1
|
Passarelli R, Pfail J, Kaldany A, Chua K, Lichtbroun B, Patel HV, Srivastava A, Golombos D, Jang TL, Packiam VT, Ghodoussipour S. The Association Between Duration of Antibiotics and Infectious Complications Following Radical Cystectomy: Analysis of the 2019-2021 NSQIP Database. Urology 2024; 189:64-69. [PMID: 38648953 DOI: 10.1016/j.urology.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 03/21/2024] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVES To identify the impact of the duration of peri-operative antibiotics on infectious complications following radical cystectomy. METHODS The National Surgical Quality Improvement Project (NSQIP) targeted database was queried for patients undergoing radical cystectomy from 2019 to 2021. Baseline patient characteristics were collected. Antibiotic duration was classified as <24 hours (short), 24-72 hours (intermediate) or >72 hours (long). Infectious complication data were collected including surgical site infection (SSI), urinary tract infection (UTI), organ space infection, pneumonia, sepsis, and clostridium difficile infection up to 30 days after surgery. Univariate and multivariable analyses were performed to compare duration of antibiotic therapy to infectious outcomes. RESULTS Of the 4363 patients who underwent radical cystectomy, 3250 (74%), 827 (19%) and 286 (6.6%) received short, intermediate, and long duration of peri-operative antibiotics, respectively. Infectious complication occurred in 954 (22%) patients, including 227 (5.2%) SSI, 280 (6.4%) UTI, 268(6.1%) organ space infection, 87 (2%) pneumonia, and 378 (8.7%) sepsis. Clostridium difficile infection occurred in 89 (2%) patients. On multivariable analysis, there was no significant difference in overall infectious complication rates with long-duration antibiotics. However, intermediate duration of antibiotics in open surgery was associated with a decreased risk of SSI (OR 0.58; 95%CI 0.37-0.91) compared to those treated with short-term antibiotics. CONCLUSION Despite guideline recommendations, 26% of patients in this database received >24 hours of peri-operative antibiotics without decreased risk of overall infectious complication. An intermediate course of antibiotics decreased risk of SSI in open surgery compared to the guideline recommend <24-hour course. Greater education regarding antibiotic stewardship and further studies investigating infectious complications are warranted.
Collapse
Affiliation(s)
- Rachel Passarelli
- Division of Urology, Rutgers Robert Wood Johnson, New Brunswick, NJ.
| | - John Pfail
- Division of Urology, Rutgers Robert Wood Johnson, New Brunswick, NJ
| | - Alain Kaldany
- Division of Urology, Rutgers Robert Wood Johnson, New Brunswick, NJ
| | - Kevin Chua
- Division of Urology, Rutgers Robert Wood Johnson, New Brunswick, NJ
| | | | - Hiren V Patel
- Department of Urology, University of California at San Francisco, San Francisco, CA
| | - Arnav Srivastava
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor MI
| | - David Golombos
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Thomas L Jang
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Vignesh T Packiam
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Saum Ghodoussipour
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| |
Collapse
|
2
|
Blachman-Braun R, Gurayah AA, Mason MM, Hougen HY, Gonzalgo ML, Nahar B, Punnen S, Parekh DJ, Ritch CR. Incidence and predictors of deep incisional and organ/space surgical site infection following radical cystectomy. Urol Oncol 2023; 41:455.e17-455.e24. [PMID: 37524577 DOI: 10.1016/j.urolonc.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 06/01/2023] [Accepted: 06/26/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVE To investigate clinical risk factors associated with postoperative deep incisional or organ/space surgical site infections (SSI) following radical cystectomy (RC) in a well characterized and large contemporary cohort. METHODS We used the American College of Surgeons National Surgical Quality Improvement Program database to identify adult patients who underwent RC for bladder cancer between 2015 and 2020 (n = 13,081). We conducted multivariable-adjusted logistic regression and Cox adjusted proportional hazards regression analysis to identify clinical predictors of deep incisional or organ/space SSI in the 30-day postoperative-period following RC. RESULTS Deep incisional or organ/space SSI risk increased with continent urinary diversion (HR = 1.61, 95% CI: 1.38-1.88; P < 0.001), obesity (HR = 1.60, 95% CI: 1.35-1.90; P < 0.001), diabetes mellitus (HR = 1.30, 95% CI: 1.13-1.51; P < 0.001), and being functionally dependent before surgery (HR = 2.09, 95% CI: 1.44-3.03; P < 0.001). CONCLUSIONS Postoperative deep incisional or organ/space SSIs following RC occur more frequently in patients who were obese, diabetic, functionally dependent before surgery, and those who underwent continent urinary diversion. These findings may assist urologists in preoperative counseling, medical optimization, and choice of urinary diversion approach, as well as improved patient monitoring and identification of candidates for intervention postoperatively.
Collapse
Affiliation(s)
- Ruben Blachman-Braun
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL.
| | | | | | - Helen Y Hougen
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Mark L Gonzalgo
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL; Sylvester Comprehensive Cancer Center, Miami, FL
| | - Bruno Nahar
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL; Sylvester Comprehensive Cancer Center, Miami, FL
| | - Sanoj Punnen
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL; Sylvester Comprehensive Cancer Center, Miami, FL
| | - Dipen J Parekh
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL; Sylvester Comprehensive Cancer Center, Miami, FL
| | - Chad R Ritch
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL; Sylvester Comprehensive Cancer Center, Miami, FL
| |
Collapse
|
3
|
Berndl F, Frerichmann J, Berndl T. Prevention and management of urinary tract infections after cystectomy. Curr Opin Urol 2023; 33:200-205. [PMID: 36861762 DOI: 10.1097/mou.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
PURPOSE OF REVIEW To give an overview of the most relevant recent literature about urinary tract infections (UTI) after radical cystectomy and to discuss them in the context of new individualized therapy approaches and possible preventive measures. RECENT FINDINGS UTI following radical cystectomy is a common complication associated with significant morbidity and readmission risk. Recent literature focuses on the identification of risk factors and the optimization of management. The risk factors most commonly associated with increased risk for UTI were perioperative blood transfusions and orthotopic neobladder (ONB). Furthermore, the effect of perioperative antibiotic regimens on rates of postoperative infections has been studied, but no consistent significant changes in UTI rates have yet been identified. Guidelines should be based on urologic studies and, wherever appropriate, should be uniform in design to encourage more frequent adherence. Furthermore, understanding the pathomechanisms leading to the development of UTI after radical cystectomy needs to be more central to discussions. SUMMARY Uniform definition of UTI, characteristics of bacterial pathogens involved, and type and duration of antibiotics used and identification of clinical risk factors must be the focus of well designed prospective studies to enable reduction of the most common complication after radical cystectomy.
Collapse
|
4
|
Antonelli L, Sebro K, Lahmar A, Black PC, Ghodoussipour S, Hamilton-Reeves JM, Shah J, Bente Thoft J, Lerner SP, Llorente C, Lucca I, Preston MA, Psutka SP, Sfakianos JP, Vahr Lauridsen S, Williams SB, Catto J, Djaladat H, Kassouf W, Loftus K, Daneshmand S, Fankhauser CD. Association Between Antibiotic Prophylaxis Before Cystectomy or Stent Removal and Infection Complications: A Systematic Review. Eur Urol Focus 2023:S2405-4569(23)00028-7. [PMID: 36710211 DOI: 10.1016/j.euf.2023.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/24/2022] [Accepted: 01/17/2023] [Indexed: 01/29/2023]
Abstract
CONTEXT Patients undergoing radical cystectomy frequently suffer from infectious complications, including urinary tract infections (UTIs) and surgical site infections (SSIs) leading to emergency department visits, hospital readmission, and added cost. OBJECTIVE To summarize the literature regarding perioperative antibiotic prophylaxis, ureteric stent usage, and prevalence of infectious complications after cystectomy. EVIDENCE ACQUISITION A systematic review of PubMed/Medline, EMBASE, Cochrane Library, and reference lists was conducted. EVIDENCE SYNTHESIS We identified 20 reports including a total of 55 306 patients. The median rates of any infection, UTIs, SSIs, and bacteremia were 40%, 20%, 11%, and 6%, respectively. Perioperative antibiotic prophylaxis differed substantially between reports. Perioperative antibiotics were used only during surgery in one study but were continued over several days after surgery in all other studies. Empirical use of antibiotics for 1-3 d after surgery was described in 12 studies, 3-10 d in two studies, and >10 d in four studies. Time to stent removal ranged from 4 to 25 d after cystectomy. Prophylactic antibiotics were used before stent removal in nine of 20 studies; two of these studies used targeted antibiotics based on urine cultures from the ureteric stents, and the other seven studies used a single shot or 2 d of empirical antibiotics. Studies with any prophylactic antibiotic before stent removal found a lower median percentage of positive blood cultures after stent removal than studies without prophylactic antibiotics before stent removal (2% vs 9%). CONCLUSIONS We confirmed a high proportion of infectious complications after cystectomy, and a heterogeneous pattern of choice and duration of antibiotics during and after surgery or stent removal. These findings highlight a need for further studies and support quality prospective trials. PATIENT SUMMARY In this review, we observed wide variability in the use of antibiotics before or after surgical removal of the bladder.
