Endourologic Procedures

Antimicrobial prophylaxis for urologic surgery is stratified by lower tract and upper tract instrumentation, along with patient risk factors ( Table 7.2 ). Simple cystoscopy has traditionally been a procedure that does not warrant routine antimicrobial prophylactics. Although the literature is not conclusive, it appears there is limited evidence for the use of antibiotics for ambulatory patients who undergo cystoscopy without risk factors such as advanced age, smoking, anatomic anomalies, steroid use, decreased immune function, and urethral catheters. In a study of 3108 patient cystoscopies without antibiotic prophylaxis, 673 (22%) had asymptomatic bacteriuria and 2435 (78%) had sterile urine. A febrile UTI developed within 30 days of cystoscopy in 59 patients (1.9%). Therapy before outpatient flexible cystoscopy does not appear necessary in patients who have no clinical signs or symptoms of acute UTI, including bacteriuria. Guideline recommendations for cystoscopy with manipulation including transurethral resection of bladder tumor and prostate, include antimicrobial prophylaxis. Although prophylactic antibiotics have been shown to decrease the incidence of post-TURP bacteriuria, high fever, bacteremia, and additional antibiotic treatment, the prescribing patterns of urologists vary significantly prior to TURP with low compliance to guidelines. Berry and Barratt conducted a meta-analysis of 32 randomized controlled trials evaluating antimicrobial prophylaxis in TURP patients, including 4260 patients. The authors found antibiotic prophylaxis significantly decreases the incidence of bacteriuria and clinical septicemia in men with preoperative sterile urine undergoing TURP. Taken together, these studies highlight (1) the need for preoperative urine culture when feasible, (2) that a single dose of perioperative antibiotics appears sufficient to decrease infectious risk, and (3) that maintaining closed urinary drainage and minimizing drainage may reduce postoperative infection rates. Even though guidelines recommend antimicrobial prophylaxis for TURBT, data remain controversial. Studies have shown antibiotics for TURBT in patients with no risk factors for infectious complications may not be necessary where use of antibiotics might be deferred until postoperative infections develop.

Fluoroquinolone and TMP-SMX remain the mainstay prophylactic antibiotic of choice for the majority of endo­urologic procedures. Ureteroscopy, which is the mainstay for ureteral and renal calculi and a diagnostic procedure for upper tract urothelial tumors, merits antibiotic prophylaxis. For ureteroscopic stone treatment, the postoperative UTI rate is low (<2.5%). Antibiotic prophylaxis significantly reduces the incidence of pyuria and tends to diminish the risk of bacteriuria and UTI. However, recent studies have demonstrated that in patients with a negative baseline urine culture undergoing ureteroscopy for ureteral or renal stones, rates of postoperative UTI and fever were not reduced by preoperative antibiotic prophylaxis, highlighting the need for antibiotic stewardship. A continuous antibiotic low-dose treatment during the entire JJ stent indwelling time does not reduce the quantity or severity of UTIs compared with a peri-interventional antibiotic prophylaxis only. The use of oral peri-stent removal antibiotic prophylaxis is sufficient to prevent symptomatic UTIs in patients who have undergone uncomplicated ureteroscopy for urolithiasis. The judicious use of antibiotics in uncomplicated cases may help lower the incidence of resistant organisms and other complications related to the widespread use of antibiotics. In patients with pyelonephritis secondary to obstructive stones, antimicrobial resistance makes the selection of empiric antibiotic treatment challenging because of discordance between voided urine cultures and those captured at the time of decompression. It is imperative to obtain both voided urine and urine from the kidney to ensure adequate antibiotic coverage. After uncomplicated ureteroscopy for urolithaisis, the use of oral peri-stent removal antibiotic prophylaxis has been found to be sufficient to prevent symptomatic UTIs.

