The Role of Prophylactic Antibiotics After Minimally Invasive Pyeloplasty With Ureteral Stent Placement in Children

The construction of a nomogram to predict the prognosis and recurrence risks of UPJO

Objective

This study was conducted to explore the risk factors for the prognosis and recurrence of ureteropelvic junction obstruction (UPJO).

Methods

The correlation of these variables with the prognosis and recurrence risks was analyzed by binary and multivariate logistic regression. Besides, a nomogram was constructed based on the multivariate logistic regression calculation. After the model was verified by the C-statistic, the ROC curve was plotted to evaluate the sensitivity of the model. Finally, the decision curve analysis (DCA) was conducted to estimate the clinical benefits and losses of intervention measures under a series of risk thresholds.

Results

Preoperative automated peritoneal dialysis (APD), preoperative urinary tract infection (UTI), preoperative renal parenchymal thickness (RPT), Mayo adhesive probability (MAP) score, and surgeon proficiency were the high-risk factors for the prognosis and recurrence of UPJO. In addition, a nomogram was constructed based on the above 5 variables. The area under the curve (AUC) was 0.8831 after self cross-validation, which validated that the specificity of the model was favorable.

Conclusion

The column chart constructed by five factors has good predictive ability for the prognosis and recurrence of UPJO, which may provide more reasonable guidance for the clinical diagnosis and treatment of this disease.

Does prophylactic antibiotics post pediatric pyeloplasty reduce the incidence of febrile UTIs?

PURPOSE

The use of postoperative prophylactic antibiotics in pediatric upper urinary tract reconstruction remains controversial. In this study, we examined whether low dose antibiotics administered following pediatric pyeloplasty reduce the incidence of febrile urinary tract infections at our institution. As a secondary outcome, in those patients with infection, additional analysis was performed to better quantify which patient population benefits the most from low dose prophylactic antibiotics.

METHODS

Institutional review board approval (IRB) was obtained. All methods were carried out in accordance with relevant guidelines and regulations. A retrospective study was performed in patients who underwent pyeloplasty (2011-2017) at our institution. Surgical approach (laparoscopic versus robotic assisted versus open, with or without internal JJ ureteral stent) were based on surgeon preference. Patients of 8 fellowship trained pediatric urologists were included in the study period. Patients with prior history of urologic interventions or other congenital genitourinary tract abnormalities were excluded. Demographics (age, gender, ethnicity, insurance status), prior history of culture proven urinary tract infection, surgical details (administration of perioperative antibiotics), and postoperative outcomes including; 1) re-admission 30 days post-surgery, 2) any urine cultures collected due to suspected urinary tract infection.

RESULTS

A total of 209 patients (149 boys, 60 girls) met our inclusion criteria with 55/209 (26%) receiving postoperative prophylactic antibiotics. The average age was 6 years (range: 2 months-18 years). Indwelling ureteral stent was used in 176 (84%) patients. Eleven patients (5%) had a culture-proven urinary tract infection within 30-days postoperatively. No significant differences were seen in postoperative complications or incidence of urinary tract infection when comparing surgical approaches, +/- ureteral stent, or the use of antibiotics. Secondary analysis noted statistically significant increase in post-operative urinary tract infection in younger children (2.8 v. 6.2 years, p = 0.02), those patients who had a positive preoperative urine culture (8/11, p = 0.01) and those with public health insurance (p = 0.038).

CONCLUSION

The incidence of postoperative urinary tract infection following pyeloplasty in our cohort was relatively low. There was a higher incidence of urinary tract infection in patients less than 3 years old. The use of antibiotics in patients post pyeloplasty did not appear to affect the incidence of post-operative urinary tract infection, however, they may have a role in children who have not yet potty trained and in patients with positive preoperative urine culture.

