A Randomized Controlled Trial of Preoperative Prophylactic Antibiotics for Percutaneous Nephrolithotomy in Moderate to High Infectious Risk Population: A Report from the EDGE Consortium

High-Risk Patients Undergoing Holmium Laser Enucleation of the Prostate Have Fewer Infections with a Longer Course of Preoperative Antibiotics

Introduction: There are minimal data to guide antibiotic management of patients undergoing holmium laser enucleation of the prostate (HoLEP) for benign prostatic hyperplasia. Specifically, management of high-risk patients who are catheter dependent or have positive preoperative urine cultures varies widely. We aimed to evaluate the effect of preoperative antibiotic duration on infectious complications in high-risk patients undergoing HoLEP. Methods: A multi-institutional retrospective review of patients undergoing HoLEP between 2018 and 2023 at five institutions was performed. Patients were defined as high risk if they were catheter-dependent (indwelling urethral catheter, self-catheterization, or suprapubic tube) or had a positive preoperative urine culture. These patients were categorized into long course (>3 days) or short course (≤3 days) of preoperative antibiotics. The primary outcome was 30-day infectious complications defined as a positive urine culture with symptoms. A t-test or Wilcoxon rank-sum test was used for continuous variables and Fisher's exact test was used for categorical variables. Logistic regression analysis was conducted to identify associations with infectious complications. Results: Our cohort included 407 patients, of which 146 (36%) and 261 (64%) were categorized as short course and long course of preoperative antibiotics, respectively. Median preoperative antibiotic duration was 1 day (interquartile range [IQR]: 0, 3 days) and 7 days (IQR: 5, 7 days) in the short and long cohorts, respectively. Thirty-day postoperative infectious complications occurred in 11 (7.6%) patients who received a short course of antibiotics and 5 (1.9%) patients who received a long course of antibiotics (odds ratio 0.24, 95% confidence interval 0.07-0.67; p = 0.009). Variables such as age, positive urine culture, and postoperative antibiotic duration were not significantly associated with postoperative infection after propensity score weighting. Conclusion: In high-risk patients undergoing HoLEP, infectious complications were significantly lower with a long course vs short course of antibiotics. Further prospective trials are needed to identify optimal preoperative antibiotic regimens.

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.

Preoperative urine culture with contaminants is not associated with increased risk for urinary tract infection after ureteroscopic stone treatment

PURPOSE

We aimed to assess whether the presence of contaminants in the pre-operative urine culture (preop-UC) predicts postoperative urinary tract infection (postop-UTI) in patients undergoing elective ureteroscopy with laser lithotripsy.

METHODS

A retrospective chart review was performed from 01/2019 to 12/2021 examining patients with unilateral stone burden ≤ 2 cm who underwent ureteroscopy with laser lithotripsy and had a preop-UC within 3 months. Positive, negative, contaminated, and polymicrobial definitions for UCs were established in accordance with current guidelines. Patients with positive and polymicrobial cultures were excluded. Postop-UTI was defined as the presence of urinary symptoms and a positive UC within 30 days of the procedure. Multivariable logistic regression models were utilized to evaluate risk factors for contamination in the preop-UC and the risk of postop-UTI.

RESULTS

A total of 201 patients met the inclusion-exclusion criteria. Preop-UC was negative in 153 patients and contaminated in 48 patients. Significant contaminant-related factors included female gender and increased BMI. Postop-UTI was diagnosed in 3.2% of patients with negative preop-UCs and 4.2% of patients with contaminants, with no difference between groups (p = 0.67). The regression model determined that the presence of contaminants in preop-UC failed to predict postop-UTI (OR 0.69, p = 0.64).

CONCLUSION

The presence of contaminants in preop-UCs is not associated with an increased risk of postop-UTIs after ureteroscopy. Our study supports that contaminants in the preop-UC can be interpreted as a negative UC in terms of postop-UTI risk stratification. Preoperative antibiotics should not be prescribed for patients undergoing uncomplicated ureteroscopy for stone surgery in the setting of a contaminated preop-UC.

