Absence of prophylactic antibiotics in minimum incision endoscopic urological surgery (MEUS) of adrenal and renal tumors

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Intraoperative Only versus Extended Duration Use of Antimicrobial Prophylaxis for Infectious Complications in Radical Cystectomy with Intestinal Urinary Diversion

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.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Safety of clean urologic operations without prophylaxis antibiotic therapy in Cipto Mangunkusumo Hospital, Jakarta: A double-blind randomized controlled trial study

OBJECTIVE

This study was conducted to identify the safety measures of performing clean urologic operations without administration of prophylaxis antibiotics.

METHODS

We conducted a double-blind randomized controlled trial with patients who underwent clean urologic operations in Cipto Mangunkusumo Hospital, Jakarta, Indonesia, from April 2013 to January 2014. The local and systemic infection states were compared between the prophylaxis and placebo groups. Local infection was identified as surgical site infection and systemic infection as fever and leukocytosis.

RESULTS

A total of 42 patients participated in the study (21 patients in each group), comprising 14 (33.3%) children and 28 (66.7%) adults. The most frequently performed operation was surgical sperm retrieval. No patients in either group were found to have local or systemic infection. However, there was a statistical difference in the white blood cell counts between the two groups (p = 0.003), although there was no sign of local or systemic infection in any of the patients.

CONCLUSION

Clean urologic operations without prophylaxis antibiotic therapy can be safely applied to urologic patients.

Successful reduction of hospital-acquired methicillin-resistant Staphylococcus aureus in a urology ward: a 10-year study

BACKGROUND

To eradicate hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) using a stepwise infection control strategy that includes an avoidance of antimicrobial prophylaxis (AMP) based on surgical wound classification and an improvement in operative procedures in gasless single-port urologic surgery.

METHODS

The study was conducted at an 801-bed university hospital. Since 2001, in the urology ward, we have introduced the stepwise infection control strategy. In 2007, surveillance cultures for MRSA in all urological patients were commenced. The annual incidence of MRSA was calculated as a total number of newly identified MRSA cases per 1,000 patient days. Trend analysis was performed using a Poisson regression.

RESULTS

Over the study period, 139,866 patients, including 10,201 urology patients, were admitted to our hospital. Of these patients, 3,719 patients, including 134 ones in the urology ward, were diagnosed with MRSA throughout the entire hospital. Although the incidence of MRSA increased throughout the entire hospital (p = 0.002), it decreased significantly in the urology ward (p < 0.0001). Of the 134 cases, 45 (33.6%) were classified as "imported," and 89 (66.4%) as "acquired." In the urology ward, the incidence of acquired MRSA decreased significantly over time (p < 0.0001), whereas the incidence of imported MRSA did not change over time (p = 0.66). A significant decrease (p < 0.0001) in the incidence of clinically significant MRSA infection over time was found.

CONCLUSIONS

Stepwise infection control strategy that includes a reduction or avoidance of antimicrobial prophylaxis in minimally invasive surgery can contribute to a reduction in hospital-acquired MRSA.

TRIAL REGISTRATION

Current study has approved by the institutional ethical review board (No.1141).

[Prospective multi-institutional analysis according to the "Japanese guidelines for prevention of perioperative infections in urological field"]

OBJECTIVE

The "Japanese guidelines for prevention of perioperative infections in urological field" was edited by the Japanese Urological Association in 2007. They are the first Japanese guidelines for antimicrobial prophylaxis specifically to prevent perioperative infections in the urological field. We report here the results of a multicenter prospective study conducted to examine the validity and usefulness of these guidelines.

PATIENTS AND METHODS

The subjects were 513 patients who had undergone urological surgeries between July and September 2008 at 10 nationwide university institutions in the Japanese Society of UTI Cooperative Study Group. These surgeries were transurethral resection of bladder (TURBT), transurethral resection of prostate (TURP), adrenalectomy, nephrectomy, nephroureterectomy, radical prostatectomy and total cystectomy. Analysis was performed on patient information, surgical procedures, types and durations of administration of prophylactic antibiotic agents, and the presence of surgical site infections (SSI) and remote infections (RI).