Collapse
Affiliation(s)
- Luca Antonelli
- Department of Urology, Luzerner Kantonsspital, University of Lucerne, Lucerne, Switzerland; Department of Urology, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Kirby Sebro
- Department of Urology, Western General Hospital, Edinburgh, UK
| | - Abdelilah Lahmar
- Medicine, Faculty of Medicine and Pharmacy, Mohammed VI University Hospital, Oujda, Morocco
| | - Peter C Black
- Vancouver Prostate Centre and Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Saum Ghodoussipour
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | | | - Jay Shah
- Department of Urology, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Seth Paul Lerner
- Scott Department of Urology, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Carlos Llorente
- Department of Urology and Research Unit, Hospital Universitario Fundación Alcorcon, Alcorcón, Madrid, Spain
| | - Ilaria Lucca
- Department of Urology, CHUV, Lausanne, Switzerland
| | - Mark A Preston
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah P Psutka
- Department of Urology, University of Washington, Seattle, WA, USA
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Susanne Vahr Lauridsen
- Department of Urology, Copenhagen University Hospital, Copenhagen, Denmark; WHO-CC, Parker Institute Bispebjerg & Frederiksberg University Hospital, Copenhagen, Denmark
| | - Stephen B Williams
- Division of Urology, Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - James Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Hooman Djaladat
- Institute of Urology, Kenneth Norris Jr. Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Wassim Kassouf
- Department of Surgery (Urology), Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Katherine Loftus
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn school of Medicine at Mount Sinai, New York, NY, USA
| | - Siamak Daneshmand
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Christian D Fankhauser
- Department of Urology, Luzerner Kantonsspital, University of Lucerne, Lucerne, Switzerland.
| |
Collapse
|
5
|
Fasanella D, Marchioni M, Domanico L, Franzini C, Inferrera A, Schips L, Greco F. Neobladder "Function": Tips and Tricks for Surgery and Postoperative Management. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081193. [PMID: 36013372 PMCID: PMC9409805 DOI: 10.3390/life12081193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/21/2022] [Accepted: 07/29/2022] [Indexed: 11/23/2022]
Abstract
Orthotopic neobladder (ONB) reconstruction is a continent urinary diversion procedure increasingly used in patients with muscle-invasive bladder cancer following radical cystectomy (RC). It represents a valid alternative to the ileal duct in suitable patients who do not prefer a stoma and are motivated to undergo adequate training of the neobladder. Careful patient selection, taking into account the absolute and relative contraindications for ONB as well as an adequate recovery protocol after surgery are integral to the success of this procedure and the oncological and functional outcomes. The objective of this review is to summarize the current data on RC with ONB in terms of patient selection, preoperative preparation, surgical techniques and functional (continence and sexual activity) and oncological outcomes, with particular attention to the management of complications and the impact on quality of life (QoL).
Collapse
Affiliation(s)
- Daniela Fasanella
- Urology Unit, Department of Medical, Oral and Biotechnological Sciences, G. d’Annunzio University of Chieti, SS Annunziata Hospital, 66100 Chieti, Italy
| | - Michele Marchioni
- Urology Unit, Department of Medical, Oral and Biotechnological Sciences, G. d’Annunzio University of Chieti, SS Annunziata Hospital, 66100 Chieti, Italy
| | - Luigi Domanico
- Urology Unit, Centro Salute Uomo, Via Palma il Vecchio 4a, 24122 Bergamo, Italy
| | - Claudia Franzini
- Urology Unit, Centro Salute Uomo, Via Palma il Vecchio 4a, 24122 Bergamo, Italy
| | - Antonino Inferrera
- Urology Unit, Centro Salute Uomo, Via Palma il Vecchio 4a, 24122 Bergamo, Italy
| | - Luigi Schips
- Urology Unit, Department of Medical, Oral and Biotechnological Sciences, G. d’Annunzio University of Chieti, SS Annunziata Hospital, 66100 Chieti, Italy
| | - Francesco Greco
- Urology Unit, Centro Salute Uomo, Via Palma il Vecchio 4a, 24122 Bergamo, Italy
- Correspondence: ; Tel.: +39-3317918535
| |
Collapse
|
6
|
Labbate CV, Kuchta K, Park S, Agarwal PK, Smith ND. Incidence of Preoperative Antibiotic Use and Its Association with Postoperative Infectious Complications after Radical Cystectomy. Urology 2022; 164:169-177. [PMID: 35218864 DOI: 10.1016/j.urology.2022.01.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/19/2021] [Accepted: 01/19/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine exposure rates to antibiotics prior to radical cystectomy and determine if there is correlation with post-operative infections. METHODS AND MATERIALS 2248 patients were identified in the 2016 SEER-Medicare linkage who underwent radical cystectomy between 2008 and 2014 with complete prescription information. An outpatient prescription for an antibiotic within 30 days prior to cystectomy was considered exposure. Antibiotic class and combinations were recorded. Postoperative infectious diagnoses and readmissions were tabulated within 30 days of cystectomy. RESULTS Fifty one percent of patients (n = 1149) were prescribed an outpatient antibiotic prior to cystectomy. Patients receiving antibiotics were more likely to be female (31% vs 25%, P < .01) and had been diagnosed with an infection (17% vs 11%, P < .01). Antibiotic bowel prophylaxis was prescribed to 42% of patients receiving antibiotics. Postoperatively, the exposure group had higher rates of any infection, (56% vs 51% P < .01) and UTI (36% vs 31% P < .01). All-cause readmission within 30 days was higher in the exposure cohort (26% vs 22%, P = .02) Multivariable logistic regression showed outpatient preoperative antibiotics were an independent risk factor for any infection (HR 1.19, P < .05) and readmission (hazards ratio 1.24, P = .03) in the 30 days after radical cystectomy. CONCLUSION Outpatient antibiotic use prior to radical cystectomy is common and may be associated with increased risk of postoperative infection and readmission. Antibiotic use prior to radical cystectomy should be examined as a modifiable factor to decrease post-operative morbidity.
Collapse
Affiliation(s)
| | | | - Sangtae Park
- North Shore University Health System, Evanston, IL
| | | | - Norm D Smith
- North Shore University Health System, Evanston, IL
| |
Collapse
|
7
|
Schneidewind L, Torabi L, Dräger DL, Hakenberg OW. Reduction of Perioperative Antibiotic Prophylaxis in Open Radical Cystectomy with Ileal Conduit Is Feasible: Results of a Prospective Clinical Trial. Urol Int 2021; 106:825-831. [PMID: 34903704 PMCID: PMC9533434 DOI: 10.1159/000520564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 10/13/2021] [Indexed: 11/19/2022]
Abstract
Introduction The aim of this study is to perform a prospective clinical trial in antibiotic prophylaxis, infectious complication, and colonization of ileal conduit (IC) following radical cystectomy (RC) since urinary tract infections (UTIs) and surgical site infections (SSIs) contribute significantly to the morbidity associated with RC and IC. Moreover, an optimal regimen of antibiotic prophylaxis has not been established, yet. Material and Methods After a positive vote of ethical review committee and the registration at the German Clinical Trials Register (DKRS 00020406), we started a prospective clinical unicentric not interventional study. The urine samples were collected by sterile catheterization of the IC. All patients received an antibiotic prophylaxis with 3 × 500 mg metronidazole and 3 × 1.5 g cefuroxime intravenously for 3 days starting on the day before RC. Ureteral stents got removed on days 9 and 10 after surgery without prior antibiotic administration. The student t test and the χ2 test or the Fisher exact test were used. For risk factor assessment, the univariate Cox regression method was applied. Results Nineteen male (63.3%) and 11 female patients (36.7%) with a median age of 70.5 years were included. Three patients developed complicated UTI (10%) on day 12 after RC with E. faecium and needed antibiotic treatment with meropenem (Clavien-Dindo II). Two patients (6.7%) developed SSI with E. faecium and needed surgery (Clavien-Dindo IIIb). Palliative RC (p < 0.0001), prior radiation therapy (p < 0.0001), and timeframe >3 months from diagnosis to RC (p = 0.036) are significantly associated with the development of complicated UTI. Interestingly, the IC got colonized with Staph. haemolyticus at day 12 after RC (n = 12; 40.0%). We must assume that our data have some limitations like a unicentric study population. Conclusion Further evaluation of reduction to single-shot antibiotic prophylaxis in nonpalliative RC with IC could be feasible.