Advancements in Performance of Percutaneous Nephrolithotomy in Ambulatory Surgery Centers: Outcomes and Lessons From 1250+ Cases

OBJECTIVE

To evaluate the safety and efficacy of routine ambulatory percutaneous nephrolithotomy (PCNL) in a freestanding ambulatory surgical center.

METHODS

Patients were treated between 2015 and 2022 by one of three experienced endourologists in Maryland. The surgery center is free-standing, with the nearest hospital approximately 10 minutes away. Patient characteristics and surgical datapoints, including need for transfer, were gathered prospectively at the time of surgery. Subset analyses were performed in patients with staghorn calculi or elevated body mass index, as they represent higher-risk populations.

RESULTS

A total of 1267 patients underwent ambulatory PCNL with a median stone diameter of 32 mm. The average recovery time was 87 minutes, with 1.7% of patients requiring transfer to the hospital, generally for postoperative hypotension or inadequate pain control. 166 patients with body mass index >40 were safely treated, with no significant difference in transfer rate (P = .5). 2.8% of patients had a complication, with the majority being Clavien-Dindo grade I or II. 88 patients with staghorn calculi were treated, with a 6% transfer rate. Staghorn calculi were the only factor found on multivariable analysis to be a significant predictor of transfer (OR 3.56 (1.17-10.82) P < .05).

CONCLUSION

Ambulatory PCNL may safely be performed in a surgery center in most patients. These outcomes reflect the real-world experience of high-volume surgeons and demonstrate a multiyear paradigm shift in PCNL from an inpatient procedure to an outpatient procedure in a surgery center.

Can Perioperative Antibiotic Choice Impact Rates of Infectious Complications After Percutaneous Nephrolithotomy? A Single-Blind, Prospective Randomized Trial

Objective: National guidelines recommend periprocedural antibiotics before percutaneous nephrolithotomy (PCNL), yet it is not clear which is superior. We conducted a randomized trial to compare two guideline-recommended antibiotics: ciprofloxacin (cipro) vs cefazolin, on PCNL outcomes, focusing on the development of systemic inflammatory response syndrome (SIRS) criteria. Methods: Adult patients who were not considered high risk for surgical or infectious complications and undergoing PCNL were randomized to receive either cipro or cefazolin perioperatively. All had negative preoperative urine cultures. Demographic and perioperative data were collected, including SIRS criteria, intraoperative urine culture, duration of hospitalization, and need for intensive care. SIRS is defined by ≥2 of the following: body temperature <96.8°F or >100.4°F, heart rate >90 bpm, respiratory rate >20 per minute, and white blood cell count <4000 or >12,000 cells/mm3. Results: One hundred forty-seven patients were enrolled and randomized (79 cefazolin and 68 cipro). All preoperative characteristics were similar (p > 0.05), except for mean age, which was higher in the cipro group (64 vs 57 years, p = 0.03). Intra- and postoperative findings were similar, with no difference between groups (p > 0.05), except a longer mean hospital stay in the cefazolin group (2 hours longer, p = 0.02). There was no difference between SIRS episodes in both univariate and multivariate analyses. Conclusions: Despite the relatively broader coverage for urinary tract pathogens with ciprofloxacin, this prospective randomized trial did not show superiority over cefazolin. Our findings therefore support two appropriate options for perioperative antibiotic prophylaxis in patients undergoing PCNL who are nonhigh risk for infectious complications.

The Saudi urological association guidelines on urolithiasis

Aims

The Saudi Urolithiasis Guidelines are a set of recommendations for diagnosing, evaluating, and treating urolithiasis in the Saudi population. These guidelines are based on the latest evidence and expert consensus to improve patient outcomes and optimize care delivery. They cover the various aspects of urolithiasis, including risk factors, diagnosis, medical and surgical treatments, and prevention strategies. By following these guidelines, health-care professionals can improve care quality for individuals with urolithiasis in Saudi Arabia.

