1. 1. Complications of Urologic Surgery and Practice
2. 2. Edited by Kevin R. Loughlin Harvard Medical School Brigham and Womens Hospital Boston, Massachusetts, USA Complications of Urologic Surgery and Practice Diagnosis, Prevention, and Management
3. 3. Informa Healthcare USA, Inc. 52 Vanderbilt Avenue New York, NY 10017 2007 by Informa Healthcare USA, Inc. Informa Healthcare is an Informa business No claim to original U.S. Government works Printed in the United States of America on acid-free paper 10 9 8 7 6 5 4 3 2 1 International Standard Book Number-10: 0-8493-4028-4 (Hardcover) International Standard Book Number-13: 978-0-8493-4028-4 (Hardcover) This book contains information obtained from authentic and highly regarded sources. Reprinted material is quoted with permission, and sources are indicated. A wide variety of references are listed. Reasonable efforts have been made to publish reliable data and information, but the author and the publisher cannot assume responsibility for the validity of all materials or for the consequence of their use. No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC) 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Complications of urologic surgery and practice : diagnosis, prevention, and management/edited by Kevin R. Loughlin. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-8493-4028-4 (Hardcover : alk. paper) ISBN-10: 0-8493-4028-4 (Hardcover : alk. paper) 1. Genitourinary organsSurgeryComplications. I. Loughlin, Kevin R. [DNLM: 1. Urologic Surgical Proceduresadverse effects. 2. Intraoperative Complicationsprevention & control. 3. Postoperative Complicationsprevention & control. WJ 168 C7369 2007] RD571.C654 2007 617.4601--dc22 2006103362 Visit the Informa Web site at www.informa.com and the Informa Healthcare Web site at www.informahealthcare.com
4. 4. You will make all kinds of mistakes, but as long as you are generous and true, and also fierce, you cannot hurt the world or even seriously distress her. She was made to be wooed and won by youth. Winston Churchill
5. 5. To my teachers, the urologists of the last generation. To my colleagues, the urologists of this generation. To my residents, the urologists of the next generation. Kevin R. Loughlin
6. 6. Preface A surgical career is interspersed with incredible highs and incredible lows. The exhilaration one feels when a procedure goes well can be followed the next day by a devastating complication. Yet, we learn much more from our failures, the complications, than we do from our successes, the triumphs. In fact, surgery is one of the few professions where usually, on a weekly basis, we discuss and analyze our complications and try to learn from them. Urologic surgical practice has seen enormous changes in the past decade. The practicing urologist is now faced with a wide array of procedures that were not even performed a few short years ago. Therefore, it is more important now than ever before to have a one-volume source that reviews the diagnosis, management, and prevention of urologic complications. This book is divided into five sections: perioperative complications, complications of open surgical procedures, pediatric surgical complications, complications of minimally inva- sive procedures, and miscellaneous complications. These divisions are intended to facilitate the use of the book by urologists who emphasize different aspects of urology in their practice. The book places special emphasis on some of the newer minimally invasive and laparoscopic pro- cedures that are becoming a large part of urologic practice. I have invited the contributors of this book to provide their insight into the prevention and management of complications that can occur during urologic surgery and practice. I want to thank each of the authors for sharing their expertise and experience with the reader. All aspects of surgery are changing rapidly in todays world, but perhaps nowhere more than in urology. Urologists have already witnessed the impact of technology and the aging of the popu- lation on their practice. Urologic care will continue to evolve rapidly in the future and it is my hope that the readers of this book will use it as a trusted companion throughout their urologic careers. Kevin R. Loughlin
