Is Post-operative Antibiotic Prophylaxis Necessary after Pyeloplasty?
Kunj R. Sheth, MD1, Kathleen Puttmann, MD1, Paige Nichols, BS2, Huirong Zhu, PhD1, Sheila Ryan, JD1, Ming-Hsien Wang, MD1.
1Texas Children's Hospital - Baylor College of Medicine, Houston, TX, USA, 2Johns Hopkins School of Medicine, Baltimore, MD, USA.
Background: In addition to pediatric pyeloplasty cases being performed via open, laparoscopic or robotic methods, the post-operative urinary drainage method can vary between an indwelling ureteral stent or an external drain. While such drainage is in place, many pediatric urologists prescribe prophylactic antibiotics while the stent or drain remains in place. However, recent data casts doubt on the utility of prophylactic antibiotics. In this study, we examine the use of prophylactic antibiotics in pediatric patients with stent placement post pyeloplasty. The primary goal is to determine if prophylactic antibiotics reduce the incidence of culture proven urinary tract infections (UTIs), and secondarily identify high patient risk groups that would most benefit from such antibiotics use.
Methods: After obtaining IRB approval, we retrospectively evaluated children between ages 1 month and 18 years who underwent dismembered pyeloplasty from December 2011 to September 2017 at our institution. Patients with a history of prior urologic interventions, solitary kidneys, or developmental abnormalities of the genitourinary tract were excluded. We collected demographics (age, gender, ethnicity, insurance), surgical details, and postoperative outcomes. Furthermore, prior UTI history, pre-, intra-, and post-operative urine cultures results within 30 days as well as antibiotic treatment before and after surgery were recorded.
Results: In the 6-year study period a total of 209 (149 boys, 60 girls) children undergoing pyeloplasty. The average age was 6 years (range: 2 months - 18 years, mean 5 years). A total of 160 patients (77%) underwent robotic-assisted laparoscopic pyeloplasty and 176 (84%) had an indwelling ureteral stent postoperatively. Eleven patients (5%) had a culture-proven febrile UTIs in the initial 30-day postoperative period. No significant differences were seen in postoperative complications or incidence of UTIs when comparing surgical approaches, renal drainage method and use of prophylactic post-operative antibiotics (Table 1). Patients with post-operative febrile UTIs were significantly younger in age (2.8 v. 6.2 years, p = 0.02) and more likely to have a positive preoperative urine culture (p = 0.01).
Conclusions: The incidence of postoperative urinary tract infection in children undergo dismembered pyeloplasty is relatively low (5%). The use of postoperative prophylactic antibiotics, surgical approach, and renal drainage method did not appear to affect the incidence of febrile UTIs. However, younger age and children with positive preoperative urine culture may benefit from postoperative antibiotic.
| Total (%) | Febrile UTI Postoperatively | p-value | |
| Average Age | 6.0 ± 5.1 years | 2.8 ± 3.22 years | 0.02 |
| Gender: Male Female | 149/209 (71%) 60/209 (29%) | 8/149 3/60 | 0.91 |
| Preoperative Culture Positive Negative | 10/209 (5%) 199/209 (95%) | 3/10 8/199 | 0.01 |
| Surgical Approach Open Robotic Laparoscopic | 31/209 (15%) 160/209 (77%) 18/209 (9%) | 0/31 11/160 0/18 | 0.23 |
| Renal Drainage Method Ureteral Stent External drain | 176/209 (84%) 35/209 (17%) | 11/176 0/35 | 0.22 |
| Post-operative Antibiotics Yes No | 55/209 (26%) 154/209 (74%) | 2/55 9/154 | 0.73 |
| Insurance Private Medicaid | 126/209 (60%) 83/209 (40%) | 5/126 6/83 | 0.35 |
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