Percutaneous access to the renal collecting system may put the patient at increased risk for bacteremia and sepsis due to traversing the renal parenchyma and merit anti­microbial prophylaxis with a first- or second-generation cephalosporin, or aminoglycoside with metronidazole or clindamycin. Reports have demonstrated a significant risk of postoperative infectious complications including sepsis despite prophylactic antibiotics during PCNL; however, the optimal duration of perioperative antibiotic administration in stone patients remains an area of debate. Antibiotic prophylaxis of patients undergoing percutaneous nephrolithotomy with a negative baseline urine culture is associated with a significant reduction in the rate of postoperative fever (2.5% vs 7.4%, p = 0.040) and other complications. Deshmukh et al. observed comparable rates of immediate fevers after PCNL with no difference in postoperative infections between patients undergoing 24 hours of perioperative antibiotics (consistent with AUA guidelines) versus –7 days of antibiotics after surgery. However, other studies have shown the benefits of prolonged antibiotic prophylaxis. Mariappan et al. prospectively evaluated patients with a stone burden of at least 2 cm or pelvicaliceal dilation and a negative preoperative urine culture who received a 7-day course of ciprofloxacin or standard antibiotics before PCNL. They noted a threefold lower rate of systemic inflammatory response syndrome in patients in the extended antibiotic arm. Multidrug resistant preoperative urine culture has been shown to be significantly predictive of an infectious complication in patients undergoing PCNL compared to the presence of a positive urine culture alone. As such, efforts have focused on curtailing the indiscriminant use of antibiotics and promoting use only when indications for administration are clear. A common finding of these studies remains that no antibiotic prophylaxis regimen will completely eliminate the risk of infection after endoscopic stone surgery.

The incidence of infectious complications after extracorporeal shock wave lithotripsy (ESWL) in patients without risk factors is low. A recent meta-analysis of nine randomized controlled trials assessing the efficiency of antimicrobial prophylaxis for shock wave lithotripsy demonstrated no statistically significant benefit of therapy in terms of reducing postoperative bacteriuria, clinical UTIs, or fever. In a prospective study evaluating the use of targeted antibiotic prophylaxis in preventing UTIs in patients undergoing shock wave lithotripsy, Honey et al. found of the 389 patients included in the determination of the primary outcome, UTI developed in only one (0.3%), urosepsis did not develop in any patients, and asymptomatic bacteriuria developed in 11 (2.8%), suggesting universal use of antibiotic in ESWL may not be needed.

AUA guidelines do not recommend routine use of antimicrobial prophylaxis during ESWL; however, it may be justified for those with increased risk for infection.

Open, Laparoscopic, and Robotic Urologic Surgery

Studies indicate that antimicrobial prophylaxis is most effective when provided prior to the initial surgical incision, which is supported by the Surgical Care Improvement Project (SCIP) sponsored by The Joint Commission. The SCIP measure dictates that prophylactic antibiotic must be received within 1 hour prior to incision (or within 2 hours before incision if vancomycin is required for prophylaxis). This allows the establishment of bactericidal tissue and serum levels at the time of skin incision to reduce the risk of infection. A landmark study in 1992 consisting of 2847 surgery patients found that the lowest incidence of postoperative infection was associated with antibiotic administration during the 1 hour prior to surgery. The risk of infection increased progressively with greater time intervals between administration and surgical incision. Results of this study showed lowest infection rates (less than 1%) for patients undergoing surgery when an antimicrobial dose was administered within 1 hour before the incision. Patients who received the antibiotics too soon (more than 2 hours prior to incision) had an infection rate of 3.8%. Likewise, patients who received the antibiotics 3 hours after incision had an infection rate of 3.3%.

Antimicrobial prophylaxis can be stratified based on entry into the urinary tract or intestine. Surgery without entry into the urinary tract includes a variety of invasive and superficial urologic procedures. Results in a cohort of 83 patients undergoing transabdominal radical nephrectomy randomized to a single dose of intravenous cephalosporin versus no perioperative prophylaxis revealed a significantly lower overall infection rate in the treatment group (8% vs 27%). In a prospective but nonrandomized comparison of 424 hand-assisted laparoscopic nephrectomies with and without antimicrobial prophylaxis (cephalosporin), wound infections occurred significantly more often in patients without prophylaxis (13% vs 5.4%).