7. 7. Contents Preface . . . . vii Contributors . . . . xiii Section I: Perioperative Complications 1. Infectious Complications of Urologic Surgery 1 Marc A. DallEra, Thomas J. Walsh, and John N. Krieger 2. Cardiovascular Issues in Urologic Surgery 17 Amy Leigh Miller and James Chen-tson Fang 3. Metabolic Complications Following the Use of Intestine and Metabolic Abnormalities Occurring with Irrigants in Urologic Surgery 31 W. Scott McDougal 4. Anesthesia for Urogenital Surgery 35 Linda S. Aglio, James A. Street, and Paul D. Allen 5. Nutritional Considerations in Urologic Surgery 49 Kris M. Mogensen and Malcolm K. Robinson Section II: Complications of Open Surgical Procedures 6. Complications of Open Renal Surgery 65 Brian K. McNeil and Robert C. Flanigan 7. Complications of Adrenal Surgery 81 Brian M. Shuch and Arie S. Belldegrun 8. Complications of Radical Retropubic Prostatectomy 91 Travis L. Bullock, Elizabeth R. Williams, and Gerald L. Andriole, Jr. 9. Modern Complications of the Radical Perineal Prostatectomy 123 Jeffrey M. Holzbeierlein and J. Brantley Thrasher 10. Complications of Open Prostate Surgery 129 Stephen S. Connolly and John M. Fitzpatrick 11. Complications of Urethral Stricture Surgery 137 Ehab A. Eltahawy, Ramon Virasoro, and Gerald H. Jordan 12. Complications of Radical Cystectomy 145 Erik Pasin, Maurizio Buscarini, and John P. Stein 13. Complications of Urinary Diversion 163 Gregory S. Adey and Robert C. Eyre
8. 8. 14. Complications of Retroperitoneal Lymphadenectomy 169 Stephen D. W. Beck, Richard Bihrle, and Richard S. Foster 15. Complications of Renal Transplantation 181 Michael J. Malone, Sanjaya Kumar, and Stefan G. Tullius 16. Complications of Genitourinary Trauma 199 Sean P. Elliott and Jack W. McAninch 17. Management of the Surgical Complications of Penile Carcinoma 207 Kevin R. Loughlin 18. Complications of Benign Adult Penile and Scrotal Surgery 213 Jeffrey C. La Rochelle and Laurence A. Levine 19. Complications of Female Incontinence Surgery 241 Craig V. Comiter Section III: Pediatric Surgical Complications 20. Complications of Orchiopexy 261 Sutchin R. Patel and Anthony A. Caldamone 21. Complications of Hypospadias Surgery 271 Joseph G. Borer and Alan B. Retik 22. Complications of Antireflux Surgery 283 Julian Wan, David Bloom, and John Park 23. Complications of Exstrophy and Epispadias Surgery 295 Joseph G. Borer and Alan B. Retik Section IV: Complications of Minimally Invasive Procedures 24. Complications of Shock Wave Lithotripsy 303 Nicole L. Miller and James E. Lingeman 25. Complications of Percutaneous Lithotripsy 323 C. Charles Wen and Stephen Y. Nakada 26. Complications of Laparoscopic Adrenal Surgery 337 Aaron Sulman and Louis Kavoussi 27. Complications of Laparoscopic Radical Prostatectomy 349 Patricio C. Gargollo and Douglas M. Dahl 28. Complications of Robotic Prostatectomy 369 Mani Menon and Akshay Bhandari 29. Complications of Transurethral Surgery 381 Miguel Srougi and Alberto A. Antunes 30. Complications of Minimally Invasive Treatments for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia 393 Brian T. Helfand and Kevin T. McVary 31. Complications of Minimally Invasive Renal Surgery 425 Sangtae Park and Jeffrey A. Cadeddu x Contents
9. 9. 32. Complications in Ureteroscopy 443 Brent Yanke and Demetrius Bagley Section V: Miscellaneous Complications 33. Complications of Intravesical Therapy 455 Michael A. ODonnell and Jos L. Maym 34. Complications of External-Beam Radiation Therapy 477 Clair Beard 35. Complications of Prostate Brachytherapy: Cause, Prevention, and Treatment 501 Larissa J. Lee and Anthony L. Zietman 36. Complications of Chemotherapy for Urologic Cancer 513 Elisabeth M. Battinelli and Marc B. Garnick 37. Vascular Complications of Urologic Surgery 527 Jonathan D. Gates Index . . . . 539 Contents xi
