Surgical Site Infection Rates Following Laparoscopic Urological Procedures

Predictive value of preoperative neutrophil to lymphocyte ratio and platelet to lymphocyte ratio combined with operating room factors for surgical site infection after laparoscopic radical nephrectomy in renal cell carcinoma patients

BACKGROUND

Surgical site infections (SSIs) can pose significant risks to patients undergoing surgical procedures. This study aimed to investigate the risk factors and diagnostic value of neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) for SSIs in patients undergoing laparoscopic radical nephrectomy for renal cell carcinoma.

METHODS

A retrospective analysis of 866 patients at our hospital was conducted between June 2016 and June 2022. The study divided patients into two groups: those with SSIs and those without. General data and operative room-related information were collected. Inclusion and exclusion criteria were clearly defined. Peripheral blood indicators were analysed, and observation indicators were meticulously selected, including surgery time, usage of a laminar flow operating room and intraoperative hypothermia. Statistical analysis was performed using SPSS 25.0 software, including univariate, multivariate analysis and receiver operating characteristic (ROC) curve analysis.

RESULTS

Thirty-six out of 866 patients developed SSIs. Statistically significant differences were found for surgery time, usage of non-laminar flow operating rooms and intraoperative hypothermia (p < 0.05). ROC curve analysis showed an AUC of 0.765 (95% CI: 0.636-0.868) for serum NLR and PLR, with optimal cut-off values at NLR 4.8 and PLR 196, indicating moderate to strong discriminative ability for SSIs.

CONCLUSIONS

The study identified non-laminar flow operating rooms, extended surgery time, and intraoperative hypothermia as significant risk factors for SSIs. Serum NLR and PLR were found valuable as biomarkers for SSIs diagnosis, holding potential for preoperative risk assessment and improved patient safety in renal cell carcinoma care.

Nonuse of antimicrobial prophylaxis in clean surgeries for adrenal and renal tumors: Results of the risk-based strategy in 1362 consecutive patients

OBJECTIVES

To evaluate the incidence of perioperative infections without antimicrobial prophylaxis in patients undergoing clean surgeries for adrenal and renal tumors.

METHODS

We prospectively enrolled 1362 consecutive patients who underwent minimally invasive adrenalectomy (n = 303), radical nephrectomy (n = 499), and partial nephrectomy (n = 560) using the gasless laparoendoscopic single-port surgery technique between 2005 and 2019. In 1059 patients, antimicrobial prophylaxis was not administered. The remaining 303 patients were considered at high risk for infection and received single-dose antimicrobial prophylaxis. The endpoint was the incidence of perioperative infections within 1 month from the surgery date. Perioperative infections were classified into surgical site infections, urinary tract infections, and remote infections.

RESULTS

Seventy-four patients whose collecting systems were opened during partial nephrectomy were excluded, and the remaining 1013 patients with nonuse of antimicrobial prophylaxis and 275 patients with single-dose antimicrobial prophylaxis were retrospectively analyzed. The incidence of superficial surgical site infections, deep/organ-space surgical site infections, urinary tract infections, and remote infections was 1.6%, 0.7%, 2.8%, and 1.3%, respectively, in patients with nonuse of antimicrobial prophylaxis and 0.4%, 1.8%, 1.5%, and 1.5%, respectively, in patients with single-dose antimicrobial prophylaxis. All patients who developed perioperative infections were successfully treated. No clinical or surgical variables were significantly associated with the incidence of surgical site infections. One limitation of the present study was its nonrandomized and noncontrolled design.

CONCLUSIONS

In minimally invasive clean surgeries for adrenal and renal tumors, antimicrobial prophylaxis is not necessary when individual risk of infection is considered low.

Analysis of National Trends in Hospital Acquired Conditions Following Major Urologic Surgery Before and After Implementation of the Hospital Acquired Condition Reduction Program

OBJECTIVE

To define the rates of common hospital acquired conditions (HACs) in patients undergoing major urologic surgery over a period of time encompassing the implementation of the Hospital Acquired Condition Reduction program, and to evaluate whether implementation of the HAC reimbursement penalties in 2008 was associated with a change in the rate of HACs.