Collapse
Affiliation(s)
- Laila Schneidewind
- Department of Urology, University Medical Center Rostock, Rostock, Germany
| | - Laura Torabi
- Department of Urology, University Medical Center Rostock, Rostock, Germany
| | - Desiree L Dräger
- Department of Urology, University Medical Center Rostock, Rostock, Germany
| | - Oliver W Hakenberg
- Department of Urology, University Medical Center Rostock, Rostock, Germany
| |
Collapse
|
8
|
Bardia A, Treggiari MM, Michel G, Dai F, Tickoo M, Wai M, Schuster K, Mathis M, Shah N, Kheterpal S, Schonberger RB. Adherence to Guidelines for the Administration of Intraoperative Antibiotics in a Nationwide US Sample. JAMA Netw Open 2021; 4:e2137296. [PMID: 34905007 PMCID: PMC8672234 DOI: 10.1001/jamanetworkopen.2021.37296] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Despite widespread adherence to Surgical Care Improvement Project antibiotic measures, prevention of surgical site infections (SSIs) remains a clinical challenge. Several components of perioperative antibiotic prophylaxis guidelines are incompletely monitored and reported within the Surgical Care Improvement Project program. OBJECTIVES To describe adherence to each component of perioperative antibiotic prophylaxis guidelines in regard to procedure-specific antibiotic choice, weight-adjusted dosing, and timing of first and subsequent administrations in a nationwide, multicenter cohort of patients undergoing noncardiac surgery. DESIGN, SETTING, AND PARTICIPANTS This cohort study included adult patients undergoing general, urological, orthopedic, and gynecological surgical procedures involving skin incision between January 1, 2014, and December 31, 2018, across 31 academic and community hospitals identified within the Multicenter Perioperative Outcomes Group registry. Data were analyzed between April 2 and April 21, 2021. MAIN OUTCOMES AND MEASURES The primary end point was overall adherence to Infectious Diseases Society of America guidelines, including (1) appropriateness of antibiotic choice, (2) weight-based dose adjustment, (3) timing of administration with respect to surgical incision, and (4) timing of redosing when indicated. Data were analyzed using mixed-effects regression to investigate patient, clinician, and institutional factors associated with guideline adherence. RESULTS In the final cohort of 414 851 encounters across 31 institutions, 51.8% of patients were women, the mean (SD) age was 57.5 (15.7) years, 1.2% of patients were of Hispanic ethnicity, and 10.2% were Black. In this cohort, 148 804 encounters (35.9%) did not adhere to guidelines: 19.7% for antibiotic choice, 17.1% for weight-adjusted dosing, 0.6% for timing of first dose, and 26.8% for redosing. In adjusted analyses, overall nonadherence was associated with emergency surgery (odds ratio [OR], 1.35; 95% CI, 1.29-1.41; P < .001), surgery requiring blood transfusions (OR, 1.30; 95% CI, 1.25-1.36; P < .001), off-hours procedures (OR, 1.08; 95% CI, 1.04-1.13; P < .001), and procedures staffed by a certified registered nurse anesthetist (OR, 1.14; 95% CI, 1.11-1.17; P < .001). Overall adherence to guidelines for antibiotic administration improved over the study period from 53.1% (95% CI, 52.7%-53.5%) in 2014 to 70.2% (95% CI, 69.8%-70.6%) in 2018 (P < .001). CONCLUSIONS AND RELEVANCE In this cohort study, although adherence to perioperative antibiotic administration guidelines improved over the study period, more than one-third of surgical encounters remained discordant with Infectious Diseases Society of America recommendations. Future quality improvement efforts targeting gaps in practice in relation to guidelines may lead to improved adherence and possibly decreased SSIs.
Collapse
Affiliation(s)
- Amit Bardia
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
| | - Miriam M. Treggiari
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
| | - George Michel
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
| | - Feng Dai
- Yale Center for Analytical Sciences, New Haven, Connecticut
| | - Mayanka Tickoo
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Mabel Wai
- Department of Pharmacy, Yale New Haven Hospital, New Haven, Connecticut
| | - Kevin Schuster
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Michael Mathis
- Department of Anesthesiology, University of Michigan School of Medicine, Ann Arbor
| | - Nirav Shah
- Department of Anesthesiology, University of Michigan School of Medicine, Ann Arbor
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan School of Medicine, Ann Arbor
| | | |
Collapse
|
9
|
Kim AH, Ruel NH, Yamzon J, Zhumkhawala AA, Lau CS, Yuh BE, Chan KG. Novel Antibiotic-Irrigating Wound Protector Reduces Infectious Complications in Robot-Assisted Radical Cystectomy with Extracorporeal Urinary Diversion. Urology 2021; 159:160-166. [PMID: 34678310 DOI: 10.1016/j.urology.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/30/2021] [Accepted: 10/06/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine whether use of an antibiotic-irrigating wound protector (AWP) reduces infectious complications after robotic radical cystectomy with extracorporeal urinary diversion (RCUD). METHODS A prospectively maintained bladder cancer database was queried for patients undergoing robotic RCUD at a tertiary referral center one year prior to implementing an AWP and one year after (2018-2020). All diversions were performed extra-corporally. 92 patients total. 46 consecutive patients using a traditional wound protector (TWP) and 46 consecutive with an AWP. Infections were classified as symptomatic urinary tract infection, blood stream infection, and surgical site infection. The incidence of infectious complications at 30- and 90-days were compared. RESULTS Baseline patient characteristics between the 2 groups showed no statistically significant differences. The overall complication rate was 65.2% in the TWP group and 26.1% in the AWP group at 30-days, and 67.4% vs 30.4% at 90-days. Focusing on infections, the 30-day complication rate was 30.4% in the TWP group compared to 6.5% in the AWP group (P =.003). This pattern persisted at 90-days with 37.0% in the TWP group compared to 6.5% in the AWP group (P =.004). Most complications were symptomatic UTI and blood stream infections, 14/24 (58%), requiring parenteral antibiotic treatment. CONCLUSION We provide preliminary data showing use of an AWP can reduce infectious complications after RCUD. While larger prospective studies are warranted, our findings are a significant step towards decreasing morbidity of an already highly morbid procedure.
Collapse
Affiliation(s)
- Albert H Kim
- City of Hope National Medical Center, Division of Urology and Urologic Oncology, Department of Surgery, Duarte, CA
| | - Nora H Ruel
- City of Hope National Medical Center, Division of Biostatistics, Department of Computational and Biostatistics, Duarte, CA
| | - Jonathan Yamzon
- City of Hope National Medical Center, Division of Urology and Urologic Oncology, Department of Surgery, Duarte, CA
| | - Ali-Ashgar Zhumkhawala
- City of Hope National Medical Center, Division of Urology and Urologic Oncology, Department of Surgery, Duarte, CA
| | - Clayton S Lau
- City of Hope National Medical Center, Division of Urology and Urologic Oncology, Department of Surgery, Duarte, CA
| | - Bertram E Yuh
- City of Hope National Medical Center, Division of Urology and Urologic Oncology, Department of Surgery, Duarte, CA
| | - Kevin G Chan
- City of Hope National Medical Center, Division of Urology and Urologic Oncology, Department of Surgery, Duarte, CA.
| |
Collapse
|
10
|
Gayarre Abril P, Subirá Ríos J, Muñiz Suárez L, Murillo Pérez C, Ramírez Fabián M, Hijazo Conejos J, Medrano Llorente P, García-Magariño Alonso J, Elizalde Benito F, Aleson Hornos G, Pérez Abad L, Rioja Zuazu J, García Artal C, Blasco Beltrán B, Carrera Lasfuentes P, Marín Zaldivar C. Urinary tract infection as the main cause of admission in cystectomized patients. Actas Urol Esp 2021; 45:247-256. [PMID: 33516599 DOI: 10.1016/j.acuro.2020.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 09/15/2020] [Accepted: 10/26/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION AND OBJECTIVES Radical cystectomy with urinary diversion associated with extended pelvic lymphadenectomy continues to be the treatment of choice in muscle invasive bladder cancer. Sixty-four percent of patients submitted to this procedure present postoperative complications, with urinary infection being responsible in 20-40% of cases. The aim of this project is to assess the rate of urinary infection as a cause of re-admission after cystectomy, and to identify protective and predisposing factors for urinary infection in our environment. Finally, we will evaluate the outcomes after the establishment of a prophylactic antibiotic protocol after removal of ureteral catheters. MATERIAL AND METHODS Retrospective descriptive study of cystectomized patients in the Urology Service of the Hospital Clínico Universitario of Zaragoza, from January 2012 to December 2018. A urinary tract infection (UTI) prevention protocol after catheter removal is established for all patients since October 2017. RESULTS UTI is responsible for 54.7% of readmissions, with 55.1% of these being due to UTI after removal of ureteral catheters. Of the patients who received with prophylaxis, 9.5% presented UTIs after withdrawal, compared to 10.6% in the group of patients without prophylaxis. The patient who is re-admitted for UTI after withdrawal has a mean catheter time of 24.3±7.2 days, compared to 24.5±7.4 days for patients in the group without UTI (P=.847). CONCLUSIONS The type of urinary diversion performed is not related to the rate of urinary infection. The regression model does not identify antibiotic prophylaxis, nor catheter time, as independent factors of UTI after catheter removal.
