and not using POP in PRP, PRIP, and OCPRWHAP for SDHR. However, cautilised of the small sample sizes of several chosen investigations for this meta-analysis, care must be exercised when dealing with its values, for example, the low P-value of the PRIP.

A Systematic Review on Postoperative Antibiotic Prophylaxis after Pediatric and Adult Male Urethral Reconstruction

In the era of antibiotic overuse and increasing antibiotic resistance, there is a gap in evidence regarding antibiotic stewardship, and in particular, perioperative antibiotic prophylaxis after urethral reconstruction. The aim of this systematic review was to evaluate the effectiveness and relevance of postoperative antibiotic prophylaxis after male pediatric and adult urethral reconstruction. An online search of MEDLINE database via PubMed was performed. The systematic review was registered in PROSPERO (CRD42022348555) and was conducted according to the PRISMA guidelines and AMSTAR 2 checklist. A narrative synthesis of included studies was performed. After the screening of 1176 publications, six studies regarding antibiotic prophylaxis after hypospadias reconstruction and two studies regarding antibiotic prophylaxis after urethroplasty in adults were eligible to be included in the systematic review. All but one of the studies on hypospadias repair showed no benefit from postoperative antibiotic prophylaxis. The level of evidence on postoperative antibiotic prophylaxis after urethroplasty in adults is low. Neither of the two studies included in the review showed a benefit from antibiotic use. Postoperative prophylaxis after hypospadias repair is not effective in preventing urinary tract infections and wound infections. It seems that the use of postoperative prophylaxis after urethroplasty in adults is also not beneficial, but there is a high need for high-quality scientific data.

Does prophylactic antibiotics post pediatric pyeloplasty reduce the incidence of febrile UTIs?

PURPOSE

The use of postoperative prophylactic antibiotics in pediatric upper urinary tract reconstruction remains controversial. In this study, we examined whether low dose antibiotics administered following pediatric pyeloplasty reduce the incidence of febrile urinary tract infections at our institution. As a secondary outcome, in those patients with infection, additional analysis was performed to better quantify which patient population benefits the most from low dose prophylactic antibiotics.

METHODS

Institutional review board approval (IRB) was obtained. All methods were carried out in accordance with relevant guidelines and regulations. A retrospective study was performed in patients who underwent pyeloplasty (2011-2017) at our institution. Surgical approach (laparoscopic versus robotic assisted versus open, with or without internal JJ ureteral stent) were based on surgeon preference. Patients of 8 fellowship trained pediatric urologists were included in the study period. Patients with prior history of urologic interventions or other congenital genitourinary tract abnormalities were excluded. Demographics (age, gender, ethnicity, insurance status), prior history of culture proven urinary tract infection, surgical details (administration of perioperative antibiotics), and postoperative outcomes including; 1) re-admission 30 days post-surgery, 2) any urine cultures collected due to suspected urinary tract infection.

RESULTS

A total of 209 patients (149 boys, 60 girls) met our inclusion criteria with 55/209 (26%) receiving postoperative prophylactic antibiotics. The average age was 6 years (range: 2 months-18 years). Indwelling ureteral stent was used in 176 (84%) patients. Eleven patients (5%) had a culture-proven urinary tract infection within 30-days postoperatively. No significant differences were seen in postoperative complications or incidence of urinary tract infection when comparing surgical approaches, +/- ureteral stent, or the use of antibiotics. Secondary analysis noted statistically significant increase in post-operative urinary tract infection in younger children (2.8 v. 6.2 years, p = 0.02), those patients who had a positive preoperative urine culture (8/11, p = 0.01) and those with public health insurance (p = 0.038).

CONCLUSION

The incidence of postoperative urinary tract infection following pyeloplasty in our cohort was relatively low. There was a higher incidence of urinary tract infection in patients less than 3 years old. The use of antibiotics in patients post pyeloplasty did not appear to affect the incidence of post-operative urinary tract infection, however, they may have a role in children who have not yet potty trained and in patients with positive preoperative urine culture.

Pyeloplasty with ureteral stent placement in children: Do prophylactic antibiotics serve a purpose?

OBJECTIVES

Ureteral stents are commonly used during pyeloplasty to ensure drainage and anastomotic healing. Antibiotic prophylaxis is often used due to concerns for urinary tract infection (UTI). Although many surgeons prescribe prophylactic antibiotics following pyeloplasty, practices vary widely due to lack of clear evidence-based guidelines. We hypothesize that the rate of stent UTI does not significantly vary between children who receive antibiotics and those who do not.

METHODS

We reviewed the medical records of 741 patients undergoing pyeloplasty between January 2010 and July 2018 across seven institutions. Exclusion criteria were: age older than 22 years, no stent placed, externalized stents used, and incomplete records. Surgical approach, age, antibiotic use, stent duration, Foley duration, and urine culture results were recorded. Patients were categorized into two groups, those younger than four years of age and those four years and older as proxy for likely diaper use. Univariate logistic regression was conducted to identify variables associated with UTI. Multivariable backward stepwise logistic regression was used to identify the best model with Akaike information criterion as model selection criteria. The selected model was used to calculate odds ratios and 95% confidence intervals summarizing the association between prophylactic antibiotics and stent UTI while controlling for age, gender, and intra-operative urine cultures.