In a comprehensive review of the literature regarding surgery with entry into the urinary tract, the authors concluded that the expected rate of febrile UTI is 5–10% without prophylaxis and that antimicrobial prophylaxis would significantly reduce the rate of febrile UTI, to 2–3%. In a randomized controlled trial of 91 men undergoing open prostatectomy, intravenous cefotaxime (compared to no prophylaxis) significantly reduced the incidence of postoperative infection from 46% to 5%.

Although randomized controlled trials (RCTs) involving urologic surgery involving bowel (primarily urinary diversion, with or without cystectomy) have not been reported, supportive literature from neighboring surgical specialties confirm the benefit of antimicrobial prophylaxis in the setting of surgery involving intestinal components. Tailoring preoperative antimicrobial prophylaxis during radical cystectomy to broader, culture-directed antimicrobial prophylaxis, based on institutional data to include antifungal coverage, has been shown to decrease postoperative infections. Additionally, longer durations of antibiotic coverage beyond 24 hours appear not to improve rates of septic complications during cystectomy.

Special Consideration: Heart Valves, Prostheses

Patients with preexisting implanted surgical hardware, such as artificial joints and prosthetic heart valves, are of particular interest because this foreign material may become hematogenously seeded from bacteremia induced during surgical manipulation. These infections are frequently difficult to treat and often require surgical removal of the infected material. Antibiotic prophylaxis for the prevention of infective endocarditis is not recommended in patients undergoing urologic procedures, even in patients with the highest risk of heart conditions (see Chapter 3 ).

Antimicrobial prophylaxis is not indicated for urologic patients on the basis of orthopedic pins, plates, and screws, nor is it routinely indicated for most urologic patients with total joint replacements on that basis alone. However, antimicrobial prophylaxis intended to reduce the risk of hematogenous total joint infection is recommended in patients who meet both sets of criteria shown in Table 7.3 . The recommended antimicrobial regimen in these patients include a single systemic level dose of a quinolone (e.g., ciprofloxacin, 500 mg; levofloxacin, 500 mg; ofloxacin, 400 mg) orally 1–2 hours preoperatively or ampicillin 2 g IV (or vancomycin 1 g IV over 1–2 hours in patients allergic to ampicillin) plus gentamicin 1.5 mg/kg IV 30–60 minutes preoperatively. Alternative culture-specific antibiotics may also be considered in some cases.

Surgical Site Infections

Surgical site infections (SSIs) are associated with substantial morbidity and mortality, prolonged hospital stay, and increased cost. The US Centers for Disease Control and Prevention (CDC) has developed criteria that define an SSI as an infection related to an operative procedure that occurs at or near the surgical incision within 30 days of the procedure or 90 days if prosthetic material is implanted at surgery. SSIs are the most common nosocomial infection, accounting for 38% of nosocomial infections. However, the overall risk of SSI is low; it is estimated that SSIs develop in 2–5% of the more than 30 million patients undergoing surgical procedures each year (i.e., 1 in 24 patients who undergo inpatient surgery in the United States has a postoperative SSI). SSIs complicate up to 5% of clean extraabdominal operations and up to 20% of intraabdominal procedures. SSIs almost double the direct costs of hospitalization, and patients with SSIs are more likely to be readmitted, require stay in the intensive care unit, and suffer mortality. Using the Healthcare Cost and Utilization Project National Inpatient Sample, de Lissovoy et al. evaluted 723,490 surgical hospitalizations, of which 6891 cases of SSI were identified (1%). On average, SSI extended length of stay by 9.7 days while increasing cost by $20,842 per admission. From the national perspective, these cases of SSI were associated with an additional 406,730 hospital-days and hospital costs exceeding $900 million. An additional 91,613 readmissions for treatment of SSI accounted for a further 521,933 days of care at a cost of nearly $700 million.

