Multidrug Resistant Bacteriuria Before Percutaneous Nephrolithotomy Predicts for Postoperative Infectious Complications

International Alliance of Urolithiasis (IAU) guideline on staghorn calculi management

BACKGROUND

The stone burden based management strategy reported in the guidelines published by different associations is well known for a long time. Staghorn calculi, representing the largest burden and most complex stones, is one of the most challenging cases to practicing urologists in clinical practice. The International Alliance of Urolithiasis (IAU) has released a series of guidelines on the management of urolithiasis.

PURPOSE

To develop a series of recommendations for the contemporary management management of staghorn calculi and to provide a clinical framework for urologists treating patients with these complex stones.

METHODS

A comprehensive literature search for articles published in English between 01/01/1976 and 31/12/2022 in the PubMed, OVID, Embase and Medline database is performed. A series of recommendations are developed and individually graded following the review of literature and panel discussion.

RESULTS

The definition, pathogenesis, pathophysiology, preoperative evaluation, intraoperative treatment strategies and procedural advice, early postoperative management, follow up and prevention of stone recurrence are summarized in the present document.

CONCLUSION

A series of recommendations regarding the management of staghorn calculi, along with related commentary and supporting documentation offered in the present guideline is intended to provide a clinical framework for the practicing urologists in the management of staghorn calculi.

A novel post-percutaneous nephrolithotomy sepsis prediction model using machine learning

OBJECTIVES

To establish a predictive model for sepsis after percutaneous nephrolithotomy (PCNL) using machine learning to identify high-risk patients and enable early diagnosis and intervention by urologists.

METHODS

A retrospective study including 694 patients who underwent PCNL was performed. A predictive model for sepsis using machine learning was constructed based on 22 preoperative and intraoperative parameters.

RESULTS

Sepsis occurred in 45 of 694 patients, including 16 males (35.6%) and 29 females (64.4%). Data were randomly segregated into an 80% training set and a 20% validation set via 100-fold Monte Carlo cross-validation. The variables included in this study were highly independent. The model achieved good predictive power for postoperative sepsis (AUC = 0.89, 87.8% sensitivity, 86.9% specificity, and 87.4% accuracy). The top 10 variables that contributed to the model prediction were preoperative midstream urine bacterial culture, sex, days of preoperative antibiotic use, urinary nitrite, preoperative blood white blood cell (WBC), renal pyogenesis, staghorn stones, history of ipsilateral urologic surgery, cumulative stone diameters, and renal anatomic malformation.

CONCLUSION

Our predictive model is suitable for sepsis estimation after PCNL and could effectively reduce the incidence of sepsis through early intervention.

Factors predicting infective complications following percutaneous nephrolithotomy and retrograde intrarenal surgery according to systemic inflammatory response syndrome and quick sequential organ failure assessment: A prospective study

Purpose

Myriad operative factors and characteristics of patients may influence the risk of infection in a patient undergoing stone surgery. We prospectively determined the risk factors for systemic inflammatory response syndrome (SIRS) and quick sequential organ failure assessment (qSOFA) in patients undergoing percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS).

Materials and Methods

Patients who underwent PCNL and RIRS from March 2018 to January 2020 satisfying our selection criteria were enrolled. Samples of urine from the renal pelvis, bladder, and retrieved stones were sent for culture testing. Postoperatively patients were keenly supervised for any indications of SIRS and qSOFA. The association between stone and urine cultures across various sites was examined. Regression analysis was performed to ascertain clinical variables affiliated with SIRS and qSOFA.

Results

The study included a total of 150 patients including both PCNL and RIRS, of which 23% post-PCNL and 20% post-RIRS met the criteria of SIRS and qSOFA. On univariate analysis in PCNL-Dilated pelvicalyceal system (PCS), renal pelvic urine culture (RPUC), stone culture (SC), and operative time >124 min among others were identified as risk factors whereas, in RIRS-residual calculus, RPUC, SC and operative time >62 min were risk factors. Multivariate analysis identified dilated PCS and SC for PCNL and only intraoperative RPUC for RIRS as independent risk factors. Only a significantly strong correlation among culture analysis was found between RPUC and SC in both the procedures.