Panel

The Saudi Urolithiasis Guidelines Panel consists of urologists specialized in endourology with expertise in urolithiasis and consultation with a guideline methodologist. All panelists involved in this document have submitted statements disclosing any potential conflicts of interest.

Methods

The Saudi Guidelines on Urolithiasis were developed by relying primarily on established international guidelines to adopt or adapt the most appropriate guidance for the Saudi context. When necessary, the panel modified the phrasing of recommendations from different sources to ensure consistency within the document. To address areas less well covered in existing guidelines, the panel conducted a directed literature search for high quality evidence published in English, including meta analyses, randomized controlled trials, and prospective nonrandomized comparative studies. The panel also searched for locally relevant studies containing information unique to the Saudi Arabian population. The recommendations are formulated with a direction and strength of recommendation based on GRADE terminology and interpretation while relying on existing summaries of evidence from the existing guidelines.

Antimicrobial Prophylaxis for Percutaneous Nephrolithotomy: Contemporary Practice Patterns

Background: Updated in 2019, the American Urological Association's (AUA) Best Practice Statement on Urologic Procedures and Antimicrobial Prophylaxis outlines prophylaxis for percutaneous nephrolithotomy (PCNL). Recent studies have challenged these recommendations. We hypothesized that endourologists do not routinely follow the AUA's statement on antibiotic use during PCNL and assessed their prescribing patterns. Methods: A 24-question survey was distributed to members of the Endourological Society. The primary outcome was adherence to the AUA's recommendations. Two multiple logistic regression analyses were performed with demographics and antibiotic preference as predictors of following the AUA. Results: A total of 51.4% of endourologists follow the AUA Best Practice Statement for antimicrobial prophylaxis of uncomplicated PCNL. No demographic data were predictive of following the AUA. 90.9% and 83.6% reported they have "never" used the first-line recommendation options of metronidazole and aztreonam, respectively. Preferred antibiotics were cephalosporins (uncomplicated 60%, complicated 52.6%), fluoroquinolones (13.3%, 7.2%), aminoglycosides (12.7%, 17.8%), penicillins (7.9%, 11.2%), carbapenems (0.6%, 0.7%), trimethoprim-sulfamethoxazole (2.4%, 5.9%), fosfomycin (0.6%, 0.7%), nitrofurantoin (2.4%, 2.6%), aztreonam (0%, 0.7%), and clindamycin (0%, 0.7%). For uncomplicated PCNL, 63.1% prescribe ≤24 hours of perioperative antibiotics. For complicated PCNL, 16.2% prescribe ≤24 hours of perioperative antibiotics, while 20.4% begin antibiotics 7 or more days prior. Conclusions: Nearly half of respondents do not follow the AUA's recommendations for antibiotic choice for PCNL. Few endourologists prescribe 7 days of preoperative antibiotics for complicated PCNL despite supporting data. Metronidazole and aztreonam are rarely used as a first-line antibiotic choice for PCNL and their roles needs to be further evaluated as first-line prophylaxis recommendations. Updates on antibiotic recommendations for PCNL are needed based on current literature, antimicrobial stewardship, and contemporary practice patterns.

Prospective Randomized Trial of Antibiotic Prophylaxis Duration for Percutaneous Nephrolithotomy in Low-Risk Patients