Collapse
|
11
|
Maibom SL, Joensen UN, Poulsen AM, Kehlet H, Brasso K, Røder MA. Short-term morbidity and mortality following radical cystectomy: a systematic review. BMJ Open 2021; 11:e043266. [PMID: 33853799 PMCID: PMC8054090 DOI: 10.1136/bmjopen-2020-043266] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To study short-term (<90 days) morbidity and mortality following radical cystectomy (RC) for bladder cancer and identify modifiable risk factors associated with these. DESIGN Systematic review. METHODS The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed and EMBASE were searched for relevant papers on 11 June 2019 and rerun on 27 May 2020. Studies reporting complications, reoperations, length of stay and mortality within 90 days were included. Studies were reviewed according to criteria from the Oxford Centre for Evidence-Based Medicine and the quality of evidence was assessed using the Newcastle-Ottawa Scale. RESULTS The search retrieved 1957 articles. Sixty-six articles were included. The quality of evidence was poor to good. Most studies were retrospective, and no randomised clinical trials were identified. Of included studies a median of 6 Martin criteria for reporting complications after surgery were fulfilled. The Clavien-Dindo classification for grading complications was most frequently used. The weighted overall complication rate after RC was 34.9% (range 28.8-68.8) for in-house complications, 39.0% (range 27.3-80.0) for 30-day complications and 58.5% (range 36.1-80.5) for 90-day complications. The most common types of complications reported were gastrointestinal (29.0%) and infectious (26.4%). The weighted mortality rate was 2.4% (range 0.9-4.7) for in-house mortality, 2.1% (0.0-3.7) for 30-day mortality and 4.7% (range 0.0-7.0) for 90-day mortality. Age and comorbidity were identified as the best predictors for complications following RC. CONCLUSION Short-term morbidity and mortality are high following RC. Reporting of complications is heterogeneous and the quality of evidence is generally low. There is a continuous need for randomised studies to address any intervention that can reduce morbidity and mortality following RC. PROSPERO REGISTRATION NUMBER 104937.
Collapse
Affiliation(s)
- Sophia Liff Maibom
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Ulla Nordström Joensen
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Alicia Martin Poulsen
- Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Henrik Kehlet
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
- Section for Surgical Pathophysiology, The Juliane Marie Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Klaus Brasso
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Martin Andreas Røder
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
12
|
Dressler FF, Dogan S, Hennig M, Frank T, Struck J, Cebulla A, Salem J, Borgmann H, Klatte T, Kramer MW, Hofbauer S. [Current practice patterns of perioperative cystectomy management in Germany: a questionnaire survey]. Aktuelle Urol 2021; 52:82-87. [PMID: 32726815 DOI: 10.1055/a-1025-2523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Radical cystectomy (RCX) is the standard treatment for muscle-invasive and treatment-refractory non-invasive bladder cancer, but that is associated with high morbidity. We now survey current practice patterns on perioperative management among German urological departments of all sizes METHODS: Members of the German Association of Urology and the German Society of Residents in Urology (GeSRU) were contacted by email and asked to answer a 24-item online questionnaire covering clinically relevant aspects of current guidelines and controversies. RESULTS Responses were obtained from at least 19 % of all German urological centers. About 60 % performed preoperative staging using CT urography and chest CT. The most common perioperative antibiotic prophylaxis was a third generation cephalosporin combined with metronidazole (46 %), administered for a median of 5 days. Stentograms for ileal conduit and neobladder are routinely performed in 38 % and 55 % of patients, respectively. Ureteral stents were usually removed 11 - 12 days after the procedure (ileal conduit and neobladder). Based on the surrogate parameters of preoperative bowel preparation, postoperative start of oral nutrition and use of nasogastric tube, fast-track concepts such as ERAS were not generally established (< 50 %). Robot-assisted cystectomy appears to be performed in 15 % of German urological centers and was associated with the number of performed cystectomies (p < 0.001). CONCLUSIONS Most aspects of perioperative management in cystectomy patients - staging diagnostics, use of antibiotics, stent removal - are performed in accordance with current guidelines. Other clinical questions such as stent imaging before removal and fast track concepts are handled heterogeneously. Guideline-adherence was not associated with hospital size or number of procedures performed.
Collapse
Affiliation(s)
| | | | - Martin Hennig
- Universität zu Lübeck Sektion Medizin, Urologie, Lübeck
| | - Tanja Frank
- RoMed Klinikum Rosenheim, Urologie, Rosenheim
| | - Julian Struck
- Universität zu Lübeck Sektion Medizin, Urologie, Lübeck
| | | | | | - Hendrik Borgmann
- Johannes Gutenberg Universität Universitätsmedizin, Klinik und Poliklinik für Urologie, Mainz
| | - Tobias Klatte
- Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Urology, Bournemouth, UK
| | | | | |
Collapse
|
13
|
Haywood S, Donahue TF, Bochner BH. Management of Common Complications After Radical Cystectomy, Lymph Node Dissection, and Urinary Diversion. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
14
|
Numao N, Fujiwara R, Uehara S, Yasuoka S, Fujiwara M, Komai Y, Yuasa T, Yamamoto S, Fukui I, Yonese J. Intraoperative Only versus Extended Duration Use of Antimicrobial Prophylaxis for Infectious Complications in Radical Cystectomy with Intestinal Urinary Diversion. Urol Int 2020; 104:954-959. [PMID: 32814326 DOI: 10.1159/000509881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 07/02/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION In spite of the high incidence of infectious complications (ICs), appropriate duration of antimicrobial prophylaxis (AMP) for radical cystectomy (RC) with intestinal urinary diversion (IUD) has not been established. We compared the incidence of ICs after RC with IUD in patients using only intraoperative AMP or extended duration AMP. Risk factors for ICs were also investigated. PATIENTS AND METHODS One hundred twenty-three consecutive patients who underwent RC with IUD were divided into 2 groups based on the AMP duration (intraoperative only vs. extended duration for a median of 3 days). Between the groups, the incidence of ICs was compared. Risk factors for ICs were investigated in multivariate analysis. RESULTS The IC rate was 44%. No significant difference was found in the rate of ICs between the groups. The IC rate was significantly higher in patients with lower estimated glomerular filtration rate (eGFR). Rates of ICs were 60 and 38% in patients with eGFR of less than 60 and equal or more than 60 mL/min/1.73 m2, respectively. CONCLUSIONS Our result indicates that AMP that is administered more than intraoperatively may be excessive in RC with IUD. Patients with a lower eGFR should be particularly cared for postoperative ICs.
Collapse
Affiliation(s)
- Noboru Numao
- Department of Genitourinary Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan,
| | - Ryo Fujiwara
- Department of Genitourinary Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Sho Uehara
- Department of Urology, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shotaro Yasuoka
- Department of Genitourinary Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Motohiro Fujiwara
- Department of Genitourinary Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshinobu Komai
- Department of Genitourinary Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takeshi Yuasa
- Department of Genitourinary Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shinya Yamamoto
- Department of Genitourinary Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Iwao Fukui
- Department of Genitourinary Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Junji Yonese
- Department of Genitourinary Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| |
Collapse
|
15
|
Abstract
The objective of this study was to identify the occurrence of complicated surgical wounds (CSWs) and to analyze the associated factors in hospitalized patients at an oncology institution. This was an epidemiological, observational, cross-sectional, descriptive, and correlational study conducted in the intensive care and hospitalization units forming part of a large cancer hospital. Sociodemographic and clinical data were collected from medical records and physical examinations of the skin. Associations between the dependent variable (presence of CSWs) and the independent variables were obtained by chi-square tests and odds ratio (OR) calculations with a 95% confidence interval. Logistic regression (LASSO) was used to verify the possible predictors of the outcome. The sample consisted of 341 patients, specifically individuals who are White (46.9%), married (53.4%), and men (58.1%) with an average age of 59.2 years. Complicated surgical wounds were present in 3.2% of patients, and the most frequent types of complications were dehiscence (40%), infection (26.7%), and fistula (20%) present in the abdominal (40%), cephalic (26.7%), and cervical (13.3%) regions. Senile purpura, diaper use, and infection were the clinical variables associated with the occurrence of CSWs (p = .044, p = .001, and p < .001, respectively). Based on the logistic regression, the presence of infection (p < .001; OR = 90.8; 95% CI [18.42, 538.79]) persisted as a predictor of the occurrence of CSWs. From these observations, recommendations regarding best practices for the prevention of CSWs are made, specifically for patients with cancer.