Conclusion

Intraoperative RPUC and SCs are better predictors of post-PCNL SIRS while Intraoperative RPUC and duration of surgery are better predictors of post-RIRS sepsis. We, therefore, recommend that both these cultures must routinely be obtained in the above procedures to identify the offending organisms and amend antibiotic therapy during treatment and surgical duration should be kept <62 min in RIRS. SIRS serves as a sensitive review tool which is specifically useful for initial care and on the contrary qSOFA is well suited for patients at greater risk of demise, thereby guiding clinicians to decide future care and course of treatment of patients.

The clinical role of bacteremia and bacterial spread into the irrigation fluid during percutaneous nephrolithotomy: a prospective study

PURPOSE

Backflow of pathogens and endotoxins from the renal pelvis to the bloodstream is one supposed mechanism for infectious complications development after endourological stones surgery. The aim of this study is detecting to prove bacterial spread into irrigation fluid and bloodstream during percutaneous nephrolithotomy (PCNL) and to correlate these findings with clinical and microbiological parameters and infectious complications (IC).

METHODS

Bladder urine culture (BUC) was retrieved before PCNL; during the procedure, 2 blood samples (BC) and an irrigation fluid sample during fragmentation (SFUC) were collected for culture. Stone culture (SC) was also obtained. Patients were evaluated post-operatively for IC.

RESULTS

Sixty-one patients were prospectively included. IC occurred in 15 patients (24.6%). SFUC was positive in 7/61 (11.5%); BC in 10/61 (16.4%). Among patients with positive BC; BUC, SFUC and SC were positive in 9 (90%), 6 (60%), and 8 (80%) cases, respectively. Out of 10 patients with positive BC, 4 developed post-operative IC. Pre-operative renal impairment (p = 0.04), intraoperative-evaluated stone residual (p = 0.02), BUC (p = 0.004), and SC (p = 0.008) were associated with IC. No correlation was found between bacterial spread in the irrigation fluid and blood and IC.

CONCLUSION

We proved that bacteria can be detected into the irrigation fluid and blood during PCNL. This transient bacteremia appears to be unrelated to IC development.

The effect of preoperative urine culture and bacterial species on infection after percutaneous nephrolithotomy for patients with upper urinary tract stones