Antibiotic Prophylaxis for the Prevention of Urinary Tract Infections in Children: Guideline and Recommendations from the Emilia-Romagna Pediatric Urinary Tract Infections (UTI-Ped-ER) Study Group

Background: Urinary tract infection (UTI) represents one of the most common infectious diseases and a major cause of antibiotic prescription in children. To prevent recurrent infections and long-term complications, low-dose continuous antibiotic prophylaxis (CAP) has been used. However, the efficacy of CAP is controversial. The aim of this document was to develop updated guidelines on the efficacy and safety of CAP to prevent pediatric UTIs. Methods: A panel of experts on pediatric infectious diseases, pediatric nephrology, pediatric urology, and primary care was asked clinical questions concerning the role of CAP in preventing UTIs in children. Overall, 15 clinical questions were addressed, and the search strategy included accessing electronic databases and a manual search of gray literature published in the last 25 years. After data extraction and narrative synthesis of results, recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology. Results: The use of CAP is not recommended in children with a previous UTI, with recurrent UTIs, with vesicoureteral reflux (VUR) of any grade, with isolated hydronephrosis, and with neurogenic bladder. CAP is suggested in children with significant obstructive uropathies until surgical correction. Close surveillance based on early diagnosis of UTI episodes and prompt antibiotic therapy is proposed for conditions in which CAP is not recommended. Conclusions: Our systematic review shows that CAP plays a limited role in preventing recurrences of UTI in children and has no effect on its complications. On the other hand, the emergence of new antimicrobial resistances is a proven risk.

Ureteral Stent Colonization and Urinary Tract Infection in Children Undergoing Minimally Invasive Pyeloplasty

INTRODUCTION

 Minimally invasive pyeloplasty (MIP), namely, laparoscopic and robot-assisted interventions, has gained popularity in recent years. Double-J ureteral stents are frequently inserted during surgery. Foreign bodies in the urinary tract are considered as risk factor for developing urinary tract infection (UTI). This study aimed to specify the bacteria cultured from urine and stents responsible for UTI in children with indwelling ureteral stents undergoing MIP.

PATIENTS AND METHODS

 We retrospectively reviewed medical records of 30 children (22 boys and 8 girls) who had undergone MIP between 2014 and 2017. Median age at surgery was 2.7 years (interquartile range [IQR]: 0.5-7.9). Urine cultures were obtained before surgery, before stent removal, 1 month after stent removal, and if UTI was suspected. Stents were removed 4 to 8 weeks after surgery and cultured. Patients' demographics, types of stents, and surgical details were recorded.

RESULTS

 Median stent indwelling time was 5.09 weeks (IQR: 4-6). Postoperative febrile UTI developed in 4/30 (13%) patients. Afebrile UTI occurred in another 4/30 (13%) patients. Stent cultures were positive in 19/30 (63%) patients. Stent and urinary cultures were identical in only one patient. Three of four patients with preoperative asymptomatic bacteriuria developed postoperative UTI. There was no association between UTI, gender, stent diameter, and duration of indwelling catheter.

CONCLUSION

 After MIP, febrile UTI and afebrile UTI occurred in about one quarter of patients. Pathogens isolated postsurgically from urinary cultures were unrelated to those colonizing the stents. Therefore, routine stent culturing is of low clinical significance. Moreover, small-caliber stents and longer indwelling periods were not risk factors for UTI. Optimizing antibiotic treatment for children with preoperative UTI may potentially prevent morbidity after surgery.

Pyeloplasty with ureteral stent placement in children: Do prophylactic antibiotics serve a purpose?

OBJECTIVES

Ureteral stents are commonly used during pyeloplasty to ensure drainage and anastomotic healing. Antibiotic prophylaxis is often used due to concerns for urinary tract infection (UTI). Although many surgeons prescribe prophylactic antibiotics following pyeloplasty, practices vary widely due to lack of clear evidence-based guidelines. We hypothesize that the rate of stent UTI does not significantly vary between children who receive antibiotics and those who do not.

METHODS

We reviewed the medical records of 741 patients undergoing pyeloplasty between January 2010 and July 2018 across seven institutions. Exclusion criteria were: age older than 22 years, no stent placed, externalized stents used, and incomplete records. Surgical approach, age, antibiotic use, stent duration, Foley duration, and urine culture results were recorded. Patients were categorized into two groups, those younger than four years of age and those four years and older as proxy for likely diaper use. Univariate logistic regression was conducted to identify variables associated with UTI. Multivariable backward stepwise logistic regression was used to identify the best model with Akaike information criterion as model selection criteria. The selected model was used to calculate odds ratios and 95% confidence intervals summarizing the association between prophylactic antibiotics and stent UTI while controlling for age, gender, and intra-operative urine cultures.