RESULTS

Of 513 patients, 387 (75.4%) were administered prophylactic antibiotic agents according to the guidelines. In these patients, the incidences of SSI and RI were 5.9% and 4.1%, respectively. Multivariate analysis showed that significant factors for SSI were the surgical risk (according to the ASA physical status classification system), diabetes, and operation time, and that the only significant factor for RI was the operation time.

CONCLUSIONS

More large-scale study and evidences are necessary in order to demonstrate the validity and usefulness of these guidelines.

Prophylactic antibiotic guidelines in modern interventional radiology practice

Modern interventional radiology practice is continuously evolving. Developments include increases in the number of central venous catheter placements and tumor treatments (uterine fibroid therapy, radio- and chemoembolization of liver tumor, percutaneous radiofrequency and cryoablation), and new procedures such as abdominal aortic aneurysm stent-graft repair, vertebroplasty, kyphoplasty, and varicose vein therapies. There have also been recent advancements in standard biliary and urinary drainage procedures, percutaneous gastrointestinal feeding tube placement, and transjugular intrahepatic portosystemic shunts. Prophylactic antibiotics have become the standard of care in many departments, with little clinical data to support its wide acceptance. The rise in antibiotic-resistant strains of organisms in all hospitals worldwide have forced every department to question the use of prophylactic antibiotics. The authors review the evidence behind use of prophylactic antibiotics in standard interventional radiology procedures, as well as in newer procedures that have only recently been incorporated into interventional radiology practice.

Antimicrobial prophylaxis is not necessary in clean category minimally invasive surgery for renal and adrenal tumors: a prospective study of 373 consecutive patients

OBJECTIVE

To assess the feasibility of the nonuse of antimicrobial prophylaxis (AMP) on the incidence of infectious complications after clean category minimally invasive surgery for renal and adrenal tumors.

METHODS

We evaluated 415 consecutive patients who underwent gasless laparoendoscopic single-port surgery (GasLESS) for renal or adrenal tumors between 2006 and 2010. Forty-two patients with poorly controlled diabetes mellitus, coexisting infection, or opening of the urinary tract during partial nephrectomy were excluded from this study. The remaining 373 patients underwent radical nephrectomy (n = 187), partial nephrectomy (n = 103), or adrenalectomy (n = 83) without AMP. Perioperative infections were categorized into superficial surgical site infection (SSI), deep SSI, and remote infection (RI) and graded using an established 5-grade modification of the original Clavien-Dindo classification system. We investigated the association between the incidence of infectious complications and clinical or perioperative factors.

RESULTS

Infectious complications occurred in 16 cases (4.3%), including 4 superficial SSIs (1.1%), 2 deep SSIs (0.5%), and 10 RIs (2.7%). Neither superficial SSI nor deep SSI was significantly associated with any clinical or perioperative factors. The incidence of RI, however, was associated with longer operative time and higher National Nosocomial Infection Surveillance (NNIS) risk index. All perioperative infections were successfully treated with antibiotics without surgical interventions. No infectious complications equal to or greater than grade IIIa occurred.

CONCLUSION

The nonuse of AMP and the on-demand use of antibiotics seem to be sufficient for perioperative infectious management in clean category minimally invasive surgery for renal and adrenal tumors.

A prospective study of single-dose antibiotic prophylaxis in live donor nephrectomy

Purpose

To perform a prospective analysis of the clinical outcomes of prophylactic antibiotic treatment before the standard surgical modality of living donor nephrectomy (LDN) without postoperative antibiotic treatment.

Materials and Methods

From November 2005 to June 2010, a total of 470 patients underwent LDN at our medical institution, and 280 of these patients were injected with 1 g cephalosporin 30 minutes before the operation. The group receiving prophylactic antibiotics was compared with a control group composed of 190 patients who received injections of 2 g cephalosporin per day for 5 days after the operation. The presence of fever, incidence of blood transfusion, and period of drainage use were compared between the two groups.