RESULTS

672 patients were included; 338 received antibiotic prophylaxis and 334 did not. These groups differed in mean age (3.91 vs. 6.91 years, P < .001), mean stent duration (38.5 vs. 35.32 days, P < .001), and surgical approach (53.25% vs. 32.04% open vs. laparoscopic, P < .001). The incidence of stent UTI was low overall (7.59%) and similar in both groups: 31/338 (9.17%) in the prophylaxis group and 20/334 (5.99%) in the non-prophylaxis group (P = .119). Although female gender, likely diaper use, and positive intra-operative urine culture were each associated with significantly higher odds of stent UTI, prophylactic antibiotic use was not associated with significant reduction in stent UTI in any of these groups. Surgical approach, stent duration, and Foley duration were not associated with stent UTI.

CONCLUSION

Incidence of stent UTI is low overall following pyeloplasty. Prophylactic antibiotics are not associated with lower rates of stent UTI following pyeloplasty even after controlling for risk factors of female gender, likely diaper use, and positive intra-operative urine culture. Routine administration of prophylactic antibiotics after pyeloplasty does not appear to be beneficial, and may be best reserved for those with multiple risk factors for UTI.

Clostridium difficile: What is the risk?

INTRODUCTION

Clostridium difficile infections (CDIs) are rising among pediatric patients in the community and hospital setting. Children undergoing transplants and bowel surgery are at a higher risk, while renal surgery has a lower risk. We hypothesize children undergoing pediatric urologic procedures are uncommonly diagnosed with postoperative CDI.

OBJECTIVE

To study CDI in pediatric patients undergoing urologic surgery and identify associated perioperative factors.

STUDY DESIGN

The American College of Surgeons National Surgical Quality Improvement Program Pediatric data file was queried for children undergoing surgery with pediatric urology or urology between 2015 and 2017. Data points included patient demographics (age, gender, race, ASA classification), surgery performed, and perioperative outcomes (operative time, admission status, length of stay, complications, readmission, and reoperation). Students T-test and Chi-square analyses were applied to detect differences between those with CDI and those without CDI.

RESULTS

Of the 27,193 patients undergoing urologic surgery, 36 (0.13%) were diagnosed with CDI. The surgeries are presented in the Summary Figure. Patients with CDI were more likely to be female (50% vs 28%, p = 0.003) than those without. There was no difference in mean age or race. Children with CDI had higher ASA classifications (p < 0.001). Their mean operative times were longer (156.1 ± 19.6 vs 105.2 ± 0.6 min, p < 0.001), as were their mean lengths of stay (4.6 ± 0.8 vs 1.3 ± 0.0 days, p < 0.001). CDI patients were more likely to have other complications (29% vs 6%, p < 0.001). Among patients with CDI, 19.4% experienced concomitant infectious complications. There was no difference in reoperation rate, but more patients with CDI required readmission (56% vs 4%, p < 0.001). A third of children with CDI had undergone vesicoureteral reflux correction, comprising 0.3% of the included procedures. Over 11% of children with CDI had undergone nephrectomy, comprising 1.1% of the included procedures for the highest rate.

DISCUSSION

CDI are uncommon following pediatric urologic procedures. No patients undergoing inguinal or scrotal cases developed CDI, while only one patient developed CDI after penile surgery. Our study does have several important limitations: we are unable to provide clinical information about the exact diagnoses, CDI risk factors such as antibiotic usage or comorbid conditions, and the number of patients who were tested for CDI.

CONCLUSION

While pediatric urologists are unlikely to encounter postoperative CDI, when they occur, they are associated with longer lengths of stay, increased readmission rates, and an increased rate of non-CDI complications.

Randomized trial of prophylactic antibiotics vs. placebo after midshaft-to-distal hypospadias repair: the PROPHY Study

BACKGROUND

Use of prophylactic antibiotics after stented hypospadias repair is very common, but most research has not identified any clinical benefits of this practice. Only one study has found that postoperative prophylaxis reduces symptomatic urinary tract infections (UTIs). Data from the same trial suggested that prophylaxis may also reduce urethroplasty complications. No studies on this subject have been placebo-controlled.

OBJECTIVE

We performed a randomized, double-blind, placebo-controlled study to evaluate the effect of postoperative prophylactic antibiotics on the incidence of infection or urethroplasty complications after stented repair of midshaft-to-distal hypospadias.

STUDY DESIGN

Boys were eligible for this multicenter trial if they had a primary, single-stage repair of mid-to-distal hypospadias with placement of an open-drainage urethral stent for an intended duration of 5-10 days. Participants were randomized in a double-blind fashion to receive oral trimethoprim-sulfamethoxazole or placebo twice daily for 10 days postoperatively. The primary outcome was a composite of symptomatic UTI, surgical site infection (SSI), and urethroplasty complications, including urethrocutaneous fistula, meatal stenosis, and dehiscence. Secondary outcomes included each component of the primary outcome as well as acute adverse drug reactions (ADRs) and C. difficile colitis.