Collapse
|
16
|
Wessels F, Lenhart M, Kowalewski KF, Braun V, Terboven T, Roghmann F, Michel MS, Honeck P, Kriegmair MC. Early recovery after surgery for radical cystectomy: comprehensive assessment and meta-analysis of existing protocols. World J Urol 2020; 38:3139-3153. [PMID: 32124020 PMCID: PMC7716903 DOI: 10.1007/s00345-020-03133-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 02/09/2020] [Indexed: 01/08/2023] Open
Abstract
Purpose Different enhanced recovery after surgery (ERAS) protocols (EP) for radical cystectomy (RC) have been published. Protocols highly differ in number of included items and specific measures. Materials and methods A systematic review and meta-analysis on EPs in RC were performed using the databases MedLine, Cochrane Library, Web of science, and Google Scholar. The specific ERAS measures of the protocols were extracted, analyzed, and compared. Pooling of available outcome data was performed for length of stay, complications, readmission rate, and time to defecation. Results The search yielded a total of 860 studies of which 25 studies were included in qualitative and 22 in quantitative analysis. Oral bowel preparation (BP) was omitted in 24/25 (96%) EPs, optimized fluid management was administered in 22/25 (88%) EPs and early mobilization (postoperative day 1) in 21/25 (84%). Gum chewing (n = 12, 46%), metoclopramide (n = 11, 44%), and alvimopan (n = 6, 24%) were the most common measures to prevent postoperative ileus. Our meta-analysis revealed a significant benefit in favor of EPs for the outcome parameters length of stay [mean difference (MD) − 3.46 d, 95% confidence interval (CI) − 4.94 to − 1.98, p < 0.01], complications [Odds ratio (OR) = 0.76, 95% CI 0.61–0.94, p = 0.01] and time to defecation (MD − 1.37 d, 95% CI − 2.06 to − 0.69, p < 0.01). Readmission rate did not show a significant difference (OR = 0.73, 95% CI 0.52–1.03, p = 0.07). Conclusion Current EPs focus on omitting oral BP, early mobilization, and optimized fluid management while they differ in methods preventing postoperative ileus. Our meta-analysis revealed a benefit in introducing these protocols into clinical practice.
Collapse
Affiliation(s)
- F Wessels
- Department of Urology, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - M Lenhart
- Department of Urology, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - K F Kowalewski
- Department of Urology, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - V Braun
- Library for the Medical Faculty, Mannheim of Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68165, Mannheim, Germany
| | - T Terboven
- Department of Anesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68165, Mannheim, Germany
| | - F Roghmann
- Department of Urology, Marien Hospital, Ruhr-University Bochum, Herne, Germany
| | - M S Michel
- Department of Urology, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - P Honeck
- Department of Urology, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - M C Kriegmair
- Department of Urology, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| |
Collapse
|
17
|
Rodrigues Pessoa R, Urkmez A, Kukreja N, Baack Kukreja J. Enhanced recovery after surgery review and urology applications in 2020. BJUI COMPASS 2020; 1:5-14. [PMID: 35474909 PMCID: PMC8988792 DOI: 10.1002/bco2.9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 01/28/2020] [Accepted: 01/28/2020] [Indexed: 02/01/2023] Open
Abstract
Purpose: To explore enhanced recovery after surgery (ERAS) components and their current application to major urologic surgeries, barriers to implementation and maintenance of the associated quality improvement. Data Identification: An English language literature search was done using PubMed. Study Selection: After independent review, 55 of the original 214 articles were selected to specifically address the stated purpose. Data Extraction: Clinical trials were included, randomized trials were prioritized, but robust observational studies were also included. Results of Data Synthesis: Many ERAS components have good data to support usage in radical cystectomy (RC) patients. Most ERAS programs include multidisciplinary teams carrying out multimodal pathways to hasten recovery after a major operation. ERAS components generally include preoperative counseling and medical optimization, venous thromboembolism prophylaxis, ileus prevention, avoidance of fluid overload, normothermia maintenance, early mobilization, pain control and early feeding, all leading to early discharge without increased complications or readmissions. Although there may not be specific data pertaining to other major urologic operations, the principles remain similar and ERAS is easily applicable. Conclusion: The benefits of ERAS programs are well established for RC and principles are easily applicable to other major urology operations. Barriers to implantation and maintenance of ERAS must be recognized to continue to maintain the benefits of these programs.
Collapse
Affiliation(s)
| | - Ahmet Urkmez
- Department of Urology University of Texas MD Anderson Cancer Center Houston TX USA
| | - Naveen Kukreja
- Department of Anesthesia University of Colorado Aurora CO USA
| | | |
Collapse
|
18
|
Ghoreifi A, Van Horn CM, Xu W, Cai J, Miranda G, Bhanvadia S, Schuckman AK, Daneshmand S, Djaladat H. Urinary tract infections following radical cystectomy with enhanced recovery protocol: A prospective study. Urol Oncol 2020; 38:75.e9-75.e14. [PMID: 31956079 DOI: 10.1016/j.urolonc.2019.12.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 11/14/2019] [Accepted: 12/23/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Urinary tract infection (UTI) following radical cystectomy (RC) is a common complication associated with significant morbidity and risk of readmission. Recent literature has assessed the effect of perioperative antibiotic regimens on the rate of postoperative infections but not yet yielded with significant changes in UTI rates. Our study focused on the effect of postoperative suppressive regimens on the rate of UTI following radical cystectomy with Enhanced Recovery After Surgery (ERAS) protocol. METHODS We retrospectively reviewed 427 patients who underwent RC with ERAS protocol between May 2012 and January 2017 at our institution. The ERAS protocol infection prevention measures included 24-hr perioperative antibiotic followed by suppressive antibiotic until removal of catheter/stents. A patient was found to have a UTI if they had a positive urine culture and documented symptoms, positive urine culture with treatment per practitioner discretion, or negative or unavailable urine culture but the clinical presumption of UTI that got treatment. Urosepsis was defined if any of UTI episodes were associated with positive blood culture. Patients' characteristics, UTI events, and urine culture sensitivities were reviewed for analysis. RESULTS The incidence of UTI and urosepsis was 36.1% and 7.13% within 90-days following RC, respectively. The median time to the first UTI was 13 days (IQR 8-35). Candida (25.57%) and Escherichia coli (22.16%) were the most commonly identified pathogens. UTI and urosepsis were significantly lower in patients who received suppressive fluoroquinolones compared to other antibiotic regimens (32.72% vs. 45.24%, P = 0.04 for UTI and 5.25% vs. 11.90%, P = 0.04 for urosepsis). In multivariable analysis, orthotopic neobladder and perioperative transfusion were significantly associated with increased UTI rate (OR = 2.3 and 1.71, p < 0.05, respectively). CONCLUSIONS UTI is common following RC and urinary diversion with ERAS protocol. The most common isolated pathogens are candida and Escherichia coli. Orthotopic neobladder and perioperative transfusion are independent risk factors for postoperative UTI. The use of suppressive fluoroquinolones is associated with a significant decrease in UTI rate.
Collapse
Affiliation(s)
- Alireza Ghoreifi
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Christine M Van Horn
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Willem Xu
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Jie Cai
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Gus Miranda
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Sumeet Bhanvadia
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Anne K Schuckman
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Siamak Daneshmand
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Hooman Djaladat
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA.