RESULTS

672 patients were included; 338 received antibiotic prophylaxis and 334 did not. These groups differed in mean age (3.91 vs. 6.91 years, P < .001), mean stent duration (38.5 vs. 35.32 days, P < .001), and surgical approach (53.25% vs. 32.04% open vs. laparoscopic, P < .001). The incidence of stent UTI was low overall (7.59%) and similar in both groups: 31/338 (9.17%) in the prophylaxis group and 20/334 (5.99%) in the non-prophylaxis group (P = .119). Although female gender, likely diaper use, and positive intra-operative urine culture were each associated with significantly higher odds of stent UTI, prophylactic antibiotic use was not associated with significant reduction in stent UTI in any of these groups. Surgical approach, stent duration, and Foley duration were not associated with stent UTI.

CONCLUSION

Incidence of stent UTI is low overall following pyeloplasty. Prophylactic antibiotics are not associated with lower rates of stent UTI following pyeloplasty even after controlling for risk factors of female gender, likely diaper use, and positive intra-operative urine culture. Routine administration of prophylactic antibiotics after pyeloplasty does not appear to be beneficial, and may be best reserved for those with multiple risk factors for UTI.

Magnetic Double-J-Stent Removal Without General Anaesthesia in Children

OBJECTIVES

To show the feasibility of magnetic double-J-stent (mDJS) removal without general anaesthesia in infants and children.

METHODS

A retrospective analysis of mDJS removals was conducted between February 2018 and July 2020 in a cohort of 32 consecutive paediatric patients. Only patients with unilateral ureteric stenting were included. Stent retrieval was performed in an outpatient setting. In males the junction of the retrieval-catheter and the mDJS was confirmed by transabdominal ultrasound. All patients were followed-up for 4-12 weeks after stent removal.

RESULTS

Thirty-two patients (54% males) were included. Median age was 3.8 years (range 1 month - 15 years). Ureteral stents remained in place for a median of 67.5 days (range 2 days - 6 months). General anaesthesia was necessary in one single patient due to expressed patient's and caregiver's wish. Thirty-one patients had stent removal without need for general anaesthesia. Thereof, nitrous oxide was used in 12 patients (37.5%), fentanyl in 3 patients (9.4%), midazolam in 3 patients (9.4%), and 17 patients (53.1%) did not need sedation at all. Seven patients (21.9%) being 8 months or younger had received peroral saccharosis. No complications occurred during stent removal. Retrieval was successful at first catheterization in 30 patients (93.8%). Two male patients needed a second catheterization (6.3%).

CONCLUSION

The use of magnetic DJS is safe in the paediatric population and spares general anaesthesia during removal in almost all patients.

Urinary Tract Infection After Robot-assisted Laparoscopic Pyeloplasty: Are Urine Cultures and Antibiotics Helpful?

OBJECTIVE

To evaluate how variations in peri-operative urine culture (UCx) and antibiotic prophylaxis utilization following robot assisted laparoscopic pyeloplasty (RALP) affect post-RALP urinary tract infection (UTI) rates in children, then use data to generate a standardized care pathway.

METHODS

Patients undergoing RALP at a single institution from January 2014 to October 2018 were retrospectively reviewed. Patients with vesicoureteral reflux, neurogenic bladder, intermittent catheterization, <=2 months follow-up after stent removal, or age >=18 years were excluded. UCx use, UCx results, and pre- and post-RALP antibiotic use were recorded. The primary outcome was symptomatic UTI, tracked until 60 days after stent removal. UTI was defined as presence of fever or urinary symptoms, a positive UCx with >=10,000 colony forming units of one uropathogen, and a positive urinalysis.

RESULTS

A total of 152 patients were included (72% male [73% circumcised], 61% white, and 23% Hispanic). One underwent a re-operative pyeloplasty, yielding 153 encounters. Eight patients (5.2%; 95% CI 1.7-8.7%) developed post-RALP UTI. Uncircumcised status and use of pre-operative prophylactic antibiotics were associated with post-RALP UTI (P = .03 and P < .01, respectively). Use of post-RALP antibiotics, whether prophylactic or therapeutic, was not associated with lower UTI rates (P = .92). Positive pre-RALP UCx and positive intra-operative stent removal UCx were associated with higher UTI rates (P = .03 and P < .01, respectively).

CONCLUSION

UTI occurred in 5.2% of our cohort of >150 patients. As post-RALP antibiotic use was not associated with lower UTI rates, prophylactic antibiotics may be reserved for patients with risk factors. A standardized care pathway could safely reduce unnecessary utilization of UA/UCx and antibiotics.