To study the relationship between preoperative urine culture, bacterial species and infection after percutaneous nephrolithotomy in patients with upper urinary tract stones, and summarize the clinical characteristics of different bacterial infections. From January 2014 and January 2020, 963 patients with upper urinary tract stones who underwent PCNL in the department of urology of Fujian provincial hospital were included in the study. Information included the patient’s age, gender, weight, diabetes, chronic disease history, urine routine, preoperative urine culture results, stone size, number of stones, hydronephrosis level, operation time, body temperature, heart rate, blood pressure, breathing rate, hemoglobin, serum creatinine, bilirubin, platelets and whether there was preoperative infection were recorded. 141 patients (14.6%) had a positive urine culture before surgery, and 7 of them had multiple bacterial infections. The most common pathogenic bacteria was Escherichia coli, followed by Enterococcus and Klebsiella pneumoniae. A total of 74 cases (7.7%) of 963 patients with infection after PCNL occurred, 24 cases (32.4%) of infected patients progressed to urinary septic shock. Univariate analysis shown that the probability of infection in patients with long operation time and positive urine culture was significantly higher, and the difference was statistically significant. Further multivariate logistic regression analysis shown that positive urine culture before operation and long operation time were independent risk factors for infection after PCNL. Among the 29 patients with septic shock, 18 cases (62.1%) had a positive urine culture before surgery. The incidence (43.9%) of postoperative infection in Escherichia coli positive patients was significantly higher than that in the negative group, and the difference was statistically significant. The rate of patients with Escherichia coli infection progressing to septic shock was 9 cases (60%). 2 patients with Enterococcus faecium infection and 2 patients with Klebsiella pneumoniae infection all progressed to septic shock. The age of patients with post-PCNL infection caused by Escherichia Coli, Enterococcus faecium and Klebsiella pneumoniae were 58.53 ± 11.73 years, 76.5 years and 74 years.The body temperature of patients with post-PCNL infection caused by Escherichia Coli, Enterococcus faecium and Klebsiella pneumoniae were 39.10 ± 0.25 °C, 39.45 °C and 38.65 °C. The highest pct value of patients with post-PCNL infection caused by Escherichia Coli, Enterococcus faecium and Klebsiella pneumoniae were 80.62 ± 31.45 ng/mL, 24.32 ng/mL and 8.45 ng/mL. The nitrite positive rate of patients with post-PCNL infection caused by Escherichia Coli, Enterococcus faecium and Klebsiella pneumoniae were 64.51%, 16.6% and 0. Postoperative infection of PCNL is significantly correlated with positive preoperative urine culture, and positive preoperative urine culture is an independent risk factor for postoperative infection. The most common pathogen of postoperative infection of PCNL is Escherichia coli, followed by Enterococcus and Klebsiella pneumoniae. Patients with Escherichia coli infection are often positive for nitrite before surgery, mainly manifested by high fever, and PCT is significantly increased (often exceeded 100 ng/ml). Enterococcus faecium and Klebsiella pneumoniae infections mostly occur in elderly patients and often progress to septic shock. Patients with Enterococcus faecium infection have a high fever, and the PCT value is significantly higher (often exceeded 20 ng/ml). Patients with Klebsiella pneumoniae infection have a moderate fever, and the PCT value generally does not exceeded 10 ng/ml. Long operation time is another independent risk factor for PCNL infection.

Prevention and Management of Infectious Complications of Retrograde Intrarenal Surgery

Kidney stone disease (KSD) is a commonly encountered ailment in urologic practice. Urinary tract infection (UTI) is commonly associated with KSD, both as an etiology (e.g., struvite and carbonate apatite stones), and as a complication (i.e., obstructive pyelonephritis and post-operative UTI). Indeed, a significant portion of the economic burden of KSD is skewed toward stones associated with infection. UTI is the most common post-operative complication related to stone intervention with progression to urosepsis as a rare but serious consequence. Risk for infection is influenced by a variety of factors including co-morbid conditions, anatomic abnormalities, prior surgical procedures, and local anti-microbial susceptibility. Understanding these risks and the proper steps to mitigate them is an essential component in reducing post-operative morbidity and mortality. Retrograde intrarenal surgery is routinely used for the treatment of KSD. The objective of this review article is to examine the current literature and guidelines for the prevention and management of stone-related infectious complications associated with retrograde intrarenal surgery. Special attention will be given to the incidence, etiology, and antibiotic prophylaxis choice in the management of stone-related infections. Intraoperative risk mitigation techniques will be discussed in conjunction with the management of post-operative infections. Antibiotic stewardship and the potential benefits of reduced empiric antibiotic treatment will also be discussed.

Feasibility and relevance of urine culture during stone fragmentation in patients undergoing percutaneous nephrolithotomy and retrograde intrarenal surgery: a prospective study

PURPOSE

We evaluated if, during lithotripsy, bacteria may be detected in the irrigation fluid of percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS). The concordance between urine culture from stone fragmentation (SFUC), bladder (BUC), renal pelvic (RPUC) and stone (SC) was analyzed. We also assessed the correlation between variables and cultures and their association with systemic inflammatory response syndrome (SIRS) and of a positive SC.