RESULTS

Infection or urethroplasty complications occurred in 10 of 45 boys (22%) assigned to receive antibiotic prophylaxis as compared with 5 of 48 (10%) who received placebo (relative risk [RR], 2.1; 95% confidence interval [CI], 0.8 to 5.8; p = 0.16). There were no significant differences between groups in symptomatic UTIs, SSIs, or any urethroplasty complications. Mild ADRs occurred in 3 of 45 boys (7%) assigned to antibiotics as compared with 5 of 48 (10%) given placebo (RR, 0.6; 95% CI, 0.2 to 2.5; p = 0.72). There were no moderate-to-severe ADRs, and no patients developed C. difficile colitis.

CONCLUSIONS

In this placebo-controlled trial of 93 patients, prophylactic antibiotics were not found to reduce infection or urethroplasty complications after stented mid-to-distal hypospadias repair. The study did not reach its desired sample size and was therefore underpowered to independently support a conclusion that prophylaxis is not beneficial. However, the result is consistent with most prior research on this subject.

GOV IDENTIFIER

NCT02096159.

Comparative analysis of perioperative prophylactic antibiotics in prevention of surgical site infections in stented, distal hypospadias repair

PURPOSE

There is limited evidence that prophylactic antibiotics prevent surgical site infection in stented, distal hypospadias repair. Our hypothesis is that the use of prophylactic antibiotics does not affect the rate of surgical site infection in this setting.

METHODS

We conducted a retrospective study of consecutive patients over a 6-year period with distal penile hypospadias treated with urethral stenting. Variables analyzed include age, type of repair, usage of preoperative and/or postoperative antibiotics, and length of follow-up. Patients with a history of proximal or re-operative hypospadias repair were excluded. Surgical site infection was defined by the presence of postoperative penile erythema and/or purulent drainage treated with therapeutic antibiotics. Secondary outcome analysis included the presence of other hypospadias complications.

RESULTS

441 consecutive subjects met our inclusion criteria with a mean age of 13.3 months. Patients were categorized into groups: Group 1 - Preoperative antibiotics (n = 64), Group 2 - Both Preoperative & Postoperative antibiotics (n = 159), Group 3 - Postoperative antibiotics (n = 122), Group 4 - No Preoperative or Postoperative antibiotics (n = 96). Two surgical site infections were reported out of the 441 patients: 1 in Group 3 and 1 in Group 4 (p = 0.513). There was no significant difference in the total patients with a hypospadias complication between groups. In the table below, Groups 1-3 were combined (345 patients) for comparison to Group 4 (No antibiotics, 96 patients) for further analysis with no difference in SSIs (p = 0.388) or respective hypospadias complications.

CONCLUSIONS

The use of perioperative prophylactic antibiotics, both before and after surgery for distal, stented hypospadias repair, have not been shown to reduce the rate of surgical site infections nor hypospadias complications. Consequently, the benefit of prophylactic antibiotics in this setting is unclear.

Urinary Tract Infection After Robot-assisted Laparoscopic Pyeloplasty: Are Urine Cultures and Antibiotics Helpful?

OBJECTIVE

To evaluate how variations in peri-operative urine culture (UCx) and antibiotic prophylaxis utilization following robot assisted laparoscopic pyeloplasty (RALP) affect post-RALP urinary tract infection (UTI) rates in children, then use data to generate a standardized care pathway.

METHODS

Patients undergoing RALP at a single institution from January 2014 to October 2018 were retrospectively reviewed. Patients with vesicoureteral reflux, neurogenic bladder, intermittent catheterization, <=2 months follow-up after stent removal, or age >=18 years were excluded. UCx use, UCx results, and pre- and post-RALP antibiotic use were recorded. The primary outcome was symptomatic UTI, tracked until 60 days after stent removal. UTI was defined as presence of fever or urinary symptoms, a positive UCx with >=10,000 colony forming units of one uropathogen, and a positive urinalysis.

RESULTS

A total of 152 patients were included (72% male [73% circumcised], 61% white, and 23% Hispanic). One underwent a re-operative pyeloplasty, yielding 153 encounters. Eight patients (5.2%; 95% CI 1.7-8.7%) developed post-RALP UTI. Uncircumcised status and use of pre-operative prophylactic antibiotics were associated with post-RALP UTI (P = .03 and P < .01, respectively). Use of post-RALP antibiotics, whether prophylactic or therapeutic, was not associated with lower UTI rates (P = .92). Positive pre-RALP UCx and positive intra-operative stent removal UCx were associated with higher UTI rates (P = .03 and P < .01, respectively).

CONCLUSION

UTI occurred in 5.2% of our cohort of >150 patients. As post-RALP antibiotic use was not associated with lower UTI rates, prophylactic antibiotics may be reserved for patients with risk factors. A standardized care pathway could safely reduce unnecessary utilization of UA/UCx and antibiotics.

Inclusion of surgical antibiotic regimens in pediatric urology publications: A systematic review

BACKGROUND

Perioperative antibiotics prevent infections after surgery. Guidelines for antibiotic use allow the surgeon to balance the risks of adverse events and drug resistance with the benefit of reduced infection rates. However, due to a lack of evidence-based guidelines within pediatric urology, antibiotic practices vary widely. We performed a systematic literature review to investigate when and how authors report their antibiotic usage and infectious outcomes. Our aim was to analyze the available data on perioperative antibiotics and infection rates within pediatric urology.

