Urinary Tract Infection After Robot-Assisted Laparoscopic Pyeloplasty: Are Urine Cultures and Antibiotics Helpful?
Yvonne Y. Chan, MD1, Ilina Rosoklija, MPH1, Rachel Shannon, BS1, Ashima Singal, MD2, Anthony D'Oro, BA1, Patrick Meade, BA1, Edward M. Gong, MD1, Bruce W. Lindgren, MD1, Emilie K. Johnson, MD, MPH1.
1Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA, 2Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
Background: Utilization of pre- and intra-operative urine cultures (UCx) and urinalysis (UA) and post-operative prophylactic antibiotics after robot-assisted laparoscopic pyeloplasty (RALP) differ by surgeon. However it is unclear whether these differences in practice patterns influence post-RALP urinary tract infection (UTI) rates. This study aims to evaluate the relationship between pre- and intra-operative UCx utilization and post-operative antibiotic prophylaxis and whether these factors are associated post-RALP UTI.
Methods: A retrospective review of patients who underwent RALP at a single institution from January 2014-October 2018 was performed. Patients with a history of vesicoureteral reflux, neurogenic bladder, intermittent catheterization, <2 months followup after stent removal, or age >=18 years were excluded. The primary outcome was symptomatic UTI after RALP, tracked until 60 days after ureteral stent removal. UTI was defined as fever or urinary symptoms, a positive UCx with >=10,000 colony forming units of a single uropathogen, and a positive UA.
Results: 152 patients were included (72% male [73% circumcised], 61% white, 23% Hispanic). One patient had a reoperation for recurrent UPJ obstruction during the study period, yielding 153 surgical encounters. Twenty-two percent of patients had a reported history of UTI prior to RALP, and 15% were on prophylactic antibiotics. UCx or UA were ordered prior to pyeloplasty in 65% of the cases and were positive in 22% of the cases. Intraoperative UCx was obtained at pyeloplasty and stent removal in 94% and 91% of cases, respectively; UCx was positive in 3% and 3% of cases, respectively. 55% received post-RALP prophylactic antibiotics. Eight patients (5.2%; 95% confidence interval 1.7-8.7%) developed post-RALP UTI (Table 1- Factors associated with post-RALP UTI). Uncircumcised status and use of preoperative prophylactic antibiotics were associated with post-RALP UTI (p=0.02 and p<0.01, respectively). Use of post-RALP antibiotic prophylaxis was not associated with development of post-RALP UTI (p=1.0). Positive pre-RALP UCx/UA was associated with post-RALP UTI (p=0.03), whereas intraoperative UCx results during pyeloplasty had no association. UCx/UA prior to stent removal had no association with post-RALP UTI, but those with negative intraoperative UCx during stent removal had lower rates of UTI (p<0.01).
Conclusions: In this cohort of >150 children undergoing RALP at our institution, the rate of UTI from RALP to 60 days after stent removal was 5.2%. Variability was noted in utilization of preoperative and intraoperative UA/UCx and post-RALP antibiotic prophylaxis. As post-RALP antibiotic prophylaxis was not associated with lower UTI rates, consideration may be given to reserve them for patients with risk factors including uncircumcised status, use of preoperative chronic antibiotic prophylaxis, and positive pre-pyeloplasty and intraoperative stent removal UA/UCx. Development of a care pathway for patients undergoing RALP could help to safely decrease unnecessary utilization of UA/UCx and antibiotics without affecting post-RALP UTI rates.
| Table 1. Demographic and Clinical Factors Associated with Post-RALP UTI - Univariate Analysis | |||
| No UTI | UTI | p-value* | |
| Sex | 1.0 | ||
| Female | 40 (28%) | 2 (25%) | |
| Male | 104 (72%) | 6 (75%) | |
| Circumcised | 0.023 | ||
| No | 20 (19%) | 4 (67%) | |
| Yes | 79(76%) | 2 (33%) | |
| Not documented | 5 (5%) | 0 | |
| On Pre-operative Chronic Antibiotic Prophylaxis | <0.01 | ||
| No | 125 (87%) | 3 (38%) | |
| Yes | 18 (12.5%) | 5 (62%) | |
| Not documented | 1 (0.5%) | 0 | |
| History of UTI | 0.07 | ||
| No | 114 (79%) | 4 (50%) | |
| Yes | 30 (21%) | 4 (50%) | |
| Pre-operative pyeloplasty Cx/UA result | 0.03 | ||
| Negative | 72 (50%) | 1 (13%) | |
| Positive | 30 (21%) | 4 (50%) | |
| Unavailable/Not ordered | 43 (29%) | 3 (37%) | |
| Pyeloplasty intra-operative culture results | 1.0 | ||
| Negative | 132 (91%) | 8 (100%) | |
| Positive | 4 (3%) | 0 | |
| Not obtained | 9 (6%) | 0 | |
| Post-pyeloplasty antibiotics prescribed on discharge | 1.0 | ||
| No | 65 (45%) | 4 (50%) | |
| Yes | 89 (55%) | 4 (50%) | |
| Stent removal pre-operative culture/UA results | 0.43 | ||
| Negative | 58 (40%) | 3 (37%) | |
| Positive | 36 (25%) | 4 (50%) | |
| Unavailable/Not ordered | 51 (34%) | 1 (13%) | |
| Stent removal intra-operative culture results | <0.01 | ||
| Negative | 127 (87%) | 4 (50%) | |
| Positive | 1 (1%) | 4 (50%) | |
| Not obtained | 14 (10%) | 0 | |
| Unknown | 3 (2%) | 0 | |
| *Univariate analysis by Fisher's exact test. | |||
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