Clinical criteria for defining SSI include one or more of the following: (1) a purulent exudate draining from a surgical site, (2) a positive fluid culture obtained from a surgical site that was closed primarily, (3) a surgical site that is reopened in the setting of at least one clinical sign of infection (pain, swelling, erythema, warmth) and is culture positive or not cultured, and (4) the surgeon’s diagnosis of infection. SSIs are classified as incisional or organ/space. Incisional SSIs are further divided into superficial, those involving only the skin or subcutaneous tissue, or deep, those involving deep soft tissues of an incision. Organ/space SSIs account for one-third of all SSIs, but are associated with more than 90% of deaths related to SSIs.

In addition to antibiotic prophylaxis, several other measures may decrease rates of SSIs including surgeon hand antiseptic, patient skin preparation, and hair removal. In a Cochrane database review of preoperative skin antiseptics for preventing surgical wound infections after clean surgery, the authors found evidence that preoperative skin preparation with 0.5% chlorhexidine in methylated spirits was associated with lower rates of SSIs following clean surgery than alcohol-based povidone iodine paint. In a cohort of patients submitted to open prostatectomy, the type of antiseptic did not affect SSI risk (0.5% povidone-iodine or chlorhexidine in an alcohol base).

The alcohol-based hand rub has been shown to be more efficacious for surgical antisepsis when compared to conventional surgical scrub. Whether this translates into a decrease in SSI is not clear. In a literature review of surgical hand antisepsis to reduce surgical site infection, alcohol rubs used in preparation for surgery by the scrub team are as effective as aqueous scrubbing in preventing SSIs, but the analysis data were limited by study methods and quality. Avagard Hand Antiseptic (3M, St. Paul, MN) has been shown to provide comparable hand antisepsis to the traditional surgical scrub in a variety of pediatric urologic procedures. Avagard Hand Antiseptic was noted to be superior to the surgical hand scrub in cost-effectiveness and time efficiency.

Preoperative hair removal has been used to prevent surgical site infections; however, a meta-analysis of 19 randomized controlled trials confirmed the absence of any benefit of depilation to prevent surgical site infection, as well as the higher risk of surgical site infection when shaving is used for depilation.

The proportion of patients developing SSIs depends on the type of surgery. Although SSI rates are low in urologic surgery, minimally invasive surgery compared to open surgery is significantly associated with reduced rates of SSIs, including prostatectomy (1.0% vs 2.4%) and partial nephrectomy (0.54% vs 1.3%). The SSI rate in minimally invasive adrenal and renal surgery is low (1.6%), and reports have suggested that antimicrobial prophylaixis may be avoided in this clean category minimally invasive surgery. On-demand use of antibiotics in the renal and adrenal surgery seem to be sufficient for perioperative infectious management. In 556 patients undergoing urologic laparoscopic procedures, 14 surgical site infections (2.5%) were identified at mean postoperative day 21.5. Of the 14 surgical site infections, 10 (71.4%) were located at a specimen extraction site. Infection is associated with prolonged operative time and increasing body mass index.

In a study of 200 patients who underwent either inguinal or scrotal surgery, both of which are classified as clean surgery, the overall SSI infection rate was 3.5%. However, the frequencies of SSI were 6.5% in the patients with urologic inguinal surgery and 1.6% in those with scrotal surgery even though all patients received a first- or second-generation cephalosporin as antimicrobial prophylaxis. The frequency of SSI in the patients with urologic inguinal surgery was not negligible even though it is considered a clean operation, and this highlights the need for SSI prevention.

Implanted urologic devices are at increased risk for infection. Haraway et al. evaluated 136 patients who underwent sacral neuromodulation implantation and found 5.9% experienced infections that required device explantation. Preoperative antibiotic selection was a significant factor in preventing subsequent infection and explantation where cefazolin was less effective in preventing infection compared with the other antibiotic regimens. Implanted seeds do not appear to have the same risk of infection. In 826 patients with localized prostate cancer who underwent a transperineal (125)I brachytherapy, all of who received antimicrobial prophylaxis, 0.73% of patients had a perioperative infection. Bacteriuria and preoperative hair removal were risk factors of perioperative infection with statistical significance (p = 0.007 and p = 0.004, respectively), highlighting additional measures to prevent perioperative infectious complications.

