The source of organisms in the post-prostatectomy bacteriuria of patients with pre-operative sterile urine

The postoperative bacteriuria score: a new way to predict nosocomial infection after prostate surgery

OBJECTIVE

Urinary tract infections are the leading nosocomial urologic infections and may be a cause of added morbidity and costs, and sometimes sepsis. The aim of this study was to design a predictive score for these complications after prostate surgery.

DESIGN

Multicenter prospective survey.

SETTING

Eleven French urology centers.

PATIENTS

All patients undergoing transurethral resection of prostate (TURP) during a 3-month period.

RESULTS

The overall incidence of postoperative bacteriuria was 25.0% (95% confidence interval, 17.7%-29.5%). Almost all patients (95.7%) received antibiotic prophylaxis. A predictive postoperative bacteriuria score (POBS), with a 6-point scale of 0 to 5, was constructed on the basis of independent risk factors identified in multivariate analysis of a test sample of patients (n=135) and tested in a validation sample (n=73). Significantly more infections occurred in patients with a POBS of 2 or higher (87 [8%] vs 48 [50%]; P<.0001). With the test sample, this yielded a sensitivity of 77%, a specificity of 77%, a positive predictive value of 50%, a negative predictive value of 92%, and a global accuracy of 77%.

CONCLUSIONS

POBS could be used to distinguish patients at risk of developing infection after TURP. This information might be useful for implementing selective prevention measures or for adjustment for differences in nosocomial infection rates when comparing data between urology centers.

Suprapubic Prostatectomy With a Novel Catheter

PURPOSE

We evaluated the postoperative morbidity and technical complications of a new handmade catheter used for suprapubic prostatectomy.

MATERIALS AND METHODS

A total of 146 patients with lower urinary tract symptoms who had indications for open prostatectomy were enrolled in the study from January 2003 to August 2004. Of the patients 96 were treated with a novel technique without a urethral catheter but with a special handmade cystostomy catheter, while the other 50 underwent the traditional procedure using cystostomy and a urethral catheter. The same surgical team operated on the 2 groups. Clot retention episodes, hemoglobin decreases, irritative symptoms, voiding status after cystostomy removal and incontinence were evaluated postoperatively. Three months later we followed the patients with symptom score, maximum flow rate and cystoscopic examination.

RESULTS

Preoperatively mean International Prostate Symptom Score was 31.6 in each group. Postoperatively none of the patients with the novel catheter complained of significant irritative urinary symptoms, clot retention and true or stress urinary incontinence. Of the cohorts 94% were satisfied with voiding but 86% of controls were satisfied. There was no report of urinary tract infection or epididymo-orchitis in the cohorts, while we found epididymo-orchitis in 4 controls (8%). Three months after the operation the mean International Prostate Symptom Score was 4.4 (range 1 to 7) and the mean maximum flow rate was 22.6 ml per second (range 14 to 25) in patients with the novel catheter, and 4.2 (range 1 to 7) and 22.5 ml per second (range 15 to 25), respectively, in those with the traditional catheter. At followup there was no bladder neck contracture but 4 patients (4.1%) showed some degree of membranous urethral stricture. We also noted 7 controls (14%) with urethral stricture.

CONCLUSIONS

Transurethral prostate resection has been introduced as the surgical treatment of choice in patients with benign prostatic hyperplasia. However, open adenomectomy still has a place. Urethral catheter-free suprapubic prostatectomy can be safely applied with a low postoperative risk of infection, incontinence and stricture formation.

[Anaesthesia and prostate surgery]

OBJECTIVES

To review the current data about anaesthetic management in prostate surgery with special regards on analysis and prevention of specific risks, appropriate anaesthetic procedure keeping with surgery and patient, recognition and treatment of adverse events.

DATA SOURCES AND EXTRACTION

The Pubmed database was searched for articles (1990-2004) combined with references analysis of major articles on the field.