METHODS

Using American College of Surgeons National Surgical Quality Improvement Program data, we determined rates of HACs in patients undergoing major inpatient urologic surgery from 2005 to 2012. Rates were stratified by procedure type and approach (open vs laparoscopic and/or robotic). Multivariable logistic regression was used to determine the association between year of surgery and HACs.

RESULTS

We identified 39,257 patients undergoing major urologic surgery, of whom 2300 (5.9%) had at least one hospital acquired condition. Urinary tract infection (2.6%) was the most common, followed by surgical site infection (2.5%) and venous thrombotic events (0.7%). Multivariable logistic regression analysis demonstrated that open surgical approach, diabetes, congestive heart failure, chronic obstructive pulmonary disease, weight loss, and American Society of Anesthesiology class were among the variables associated with higher likelihood of HAC. We observed a nonsignificant secular trend of decreasing rates of HAC from 7.4% to 5.8% HACs during the study period, which encompassed the implementation of the Hospital Acquired Condition Reduction program.

CONCLUSION

HACs occurred at a rate of 5.9% after major urologic surgery, and are significantly affected by procedure type and patient health status. The rate of HAC appeared unaffected by National Reduction program in this cohort. Better understanding of the factors associated with HACs is critical in developing effective reduction programs.

Minilaparoscopy in urology: Systematic review

CONTEXT

There has been a boom in recent years in urological procedures using minilaparoscopy (ML).

OBJECTIVE

To conduct a systematic review of the published evidence on ML and its current role in urology.

ACQUISITION OF EVIDENCE

We performed a search on MedLine spanning October 1983 to December 2016 according to PRISMA criteria. A total of 6 comparative articles and 13 series were selected for this manuscript.

SUMMARY OF THE EVIDENCE

Only 1 study was randomised, 4 studies were prospective and comparative, and most were case series in which the operations were performed with 3-mm instruments. The most common procedures were adrenalectomy, followed by nephrectomy, living donor and pyeloplasty. Other minor conditions were also operated on, including cyst decortications, pyelolithotomies, lymphadenectomies, varicocelectomies and orchiectomies.

DISCUSSION

There have been significant technical improvements in recent years in the materials of ML. Most procedures were for reconstructive surgery and by transperitoneal approach, with a gradually increasing number of cases of oncologic surgery. Only 36.8% of the series assessed the cosmetic results with validated questionnaires, and 68.4% of the studies used the visual analogue scale to measure pain during the postoperative period.

CONCLUSIONS

The level of evidence of most published studies is low. ML is a reproducible technique for urological surgery and is safe even for operations on large surgical masses. The procedure's cosmetic and pain results after surgery are superior to those of conventional laparoscopy, although these conclusions should be taken with caution given the limitations of the current studies.

Prolonged Operative Duration Increases Risk of Surgical Site Infections: A Systematic Review

Background: The incidence of surgical site infection (SSI) across surgical procedures, specialties, and conditions is reported to vary from 0.1% to 50%. Operative duration is often cited as an independent and potentially modifiable risk factor for SSI. The objective of this systematic review was to provide an in-depth understanding of the relation between operating time and SSI.

Patients and Methods: This review included 81 prospective and retrospective studies. Along with study design, likelihood of SSI, mean operative times, time thresholds, effect measures, confidence intervals, and p values were extracted. Three meta-analyses were conducted, whereby odds ratios were pooled by hourly operative time thresholds, increments of increasing operative time, and surgical specialty.

Results: Pooled analyses demonstrated that the association between extended operative time and SSI typically remained statistically significant, with close to twice the likelihood of SSI observed across various time thresholds. The likelihood of SSI increased with increasing time increments; for example, a 13%, 17%, and 37% increased likelihood for every 15 min, 30 min, and 60 min of surgery, respectively. On average, across various procedures, the mean operative time was approximately 30 min longer in patients with SSIs compared with those patients without.

Conclusions: Prolonged operative time can increase the risk of SSI. Given the importance of SSIs on patient outcomes and health care economics, hospitals should focus efforts to reduce operative time.

Introduction to the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee Guideline for the Prevention of Surgical Site Infections

Surgical site infection (SSI) is a common type of health-care-associated infection (HAI) and adds considerably to the individual, social, and economic costs of surgical treatment. This document serves to introduce the updated Guideline for the Prevention of SSI from the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC). The Core section of the guideline addresses issues relevant to multiple surgical specialties and procedures. The second procedure-specific section focuses on a high-volume, high-burden procedure: Prosthetic joint arthroplasty. While many elements of the 1999 guideline remain current, others warrant updating to incorporate new knowledge and changes in the patient population, operative techniques, emerging pathogens, and guideline development methodology.