METHODS

This systematic review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A search strategy was devised to identify reports of pediatric urology surgery and use of antibiotics or infectious outcomes. Embase and Medline were queried with no year restrictions with subject heading terms to identify publications on common pediatric urology surgeries. The procedures studied were hypospadias repair, pyeloplasty, orchidopexy, ureteral reimplant, and circumcision. Two independent reviewers screened all titles and abstracts, followed by relevant full texts, for eligibility. Articles were included if the procedure was performed on the majority of study patients, the procedure was performed by urologic surgeons, and the population studied was a pediatric population defined as 0-18 years of age. Case reports, meta-analyses, and editorials were excluded. Data was extracted by one independent reviewer into a preformatted database. Collected data included journal type, date of publication, patient demographics, preoperative and postoperative antibiotic details including regimens, and infection outcomes. The primary outcome was reporting of antibiotic use preoperatively or postoperatively. Secondary outcomes included: reporting of infection, antibiotic class and dosage. Since all studies were diverse, only qualitative analysis was conducted.

RESULTS

We identified 1483 publications with 297 meeting inclusion criteria. Of these, 9% reported their use of preoperative antibiotics, and 34% reported their use of postoperative antibiotics. Only 6% of studies reported the specific antibiotic class, 15% reported duration, and 1% reported dosage and frequency. Infection outcomes were reported in 58% of studies. Only 57% of studies that reported on infection outcomes described their antibiotics practices.

CONCLUSIONS

Surgical antibiotic regimens and infection outcomes are infrequently included in pediatric urology studies, limiting the data available for development of evidence-based guidelines. Routine incorporation of antibiotic regimens, infection outcomes and adverse events in the pediatric urology literature will increase our ability to identify indications for antibiotics. Reporting of perioperative antibiotic outcomes in pediatric urology procedures will allow the eventual development of strong evidence-based guidelines.

Perioperative complications within 30 days of hypospadias surgery: Results from NSQIP-Pediatrics

INTRODUCTION

There are no large multi-institutional studies reporting on perioperative complications of hypospadias repairs. We sought to determine perioperative complications of hypospadias repairs from the National Surgical Quality Improvement Program Pediatrics (NSQIP-P) to aid in patient counseling.

STUDY DESIGN

This cohort study from 2012 to 2017 was conducted using NSQIP-P database. Pediatric patients undergoing hypospadias surgery were identified and compared based on 4 major categories: distal/midshaft repair, one-stage repair proximal, stage one repair, and stage two repair. Baseline demographics between the four groups and perioperative parameters were compared. Multivariable logistic regression analysis models including type of repair was used to determine associations with overall complications, infectious complications, and dehiscence.

DISCUSSION

There were 11,292 patients identified in the study population. Overall, 78% underwent distal/midshaft hypospadias repair, 12% underwent one-stage proximal repair, 1.4% underwent proximal first stage repair and 9% underwent proximal second stage repair. Multivariable logistic regression analysis revealed that proximal first stage procedures had similar overall complications to distal/mid repairs but proximal one-stage and proximal second stage procedures were associated with significantly more overall complications, local infectious complications, and dehiscence. Age, race, operative time, prematurity were also independently associated with increased overall complications. As expected, complication rates are higher in those with proximal hypospadias. In staged hypospadias, first stage has a lower complication rate compared to second stage. All complications, especially of infectious and dehiscence are the highest in the one-stage proximal and proximal second stage repairs.

CONCLUSION

We report large multi-institutional analysis of 30-day peri-operative hypospadias repair complications; this information is useful for patient counseling and education.

The use of postoperative prophylactic antibiotics in stented distal hypospadias repair: a systematic review and meta-analysis

INTRODUCTION

The current literature on the use of antibiotics perioperatively for many pediatric procedures, including hypospadias, is inconsistent. There is currently no clear evidence for the use of postoperative antibiotic prophylaxis for stented distal hypospadias repair.

OBJECTIVE

This study aims to synthesize and assess the available literature on the use versus non-use of postoperative antibiotic prophylaxis for stented distal hypospadias repair.

METHODOLOGY

Systematic literature search was performed on March 2018 for evaluation of trials that assessed the use and non-use of postoperative prophylactic antibiotics among stented distal hypospadias repair in children. Methodological quality of the studies was assessed according to the study design as recommended by the Cochrane Collaboration. The outcome assessed includes composite overall posthypospadias repair complications of infection and wound healing complications. The event rate for each treatment group was extracted to extrapolate intervention relative risk (RR) and corresponding 95% confidence interval (CI). Mantel-Haenszel method with random effect model was used in pooling of effect estimates from the included studies. Heterogeneity was assessed with subgroup analysis performed according to the study design. Publication bias was likewise determined. The protocol of this review was registered in PROSPERO (CRD42018087301) and reported in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines.