METHODS

We included 107 patients who underwent PCNL (n = 53) and RIRS (n = 54) from January 2017 to May 2018. Samples for RPUC were obtained by renal catheterization. Stone fragments and irrigation fluid sample were sent for culture.

RESULTS

SFUC was positive in 17 (15.9%), BUC in 22 (20.6%), RPUC in 26 (24.3%) and SC in 30 patients (28%). The concordance between SFUC and SC was the highest among all cultures: 94.1%. SFUC and SC grew identical microorganisms in 15/17 (88.2%) patients. Out of 17 (15.9%) patients with SIRS, 8 (7.5%) had sepsis. SFUC had the highest PPV and specificity to detect positive SC and SIRS. Previous urinary tract infection, a preoperative nephrostomy, stone diameter and composition, staghorn calculi, PCNL, positive BUC, RPUC and SFUC were predictors of infected stone. Variables that indicate complex stones, complex PCNL and an infection of the upper tract were associated with SIRS.

CONCLUSION

SFUC is technically feasible, easy to retrieve and to analyze. The spectrum of SFUC potential application in clinical practice is when is not possible to perform a SC, e.g. complete dusting or during micro-PCNL.

Predictors of urosepsis in struvite stone patients after percutaneous nephrolithotomy

Purpose

This study aims to identify clinical factors that may predispose struvite stone patients to urosepsis following percutaneous nephrolithotomy (PCNL).

Materials and Methods

A retrospective review was conducted on patients who received PCNL for struvite stones. The Systemic Inflammatory Response Syndrome (SIRS) criteria and quick-Sepsis Related Organ Failure Assessment (q-SOFA) criteria were used to identify patients who were at an increased risk for urosepsis. Statistical analysis was performed using Fisher's exactness test, Wilcoxon rank test, and logistic regression.

Results

Chart review identified 99 struvite stone patients treated with PCNL. Post-operatively, 40 patients were SIRS positive (≥2 criteria) and/or q-SOFA positive (score ≥2). Using SIRS as an approximation for urosepsis, longer operative times (p<0.001), higher pre-operative white blood cell counts (p=0.01), greater total stone surface area (p<0.0001), and pre-operative stenting (OR, 5.75; p=0.01) were identified as independent risk factors for urosepsis. Multivariate analysis demonstrated pre-operative stenting (OR, 1.46; p=0.01) to be a risk factor. With q-SOFA, univariable analysis found that antibiotic use within 3 months prior to a PCNL (OR, 4.44; p=0.04), medical comorbidities (OR, 4.80; p=0.02), longer operative times (p<0.001), lengthier post-operative hospitalization (p<0.01), and greater total stone surface area (p<0.0001) were risk factors for urosepsis. Multivariate analysis revealed that bladder outlet obstruction (OR, 2.74; p<0.003) and pre-operative stenting (OR, 1.27; p=0.01) significantly increased odds of being q-SOFA positive.

Conclusions

Several risk factors for urosepsis following PCNL for struvite stones have been identified. These risk factors should be taken into consideration in peri-operative care to mitigate the risks of urosepsis.

The impact of nephrostomy drainage prior to mini-percutaneous nephrolithotomy in patients with ESBL-positive Escherichia coli

OBJECTIVE

Extended-spectrum β-lactamase-producing Escherichia coli (ESBL-EC) is one of the most frightening multidrug-resistant bacteria that usually causes sepsis. Herein we explored the benefits of nephrostomy drainage prior to percutaneous nephrolithotomy (PCNL) on infection outcomes in patients with ESBL-EC.

PATIENTS AND METHODS

Between June 2016 and April 2019, 43 consecutive patients with ESBL-EC who received nephrostomy drainage for > 24 h prior to PCNL were retrospectively evaluated as group 1. 86 patients were randomly selected from patients with ESBL-EC who received concurrent percutaneous access during PCNL as group 2. The postoperative infection complications were compared.