Historically, preoperative mechanical bowel preparation has been considered the standard of care for patients undergoing radical cystectomy with urinary diversion. Recent data have shown the use of mechanical bowel preparation for patients undergoing radical cystectomy with an ileal conduit or orthotopic neobladder does not seem to impact the rates of perioperative infections or wound and bowel complications.

Intraabdominal Infections

Intraabdominal infections are the second most common cause of infectious mortality in intensive care units. Complicated intraabdominal infection, which extends into the peritoneal space, is associated with abscess formation and peritonitis. Uncomplicated infection, which involves intramural inflammation of the gastrointestinal tract, may progress to complicated infection if left untreated. Treatment of intraabdominal infections has evolved in recent years because of advances in supportive care, diagnostic imaging, minimally invasive intervention, and antimicrobial therapy. Based on these new advances, evidence-based guidelines for managing patients with intraabdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America.

Fluid resuscitation is a key initial step in managing intraabdominal postoperative infections. Volume depletion is common in febrile patients and is worsened by poor fluid intake because of nausea and/or vomiting and in the presence of ileus induced by intraabdominal inflammation. Patients should undergo rapid restoration of intravascular volume and additional measures as needed to promote physiologic stability. For patients with septic shock, such resuscitation should begin immediately when hypotension is identified. For patients without evidence of volume depletion, intravenous fluid therapy should begin when the diagnosis of intraabdominal infection is first suspected. Antibiotic therapy involves the administration of parenteral empirical antibiotics and should be initiated once a patient receives a diagnosis of an intraabdominal infection or once such an infection is considered likely. For patients with septic shock, antibiotics should be administered as soon as possible. They should be initiated before abscess drainage and concluded when all systemic signs of sepsis have resolved. Because abscess fluid usually contains a mixture of aerobic and anaerobic organisms, initial empiric therapy must be directed against both types of microbes. This may be accomplished with antibiotic combination therapy or with broad-spectrum, single-agent therapy. Specific therapy is then guided by the results of cultures retrieved from the abscess. In patients who are immunosuppressed, candidal species may play an important pathogenic role, and treatment with antifungals may be indicated. Fluconazole is an appropriate choice for treatment if Candida albicans is isolated. For fluconazole-resistant Candida species, therapy with an echinocandin is appropriate. Because of toxicity, amphotericin B is not recommended as initial therapy.

Drainage of infectious fluid collections is mandatory and is the first line of defense against progressive sepsis. Percutaneous computed tomography (CT)-guided catheter drainage has become the standard treatment of most intraabdominal abscesses and is preferable to surgical drainage. Patients with diffuse peritonitis should undergo an emergency surgical procedure as soon as is possible, even if ongoing measures to restore physiologic stability need to be continued during the procedure. Percutaneous drainage avoids anesthesia and possibly difficult laparotomy, prevents the possibility of wound complications from open surgery, and may reduce the length of hospitalization. It also obviates the possibility of contaminating other areas within the peritoneal cavity.

Cultures should be performed from one specimen, provided it is of sufficient volume (at least 1 mL of fluid or tissue, preferably more) and is transported to the laboratory in an appropriate transport system. For optimal recovery of aerobic bacteria, 1–10 mL of fluid should be inoculated directly into an aerobic blood culture bottle. In addition, 0.5 mL of fluid should be sent to the laboratory for Gram stain and, if indicated, fungal cultures. If anaerobic cultures are requested, at least 0.5 mL of fluid or 0.5 g of tissue should be transported in an anaerobic transport tube. Alternatively, for recovery of anaerobic bacteria, 1–10 mL of fluid can be inoculated directly into an anaerobic blood culture bottle. Susceptibility testing for Pseudomonas, Proteus, Acinetobacter, Staphylococcus aureus , and predominant Enterobacteriaceae , as determined by moderate-to-heavy growth, should be performed, because these species are more likely than others to yield resistant organisms.