Introduction and Objective: Postoperative infection and sepsis account for the most common complications following percutaneous nephrolithotomy (PCNL), as high as 14% in low-risk patients. Although the American Urological Association (AUA) recommends perioperative antibiotics for 24 hours or less for PCNL, practice patterns vary regarding duration of antibiotic therapy. We aimed to compare the efficacy of 24-hour antibiotic coverage vs short-course protocol of antibiotic prophylaxis for PCNL. Materials and Methods: Low-risk patients with a sterile preoperative urine culture undergoing PCNL were prospectively randomized to antibiotics for up to 24 hours after procedure (24Hr) or continued until external urinary catheters were removed (CR) study groups. Patients were given a first generation cephalosporin, or ciprofloxacin in patients with penicillin allergy. Exclusion criteria included age <18 years, receiving antibiotics immediately before the procedure, history of urosepsis, presence of indwelling catheter >1 week, multistage procedure, immunosuppression, pregnancy, multiple antibiotic allergies, and patients who are breastfeeding. Results: Ninety-eight patients were randomized to either 24Hr (n = 49) or CR (n = 49). Mean duration of antibiotic administration was 20.6 and 34.0 hours in the 24Hr and CR groups (p = 0.04), respectively. Age, comorbidities, stone size, operative time, number of punctures, dilations, and proportion of "tubeless" procedures were similar between groups. There were no differences in febrile episodes, rates of systemic inflammatory response syndrome, bacteremia, or culture-proven postoperative urinary tract infection between the 24Hr and CR groups. Overall complication rates were similar between groups. In a subgroup analysis which excluded "tubeless" patients (24 and 29 patients in 24Hr and CR groups, respectively), no differences were seen in postoperative outcomes. Conclusions: In a randomized, prospective study, we found that a 24-hour protocol for antibiotic prophylaxis is not associated with increased risk of infection-related events compared to giving antibiotics until external catheters are removed in patients with low infectious risk undergoing PCNL. Clinicaltrials.gov: NCT02579161.

A randomised controlled trial comparing two protocols of preoperative antibiotics in patients with positive urine culture undergoing percutaneous nephrolithotomy

AIM

To compare the outcomes of two different protocols of antibiotic prophylaxis in patients with positive urine culture undergoing percutaneous nephrolithotomy (PCNL).

MATERIALS AND METHODS

Patients were prospectively enrolled for the randomised study to either group A which included patients where an attempt to sterilise the urine was made with a 1 week course of sensitive antibiotics or group B that included patients who received a shorter duration of prophylaxis using sensitive antibiotics for 48 h prior to procedure which was continued for 48 h postoperatively. Enrolled patients had stones requiring percutaneous nephrolithotomy and had a positive preoperative urine culture. Primary outcome was difference in sepsis rates between the groups.

RESULTS

A total of 80 patients randomised into two groups of 40 each based on the antibiotic protocol used were analysed in the study. There was no difference in infectious complication rates between groups on univariate analysis. The rate of SIRS in Group A and Group B was found to be 20% (N = 8) and 22.5% (N = 9) respectively. The rate of septic shock in Group A and Group B was 7.5% and 5% respectively. On multivariate analysis, longer duration of antibiotics did not decrease the risk of sepsis compared to shorter antibiotic course (p = 0.79).

CONCLUSION

Attempts to sterilise urine before PCNL may not decrease the risk of sepsis in patients with positive urine culture undergoing PCNL and may only result in unnecessary prolonging of antibiotic usage thereby increasing the chances of antibiotic resistance.

Percutaneous management of upper tract stones: from mini to maxi percutaneous nephrolithotomy

PURPOSE OF REVIEW

Percutaneous nephrolithotomy (PCNL) continues as the gold standard for the surgical management of large renal stones. This short review is intended to highlight recent publications on PCNL of all tract sizes, from mini to standard.

RECENT FINDINGS

Literature on PCNL in the last 2 years has focused on several main themes - decreasing complications, improving postoperative pain control, and new technology to improve outcomes. Mini-PCNL continues to prove effective and safe, with a new vacuum sheath showing promise of improving stone-free rates and decreasing infections. In terms of infections, preoperative midstream urine culture continues to be a poor indicator of postoperative infection. One of the biggest changes to PCNL practice is the reintroduction of tranexamic acid, which has shown to significantly decrease bleeding and improve outcomes. In terms of postoperative pain control, local blocks are effective and low risk.

SUMMARY

There are many options for surgeons when it comes to PCNL from sheath size to pain management to preoperative medication to decrease bleeding. Future research will continue to highlight, which advances are the most beneficial.