A comparison between short- and long-term D-J stent in Anderson-Hynes pyeloplasty for pelvi-ureteric junction obstruction

PURPOSE

A double-J (D-J) stent is usually kept in situ during Anderson-Hynes (A-H) pyeloplasty for pelvi-ureteric junction (PUJ) obstruction. The aim of the study is to determine whether early removal of D-J stent is better than long-term stenting.

METHODS

In this prospective comparative study, conducted from January 2018 to April 2019 in Chittagong Medical College Hospital, patients with PUJ obstruction, age less than 12 years, were divided into group A (long-term stenting) and group B (short-term stenting) by simple randomization. Main outcome variables were urinary tract infection (UTI), stent colonization, encrustation, renal cortical thickness, differential renal function (DRF), glomerular filtration rate (GFR), and flow rate in DTPA renogram.

RESULTS

There were 31 patients in each group. Median age was 5 years (IQR: 2.3 to 7 years) and male to female ratio was 2.1:1. Frequency of post-operative UTI and stent colonization were significantly higher in group A than group B (p < 0.001). All the patients of both groups had similar improvement in renal cortical thickness, DRF, GFR, and flow rate. The study was potentially limited by its small sample size and high median age (5 years).

CONCLUSION

Early removal of D-J stent had lower incidence of UTI, stent colonization, encrustation, and stent migration.

Robot-assisted laparoscopic pyeloplasty in infants and children: is it superior to conventional laparoscopy?

INTRODUCTION

Open pyeloplasty (OP) has been the first-line treatment for ureteropelvic junction obstruction (UPJO) since it was first described by Anderson and Hynes. The use of minimally invasive surgery (MIS) to treat UPJO in the pediatric population has increased in recent years, due to decreased morbidity and shorter recovery times. Recently, robot-assisted laparoscopic pyeloplasty (RALP) has seen a steady expansion. Unlike laparoscopic pyeloplasty (LP), RALP comes with a more manageable learning curve aided by specialized technological advantages such as high-resolution three-dimensional view, tremor filtration with motion scaling, and highly dexterous wrist-like instruments. With this review, we aim to highlight the trend toward robotic pyeloplasty over laparoscopy and current available evidence on outcomes.

METHODS

We systematically searched the PubMed and EMBASE databases, and we critically reviewed the available literature on the use of laparoscopy and robotic technology in pediatric patients with UPJO.

RESULTS

Overall, we selected 19 original articles and 5 meta-analyses. The available literature showed that the robotic approach to the UPJO allowed for decreased operative times, shorter length of hospital stay, lower complication rates, with success rates comparable to LP. Conflicting results persist regarding robotic platform and equipment costs.

CONCLUSION

While laparoscopy requires advanced skills for complex reconstructive procedures, such as pyeloplasty, robot-assisted surgery offers the valuable potential of making MIS more accessible to these types of procedure. Robotic technology has contributed to shortening the learning curve by acting as a bridge between open and endoscopic approach. There is still a strong need for higher quality evidence in the form of prospective observational studies and clinical trials, as well as further cost-effectiveness analyses. As robotic surgical technology spreads, future systems will be developed, offering smaller and more flexible tools, allowing enhanced applications on pediatric patients.

Practice variation on use of antibiotics: An international survey among pediatric urologists

INTRODUCTION AND BACKGROUND

Although there is abundance in literature focusing on the use of prophylactic antibiotics for adult urological procedures, the evidence for using antibiotics following common pediatric urological procedures is limited with no specific guidelines for use. Consequently, current practices on antibiotic usage for common interventions may be variable among practicing pediatric urologists, lacking evidence-based support.

OBJECTIVE

The aim was to evaluate the current practice pattern on antibiotic usage for common interventions amongst pediatric urologists (PU) practicing in four English-speaking sectors of the world.

MATERIALS AND METHODS

An anonymous survey of five scenarios with multiple choice options was disseminated to all active practicing members of the Pediatric Urologist of Canada (PUC) and Society of Pediatric Urology of Australia and New Zealand (SPUNZA), as well as all those attending the 2016 British Association of Pediatric Urology (BAPU) and 2017 American Association of Pediatric Urology (AAPU) meetings. The response for each scenario was summarized for overall practice pattern variation and the pattern for each sector was compared using the Fisher exact test.