DATA SYNTHESIS

It is strongly recommended to settle germfree urine in the preoperative period. The thromboembolic risk of radical retropubic prostatectomy for cancer parallels lower abdomen oncologic surgery and is prolonged. Preoperative evaluation of cardiovascular, respiratory, neurological and metabolic comorbidity is a source of prognostic information and an essential tool in the management of elderly patients with prostate disease. Extreme patient positioning applied in prostate surgery induces haemodynamic and respiratory changes and are associated with severe muscular and nervous injuries. The laparoscopic access for radical prostatectomy is a growing alternative to the open surgical procedure. Acute normovolaemic haemodilution is a consistent and cost-effective blood conservation strategy in reducing allogenic blood transfusion for radical retropubic prostatectomy. Whether open transvesical or transurethral prostatectomy for treatment of benign hypertrophy depends on the size of the gland: transurethral resection is safe up to 80 g. Intrathecal anaesthesia with a T9 cephalad spread of sensory block, produces adequate conditions for transurethral prostatectomy and allows a rapid diagnosis of irrigating fluid absorption syndrome. In spite of recommended preoperative antibiotic prophylaxis, bacteriemias are frequent during transurethral prostate resection.

Comparison of local povidone-iodine antisepsis with parenteral antibacterial prophylaxis for prevention of infective complications of TURP: a prospective randomized controlled study

OBJECTIVE

To determine whether antisepsis with povidone-iodine solution applied at the external urethral meatus confers protection against infective complications following transurethral resection of the prostate (TURP) and compare that with antibacterial prophylaxis.

METHODS

A total of 167 patients with sterile urine undergoing TURP for benign prostatic hyperplasia (BPH) were prospectively randomized into three groups. Group A, had gauze soaked in saline applied at the urethral meatus (control group). In group B, the gauze was soaked in povidone-iodine instead of saline and group C had a single 1 g i.v. injection of cephradine at induction of anaesthesia with no treatment for the meatus. Bacteraemia, post-operative bacteriuria and other infective complications were compared in the three groups. Associations of bacteriuria at catheter removal and intra-operative bacteraemia with infective complications and with long term bacteriuria were also studied.

RESULTS

Bacteriuria rate at catheter removal was not significantly different in the three groups. However, intraoperative bacteraemia and bacterial growth at the external urethral meatus was significantly lower in group C. Bacteriuria at catheter removal was significantly associated with bacterial growth at the meatus but not with long term bacteriuria at 3 months. Bacteriuria at catheter removal could not accurately predict infective complications.

CONCLUSION

Post-TURP bacteriuria appears to be preceded by bacterial growth at the external urethral meatus. Antisepsis with povidone-iodine solution application at the meatus does not confer adequate protection against meatal bacterial growth as that obtained by prophylactic antibacterials. Nonetheless, neither antibacterial prophylaxis nor local antisepsis could reduce bacteriuria rate in this study.

Efficacy of antimicrobial-impregnated bladder catheters in reducing catheter-associated bacteriuria: a prospective, randomized, multicenter clinical trial

OBJECTIVES

To examine the efficacy of bladder catheters impregnated with minocycline and rifampin in reducing catheter-associated bacteriuria.

METHODS

A prospective, randomized clinical trial was conducted at five academic medical centers. Patients undergoing radical prostatectomy were randomized to receive intraoperatively either regular silicone bladder catheters (control catheters) or silicone bladder catheters impregnated with minocycline and rifampin (antimicrobial-impregnated catheters). Catheters remained in place for a mean of 2 weeks. Urine cultures were obtained at about 3, 7, and 14 days after catheter insertion. Bacteriuria was defined as the growth of organism(s) in urine at a concentration of 10(4) colony-forming units per milliliter or greater.

RESULTS

Kaplan-Meier analysis demonstrated that it took significantly longer for patients (n = 56) who received the antimicrobial-impregnated catheters to develop bacteriuria than those (n = 68) who received the control catheters (P = 0.006 by the log-rank test). Patients who received the antimicrobial-impregnated catheters had significantly lower rates of bacteriuria than those in the control group both at day 7 (15.2% versus 39.7%) and at day 14 (58.5% versus 83.5%) after catheter insertion. Patients who received the antimicrobial-impregnated catheters had significantly lower rates of gram-positive bacteriuria than the control group (7.1% versus 38.2%; P <0.001) but similar rates of gram-negative bacteriuria (46.4% versus 47.1%) and candiduria (3.6% versus 2.9%). The antimicrobial-impregnated catheters provided zones of inhibition against Enterococcus faecalis and Escherichia coli, both at baseline and on removal.

CONCLUSIONS

Bladder catheters impregnated with minocycline and rifampin significantly reduced the rate of gram-positive catheter-associated bacteriuria up to 2 weeks after catheter insertion.