Preoperative patient optimization for endourological procedures: the current best clinical practice

PURPOSE OF REVIEW

Despite technological advancements in endourological surgery, there is room for improvement in preoperative patient optimization strategies. This review updates recent best clinical practices that can be implemented for optimal surgical outcomes.

RECENT FINDINGS

Outcome and complication predictions using novel scoring systems and techniques have shown to assist clinical decision-making and patient counseling. Innovative preoperative simulation and localization methods for percutaneous nephrolithotomy have been evaluated to minimize puncture-associated adverse events. Novel antibiotic prophylaxis strategies and further recognition of risk factors that attribute to postoperative infections have shown the potential to minimize perioperative morbidity. Accumulating data on the roles of preoperative stenting and selective oral alpha-blockers adds evidence to the current paradigm of preventive measures for ureteral injury.

SUMMARY

Ample tools and technologies exist that can be utilized preoperatively to improve surgical outcomes. The combination of these innovations, along with validation in larger-scale studies, presents the cornerstone of future urolithiasis management.

Impact of Vacuum-Assisted Mini-Endoscopic Combined Intrarenal Surgery for Staghorn Stones: Analysis of Perioperative Factors of Postoperative Fever and Stone-Free Status

Background and Objective: This retrospective cohort study aimed to evaluate the clinical outcomes of vacuum-assisted mini-endoscopic combined intrarenal surgery (vmECIRS) for staghorn stones. Patients and Methods: We analyzed a total of 61 cases treated with initial vmECIRS using 14F/16F ClearPetra^® percutaneous sheaths for staghorn stones. We primarily measured complications and stone-free rates (SFRs) to evaluate the safety and efficiency of vmECIRS. In addition, pre- and intraoperative factors in patients who experienced postoperative fever >38°C and achieved an initial stone-free status were evaluated. Results: The percentages of staghorn stones were 36.1% and 63.9% for complete and partial stones, respectively. The median stone volume was 8.48 cm³. The median operation time was 117 minutes, and the mean number of procedures was 1.54. Regarding postoperative complications, postoperative fever >38°C was reported in 18 patients (29.5%). The initial and final SFRs were 50.8% and 91.8%, respectively. Among patients with emerging fever >38°C, positive urine culture was the only significant risk factor in the multivariate analysis (odds ratio [OR], 7.500; 95% confidence interval [CI], 1.772-31.751; p = 0.006). Moreover, for achieving initial stone-free status, body mass index and stone volume were significant risk factors in the multivariate analysis (OR, 0.872; 95% CI, 0.776-0.980; p = 0.021; and OR, 0.882; 95% CI, 0.784-0.994; p = 0.039, respectively). Conclusions: These findings suggest that vmECIRS is safe and effective for treatment of staghorn stones. Although current guidelines suggest that percutaneous nephrolithotomy is the gold standard surgical technique for staghorn stones, vmECIRS could also be a treatment strategy. The Clinical Trial Registration number (ID: 2022-05-17-1).

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.

Heterogeneity in stone culture protocols and endourologist practice patterns: a multi-institutional survey

Kidney stone cultures can be beneficial in identifying bacteria not detected in urine, yet how stone cultures are performed among endourologists, under what conditions, and by what laboratory methods remain largely unknown. Stone cultures are not addressed by current clinical guidelines. A comprehensive REDCap electronic survey sought responses from directed (n = 20) and listserv elicited (n = 108) endourologists specializing in kidney stone disease. Questions included which clinical scenarios prompt a stone culture order, how results influence post-operative antibiotics, and what microbiology lab protocols exist at each institution with respect to processing and resulting stone cultures. Logistic regression statistical analysis determined what factors were associated with performing stone cultures. Of 128 unique responses, 11% identified as female and the mean years of practicing was 16 (range 1-46). A specific 'stone culture' order was available to only 50% (64/128) of those surveyed, while 32% (41/128) reported culturing stone by placing a urine culture order. The duration of antibiotics given for a positive stone culture varied, with 4-7 days (46%) and 8-14 days (21%) the most reported. More years in practice was associated with fewer stone cultures ordered, while higher annual volume of percutaneous nephrolithotomy was associated with ordering more stone cultures (p < 0.01). Endourologists have differing practice patterns with respect to ordering stone cultures and utilizing the results to guide post-operative antibiotics. With inconsistent microbiology lab stone culture protocols across multiple institutions, more uniform processing is needed for future studies to assess the clinical benefit of stone cultures and direct future guidelines.