RESULT

A total of seven studies (four cohorts, three randomized controlled trials) with 986 stented distal hypospadias repairs (408 with no post-operative prophylactic antibiotics and 578 given postoperative prophylactic antibiotics) were included for the meta-analysis. Moderate to serious risk of bias was noted among the cohort studies, while the included randomized controlled trials (RCT) were of high risk of bias. Inconsistencies of effect estimates between subgroups and publication bias with small study effect were likely present. The overall pooled effect estimates comparing treatment groups showed no significant difference for outcomes of overall composite postoperative complication (RR 0.93, 95% CI 0.45, 1.93). Assessment of composite infection related complications and wound healing complications likewise did not show any significant between-group differences (RR 1.28, 95% CI 0.49, 3.35 and RR 1.01, 95% CI 0.48, 2.12; respectively) (Table). Asymptomatic bacteriuria was noted to be significantly higher among the intervention group with no postoperative prophylactic antibiotics (RR 4.01, 95% CI 1.11, 14.54).

CONCLUSION

The available evidence to date was assessed to be of high risk. The low level of evidence generated suggests that there is limited utility in the use of postoperative prophylactic antibiotics to prevent clinically significant posthypospadias repair complications.

Thirty-day hospital readmissions after augmentation cystoplasty: A Nationwide readmissions database analysis

INTRODUCTION

Reducing hospital readmissions is a growing priority for hospitals and clinicians in their efforts to improve quality of care and curtail costs. Augmentation cystoplasty is among the most complex and high-morbidity operations in pediatric urology, with up to 25% of patients experiencing a postoperative complication. However, there is a paucity of literature addressing the incidence and characteristics of hospital readmissions after these procedures. This information may be useful in tailoring perioperative interventions to reduce rehospitalization in this population.

OBJECTIVE

This study sought to determine the rate, causes, risk factors, and costs associated with 30-day readmissions for children undergoing augmentation cystoplasty.

STUDY DESIGN

We analyzed the Nationwide Readmissions Database (NRD) for children (≤18 years of age) who underwent augmentation cystoplasty for any indication between 2010 and 2014. Rates, causes, and costs of 30-day readmissions were determined. Multivariate logistic regression was used to identify risk factors for readmission.

RESULTS

Among 1873 identified cases, the 30-day readmission rate was 19.6%, with an average cost per readmission of $11,667. The most common reasons for readmission were gastrointestinal complications (19.6%), urinary tract infections (14.1%), and wound complications (11.2%). The median time to readmission was 13 days (interquartile range 6-19 days). Non-infectious genitourinary complications (e.g. hydronephrosis) ($25,286) and gastrointestinal complications ($12,924) led to the costliest readmissions, while dehydration/vomiting ($3739) and fever ($4803) were the least costly. On multivariate regression, the only significant risk factor for readmission was an indication of neurogenic bladder (OR 3.82, 95% CI 1.03-14.20, p = 0.04).

DISCUSSION

We present the first study to capture readmissions with 30 days of discharge to the same or outside hospitals after augmentation cystoplasty. Limitations include inability to separate planned and unplanned readmissions and 30-day follow-up period, which prevented analysis of readmissions caused by late complications.

CONCLUSION

Approximately one in five children undergoing augmentation cystoplasty are readmitted within 30 days. An indication of neurogenic bladder is an independent risk factor, while gastrointestinal complications and urinary tract infections are the most common reasons for readmission.

Tourniquet and adrenaline use in hypospadias surgery: a survey on the current practice in Turkey

OBJECTIVE

Aim of the study is to determine the hemostatic techniques among pediatric urologists in Turkey.

MATERIAL AND METHODS

Questionnaire forms were sent to 459 pediatric urologist by e-mail.

RESULTS

Ninety eight of 459 participants answered the questionnaire forms. Eighty-one (84.4%) of the participants were using tourniquet. The participants who didn't use tourniquet stated their justifications as follows: lack of need (n=10: 66.7%), development of edema, ischemia, delay of wound-graft healing and fistula risk (n=5: 33.3%). The indications of tourniquet use were stated as follows: penile (91.4%: n=74), distal (72.8%: n=59), penoscrotal (55.6%: n=45) hypospadias; fistula repair (33.3%: n=27), cripple hypospadias (33.3%: n=27), repair with flaps (30.9%: n=25), repair with grafts (27.2%: n=22), and isolated penile curvature (21%: n=17). Most commonly used tourniquet material (49.9%) was latex glove. Erection test was applied by 43.8% of participants. Scalp vein set was the most commonly (54.8%) used injector during erection test. Only 9.4% of participants were using adrenaline. Adrenaline dosages used at 1/100.000 dilution by 55.6%, lidocaine with 1/100.000 adrenaline by 44.4% of participants.

CONCLUSION

Beside a few experimental ones there is a paucity of studies that can serve as a guideline for using these techniques in the literature. There is a necessity of realizing prospective, randomized studies with long-term follow up to evidence that postoperative complications could develop secondary to hemostatic techniques and also to facilitate safe use of these techniques.