RESULTS

Although the total infection complications were not statistically different (11.6% vs. 25.6%, p = 0.066), the severity seemed to be worse among group 2 subjects. Severe infections, including urosepsis (4.7% vs.13.9%) and septic shock (2.3% vs 4.6%), were observed at twice or greater rates in group 2. Blood transfusions were also more frequent (2.3% vs. 13.9%, p = 0.039). Multivariate analysis demonstrated that preoperative drainage was an independent risk factor for postoperative infection events (OR 2.31 CI 1.14-3.48, p = 0.017). Subgroup analyses indicated that preoperative drainage may largely reduce the incidence of urosepsis in patients with hydronephrosis or without receiving preoperative carbapenem therapy.

CONCLUSION

Because of the high rate of severe infection after PCNL in patients with ESBL‑positive E. coli, preoperative nephrostomy drainage for > 24 h is an effective measure to reduce the risk of severe infection complications, especially in patients with hydronephrosis or those without preoperative carbapenem therapy.

Risk Factors of Urinary Tract Infection After Ureteral Stenting in Patients with Renal Colic During Pregnancy

Introduction: To investigate risk factors associated with urinary tract infection (UTI), following ureteral stenting, for patients with renal colic during pregnancy. Patients and Methods: Patients with renal colic during pregnancy who underwent ureteral stenting in The First Affiliated Hospital of Guangzhou Medical University between 2009 and 2019 were examined retrospectively. Ureteral stenting patients who had UTIs after hospital discharge and before delivery were classified as the infected group. Multivariate logistic regression analysis was used to assess the risk factors associated with UTI after ureteral stenting. Results: A total of 102 patients were enrolled into the study. Mean age was 30 years (interquartile range [IQR]: 26-33 years) and mean gestation age was 22 weeks (IQR: 18-28 weeks). UTI occurred in 21 patients (20.6%). Compared with noninfected patients, infected patients had a higher rate of positive urine culture (52.4% vs 13.6%, p = 0.000), kidney stones ≥10 mm (81% vs 35.8%, p = 0.000), residual stones after ureteral stenting (71.4% vs 43.2%, p = 0.021), and different surgical indications and gestational ages (18 vs 23 weeks, p = 0.00). Multifactor analysis showed that gestational age, positive urine culture (odds ratio [OR] = 6.233, 95% confidence interval [CI]: 1.830-21.227), and stones ≥10 mm (OR = 0.124, 95% CI: 0.031-0.495) were independent risk factors for UTI after ureteral stenting in patients with renal colic. In the infection group, Escherichia coli was the most commonly found organism (47.4%). Conclusions: Gestational age, positive urine culture before surgery, and stone ≥10 mm were risk factors for UTI after ureteral stenting in pregnant patients with renal colic. E. coli was the main pathogen of UTI after this procedure. Preoperative anti-infection treatment needs to be based on drugs that are sensitive to E. coli.

Renal pelvis urine Gram stain as a traditional, but new marker in predicting postoperative fever and stone culture positivity in percutaneous nephrolithotomy: an observational, prospective, non-randomized cohort study

PURPOSE

The aim of this study was to evaluate the diagnostic value of renal pelvis urine Gram staining (RPUGS) in predicting postoperative fever and renal stone culture (RSC) positivity in percutaneous nephrolithotomy (PCNL).

METHODS

Totally 141 consecutive patients undergoing PCNL for renal stone were included between January 2018 and December 2019. The RPUGS and renal pelvis urine culture (RPUC) were performed using urine sample from renal collecting system, while RSC was performed using stone fragments. Patients were divided into two groups as Group 1 (n = 119) without postoperative fever (< 38 °C) and Group 2 (n = 22) with postoperative fever (≥ 38 °C). Stone culture and Gram staining models were created for predicting postoperative fever using constant covariates of the presence of residual stone, hydronephrosis, and stone burden.