After drainage, clinical improvement should occur within 48–72 hours. Lack of improvement within this time frame mandates repeat CT scanning to check for additional abscesses. Surgical drainage becomes mandatory if residual fluid cannot be evacuated with catheter irrigation, manipulation, or additional drain placement. Contraindications to surgical correction of abdominal abscesses are based on the patient’s comorbidities and on the individual’s ability to tolerate surgery. The surgical approach may be either laparoscopic or open. Transperitoneal exploration is indicated for multiple abscesses not amenable to CT-guided drainage, such as interloop collections or an enteric fistula feeding the abscess. In the latter situation, draining the abscesses with an enteric communication may be possible for several days before a laparotomy is performed to control the fistula.

Criteria for removal of percutaneous catheters include resolution of sepsis signs, minimal drainage from the catheter, and resolution of the abscess cavity as demonstrated by ultrasonography or CT. Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome. In patients who have persistent or recurrent clinical evidence of intraabdominal infection after 4–7 days of therapy, appropriate diagnostic investigation should be undertaken. This should include CT or ultrasound imaging. Antimicrobial therapy effective against the organisms initially identified should be continued. Persistent drainage usually reflects the presence of an enteric fistula, and a CT scan with contrast should be performed. Frequently, this fistula can be documented by sinography.

Complications of percutaneous drainage include bleeding or inadvertent puncture of the gastrointestinal tract.

Postoperative Urinary Tract Infections

UTIs are the most common type of nosocomial infection and are frequently postoperative in nature, most commonly the result of manipulating the urinary tract or having an indwelling catheter.

Postoperative UTIs are observed more commonly after major urologic surgery compared with endoscopic procedures, especially after prostate surgery. There are two critical times for the development of infectious complications following prostatic surgery: the perioperative period and the time of catheter removal where 25% of men will have a positive urine culture. In a study of 729 consecutive radical prostatectomies, UTI was observed less frequently among patients receiving short-term antibiotic therapy (3.1% vs. 7.3%) after catheter removal compared with those not receiving antibiotics (p = 0.019). One would need to prescribe antibiotic therapy to 24 patients to prevent one case of UTI.

A positive urine culture is a very common finding in patients with an orthotopic bladder, occurring in >50% of patients. Symptomatic UTI, however, occurs at lower rates but remains a common complication after neobladder reconstruction, usually occurring within the first 3 months of surgery.

Sepsis: Early Recognition and Treatment

Development of sepsis after surgery imposes a significant clinical resource and health-care burden. Factors associated with the development of postoperative sepsis are frequently procedure dependent and are more common with bacteriuria, but also patient comorbidities such as diabetes and hypertension, as well as smoking history along with race, age, hospital size, and hospital location, impact sepsis rates. The American College of Chest Physicians and Society of Critical Care Medicine originally classified the continuum of an inflammatory response to microorganisms as systemic inflammatory response syndrome, sepsis, severe sepsis, and septic shock. These definitions have recently been modified in a consensus by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine and no longer employ the term systemic inflammatory response syndrome . The change in definitions was prompted by the increased recognition of the pathobiology and need to clinically define sepsis and septic shock. In addition, a new score called quickSOFA (Sequential Organ Failure Assessment score: qSOFA) was devised and validated for the clinical criteria of sepsis. Early recognition and management of sepsis optimizes outcome. Therefore patients in whom this problem is suspected after genitourinary surgery should be prioritized and receive timely care. To diagnose sepsis and septic shock as early as possible, it is necessary to have clear definitions of infection, organ dysfunction, and global tissue hypoxia and to recognize the clinical and laboratory findings that are indicative of these conditions ( Table 7.4 ).

Table 7.4

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