Prophylactic Antibiotics After Stented, Distal Hypospadias Repair: Randomized Pilot Study

The usage of prophylactic oral antibiotics following distal hypospadias repair with stenting has been recently challenged. This study evaluated the incidence of symptomatic urinary tract infections (UTIs) following stented, distal hypospadias repair and the impact of prophylactic antibiotic therapy. Subjects 0 to 5 years of age with distal hypospadias were randomized to either Group 1 (antibiotics) or Group 2 (no prophylactic therapy). Urinalysis/urine culture was obtained intraoperatively with no preoperative antibiotics given. Phone interviews at 1 month and 3 months after surgery were done. Forty-eight patients were successfully randomized to either Group 1 (24) or Group 2 (24). The incidence of symptomatic UTI in this pilot study is low, and prophylactic antibiotic therapy does not appear to lower the incidence of symptomatic UTI. A larger, randomized, multicenter trial is needed to determine whether antibiotic prophylaxis reduces the risk of symptomatic UTIs following stented, distal hypospadias repair.

Antibiotic Prophylaxis with Trimethoprim-Sulfamethoxazole versus No Treatment after Mid-to-Distal Hypospadias Repair: A Prospective, Randomized Study

Purpose

To evaluate the impact of prophylactic antibiotics after distal hypospadias repair on postoperative bacteriuria, symptomatic urinary tract infection, and postoperative complications in a prospective, randomized trial.

Materials and Methods

Consecutive patients aged 6 months to 2 years were enrolled at our institution between June 2013 and May 2017. Consenting patients were randomized to antibiotic prophylaxis with trimethoprim-sulfamethoxazole versus no antibiotic. Patients had catheterized urine samples obtained at surgery and 6–10 days postoperatively. The primary outcome was bacteriuria and pyuria at postoperative urine collection. Secondary outcomes included symptomatic urinary tract infection and postoperative complications.

Results

70 patients consented to the study, of which 35 were randomized to receive antibiotics compared to 32 who did not. Demographics, severity of hypospadias, and type of repair were similar between the groups. Patients in the treatment group had significantly less pyuria (18%) and bacteriuria (11%) present at stent removal compared to the nontreatment group (55% and 63%; p=0.01 and p < 0.001, resp.). No patient had a symptomatic urinary tract infection. There were 11 postoperative complications.

Conclusions

Routine antibiotic prophylaxis appears to significantly decrease bacteriuria and pyuria in the immediate postoperative period; however, no difference was observed in symptomatic urinary tract infection or postoperative complications. Clinical Trial Registration Number NCT02593903.

Urinary tract infection after retrograde urethrogram in children: A multicenter study

INTRODUCTION

The risk of post-procedural urinary tract infection (ppUTI) after retrograde urethrogram (RUG) has not been well quantified. Prophylactic antibiotics may reduce the risk, but must be weighed against the risks of antibiotic resistance. Prior research has shown that this risk is variable after voiding cystourethrogram (0-42% reported ppUTI rate) and appears to be low after urodynamics (0-4.8%) but this risk has not been well documented for patients undergoing RUG.

OBJECTIVE

We aimed to (1) describe the rate of ppUTI after RUG, and (2) examine factors associated with use of antibiotics at the time of RUG.

STUDY DESIGN

We conducted a retrospective cohort study of children undergoing RUG at two hospitals January 1, 2004, to December 31, 2014. ppUTI within 7 days was measured. Antibiotic prophylaxis was determined. Relationships between clinical characteristics and receipt of pre-procedure antibiotics were evaluated using univariate statistics.

RESULTS

Forty-two patients (100% male, median age 11.7 years) underwent 47 RUGs. Indications included trauma (27%), hypospadias (17%), and non-hypospadias (27%) stricture. Study indication and antibiotic administration practices are illustrated in the Figure. Three patients (6.4%) had a history of posterior urethral valves (PUV); one had neurogenic bladder (NGB) (2.4%). Two (4%) studies were performed within 30 days of a clinical UTI and 11% had a positive urinalysis or culture within 30 days pre-RUG. UTI in the 30 days before RUG was not associated with antibiotic prescription (p > 0.99). One child (2.1%; 95% CI 0-6.3%) had a ppUTI: a 7-year-old, uncircumcised male with a history of PUV and voiding dysfunction who was asymptomatic at the time of RUG.

DISCUSSION

Although the risk of ppUTI after RUG appears to be low, the rare occurrence of an iatrogenic UTI can lead to high cost and patient morbidity, particularly in cases similar to our patients who required inpatient admission for intravenous antibiotics. To help balance the risk of UTI with the associated healthcare costs and morbidity with the concerns about antibiotic overuse and potential exposure to drug reaction, data from this study may inform future development of evidence-based guidelines targeting only patients at highest risk for ppUTI with antibiotic prophylaxis.

CONCLUSIONS

The risk of ppUTI after RUG is low. Antibiotic prophylaxis was unrelated pre-RUG UTI in our population. These results indicate the need for pre-procedural antibiotic prescribing guidelines, and suggest that routine antibiotics prior to RUG are not indicated unless the patient has another indication for antibiotics.

Prophylactic antibiotic use in pediatric patients undergoing urinary tract catheterization: a survey of members of the Society for Pediatric Urology

Background

Current organizational guidelines regarding use of antibiotics during urinary tract catheterization are based on limited evidence and are not directly applicable to the pediatric urology population. We seek to improve understanding of this population by first evaluating current practices. This study aims to investigate practice patterns and attitudes of pediatric urologists regarding the use of antibiotics in the setting of urinary tract catheterization.

