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Post-operative Urinary Tract Infection Following Pediatric Pyeloplasty: A Multi center Analysis of Predictive Factors and the Role of Antibiotic Prophylaxis
Binyamin B. Neeman, MD1, Boris Chertin, Prof.1, Peter Rubin, MD1, Camila Nigri, Dr1, Moayad Beibooh, Dr1, Ilan Kafka, Dr1, Dolev Peretz, Dr1, Jaudat Jaber, Dr1, Galia Raisin, Dr1, Stanislav Kocherov, Dr2, Leon Chertin, Dr3.
1Shaare zedek medical center, Jerusalem, Israel, 2Shamir Medical Center, Zerifin, Israel, 3Le Bonheur Children's Hospital, Memphis, TN, USA.
BACKGROUND: Post-operative urinary tract infection (UTI) is a recognized complication following pediatric pyeloplasty. Despite widespread use of prophylactic antibiotics at discharge, the benefit of this practice remains unproven, and prior studies have been unable to stratify outcomes by surgical approach or drain configuration. This study aimed to identify independent predictors of post-operative infection and to determine whether prophylactic antibiotic therapy at discharge reduces infection risk after pyeloplasty.
METHODS: A retrospective multicenter study was conducted across two centers. Data were collected on preoperative characteristics (hydronephrosis grade, differential renal function, and associated urinary tract anomalies), intraoperative variables (surgical approach, operative time, drain type, and pelvic reduction), and postoperative outcomes. All patients received perioperative first-generation cephalosporin prophylaxis; post-discharge antibiotics were prescribed at surgeon discretion. Post-operative UTI was defined as a febrile or symptomatic episode confirmed by positive urine culture. Univariate analyses were performed using chi-square and Mann-Whitney U tests, followed by multivariable logistic regression to identify independent predictors of infection. Statistical significance was set at p < 0.05.
RESULTS: A total of 435 patients were included: 303 males (69.7%) and 132 females (30.3%). Minimally invasive surgery (robotic/laparoscopic) was performed in 67.6% and open surgery in 32.4%. The most common drain type was double-J stent (DJS) alone (60.5%), followed by Pippi Salle (21.6%), combined DJS + PCN (8.5%), no drain (3.4%), and PCN alone (1.1%); drain type was unrecorded in 21 patients (4.8%). Prophylactic antibiotics at discharge were prescribed in 168 patients (38.6%). Post-operative infection occurred in 80 patients (18.4%). Age, sex, operative time, drain duration, laterality, and concomitant anomalies (pelvic kidney, horseshoe kidney) were not significant predictors. Drain type was the strongest predictor of infection (p = 0.003). Compared to DJS alone (14.8%), significantly higher rates were observed with Pippi Salle drains (26.6%; OR 1.72, 95% CI 1.10-2.67, p = 0.016) and combined DJS + PCN (35.1%; OR 1.61, 95% CI 1.17-2.21, p = 0.004). Open surgery was associated with higher infection rates on univariate analysis (25.5% vs. 15.0%, p = 0.011), but this association did not persist after multivariable adjustment (OR 1.30, p = 0.402), suggesting confounding by drain type. Pelvic reduction was independently associated with lower infection risk (OR 0.53, 95% CI 0.30-0.91, p = 0.023). Prophylactic antibiotics at discharge were not associated with reduced infection risk (OR 0.95, p = 0.760), including within drain-specific subgroups. Bilateral cases (10 patients, 2.3%) and redo pyeloplasty (27 patients, 6.2%) showed numerically higher infection rates, though neither reached statistical significance.
CONCLUSIONS: Prophylactic antibiotics at discharge did not reduce post-operative infection rates after pediatric pyeloplasty, including in drain-specific subgroup analysis. Drain configuration was the primary determinant of infection risk, with external drainage and combined DJS + PCN associated with significantly higher rates than DJS alone. Pelvic reduction was independently protective, likely reflecting improved urinary drainage dynamics and reduced pelvic dead space, independent of surgical approach. These findings support a risk-stratified approach to antibiotic use guided by drain selection, rather than routine prophylaxis for all patients.
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