Prospective study analyzing risk factors and characteristics of healthcare-associated infections in a Urology ward

PURPOSE

Healthcare-associated infections (HAIs) in urological patients have special features due to specific risk factors. Our objective was to evaluate the characteristics and risk factors for HAIs in patients hospitalized in a Urology ward.

MATERIALS AND METHODS

We evaluated prospectively, from 2012 to 2015, the incidence, types and risk factor for HAIs, microbiological and resistance patterns.

RESULTS

The incidence of HAIs was 6.3%. The most common types were urinary infections (70.5%) and surgical site infections (22.1%). Univariate analysis showed an increased risk of HAIs among patients with American Society of Anesthesiologists physical status classification system III-IV (odds ratio [OR], 1.39; p<0.001), immunosuppression (OR, 1.80; p=0.013), previous urinary infection (OR, 4.46; p<0,001), and urinary catheter before admission (OR, 1.74; p<0.001). The surgical procedures with the highest incidence of HAIs were radical cystectomy (54.2%) and renal surgery (8.7%). The most frequently isolated microorganisms were Escherichia coli (25.1%), Enterococcus spp. (17.5%), Klebsiella spp. (13.5%) and Pseudomonas aeruginosa (12.3%). Enterococcus sp was the most common microorganism after radical cystectomy and in surgical site infections, E. coli showed resistance rates of 53.5% for fluoroquinolones, 9.3% for amikacin. The percentage of extended-spectrum betalactamase producing E. coli was 24.7%. Klebsiella spp. showed resistance rates of 47.8% for fluoroquinolones, 7.1% for amikacin and 4.3% for carbapenems. Enterococcus spp showed resistance rates of 1.7% for vancomycin and; P. aeruginosa of 33.3% for carbapenems and 26.2% for amikacin.

CONCLUSIONS

Comorbidities, previous urinary infections, and urinary catheter are risk factors for HAIs. The microorganisms most commonly isolated were E. coli, Enterococcus and P. aeruginosa. Prospective monitoring may decrease the incidence of infections.

Diabetes and Risk of Surgical Site Infection: A Systematic Review and Meta-analysis

OBJECTIVE To determine the independent association between diabetes and surgical site infection (SSI) across multiple surgical procedures. DESIGN Systematic review and meta-analysis. METHODS Studies indexed in PubMed published between December 1985 and through July 2015 were identified through the search terms "risk factors" or "glucose" and "surgical site infection." A total of 3,631 abstracts were identified through the initial search terms. Full texts were reviewed for 522 articles. Of these, 94 articles met the criteria for inclusion. Standardized data collection forms were used to extract study-specific estimates for diabetes, blood glucose levels, and body mass index (BMI). A random-effects meta-analysis was used to generate pooled estimates, and meta-regression was used to evaluate specific hypothesized sources of heterogeneity. RESULTS The primary outcome was SSI, as defined by the Centers for Disease Control and Prevention surveillance criteria. The overall effect size for the association between diabetes and SSI was odds ratio (OR)=1.53 (95% predictive interval [PI], 1.11-2.12; I2, 57.2%). SSI class, study design, or patient BMI did not significantly impact study results in a meta-regression model. The association was higher for cardiac surgery 2.03 (95% PI, 1.13-4.05) compared with surgeries of other types (P=.001). CONCLUSIONS These results support the consideration of diabetes as an independent risk factor for SSIs for multiple surgical procedure types. Continued efforts are needed to improve surgical outcomes for diabetic patients. Infect. Control Hosp. Epidemiol. 2015;37(1):88-99.

Robot assisted laparoscopic pyeloplasty in obese and non-obese patients

OBJECTIVE

We assessed whether increased BMI has a negative impact in children undergoing robot assisted laparoscopic pyeloplasty (RALP).

PATIENTS AND METHODS

Records of patients who underwent RALP were retrospectively reviewed and separated into healthy weight, overweight, and obese cohorts based on age-adjusted BMI percentile, and surgical and postsurgical outcomes were evaluated.