10. 10. Contributors Gregory S. Adey Division of Urologic Surgery, Mercy Hospital, Portland, Maine, U.S.A. Linda S. Aglio Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Womens Hospital, Boston, Massachusetts, U.S.A. Paul D. Allen Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Womens Hospital, Boston, Massachusetts, U.S.A. Gerald L. Andriole, Jr. Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A. Alberto A. Antunes Division of Urology, University of Sao Paulo Medical School, Sao Paulo, Brazil Demetrius Bagley Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A. Elisabeth M. Battinelli Division of Hematology and Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A. Clair Beard Department of Radiation Oncology, Dana-Farber/Brigham and Womens Cancer Center, Boston, Massachusetts, U.S.A. Stephen D. W. Beck Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A. Arie S. Belldegrun Division of Urologic Oncology, Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A. Akshay Bhandari Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan, U.S.A. Richard Bihrle Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A. David Bloom Department of Urology, University of Michigan, Ann Arbor, Michigan, U.S.A. Joseph G. Borer Department of Urology, Childrens Hospital and Harvard Medical School, Boston, Massachusetts, U.S.A. Travis L. Bullock Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A. Maurizio Buscarini Department of Urology, University of Southern California, Norris Comprehensive Cancer Center, Los Angeles, California, U.S.A. Jeffrey A. Cadeddu Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A. Anthony A. Caldamone Division of Pediatric Urology, Hasbro Childrens Hospital, Brown Medical School, Providence, Rhode Island, U.S.A.
11. 11. Craig V. Comiter Department of Surgery, Section of Urology, University of Arizona Health Sciences Center, Tucson, Arizona, U.S.A. Stephen S. Connolly Department of Urology, Mater Misericordiae Hospital, University College, Dublin, Ireland Douglas M. Dahl Harvard Medical School and Department of Urology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A. Marc A. DallEra Department of Urology, University of Washington School of Medicine and The VA Puget Sound Health Care System, Seattle, Washington, U.S.A. Sean P. Elliott Department of Urologic Surgery, University of Minnesota, Minneapolis, Minnesota, U.S.A. Ehab A. Eltahawy Ain Shams University, Cairo, Egypt Robert C. Eyre Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A. James Chen-tson Fang Division of Cardiovascular Medicine, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio, U.S.A. John M. Fitzpatrick Academic Department of Surgery, Mater Misericordiae Hospital and University College, Dublin, Ireland Robert C. Flanigan Department of Urology, Loyola University Medical Center, Maywood, Illinois, U.S.A. Richard S. Foster Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A. Patricio C. Gargollo Harvard Medical School and Department of Urology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A. Marc B. Garnick Division of Hematology and Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A. Jonathan D. Gates Division of Vascular and Endovascular Surgery, Harvard Medical School and Division of Trauma, Burns, and Surgical Critical Care, Trauma Center, Brigham and Womens Hospital, Boston, Massachusetts, U.S.A. Brian T. Helfand Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A. Jeffrey M. Holzbeierlein Department of Urology, University of Kansas Medical Center, Kansas City, Kansas, U.S.A. Gerald H. Jordan Urology of Virginia and Department of Urology, Eastern Virginia Medical School, Norfolk, Virginia, U.S.A. Louis Kavoussi Smith Institute for Urology, North Shore-Long Island Jewish Health System, New Hyde Park, New York, U.S.A. John N. Krieger Department of Urology, University of Washington School of Medicine and The VA Puget Sound Health Care System, Seattle, Washington, U.S.A. Sanjaya Kumar Division of Transplant Surgery, Brigham and Womens Hospital, Boston, Massachusetts, U.S.A. Jeffrey C. La Rochelle Department of Urology, Rush University Medical Center, Chicago, Illinois, U.S.A. xiv Contributors