The antibiotic strategies during percutaneous nephrolithotomy in China revealed the gap between the reality and the urological guidelines

Background

Correct perioperative antibiotic strategies are crucial to prevent postoperative infections during percutaneous nephrolithotomy (PCNL). We aimed to compare the realistic antibiotic strategies applied in China with current urological guidelines.

Methods

Between April and May 2020, urologists from China were invited to finish an online cross-sectional survey. The questionnaire was designed according to the current urological guidelines and literatures.

Results

3393 completed responses were received. 61.1% (2073/3393) respondents had urological experience of more than 10 years. 72.4% urologists chose multiple-dose antibiotics for patients with both negative urine culture (UC-) and negative urine microscopy (UM-) preoperatively. Respondents in central China (OR = 1.518; 95% CI 1.102–2.092; P = 0.011), east China (OR = 1.528; 95% CI 1.179–1.979; P = 0.001) and northeast China (OR = 1.904; 95% CI 1.298–2.792; P = 0.001) were more likely to prescribe multiple-dose antibiotic for UC-UM- patients. Notably, the respondents who finished PCNL exceeded 100 cases per year were in favor of single-dose administration (OR = 0.674; 95% CI 0.519–0.875; P = 0.003). There are only 8.3% urologists chose single-dose antibiotic for UC-UM+ patients, whereas 65.5% administered antibiotics for 1–3 days. Meanwhile, for UC+ patients, 59.0% of the urologists applied antibiotics shorter than 1 week, and only 26.3% of the urologists carried out routine re-examination of UC. Moreover, postoperative antibiotics were frequently prescribed for 3–6 days (1815; 53.5%). Finally, although 88.2% urologists considered stone culture important for management of postoperative antibiotics as the guideline recommended, only 18.5% performed it routinely.

Conclusions

The antibiotic strategies are different between current practice in China and the urological guidelines. The dissimilarities suggested that further studies should be conducted to investigate the reasons of the differences and standardize the application of antibiotics.

Salvage versus primary holmium laser enucleation of the prostate: trends, outcomes and safety analysis

PURPOSE

To study the safety, efficacy and trends in index procedures leading to salvage holmium laser enucleation of the prostate (S-HoLEP).

METHODS

This was a single-institution retrospective review of HoLEPs performed between 2006 and 2020. Patients who underwent S-HoLEP were compared to those undergoing primary holmium laser enucleation of the prostate (P-HoLEP). The endpoint of primary interest were functional outcomes. Changes in index procedures over the study period were analyzed.

RESULTS

A total of 633 HoLEPs were performed during the study, with 217 being S-HoLEP. The S-HoLEP cohort was older than P-HoLEP cohort, 71.2 years vs 68.8 years (p = 0.03). All other factors were well matched. The most common index procedures prior to S-HoLEP included transurethral resection of the prostate (TURP) (87, 40.1%), transurethral microwave thermotherapy (TUMT) (44, 20.3%), photoselective vaporization of the prostate (PVP) (24, 11.1%) and prostatic urethral lift (PUL) (24, 11.1%). Preoperative prostate volume, IPSS and Q_max were similar between groups. Intra-operatively, S-HoLEP had longer procedure and morcellation times (p = 0.01 and 0.007). Postoperatively, the S-HoLEP cohort had longer catheter duration and hospitalization (both p < 0.001). Postoperative Q_max, IPSS and 90-day complication rates were similar. On temporal analysis, minimally invasive surgical therapies (MIST) have become more prevalent as index procedures.