| |
Collapse
|
19
|
Clark JY, Raman JD. Urinary tract infection after radical cystectomy: a vexing problem despite prophylactic antibiotics. Transl Androl Urol 2019; 8:S510-S513. [PMID: 32042634 PMCID: PMC6989856 DOI: 10.21037/tau.2019.07.07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 07/09/2019] [Indexed: 11/06/2022] Open
Affiliation(s)
- Joseph Y Clark
- Department of Surgery (Urology), Penn State Health, Hershey, PA, USA
| | - Jay D Raman
- Department of Surgery (Urology), Penn State Health, Hershey, PA, USA
| |
Collapse
|
20
|
Affiliation(s)
- David F Friedlander
- Fellow in Endourology/Minimally Invasive Surgery, University of California-San Diego Health System, San Diego, CA, USA
| |
Collapse
|
21
|
Skinner OT, Boston SE, Maxwell PL. Interventions and experience after complicated total cystectomy in a dog with transitional cell carcinoma. Vet Surg 2019; 49:811-817. [PMID: 31602683 DOI: 10.1111/vsu.13330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/20/2019] [Accepted: 09/07/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To report surgical and postoperative management of complicated total cystectomy in a dog with transitional cell carcinoma (TCC). STUDY DESIGN Case report. ANIMALS One male neutered Shetland sheepdog. METHODS The dog was presented after a 1-month history of stranguria, unresponsive to oral antibiotic therapy. A craniodorsal bladder mass was identified by computed tomography (CT), and partial cystectomy was performed with 1-cm gross lateral margins (day 1). Results of histopathology provided evidence for a diagnosis of TCC, and the dog was treated with adjuvant mitoxantrone. The dog presented with uroperitoneum on day 67 after recurrence and spontaneous perforation. Total cystectomy and ureterourethral anastomosis were performed. Ureteral obstruction developed after removal of catheters that had been placed intraoperatively. Surgical revision included resection of the anastomosis site, bilateral ureteral stenting, and transection and reorientation of the distal urethra to facilitate tension-free closure. Postoperative leakage was managed with bilateral percutaneous nephrostomy tube placement. RESULTS The dog was discharged on day 88. Adjuvant treatment with vinblastine was pursued. Local recurrence was noted at day 154. Subcutaneous ureteral bypass was performed on day 247 to manage repeat obstruction. Repeated urinary tract infections were subsequently encountered. The dog was euthanized on day 368 because of abdominal discomfort and inappetence, with evidence of progressive urethral, ureteric, and abdominal wall TCC. CONCLUSION Complicated cystectomy can be managed to provide survival comparable to previous reports regarding total cystectomy. CLINICAL SIGNIFICANCE Nephrostomy tube placement, ureteral stenting, and subcutaneous ureteral bypass may be considered to manage complicated cystectomy. Preemptive stenting or urinary diversion may help prevent complications.
Collapse
Affiliation(s)
- Owen T Skinner
- University of Missouri Veterinary Health Center, Columbia, Missouri
| | - Sarah E Boston
- University of Florida Small Animal Hospital, Gainesville, Florida
| | - Paige L Maxwell
- University of Florida Small Animal Hospital, Gainesville, Florida
| |
Collapse
|
22
|
Tully KH, Krimphove MJ, Reese SW, Kibel AS, Noldus J, Krasnow RE, Trinh QD, Sonpavde GP, Chang SL, Mossanen M. Trends in Adherence to Thromboprophylaxis Guideline in Patients Undergoing Radical Cystectomy. Urology 2019; 135:44-49. [PMID: 31586570 DOI: 10.1016/j.urology.2019.09.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/08/2019] [Accepted: 09/25/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To examine the use of in-hospital pharmacologic thromboprophylaxis (PTP) in patients undergoing radical cystectomy between 2004 and 2014 and to assess the risk of venous thromboembolism (VTE) across the study period. MATERIAL AND METHODS We identified 8322 patients without contraindications to PTP undergoing radical cystectomy in the US using the Premier Healthcare Database. Nonparametric Wilcoxon type test for trend was employed to examine the trend of PTP utilization across the study period. Ensuing, we employed multivariable logistic regression and generalized linear regression models to examine the odds of receiving PTP and the risk of being diagnosed with VTE, respectively. RESULTS Based on VTE risk-stratification, the majority of patients (87.8%) qualified as "high-risk." Across the study period the use of PTP increased (Odds ratio 1.02, 95% confidence interval (CI) 1.00-1.03, P = .044), but remained underutilized as the maximum percentage of patients receiving in-hospital PTP did not exceed 58.6%. The risk of VTE did not vary across the study period (risk ratio 0.97, 95%CI 0.92-1.02, P = .178). CONCLUSION Utilization of PTP increased throughout the study period, while the risk of VTE did not change. Future studies are necessary to improve implementation of guideline-driven care, as PTP remained underutilized throughout the study period.
Collapse
Affiliation(s)
- Karl H Tully
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Marieke J Krimphove
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Urology, University Hospital Frankfurt, Frankfurt, Germany
| | - Stephen W Reese
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Adam S Kibel
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Joachim Noldus
- Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Ross E Krasnow
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Quoc-Dien Trinh
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Guru P Sonpavde
- Lank Center for Genitourinary Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard, Medical School, Boston, MA
| | - Steven L Chang
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Matthew Mossanen
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| |
Collapse
|
23
|
Cheng KW, Shah A, Bazargani S, Miranda G, Cai J, Aron M, Schuckman A, Desai M, Gill I, Daneshmand S, Djaladat H. Factors influencing ICU admission and associated outcome in patients undergoing radical cystectomy with enhanced recovery pathway. Urol Oncol 2019; 37:572.e13-572.e19. [PMID: 31326314 DOI: 10.1016/j.urolonc.2019.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 05/25/2019] [Accepted: 06/21/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE To characterize drivers of ICU admission during index hospitalization after Radical Cystectomy (RC) with Enhanced Recovery After Surgery (ERAS) protocol, as well as corresponding outcomes. METHODS A retrospective review of an IRB-approved cystectomy database was conducted. All patients who underwent RC with ERAS protocol from 2012 to 2017 were included. EXCLUSION CRITERIA adjunct nephrectomy or urethrectomy. RESULTS A total of 512 patients were identified. ICU admission in index hospitalization was reported in 33 patients (6.4%), 26 with unplanned ICU transfer after initial non-ICU level of care and 7 with planned direct postoperative ICU admission. Higher age and Charlson Comorbidity Index ≥3 were significant risk factors for unplanned ICU admission. On multivariate analysis, age remained associated (odds ratio 1.05, 95% confidence interval 1.008, 1.1, P = 0.02) and Charlson Comorbidity Index ≥3 kept the trend (odds ratio 2.16, 95% confidence interval 0.86 - 5.07, P = 0.08) with this increased risk of ICU admission. Patients in the unplanned ICU group spent a median of 3 days (range: 0-32) at non-ICU level of care before ICU transfer; cardiac indications were the most common reason for transfer (52%). Patients who required unplanned ICU transfer had a median length of stay of 11.5 days, compared to a length of stay of 5 days (P < 0.01) for non-ICU patients. Ninety-day readmission and mortality rates were higher in the planned ICU cohort when compared to the unplanned ICU cohort. A low rate of ICU admission (2.7%) in the corresponding 90-day postoperative period was reported for the group not requiring ICU admission during index hospitalization. CONCLUSION ICU admission is uncommon following RC with ERAS protocol. Advanced age and comorbidity index are significantly associated with unplanned ICU transfer. Planned ICU admissions are not shown to be associated with improved outcomes compared to unplanned ICU admissions. Further efforts to elucidate the role of ICU care in the context of the ERAS protocol is important for targeted care optimization and appropriate postoperative planning.
Collapse
Affiliation(s)
- Kai W Cheng
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Ankeet Shah
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Soroush Bazargani
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Gus Miranda
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Jie Cai
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Monish Aron
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Anne Schuckman
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Mihir Desai
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Inderbir Gill
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Siamak Daneshmand
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Hooman Djaladat
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA.
| |
Collapse
|
24
|
Kolwijck E, Seegers AEM, Tops SCM, van der Heijden AG, Sedelaar JPM, Ten Oever J. Incidence and microbiology of post-operative infections after radical cystectomy and ureteral stent removal; a retrospective cohort study. BMC Infect Dis 2019; 19:303. [PMID: 30943902 PMCID: PMC6448312 DOI: 10.1186/s12879-019-3932-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Post-operative infections are frequent after radical cystectomy with urinary diversion surgery (UDS). Reduction of post-operative infections necessitates appropriate peri-operative antimicrobial prophylaxis targeting causative bacteria. We assessed the incidence and microbiology of infections in the 30-day post-operative period after UDS and investigated effectiveness of the currently used peri-operative antibacterial prophylaxis. METHODS Retrospective cohort study of all patients undergoing UDS in a tertiary university medical center from January 2014 until September 2016. Antibiotic prophylaxis consisted of cefazolin plus metronidazol according to the Dutch national guideline. Primary outcome was the incidence of post-operative infections within 30 days. Risk factors for post-operative infections and antimicrobial susceptibility profiles of cultured bacteria were also assessed. RESULTS 147 patients were included. 69 patients (46.9%) had 82 post-operative infections, 27 of which were patients with bacteremia (18.4%). Highest incidence of infections was on day 4-5 and on day 8-10 postoperatively. The second peak was associated with ureteral stent removal. 4.8% of 147 study patients developed bacteremia 24 h after stent removal, which counted for 25.9% of all bacteremia episodes found in this study. Enterobacteriaceae were cultured in 67.9% of blood cultures and were only highly susceptible to ciprofloxacine, piperacillin-tazobactam (90%), meropenem and gentamicin (100%). Multivariate logistic regression analysis showed orthotopic Hautmann neobladder to be associated with increased infections complications: odds ratio 4.1 (95% confidence interval 1.6-10.5), p = 0.03. CONCLUSIONS The incidence of infections after radical cystectomy is high and particularly ureteral stent removal was associated with both bacteremia and complicated urinary tract infections. Based on the results of this study, antibiotic prophylaxis might need to be broadened for patients undergoing radical cystectomy. Further research is required to investigate whether current guidelines need to be altered concerning administration of antibiotic prophylaxis just before stent removal.