12. 12. Larissa J. Lee Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, U.S.A. Laurence A. Levine Department of Urology, Rush University Medical Center, Chicago, Illinois, U.S.A. James E. Lingeman Clarian Health, Indiana University School of Medicine and International Kidney Stone Institute, Indianapolis, Indiana, U.S.A. Kevin R. Loughlin Harvard Medical School and Division of Urology, Brigham and Womens Hospital, Boston, Massachusetts, U.S.A. Michael J. Malone Division of Transplant Surgery, Brigham and Womens Hospital, Boston, Massachusetts, U.S.A. Jos L. Maym Department of Urology, University of Iowa, Iowa City, Iowa, U.S.A. Jack W. McAninch Department of Urology, University of California at San Francisco, San Francisco General Hospital, San Francisco, California, U.S.A. W. Scott McDougal Harvard Medical School and Department of Urology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A. Brian K. McNeil Department of Urology, Loyola University Medical Center, Maywood, Illinois, U.S.A. Kevin T. McVary Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A. Mani Menon Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan, U.S.A. Amy Leigh Miller Division of Cardiovascular Medicine, Brigham and Womens Hospital, Boston, Massachusetts, U.S.A. Nicole L. Miller Department of Endourology and Minimally Invasive Surgery, Clarian Health, Indiana University School of Medicine and International Kidney Stone Institute, Indianapolis, Indiana, U.S.A. Kris M. Mogensen Metabolic Support Service, Department of Surgery, Brigham and Womens Hospital, Boston, Massachusetts, U.S.A. Stephen Y. Nakada Division of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, U.S.A. Michael A. ODonnell Department of Urology, University of Iowa, Iowa City, Iowa, U.S.A. John Park Department of Urology, University of Michigan, Ann Arbor, Michigan, U.S.A. Sangtae Park Department of Urology, University of Washington Medical Center, Seattle, Washington, U.S.A. Erik Pasin Department of Urology, University of Southern California, Norris Comprehensive Cancer Center, Los Angeles, California, U.S.A. Sutchin R. Patel Division of Pediatric Urology, Hasbro Childrens Hospital, Brown Medical School, Providence, Rhode Island, U.S.A. Alan B. Retik Department of Urology, Childrens Hospital and Harvard Medical School, Boston, Massachusetts, U.S.A. Malcolm K. Robinson Metabolic Support Service, Department of Surgery, Brigham and Womens Hospital, and Harvard Medical School, Boston, Massachusetts, U.S.A. Contributors xv
13. 13. Brian M. Shuch Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A. Miguel Srougi Division of Urology, University of Sao Paulo Medical School, Sao Paulo, Brazil John P. Stein Department of Urology, University of Southern California, Norris Comprehensive Cancer Center, Los Angeles, California, U.S.A. James A. Street Department of Anesthesia, Emerson Hospital, Concord, Massachusetts, U.S.A. Aaron Sulman Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A. J. Brantley Thrasher Department of Urology, University of Kansas Medical Center, Kansas City, Kansas, U.S.A. Stefan G. Tullius Division of Transplant Surgery, Brigham and Womens Hospital, Boston, Massachusetts, U.S.A. Ramon Virasoro Department of Urology, Eastern Virginia Medical School, Norfolk, Virginia, U.S.A. Thomas J. Walsh Department of Urology, University of Washington School of Medicine and The VA Puget Sound Health Care System, Seattle, Washington, U.S.A. Julian Wan Department of Urology, University of Michigan, Ann Arbor, Michigan, U.S.A. C. Charles Wen Division of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, U.S.A. Elizabeth R. Williams Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A. Brent Yanke Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A. Anthony L. Zietman Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, U.S.A. xvi Contributors
14. 14. Section I: PERIOPERATIVE COMPLICATIONS 1 Infectious Complications of Urologic Surgery Marc A. DallEra, Thomas J. Walsh, and John N. Krieger Department of Urology, University of Washington School of Medicine and The VA Puget Sound Health Care System, Seattle, Washington, U.S.A. INTRODUCTION This chapter reviews infectious complications of urologic surgery from our perspective as practicing urologists. We focus on the urinary tract and surgical site infections (SSIs) that are of most interest to other urologists. Because of limited space, we omitted important postoperative problems that are less relevant to urological practice, such as respiratory infections and antibiotic- associated bowel problems. We highlight studies of special interest and outline our own clinical approach to management of urologic patients with postoperative infectious complications. URINARY TRACT INFECTIONS COMPLICATING UROLOGIC PROCEDURES The risk of urinary tract infection (UTI) following endoscopic