CONCLUSION

S-HoLEP is safe and efficacious for patients requiring additional BPH surgical intervention. S-HoLEP patients had longer operative times and hospital stays but equivalent postoperative functional outcomes compared to P-HoLEP. As MIST mature and gain traction, it is expected that rates of S-HoLEP will continue to rise.

Antibiotic prophylaxis for percutaneous nephrolithotomy: An updated systematic review and meta-analysis

Introduction

A single dose of preventive antibiotics is known to be sufficient to reduce the rate of infection-related complications in percutaneous nephrolithotomy (PCNL). However, some studies reported that the extended dose showed lower complications for high-risk groups. Therefore, we performed a systematic review and meta-analysis comparing single- and extended-dose antibiotic prophylaxis for PCNL.

Materials and methods

Relevant studies that compared single- and extended-dose antibiotic prophylactic therapies were identified. Articles were selected from PubMed, EMBASE, KoreaMed, and Google Scholar up to September 2021. Fever and systemic inflammatory response syndrome (SIRS) were compared by meta-analysis. A subgroup analysis was performed according to the degree of risk to the patient.

Results

A total of 10 articles were included in this study. There were no significant differences between single dose and extended dose in the rate of fever [p = 0.93, OR = 0.96, 95% confidence interval (CI) 0.44–2.13, I² = 64%]. Extended dose showed lower rate of SIRS compared to single dose (p = 0.0005, OR = 1.81, 95% CI 1.30–2.53, I² = 53%); in the subgroup analysis, extended dose also showed lower rates of SIRS compared to single dose in high-risk patients (p <0.0001, OR = 3.53, 95% CI 1.91–6.54, I² = 36%).

Conclusions

The results of our meta-analysis showed that single-dose antibiotic prophylaxis can be effective for PCNL, but extended-dose antibiotics can be required in high-risk patients to reduce post-PCNL infection-related complications.

Infectious complications of endourological treatment of kidney stones: A meta-analysis of randomized clinical trials

OBJECTIVE

Endourological treatment is associated with a risk of postoperative febrile urinary tract infections and sepsis. The aim of this study was to review the reported rate of infectious complications in relation to the type and modality of the endourologic procedure.

METHODS

This systematic review was conducted in accordance with the PRISMA guidelines. Two electronic databases (PubMed and EMBASE) were searched. Out of 243 articles retrieved we included 49 studies after full-text evaluation.

RESULTS

Random-effects meta-analysis demonstrated that retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) were associated with not significantly different odds of getting fever (OR = 1.54, 95% CI: 0.99 to 2.39; p = 0.06) or sepsis (OR = 1.52, 95% CI: 0.37 to 6.20, p = 0.56). The odds of getting fever were not significantly different for mini PCNL compared to standard PCNL (OR = 1.11, 95% CI: 0.85 to 1.44; p = 0.45) and for tubeless PCNL compared to standard PCNL (OR = 1.34 95% CI: 0.61 to 2.91, p = 0.47). However, the odds for fever after PCNL with suctioning sheath were lower than the corresponding odds for standard PCNL (OR = 0.37, 95% CI: 0.20 to 0.70, p = 0.002). The odds of getting fever after PCNL with perioperative prophylaxis were not different from the corresponding odds after PCNL with perioperative prophylaxis plus a short oral antibiotic course (before or after the procedure) (OR = 1.31, 95% CI: 0.71 to 2.39, p = 0.38).

CONCLUSIONS

The type of endourological procedure does not appear to be decisive in the onset of infectious complications, although the prevention of high intrarenal pressure during the procedure could be crucial in defining the risk of infectious complications.   on behalf of U-merge Ltd. (Urology for emerging countries), London-Athens-Dubai.

Preoperative antibiotic therapy exceeding 7 days can minimize infectious complications after percutaneous nephrolithotomy in patients with positive urine culture

PURPOSE

To explore an appropriate duration of antibiotic therapy before percutaneous nephrolithotomy (PCNL) in patients with positive urine culture.