Methods

An online survey was sent to members of the Society for Pediatric Urology. Questionnaire sections included demographics, general questions about antibiotic use with catheterization, and specific clinical scenarios. Descriptive statistics were used, and chi-square analysis was performed to examine associations between demographics and specific responses.

Results

Of 448 pediatric urologists surveyed, 154 (34%) responded to the survey. A majority of surveyed urologists (78%) prescribe daily prophylactic antibiotics with a hypospadias stent in place, but extensive variation in use of antibiotics was reported with other catheters and tubes. Extensive variation in practice patterns was also reported for three case scenarios regarding antibiotic prophylaxis with catheterization. Urologists > 50 years of age and fellowship-trained urologists were more likely to prescribe antibiotics for hypospadias stents (p = 0.02, p = 0.03), but no other significant associations between demographic characteristics and antibiotic use were found.

Conclusions

There is substantial variation in practice patterns among surveyed pediatric urologists regarding prophylactic antibiotic use with urinary catheterization. This variation, combined with a lack of objective data and increasing pressure to decrease infectious complications and combat antibiotic resistance, highlights the need for development of management guidelines for this unique population.

Electronic supplementary material

The online version of this article (10.1186/s12894-017-0268-5) contains supplementary material, which is available to authorized users.

Variation in Surgical Antibiotic Prophylaxis for Outpatient Pediatric Urological Procedures at United States Children's Hospitals

PURPOSE

Guidelines recommend surgical antibiotic prophylaxis for clean-contaminated procedures but none for clean procedures. The purpose of this study was to describe variations in surgical antibiotic prophylaxis for outpatient urological procedures at United States children's hospitals.

MATERIALS AND METHODS

Using the PHIS (Pediatric Health Information System®) database we performed a retrospective cohort study of patients younger than 18 years who underwent clean and/or clean-contaminated outpatient urological procedures from 2012 to 2014. We excluded those with concurrent nonurological procedures or an abscess/infected wound. We compared perioperative antibiotic charges for clean vs clean-contaminated procedures using a multilevel logistic regression model with a random effect for hospital. We also examined whether hospitals that were guideline compliant for clean procedures, defined as no surgical antibiotic prophylaxis, were also compliant for clean-contaminated procedures using the Pearson correlation coefficient. We examined hospital level variation in antibiotic rates using the coefficient of variation.

RESULTS

A total of 131,256 patients with a median age of 34 months at 39 hospitals met study inclusion criteria. Patients undergoing clean procedures were 14% less likely to receive guideline compliant surgical antibiotic prophylaxis than patients undergoing clean-contaminated procedures (OR 0.86, 95% CI 0.84-0.88, p <0.0001). Hospitals that used antibiotics appropriately for clean-contaminated procedures were more likely to use antibiotics inappropriately for clean procedures (r = 0.7, p = 0.01). Greater variation was seen for hospital level compliance with surgical antibiotic prophylaxis for clean-contaminated procedures (range 9.8% to 97.8%, coefficient of variation 0.36) than for clean procedures (range 35.0% to 98.2%, coefficient of variation 0.20).

CONCLUSIONS

Hospitals that used surgical antibiotic prophylaxis appropriately for clean-contaminated procedures were likely to use surgical antibiotic prophylaxis inappropriately for clean procedures. More variation was seen in hospital level guideline compliance for clean-contaminated procedures.

Hypospadias

Hypospadias is a hypoplasia of the tissues forming the ventral side of the penis responsible of an ectopic meatus of the urethra. This congenital anomaly results in a fusion defect of the two epithelial surfaces of the urethral groove between the 11th and the 18th weeks of development. The earlier this process arrests, the more the form is proximal and severe. This is the second genital malformation in boys with 1 case per 250 male births. Its origin is often multifactorial (genetic, endocrine, placental and environmental). Three anatomical forms exist: proximal, middle and distal (the most common). Additional exams (endocrine, genetic and morphological) are realized early, before surgery, in case of severe hypospadias, familial, associated with cryptorchidism, bifid scrotum, micropenis and/or skeletal, kidney, and/or heart abnormalities. It clarifies pubertal prognosis. The surgical management is made between 6months and 12months: it limits the functional and aesthetic impact of this malformation. Many surgical techniques are described. They all have in common the three operating time: penile straightening, urethroplasty, reconstruction of the ventral side of penis. They are based on direct sutures, local flaps pedicled, and grafts (skin or mucosa). The rate of postoperative complications is between 6 and 30 %. The two main complications are fistulae and stenoses. The psychological follow-up of these children is necessary to adulthood. Surgery of hypospadias remains a delicate surgery and must be performed by experienced surgeons.

Post-surgical infections and perioperative antibiotics usage in pediatric genitourinary procedures

BACKGROUND

Post-surgical infections (PSIs) are a source of preventable perioperative morbidity. No guidelines exist for the use of perioperative antibiotics in pediatric urologic procedures.