Collapse
Affiliation(s)
- E Kolwijck
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands. .,Department of medical microbiology, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.
| | - A E M Seegers
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of medical microbiology, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
| | - S C M Tops
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of medical microbiology, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
| | - A G van der Heijden
- Department of urology, Radboud university medical center, Nijmegen, the Netherlands
| | - J P M Sedelaar
- Department of urology, Radboud university medical center, Nijmegen, the Netherlands
| | - J Ten Oever
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
| |
Collapse
|
25
|
Kolwijck E, Seegers AEM, Tops SCM, van der Heijden AG, Sedelaar JPM, Ten Oever J. Incidence and microbiology of post-operative infections after radical cystectomy and ureteral stent removal; a retrospective cohort study. BMC Infect Dis 2019. [PMID: 30943902 DOI: 10.1186/s12879.019-3932-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Post-operative infections are frequent after radical cystectomy with urinary diversion surgery (UDS). Reduction of post-operative infections necessitates appropriate peri-operative antimicrobial prophylaxis targeting causative bacteria. We assessed the incidence and microbiology of infections in the 30-day post-operative period after UDS and investigated effectiveness of the currently used peri-operative antibacterial prophylaxis. METHODS Retrospective cohort study of all patients undergoing UDS in a tertiary university medical center from January 2014 until September 2016. Antibiotic prophylaxis consisted of cefazolin plus metronidazol according to the Dutch national guideline. Primary outcome was the incidence of post-operative infections within 30 days. Risk factors for post-operative infections and antimicrobial susceptibility profiles of cultured bacteria were also assessed. RESULTS 147 patients were included. 69 patients (46.9%) had 82 post-operative infections, 27 of which were patients with bacteremia (18.4%). Highest incidence of infections was on day 4-5 and on day 8-10 postoperatively. The second peak was associated with ureteral stent removal. 4.8% of 147 study patients developed bacteremia 24 h after stent removal, which counted for 25.9% of all bacteremia episodes found in this study. Enterobacteriaceae were cultured in 67.9% of blood cultures and were only highly susceptible to ciprofloxacine, piperacillin-tazobactam (90%), meropenem and gentamicin (100%). Multivariate logistic regression analysis showed orthotopic Hautmann neobladder to be associated with increased infections complications: odds ratio 4.1 (95% confidence interval 1.6-10.5), p = 0.03. CONCLUSIONS The incidence of infections after radical cystectomy is high and particularly ureteral stent removal was associated with both bacteremia and complicated urinary tract infections. Based on the results of this study, antibiotic prophylaxis might need to be broadened for patients undergoing radical cystectomy. Further research is required to investigate whether current guidelines need to be altered concerning administration of antibiotic prophylaxis just before stent removal.
Collapse
Affiliation(s)
- E Kolwijck
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands. .,Department of medical microbiology, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.
| | - A E M Seegers
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of medical microbiology, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
| | - S C M Tops
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of medical microbiology, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
| | - A G van der Heijden
- Department of urology, Radboud university medical center, Nijmegen, the Netherlands
| | - J P M Sedelaar
- Department of urology, Radboud university medical center, Nijmegen, the Netherlands
| | - J Ten Oever
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
| |
Collapse
|
26
|
Jordan BJ, Lewis KC, Matulewicz RS, Kundu S. The Timing and Frequency of Infectious Complications after Radical Cystectomy: An Opportunity for Rescue Antibiotic Treatment. UROLOGY PRACTICE 2019. [DOI: 10.1016/j.urpr.2018.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Brian J. Jordan
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kevin C. Lewis
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard S. Matulewicz
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Shilajit Kundu
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|
27
|
Kim CJ, Kim KH, Song W, Lee DH, Choi HJ. Impact of a change in duration of prophylactic antibiotics on infectious complications after radical cystectomy with a neobladder. Medicine (Baltimore) 2018; 97:e13196. [PMID: 30461620 PMCID: PMC6392575 DOI: 10.1097/md.0000000000013196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
A profound number of prophylactic antibiotics are used after radical cystectomy with an ileal orthotopic neobladder (RCIONB) despite a negative effect of infection control. We investigated the impact of short-term prophylactic antibiotic use on infectious complications after RCIONB.We retrospectively reviewed data from 287 patients who underwent RCIONB for bladder cancer between 2012 and 2016 at a tertiary hospital. The patients were divided into 2 groups according to the pattern of prophylactic antibiotics (185 patients in a long-term group, 25-day use of 3-staged multiple antibiotics versus 102 patients in a short-term group, 24-hour use of cefotetan). The onset of complications, including bacteriuria, febrile urinary tract infection (FU), and bacteremia, and the microorganisms responsible for infections were compared between the groups. Of all 287 patients, bacteriuria, FU, and bacteremia were identified in 177 (61.7%), 85 (29.6%), and 18 (6.3%) patients, respectively. Bacteriuria was identified more frequently in the short-term group (49.2% vs 84.3%, P <.001). However, the rates of FU within 60 days of surgery were similar in both groups (28.6% vs 28.4%, P = .969). The rate of FU was not significantly different between the 2 groups. There was no significant difference in the rate of patients with bacteremia (5.4% vs 7.8%, P = .415). The most frequent microorganisms seen in bacteriuria were Enterococcus faecium and Enterococcus faecalis, in the long-term and short-term group, respectively. Antibiotic-resistant Enterococcus species were more frequently present in the long-term group.Short-term use of prophylactic antibiotics is effective for preventing urinary tract infections after RCIONB and decreasing colonization with multi-drug-resistant organisms.
Collapse
Affiliation(s)
| | - Kwang Hyun Kim
- Departments of Urology Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Wan Song
- Departments of Urology Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Dong Hyeon Lee
- Departments of Urology Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | | |
Collapse
|
28
|
Miller R, Heinlen JE. Reported rates of clostridium difficile following radical cystectomy in national datasets compared to individual institutions. Urol Oncol 2018; 36:526.e7-526.e11. [PMID: 30228097 DOI: 10.1016/j.urolonc.2018.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/28/2018] [Accepted: 08/18/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is an important cause of hospital acquired morbidity with implications for quality of care. Radical cystectomy is a surgical procedure associated with high rates of morbidity one of which is a high rate of CDI. The rate of CDI among patients undergoing radical cystectomy may be estimated based on the reports from single institutions or by querying national databases. This study aims to compare rates of CDI reported in single institution series with rates obtained from national datasets. METHODS A search was conducted on PubMed and Google Scholar using the terms "cystectomy+difficile" and "cystectomy+complication." Three hundred fifty articles were screened and 46 met criteria for inclusion based on the presence of specific rates of C. difficile following radical cystectomy. In the case of articles reporting on the same database, only the article with a larger sample size was included in the pooled analysis. One study reviewing a single institution was excluded from pooled analysis because it did not relate the rate of CDI specifically with cystectomy. Multi-institutional studies were not included in pooled analysis. RESULTS After exclusion of repeated data and multi-institutional studies, the pooled analysis consisted of 39 studies. Thirty five articles reported rates of CDI in single institutions and 4 articles reported rates found in national databases. Studies focusing on a single institution reported an average 5.02% (standard deviation = 4.88) incidence of CDI, compared to an average of 1.92% (standard deviation = 0.22) in databases. The rate of CDI found by totaling patients and incidence of infection found that databases show a rate of 1.95%, while institutions show a rate of 4.11% (P < 0.0000001). CONCLUSION The rate of CDI following radical cystectomy may be underestimated in national databases. This has implications for the development of health policy and quality measures based on the rate of CDI.