RESULTS

A significantly higher number of patients in Group 2 had RPUGS, RSC, and RPUC positivity (p < 0.001, for each). The sensitivity, specificity, positive predictive value, and negative predictive value of RPUGS in predicting postoperative fever were 72.7%, 89.9%, 57.1%, and 94.7%, respectively. It was observed that both models had similar predictive values and diagnostic performances. Although RSC and RPUGS had a similar diagnostic value in predicting postoperative fever in univariable analysis, both were found to be independent predictors in multivariable analysis (OR: 10.6, 95% CI 4.07-27.9, p < 0.001 and OR: 15.0, 95% CI 5.4-41.2, p < 0.001, respectively).

CONCLUSIONS

In conclusion, RPUGS is as effective as RSC in predicting fever after PCNL. We recommend RPUGS during PCNL to manage post-PCNL infectious complications.

Evaluation of day-care versus inpatient mini-percutaneous nephrolithotomy: a propensity score-matching study

Day-care percutaneous nephrolithotomy (day-PCNL) is being performed more routinely, however, safety remains a concern. The purpose of this study was to compare the complication rate, readmission rate and medical cost saving between day-PCNL and inpatient-PCNL. A protocol for day-PCNL was applied. A retrospective review of 86 patients planned day-PCNL by one surgeon were conducted. Using propensity matching, 86 inpatients (minimum 2-day post-operative stay) treated with the same procedure were matched. For each cohort, 14-day occurrence of complications and unplanned readmissions were recorded and compared. More than 80% of patients had multiple or staghorn stones in both groups. There were no significant differences between stone-free rate, operative time, multiple-tracts use, hemoglobin drop (each p > 0.05). Day- PCNL has a higher tubeless rate (60.8% vs. 24.4%, p < 0.001) and were less costly (mean 2732 vs. 3828 dollars) compared with inpatient PCNL. Within 14 days post-operatively, 10 day-care patients (11.6%) and 13 inpatients (15.1%) experienced complications, with no difference in rate or severity. Four patients (4.6%) required full admission (longer than 24 h) and two patents needed readmission in day-PCNL group. Day-care PCNL was more cost-effective than in-patients PCNL, with no significant difference in complications along with very low unplanned readmission during the postoperative period of 14 days. Therefore, day-care PCNL is a cost-effective choice in selected patients.

An evaluation of multidrug-resistant (MDR) bacteria in patients with urinary stone disease: data from a high-volume stone management center

PURPOSE

To investigate the prevalence of MDR bacteria in patients with urinary stones and the risk factors for its formation.

METHODS

A retrospective study was performed among patients with urinary stones in Beijing Tsinghua Changgung Hospital from December 2014 to May 2018. Patients with positive urinary cultures and drug sensitivity results were included. MDR were defined as any bacteria that have resistance to at least one agent in at least three classes of antibiotics. Bacteria distribution and resistance patterns were calculated.

RESULTS

1655 patients with urinary stones were eligible for analysis, among which 367 patients had positive urinary culture, yielding 457 isolates of 45 species. Escherichia coli remained the most common organism with a prevalence of 29.3%, followed by Enterococcus faecalis (12.0%), Proteus mirabilis (10.5%), and Klebsiella pneumonia (6.8%). 44.4% isolates were identified as MDR. The three most common Gram-negative bacteria were Escherichia coli, Proteus mirabilis, and Klebsiella pneumoniae, with a MDR rate of 84.33%, 62.5%, and 48.39%, respectively. Drug-resistant rates were different between MDR and non-MDR in ampicillin, cefazolin, ceftriaxone, cefepime, gentamicin, amikacin, and levofloxacin (all with p value < 0.05). In multivariate analysis, indwelling catheters (OR 3.1, 95% CI 1.07-8.98) and antibiotics use in the last 3 months (OR 2.14, 95% CI 1.04-4.38) were significantly associated with MDR formation.