RESULTS

A total of 126 respondents completed the survey (68.5% response rate) with at least a 65% response rate for each of the four sectors. The majority of respondents do not use antibiotics for indwelling urethral (46.8%) and suprapubic catheters (53.4%); however, they do give antibiotics for J-J stent placement (65.1%) and hypospadias surgery (84.9%), and use antibiotics after hypospadias surgery where catheters or stents are left indwelling (80.9%, 84.2%, respectively). Among those surveyed, the PUC members and AAPU PU demonstrated similar practice patterns which often significantly differed from that of SPUNZA members and BAPU attendees. Specifically, a significantly larger proportion of the North American pediatric urologists do not use antibiotics for common procedures compared with Australia, New Zealand, and the UK (Table).

DISCUSSION

In the absence of prospective studies in antibiotic use for pediatric patients to guide clinicians, there is a clear variability among sectors in the use of antibiotics for most clinical scenarios investigated. With increasing resistance patterns and possible adverse effects of antibiotics, it is important that the international pediatric urology community engage in discussions and collaborations to address this issue.

CONCLUSION

Practice patterns in antibiotic usage amongst PU varies widely, some of which may be associated with their local "culture." There is a need to understand these differences and begin to standardize treatment in the hopes of increasing appropriate use of antibiotics internationally.

Thirty-day hospital readmissions after augmentation cystoplasty: A Nationwide readmissions database analysis

INTRODUCTION

Reducing hospital readmissions is a growing priority for hospitals and clinicians in their efforts to improve quality of care and curtail costs. Augmentation cystoplasty is among the most complex and high-morbidity operations in pediatric urology, with up to 25% of patients experiencing a postoperative complication. However, there is a paucity of literature addressing the incidence and characteristics of hospital readmissions after these procedures. This information may be useful in tailoring perioperative interventions to reduce rehospitalization in this population.

OBJECTIVE

This study sought to determine the rate, causes, risk factors, and costs associated with 30-day readmissions for children undergoing augmentation cystoplasty.

STUDY DESIGN

We analyzed the Nationwide Readmissions Database (NRD) for children (≤18 years of age) who underwent augmentation cystoplasty for any indication between 2010 and 2014. Rates, causes, and costs of 30-day readmissions were determined. Multivariate logistic regression was used to identify risk factors for readmission.

RESULTS

Among 1873 identified cases, the 30-day readmission rate was 19.6%, with an average cost per readmission of $11,667. The most common reasons for readmission were gastrointestinal complications (19.6%), urinary tract infections (14.1%), and wound complications (11.2%). The median time to readmission was 13 days (interquartile range 6-19 days). Non-infectious genitourinary complications (e.g. hydronephrosis) ($25,286) and gastrointestinal complications ($12,924) led to the costliest readmissions, while dehydration/vomiting ($3739) and fever ($4803) were the least costly. On multivariate regression, the only significant risk factor for readmission was an indication of neurogenic bladder (OR 3.82, 95% CI 1.03-14.20, p = 0.04).

DISCUSSION

We present the first study to capture readmissions with 30 days of discharge to the same or outside hospitals after augmentation cystoplasty. Limitations include inability to separate planned and unplanned readmissions and 30-day follow-up period, which prevented analysis of readmissions caused by late complications.

CONCLUSION

Approximately one in five children undergoing augmentation cystoplasty are readmitted within 30 days. An indication of neurogenic bladder is an independent risk factor, while gastrointestinal complications and urinary tract infections are the most common reasons for readmission.

[A CASE OF URETERAL STENT ENCRUSTATION AFTER LAPAROSCOPIC PYELOPLASTY IN AN 11-YEAR-OLD GIRL]

Stent encrustation is one of the most serious complications of using double J stents. The management of encrusted stent is challenging, especially in children. To date, only two pediatric cases of stent encrustation, at the expected timing of removal after pyeloplasty, have been reported. In this report, we present a case of ureteral stent encrustation after laparoscopic retroperitoneal pyeloplasty in an 11-year-old girl. She underwent dismembered pyeloplasty for pelvi-ureteric junction obstruction on the left side using a double J stent (6 F, 24 cm, Polaris ™ Ultra). Postoperative course was uneventful, except for mild bladder irritability and asymptomatic pyuria. Nine weeks later, an attempt to remove the stent was made under general anesthesia. This attempt was unsuccessful as the renal coil got stuck in the anastomotic position. A retrograde 6 F flexible ureteroscopy revealed an encrusted stent with calculi. After transurethral lithotripsy with a holmium: yttrium aluminum garnet (YAG) laser, the stent was extracted. Stone analysis showed struvite. At 8-months follow-up, she was stone-free and doing well with resolution of hydronephrosis.