RESULTS

Of the 103 patients, there were 79 healthy weight and 24 overweight, with 10 of the 24 considered obese (BMI<85th, ≥85th, and ≥95th percentile for age, respectively). Cohorts were similar in respect to age, sex, laterality and symptoms. Operative time (234 min, 241 min, p=0.642; 254 min, p=0.324), EBL (7.1 ml, 10.5 ml, p=0.293; 6.8 ml, p=0.906), length of stay (1.2d, 1.2d p=0.545; 1.1d p=0.550), and narcotic administration (0.25 mg/kg, 0.25 mg/kg, p=0.545; 0.13 mg/kg, p=0.430) were similar between healthy weight, overweight, and obese cohorts, respectively. Complication rates were similar in regard to minor and major complications. There was no difference in decreased hydronephrosis (92.2%, 89.6%, p=0.440; 88.9%, p=0.730). Four patients (3.4%) required a reoperative procedure (three healthy weight, one overweight; p=NS).

CONCLUSIONS

Despite the potential difficulties with surgery in overweight patients, our data indicate that robot-assisted laparoscopic pyeloplasty can be performed as safely and effectively in overweight or obese children as in healthy weight children.

Gender differences in risk of bloodstream and surgical site infections

BACKGROUND

Identifying patients most at risk for hospital- and community-associated infections is one essential strategy for preventing infections.

OBJECTIVE

To investigate whether rates of community- and healthcare-associated bloodstream and surgical site infections varied by patient gender in a large cohort after controlling for a wide variety of possible confounders.

DESIGN

Retrospective cohort study.

PARTICIPANTS

All patients discharged from January 1, 2006 through December 31, 2008 (133,756 adult discharges and 66,592 pediatric discharges) from a 650-bed tertiary care hospital, a 220-bed community hospital, and a 280-bed pediatric acute care hospital within a large, academic medical center in New York, NY.

MAIN MEASURES

Data were collected retrospectively from various electronic sources shared by the hospitals and linked using patients' unique medical record numbers. Infections were identified using previously validated computerized algorithms.

KEY RESULTS

Odds of community-associated bloodstream infections, healthcare-associated bloodstream infections, and surgical site infections were significantly lower for women than for men after controlling for present-on-admission patient characteristics and events during the hospital stay [odds ratios (95 % confidence intervals) were 0.85 (0.77-0.93), 0.82 (0.74-0.91), and 0.78 (0.68-0.91), respectively]. Gender differences were greatest for older adolescents (12-17 years) and adults 18-49 years and least for young children (<12 years) and older adults (≥ 70 years).

CONCLUSIONS

In this cohort, men were at higher risk for bloodstream and surgical site infections, possibly due to differences in propensity for skin colonization or other anatomical differences.

Evolution and simplified terminology of natural orifice transluminal endoscopic surgery (NOTES), laparoendoscopic single-site surgery (LESS), and mini-laparoscopy (ML)

INTRODUCTION

Natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) are the next steps in the evolution of laparoscopic surgery, promising reduced morbidity and improved cosmetic result. The inconsistent terminology initially used led to confusion. Understanding the technical evolution, the current status and a unified and simplified terminology are key issues for further acceptance of both approaches.

OBJECTIVE

To present LESS and NOTES in its historical context and to clarify the associated terminology.

METHOD

Extensive literature search took place using the PubMed. Several hundred publications in general surgery and urology regarding LESS are present including the expert opinion of members the European Society of Uro-technology (ESUT).

RESULTS

The increasing interest on NOTES and LESS is reflected by a raising number of publications during the last 4 years. The initial confusion with the terminology of single-incision surgery represented a significant issue for further evolution of the technique. Thus, consortiums of experts searched a universally acceptable name for single-incision surgery. They determined that 'laparoendoscopic single-site surgery' (LESS) was both scientifically accurate and colloquially appropriate, the term being also ratified by the NOTES working group (Endourological Society) and the ESUT. For additional use of instruments, the terms hybrid NOTES and hybrid LESS should be used. Any single use of miniaturized instruments for laparoscopy should be called mini-laparoscopy.

DISCUSSION

The evolution of LESS and most likely NOTES to a new standard of minimally invasive surgery could represent an evolutionary step even greater than the one performed by the establishment of laparoscopy over open surgery.