CONCLUSIONS

MDR bacteria were common among patients with urinary stones in our center and achieved high drug-resistant rates in ampicillin, first-generation and part of third-generation cephalosporins, and fluoroquinolones. Indwelling catheters and antibiotics used in the last 3 months were independent risk factors for MDR formation. Tailored antibacterial strategies still should be established according to the local bacterial spectrum and patient condition.

Impact of positive preoperative urine cultures before pediatric lower urinary tract reconstructive surgery

PURPOSE

Children who undergo lower urinary tract reconstruction (LUTR) often have asymptomatic bacteriuria or recurrent urinary tract infections (UTI). We aimed to determine the prevalence of positive preoperative urine cultures (PPUC) before LUTR and to analyze any impact on postoperative outcomes.

METHODS

This retrospective review included all pediatric LUTR procedures utilizing bowel segments performed by one surgeon over 2 years. Preoperative cultures were obtained 1-2 days before surgery. Baseline characteristics and 90-day infection/readmission rates between patients with and without PPUC were compared using descriptive statistics, Fisher's exact, and Mann-Whitney tests with significance p < 0.05.

RESULTS

54 patients with mean age 10.1 ± 5.6 years underwent LUTR procedures using bowel including continent catheterizable channel (85%), enterocystoplasty (81%), and/or urinary diversion (9%). PPUC was present in 28 patients (52%). Postoperatively, 20% had inpatient infections, including eight UTI, four surgical site infections, and two bloodstream infections with no difference between those with or without PPUC. Within 90 days of discharge, 28% of patients were readmitted to the hospital, and there was no difference between groups. Postoperative urine cultures were positive in 83% of patients within 90 days.

CONCLUSIONS

Half of the patients undergoing LUTR have PPUC, but it does not increase the risk of postoperative infections or hospital readmissions. We believe complex LUTR can be safely performed in patients with PPUC.

Percutaneous nephrolithotomy: complications and how to deal with them

Percutaneous nephrolithotomy is a common surgical treatment for large and complex stones within the intrarenal collecting system. A wide variety of complications can result from this procedure, including bleeding, injury to surrounding structures, infection, positioning-related injuries, thromboembolic disease, and even death. Knowledge of the different types of complications can be useful in order to prevent, diagnose, and treat these problems if they occur. This review describes the diversity of complications with the goal of improving their avoidance and treatment.

Are antibiotics necessary during routine cystoscopic stent removal?

BACKGROUND

The 2008 American Urological Association (AUA) Best Practice Statement on antimicrobial prophylaxis states that prophylaxis is not warranted for subjects with normal risk profile undergoing cystourethroscopy unless manipulation such as ureteral stent removal is performed. To date no studies have specifically assessed the need for antimicrobial prophylaxis during cystoscopic ureteral stent removal. We sought to determine the risk of infectious complications following cystoscopic stent removal with and without antimicrobial prophylaxis.

METHODS

A retrospective review identified 70 subjects who underwent cystoscopic ureteral stent removal following kidney stone treatment, under the care of two separate urologists with differing practice patterns. Each cohort consisted of 35 subjects: with and without prophylactic antibiotics. Clinical variables assessed included demographics, type of stone intervention, prior urinary tract infection (UTI) history, immunocompromising comorbidities, antimicrobial class at time of stone intervention, and antimicrobial administration at cystoscopic stent removal. The primary outcome assessed was development of symptomatic UTI within 4 weeks after stent removal.

RESULTS

Overall, 35 patients (50%) received antimicrobial prophylaxis at the time of stent removal and 35 (50%) did not receive antimicrobial prophylaxis, with no demographic or clinical differences between cohorts. Two patients in the antimicrobial cohort (6%) developed a UTI and none of the patients who did not receive antimicrobial prophylaxis developed a UTI (P=0.15).

CONCLUSIONS

In our cohort study antimicrobial prophylaxis at the time of cystoscopic stent removal did not appear to provide a significant benefit in UTI prevention. Prospective studies would assist in validating these findings.