METHODS

From March 2016 to May 2018, consecutive patients with positive urine culture undergoing PCNL were prospectively registered. Initial preoperative antibiotics were given empirically. If needed, antibiotics were upgraded or adjusted to susceptible antibiotic after obtaining antibiotic-sensitivity test. Postoperative systemic inflammatory response syndrome (SIRS) was the primary outcome.

RESULTS

Among the 220 participants, the incidence of positive stone culture and SIRS were 85.5% and 36.8%. Escherichia coli (53.6%, 44.5%) and Proteus mirabilis (8.2%, 10.0%) were the top two bacteria in urine and stones. In univariable analysis, patients with postoperative SIRS had a higher rate of stone culture positivity (97.5% VS 78.4%, P < 0.001) and a shorter duration of preoperative antibiotics therapy (3.4 ± 2.7 days versus 4.2 ± 2.8 days, P = 0.037). The landscape of SIRS showed a declining trend as the elongation of preoperative antibiotics (P = 0.039). In a day-by-day comparison, SIRS was less prevalent in patients treated by pre-PCNL antibiotics ≥ 7 days than in those with antibiotics ≤ 6 days (21.7% VS 40.8%, P = 0.017). Multivariable logistic regression confirmed positive stone culture (P = 0.001, OR 11.115) as an independent risk factor and pre-PCNL antibiotics ≥ 7 days (P = 0.048, OR 0.449) as an independent protective factor for SIRS. Preoperative antibiotic ≥ 7 days decreased SIRS from 45.4 to 27.8% and from 9.1 to 0% in patients with a positive and negative stone culture, respectively.

CONCLUSION

Exceeding seven days should be appropriate duration of antibiotic therapy before PCNL in patients with positive urine cultures.

Assessing the optimal urine culture for predicting systemic inflammatory response syndrome after percutaneous nephrolithotomy and retrograde intrarenal surgery: results from a systematic review and meta-analysis

Background Systemic inflammatory response syndrome (SIRS) is a dangerous complication after percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS). We aimed to review the diagnostic accuracy of mid steam urine culture (MSUC), pelvic urine culture (PUC) and stone culture (SC) derived from the same cases to predict SIRS after PCNL and/or RIRS. Materials and methods A comprehensive literature search was performed, using MEDLINE, EMBASE, and Cochrane Central Controlled Register of Trials. Sensitivity and specificity were calculated for MSUC, PUC, and SC. The diagnostic odds ratio (DOR) was estimated for each study with a random effect and hierarchical summary receiver operating characteristic (HSROC) model leading to a corresponding 95% Confidence Interval (CI). Overall test accuracy was measured by finding the area under the curve (AUC). An AUC value >0.70 stands for adequate overall accuracy Results The search retrieved 537 papers. After screening, 21 studies involving 5238 patients were included for the meta-analysis. The pooled sensitivity for MSUC was 0.322 (95% CI 0.2228-0.432), and pooled specificity 0.854 (95% CI 0.810-0.889). The DOR was low at 2.780 (95% CI 1.769-4.368), showing poor overall diagnostic accuracy. The pooled sensitivity for PUC was 0.323 (95% CI 0.224-0.440) and specificity 0.931 (95% CI 0.896-0.954). The DOR was 6.377 (95% CI 4.065-10.004), showing a mild overall diagnostic accuracy. The pooled sensitivity for SC was 0.552 (95% CI 0.441-0.658) and specificity 0.847 (95%CI 0.798-0.886). The DOR was 6.820 (95%CI 4.435-10.488), showing mild overall diagnostic accuracy. The AUC for HSROC for MSUC was 0.65, 0.73, and 0.75 for PUC and SC, respectively. Conclusion MSUC is a poor predictor for postoperative SIRS. PUC or SC should be collected during lithotripsy to better predict the possibility of developing postoperative SIRS after PCNL and RIRS.