Collapse
Affiliation(s)
- Reece Miller
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
| | - Jonathan E Heinlen
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| |
Collapse
|
29
|
Goldberg H, Shenhar C, Tamir H, Mano R, Baniel J, Margel D, Kedar D, Lifshitz D, Yossepowitch O. Predictors of surgical site infection after radical cystectomy: should we enhance surgical antibiotic prophylaxis? World J Urol 2018; 37:1137-1143. [PMID: 30220044 DOI: 10.1007/s00345-018-2482-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 09/08/2018] [Indexed: 12/28/2022] Open
Abstract
PURPOSE To compare surgical site infections (SSI) rate after radical cystectomy (RC) over time and ascertain whether antibiotic prophylaxis should be enhanced. METHODS All medical records of RC patients in a single tertiary uro-oncology center between 2007 and 2017 were analyzed. SSI was defined using the criteria of the US Centers for Disease Control and Prevention. All bacterial culture results and antimicrobial resistance rates were recorded. Lastly, multivariable logistic regression analysis was performed to ascertain SSI predictors. RESULTS RC was performed in 405 patients, of which 96 (23.7%) developed SSI. No differences were demonstrated in the mean age, gender, NIDDM prevalence, neoadjuvant chemotherapy, positive preoperative urine culture, bowel preparation, and surgery time between both groups. However, statistically significant higher median BMI, age-adjusted Charlson Comorbidity score, usage of ceftriaxone preoperatively, and intensive care unit (ICU) hospitalization were noted in SSI patients. Overall, 62/96 (63.5%) SSI patients had a positive wound culture, with only 16.7% of the pathogens being sensitive to their perioperative antibiotics. Lastly, on multivariable analysis rising BMI, preoperative ceftriaxone and ICU hospitalization were associated with a higher SSI rate. CONCLUSIONS Preoperative BMI reduction, and maximal preoperative medical optimization in an attempt to lower ICU admittance rates, should be part of the ideal strategy for lowering SSI rates. Additionally, preoperative antibiotics should be enhanced to harbor-wide spectrum coverage, based on local resistance rates.
Collapse
Affiliation(s)
- Hanan Goldberg
- Department of Urology, Beilinson Hospital, Rabin Medical Center and Tel Aviv University Sackler School of Medicine, Petah Tikva, Israel.
| | - Chen Shenhar
- Department of Urology, Beilinson Hospital, Rabin Medical Center and Tel Aviv University Sackler School of Medicine, Petah Tikva, Israel
| | - Hadar Tamir
- Department of Urology, Beilinson Hospital, Rabin Medical Center and Tel Aviv University Sackler School of Medicine, Petah Tikva, Israel
| | - Roy Mano
- Department of Urology, Beilinson Hospital, Rabin Medical Center and Tel Aviv University Sackler School of Medicine, Petah Tikva, Israel
| | - Jack Baniel
- Department of Urology, Beilinson Hospital, Rabin Medical Center and Tel Aviv University Sackler School of Medicine, Petah Tikva, Israel
| | - David Margel
- Department of Urology, Beilinson Hospital, Rabin Medical Center and Tel Aviv University Sackler School of Medicine, Petah Tikva, Israel
| | - Daniel Kedar
- Department of Urology, Beilinson Hospital, Rabin Medical Center and Tel Aviv University Sackler School of Medicine, Petah Tikva, Israel
| | - David Lifshitz
- Department of Urology, Beilinson Hospital, Rabin Medical Center and Tel Aviv University Sackler School of Medicine, Petah Tikva, Israel
| | - Ofer Yossepowitch
- Department of Urology, Beilinson Hospital, Rabin Medical Center and Tel Aviv University Sackler School of Medicine, Petah Tikva, Israel
| |
Collapse
|
30
|
Kirkpatrick C, Haynes A, Sharma P. Antibiotic prophylaxis is not associated with reduced urinary tract infection-related complications after cystectomy and ileal conduit. Bladder (San Franc) 2018; 5:e35. [PMID: 32775477 PMCID: PMC7401989 DOI: 10.14440/bladder.2018.722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/21/2018] [Accepted: 06/26/2018] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Majority of complications after ileal conduit urinary diversion with cystectomy are related to urinary tract infections (UTIs). Controversy exists regarding use of prophylactic antibiotics after surgery. We determined if prophylactic antibiotic use during ureteral stent placement after ileal conduit urinary diversion decreased incidence of UTI-related complications. METHODS We retrospectively identified 75 consecutive patients who underwent ileal conduit urinary diversion with cystectomy at our institution from 2010 to 2016. Patients were stratified based on presence or absence of a UTI-related complication in the 90-day postoperative period. Means were compared with independent t-test and proportions with chi-square analysis. Multivariate logistic regression was performed to determine independent predictors of UTI-related complications. RESULTS Forty-five patients (60%) were prescribed prophylactic antibiotics after surgery. Mean duration of antibiotic use was 15 d, and mean duration of ureteral stenting was 25 d. Most common antibiotics used included fluoroquinolones (n = 23, 30.7%) followed by sulfamethoxazole-trimethoprim (n = 14, 18.7%). Rate of 90-day UTI-related complications was 36% (n = 27), and 90-day UTI-related readmission rate was 14.7% (n = 11). On bivariate and multivariate analysis, prophylactic antibiotic use was not associated with reduced 90-day UTI-related complications (P > 0.05). Patients prescribed prophylactic antibiotics had increased incidence of Clostridium difficile infections in the 90-day postoperative period compared to controls (20% vs. 3.3%; P = 0.038). CONCLUSIONS Prophylactic antibiotic use after ileal conduit urinary diversion with cystectomy was not associated with reduced UTI-related complications, and rate of Clostridium difficile infections was higher in this patient cohort. The effect of early removal of ureteral stents on UTI risk still has to be elucidated.
Collapse
Affiliation(s)
- Carson Kirkpatrick
- Department of Urology, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Allan Haynes
- Department of Urology, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Pranav Sharma
- Department of Urology, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| |
Collapse
|
31
|
Mossanen M, Krasnow RE, Lipsitz SR, Preston MA, Kibel AS, Ha A, Gore JL, Smith AB, Leow JJ, Trinh QD, Chang SL. Associations of specific postoperative complications with costs after radical cystectomy. BJU Int 2017; 121:428-436. [DOI: 10.1111/bju.14064] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Matthew Mossanen
- Division of Urologic Surgery; Brigham and Women's Hospital; Boston MA USA
- Center for Surgery and Public Health; Brigham and Women's Hospital; Boston MA USA
- Dana-Farber Cancer Institute; Boston MA USA
| | - Ross E. Krasnow
- Division of Urologic Surgery; Brigham and Women's Hospital; Boston MA USA
- Center for Surgery and Public Health; Brigham and Women's Hospital; Boston MA USA
- Dana-Farber Cancer Institute; Boston MA USA
| | - Stuart R Lipsitz
- Center for Surgery and Public Health; Brigham and Women's Hospital; Boston MA USA
| | - Mark A. Preston
- Division of Urologic Surgery; Brigham and Women's Hospital; Boston MA USA
- Center for Surgery and Public Health; Brigham and Women's Hospital; Boston MA USA
- Dana-Farber Cancer Institute; Boston MA USA
| | - Adam S. Kibel
- Division of Urologic Surgery; Brigham and Women's Hospital; Boston MA USA
- Center for Surgery and Public Health; Brigham and Women's Hospital; Boston MA USA
- Dana-Farber Cancer Institute; Boston MA USA
| | - Albert Ha
- Harvard Medical School; Boston MA USA
| | - John L. Gore
- Department of Urology; University of Washington; Seattle WA USA
| | - Angela B. Smith
- Lineberger Comprehensive Cancer Center; University of North Carolina at Chapel Hill; Chapel Hill NC USA
| | - Jeffrey J. Leow
- Division of Urologic Surgery; Brigham and Women's Hospital; Boston MA USA
- Dana-Farber Cancer Institute; Boston MA USA
| | - Quoc-Dien Trinh
- Division of Urologic Surgery; Brigham and Women's Hospital; Boston MA USA
- Center for Surgery and Public Health; Brigham and Women's Hospital; Boston MA USA
- Dana-Farber Cancer Institute; Boston MA USA
| | - Steven L. Chang
- Division of Urologic Surgery; Brigham and Women's Hospital; Boston MA USA
- Center for Surgery and Public Health; Brigham and Women's Hospital; Boston MA USA
- Dana-Farber Cancer Institute; Boston MA USA
| |
Collapse
|
32
|
Smith JA. This Month in Adult Urology. J Urol 2017. [DOI: 10.1016/j.juro.2017.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
33
|
Heinlen JE, Salinas L, Cookson MS. Clostridium difficile Infection in Contemporary Urologic Practice. Urology 2017; 111:23-27. [PMID: 28688849 DOI: 10.1016/j.urology.2017.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 06/20/2017] [Accepted: 06/26/2017] [Indexed: 11/29/2022]
Abstract
Clostridium difficile infection (CDI) is a high-impact hospital-acquired condition and a chief driver of excess morbidity, mortality, and treatment cost. The diagnosis, treatment, and prevention of CDI are key components of any hospital-based practice. Urologists see a small percentage of all patients with CDI, but traditionally utilize antibiotic agents that put patients at risk of CDI. Urologic procedures making use of bowel have a significantly higher rate of CDI than other procedures. This review addresses concepts that practicing urologists should be aware of and should be able to put into practice to diagnose, treat, and prevent CDI.
Collapse
Affiliation(s)
- Jonathan E Heinlen
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
| | - Linda Salinas
- Department of Internal Medicine, Institute for Infectious Disease, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Michael S Cookson
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| |
Collapse
|