OBJECTIVE

This study reports the rate of PSIs in non-endoscopic pediatric genitourinary procedures at our institution. Secondary aims evaluate the association of PSI with other perioperative variables, including wound class (WC) and perioperative antibiotic administration.

STUDY DESIGN

Data from consecutive non-endoscopic pediatric urologic procedures performed between August 2011 and April 2014 were examined retrospectively. The primary outcome was the rate of PSIs. PSIs were classified as superficial skin (SS) and deep/organ site (D/OS) according to Centers for Disease Control and Prevention guidelines, and urinary tract infection (UTI). PSIs were further stratified by WC1 and WC2 and perioperative antibiotic usage. A relative risk and chi-square analysis compared PSI rates between WC1 and WC2 procedures.

RESULTS

A total of 1185 unique patients with 1384 surgical sites were reviewed; 1192 surgical sites had follow-up for inclusion into the study. Ten total PSIs were identified, for an overall infection rate of 0.83%. Of these, six were SS, one was D/OS, and three were UTIs. The PSI rate for WC1 (885 sites) and WC2 (307 sites) procedures was 0.34% and 2.28%, respectively, p < 0.01. Relative risk of infection in WC2 procedures was 6.7 (CI 1.75-25.85, p = 0.0055). The rate of infections in WC1 procedures was similar between those receiving and not receiving perioperative antibiotics (0.35% vs. 0.33%). All WC2 procedures received antibiotics.

DISCUSSION

Post-surgical infections are associated with significant perioperative morbidity. In some studies, PSI can double hospital costs, and contribute to hospital length of stay, admission to intensive care units, and impact patient mortality. Our study demonstrates that the rate of PSI in WC1 operations is low, irrespective of whether the patient received perioperative antibiotics (0.35%) or no antibiotics (0.33%). WC2 operations were the larger source of morbidity with an infection rate of 2.28% and a 6.7 fold higher increase in relative risk.

CONCLUSIONS

WC1 procedures have a rate of infection around 0.3%, which is independent of the use of perioperative antibiotics. WC2 procedures have a higher rate of infection, with a relative risk of 6.7 for the development of PSI, and should be the target of guidelines for periprocedural prophylaxis.

The role of preoperative prophylactic antibiotics in hypospadias repair

INTRODUCTION

We sought to determine whether the use of preoperative antibiotics is effective in reducing postoperative wound infections and urinary tract infections (UTI) in hypospadias repair.

METHODS

We retrospectively reviewed all hypospadias repairs performed at the Montreal Children's Hospital between March 2009 and September 2012. All types of primary hypospadias repairs and redo cases were included. Patients with no adequate follow-up or with missing records of antibiotics were excluded. Preoperative antibiotics were given in the form of cefazolin (50 mg/kg intravenously) when appropriate. Postoperative oral antibiotics were administered as decided by the pediatric urologist. Primary outcomes included postoperative wound infection and UTI. Secondary outcomes included the need for reoperation of hypospadias due to urethrocutaneous fistula, meatal stenosis, urethral stricture and wound dehiscence.

RESULTS

In total, 157 cases of hypospadias repair were reviewed; of these 7 were excluded due to lack of follow-up. Of the remaining 150 patients, 62 received preoperative antibiotics and 88 did not. The groups were well-matched for age, hypospadias characteristics, type of repair and repair of curvature. The group that received preoperative antibiotics had a significantly higher number of stented cases (82% vs. 52% of the non-preoperative antibiotic group). Two cases of wound infection were reported (1 in the pre-operative antibiotic group and 1 in the non-preoperative antibiotic group). There was no symptomatic UTI or culture-demonstrated UTI in either group. Moreover, there was no statistically significant difference between the 2 groups in terms of primary outcomes. The complication rate was 11% (17/150 repairs) and all patients needed reoperation. This study's important limitations include the rarity of studied end points combined with the small sample and the retrospective nature of our study.

CONCLUSION

Our findings do not support the routine use of preoperative antibiotics in hypospadias repair.

The effect of preoperative antimicrobial administration on culture results in dogs undergoing cystotomy

OBJECTIVE

To evaluate the effect of preoperative antimicrobial administration on culture results in dogs undergoing cystotomy as a treatment for urolithiasis.

DESIGN

Prospective controlled study. Animals-41 dogs undergoing cystotomy for cystic calculi removal.

PROCEDURES

Urine samples were collected at time of anesthetic induction and during surgery prior to cystotomy, and a mucosal biopsy and culturette swab was collected during surgery from a control group, which received antimicrobials only after surgical culture sample collection, and from an experimental group, which received antimicrobials at the time of anesthetic induction.

RESULTS

17 of 41 patients had positive culture results at anesthetic induction. Twenty of 41 patients had positive results of cultures for the surgical sample. No dogs that had positive results before antimicrobial administration had negative results after antimicrobial administration. There were no significant changes to urinalysis results regardless of group. Calcium monohydrate uroliths were the most common stone removed (24/41), followed by magnesium ammonium phosphate uroliths (11/41).

CONCLUSIONS AND CLINICAL RELEVANCE

There was no difference in culture results (positivity and bacterial type) when antimicrobials were given at anesthetic induction versus after surgical culture sample collection for dogs undergoing cystotomy for cystic calculi removal.