Robot-assisted ureteroureterostomy in pediatric patients: current perspectives

Developments in pediatric robotic surgery have increased the feasibility of minimally invasive surgery for complex urinary tract reconstruction. Ureteroureterostomy is a commonly employed strategy for the management of a duplicated ureteral system with either upper pole obstruction or lower pole vesicoureteral reflux, and this approach minimizes the risk to a healthy ureter as might be seen in a common sheath ureteral reimplant and avoids complex dissection around the renal hilum as with a heminephrectomy. The robotic platform enables optimum instrument manipulation for an end-to-side ureteral anastomosis as well as excellent visualization deep into the pelvis for excision of the distal ureteral stump. In this study, the indications and preoperative evaluation for pediatric robotic ureteroureterostomy (RUU) were described and intraoperative considerations for a successful repair were highlighted. In order to assess the outcomes, a PubMed search was performed to find the articles focusing on RUU in the pediatric population. The institutional experience of the authors was also reviewed. As with an open procedure, both minimizing dissection on the recipient ureter and ensuring a tension-free, watertight anastomosis are key principles to minimize complications. Although port placement is similar to that in robotic pyeloplasty, small adjustments may need to be made to ensure access to the pelvis. An assistant port and/or traction sutures is often used to aid in the dissection and anastomosis. RUU was first described in 2008, and several reports have demonstrated positive short-term results. However, median follow-up times are limited with most series reporting outcomes <1 year postoperatively. A future study is required to establish the long-term efficacy of this procedure and define the optimum patient population for a robotic approach.

Adverse events associated with surgical antibiotic prophylaxis for outpatient circumcisions at US children's hospitals

INTRODUCTION

Doctors often use surgical antibiotic prophylaxis (SAP) despite limited evidence to support its efficacy. We sought to determine the association between SAP in children undergoing circumcision and the rate of perioperative adverse events.

MATERIAL AND METHODS

We performed a retrospective study of males >30 days old and <18 years old who underwent circumcision from 2004 to 2014 using the Pediatric Health Information System database. We excluded inpatients and those with any concomitant procedures. We used chi-square or Fisher's exact test to determine the association between SAP and allergic reaction and any of the following within 30 days: penile reoperation, hospital visit, or surgical site infection (SSI). We performed mixed effects logistic regression controlling for age, race, insurance, and clustering of similar practice patterns by hospital.

RESULTS

84,226 patients were included: median age 2.2 years; 61.0% public insurance, 39.6% white. 8944 (10.6%) received SAP. On bivariate analysis, there were no associations between SAP and SSI (0.1% vs. 0.2%, p = 0.5), penile reoperation (0.01% vs. 0.04%, p = 0.4), or hospital visit (5.5% vs. 5.5%, p = 0.8). Patients who received SAP were more likely to have a perioperative allergic reaction than those who did not (3.5% vs. 2.9%, p = 0.0004). On multivariate analysis, those who received SAP had 1.5 times the odds of an allergic reaction (OR 1.5, 95% CI 1.3-1.7; p < 0.0001) and a hospital visit (OR 1.2, 95% CI 1.1-1.3; p = 0.0021) compared with those who did not (Table).

DISCUSSION

SAP did not decrease the risk of penile reoperation or SSI. Use of SAP was associated with an increased risk of allergic reactions and hospital visits. Strengths of the study include its large sample size, which enabled detection of rare outcomes with adequate statistical power and the generalizability of our findings to many patients and other types of procedures. Limitations include the lack of outpatient data and the possibility that we could have overestimated the incidence of allergic reactions by including patients who received epinephrine for some other reason.

CONCLUSIONS

We found no compelling evidence to support the use of SAP in children undergoing circumcision and it was associated with an increased risk of allergic reaction and hospital visits. This study highlights the need for specialty-specific guidelines for pediatric urologic procedures regarding the use of antibiotics for prophylaxis and for vigilant monitoring of practice variation.