Results

There were no significant differences in gender, age, body mass index, incidence of blood transfusion after the operation, fever over 38℃ 3 days after the operation, or period of drain insertion between the single-dose group and the control group. The follow-up was conducted for 1 month after the operation, and 1 case of surgical site infection (SSI) was observed in each group (p=0.783).

Conclusions

Of 280 patients in the single-dose group, 1 contracted SSI. In comparison with the control group, which was dosed with prophylactic antibiotics for 5 days after the operation, the single-dose group did not have a significantly different occurrence of SSI. We found that the incidence rate of SSI did not increase, even though prophylactic antibiotics were not used after standard and conventional open surgeries, such as video-assisted minilaparotomy surgery.

Gasless single-port access endoscopic surgery in urology: minimum incision endoscopic surgery, MIES

Abstract Minimum incision endoscopic surgery (MIES) is a gasless, single-port access, cost-effective, and minimally invasive surgery that has been in development since the late 1990s. Use of MIES has steadily increased in Japan and Asia and has been introduced into Europe and the USA. In 2006, MIES was certified by the Japanese government as an advanced surgery and since 2008 it has been covered by the Japanese universal health insurance system as a new surgical technique. Briefly, MIES involves an initial minimum incision (a single port) that permits extraction of the target specimen. A wide working space through the port is then made by separating the anatomical plane extraperitoneally. This is maintained with special retractors instead of gas insufflation. All instruments including an endoscope are inserted through the port and the operation is completed. The size of the port can be tailored to the situation if necessary, which contributes to preclusion of patient selection. The procedure uses only two disposable devices that are inexpensive, resulting in low equipment costs. Surgeons have the benefits of magnified vision through endoscopy as well as stereovision and panoramic vision of naked eyes through the port, which reduces the technical demands of the procedure. Techniques for two basic MIES procedures allow MIES to be performed for most urological organs and in extraordinary cases by their modifications. Thus, the MIES system permits minimally invasive surgery without use of CO(2) gas, which is ideal from medical, environmental and economic perspectives, is cost-effective and minimizes patient selection.

Rational antibiotic therapy and the position of ampicillin/sulbactam

In the current context of increasing antimicrobial resistance, it is important to use antibiotics rationally and to re-assess regularly the clinical usefulness of commonly used agents. This review focuses on the efficacy of the beta-lactam ampicillin co-administered with the beta-lactamase inhibitor sulbactam, either parenterally (ampicillin/sulbactam) or orally (sultamicillin), for the treatment of bacterial infections. Clinical findings from the past decade confirm the results of numerous older studies and together provide good evidence to support the continued use of ampicillin/sulbactam and sultamicillin in hospital- and community-acquired infections both in adults and children. This is also recognised in recent published national and international guidelines, many of which recommend ampicillin/sulbactam as first-line therapy for various respiratory and skin infections.

Minimum incision endoscopic nephrectomy for giant hydronephrosis

Five consecutive patients with symptomatic giant hydronephrosis underwent minimum incision endoscopic nephrectomy. The originally huge renal specimen was retroperitoneally mobilized using both of endoscopy and direct vision, without the use of trocar ports or gas insufflation, via a single minimum incision that narrowly permitted extraction of the specimen. The specimen was successfully extracted from the incision in all patients. Technically, proper deflation of the hydronephrotic sac facilitates mobilization and enables extraction of the specimen. Median (range) size of incision, operative time, and estimated blood loss were 4 cm (3-5), 205 min (156-222), and 210 mL (110-350), respectively. No patient required blood transfusion or encountered operative complications. Postoperative convalescence was short and uneventful; all patients resumed oral intake and ambulance on the day following surgery, and were physically dischargeable from hospital after 2-3 postoperative days. Thus, this technique is a feasible, minimally invasive and safe procedure for symptomatic giant hydronephrosis.