urologic procedures is a complex and highly controversial topic. Much of the controversy reflects the difficulties of defining and classifying UTI, and in distinguishing among the varied urologic procedures. This section begins by defining and categorizing UTI and urologic endoscopic procedures to provide an overview of the pertinent literature and to offer a systematic approach for diagnosing and managing postoperative UTIs. Postprocedural UTIsA Clinical Approach Classically, UTI is defined as the inflammatory response of the urothelium to bacterial invasion. UTI is associated with bacteriuria and with pyuria. While this definition seems straightforward, further categorization of UTI is necessary to facilitate clinical decisions. From a clinical perspective, we prefer a simple classification of UTI into three categories: asymptomatic bacteriuria, uncomplicated UTI, and complicated UTI including urinary sepsis syndrome. This classification helps determine the appropriate clinical approach. Asymptomatic Bacteriuria Asymptomatic bacteriuria is defined as the presence of bacteria in the urine in a patient who has no symptoms or signs. This definition presumes that such bacteria are not contaminants from the skin, vagina, or prepuce. Further, the definition also presumes that the specimen has been handled properly, meaning that it has been transported promptly to the laboratory for processing. Asymptomatic bacteriuria represents one of the most commonly measured and reported urologic infections. The literature contains considerable debate about the concentration of bacteria in urine that is considered significant. The traditional threshold was >100,000 colony-forming units (CFU) per mL of a single species. This definition was based on older population surveys where patients were required to have repeated samples showing >105 CFU/mL(1). More recent literature suggests that >102 CFU/mL represents significant bacteriuria in a patient with urinary tract symptoms, but the precise definition of significant bacteriuria in an asymptomatic patient remains a subject of debate (2).
15. 15. 2 DallEra et al. Complicated vs. Uncomplicated Urinary Tract Infection The practice of classifying UTIs based upon the organ of origin (pyelonephritis, cystitis, etc.) is common in clinical practice. However, such classification makes little contribution to clinical management. The reason is that localization studies have shown that it is exceedingly difficult to distinguish bladder infection from renal infection in many populations based upon clinical signs and symptoms (3). Further, at least in outpatient women, such distinction may be arbitrary because patients with upper and lower UTIs do equally well on similar antibiotic regimens if the infections are uncomplicated. We prefer to classify patients with clinical signs or symptoms of UTI into two groups: uncomplicated UTIs and complicated UTIs. Uncomplicated UTIs occur in patients with struc- turally normal urinary tracts with intact voiding function. The uncomplicated category includes most isolated or recurrent bacterial cystitis as well as acute uncomplicated pyelonephritis in women. Complicated UTIs are infections that occur in patients with structural or functional impairment of the urinary tract. Examples of such impairments include urinary tract obstruction from stone, edema, or foreign body, or the inability to void as is the case with bladder outlet obstruction or neurologic impairment. The reason we prefer this clinical approach to UTI reflects the efficacy of antimicrobial therapies. Specifically, complicated infections often do not respond to medical therapy alone and may require relief of structural or functional obstruction, drainage of an abscess, or other urologic measures (4). Urosepsis Urosepsis is a syndrome resulting from a complicated UTI in a patient with one or more of the following signs: tachypnea, tachycardia, hyperthermia or hypothermia, or evidence of inadequate end-organ perfusion. Inadequate tissue perfusion is often accompanied by elevated plasma lactate, oliguria, or hypoxemia. Septic shock refers to sepsis syndrome that is accompanied by hypotension. Septic shock is a rare event after urologic procedures. Fortunately, septic shock following urologic procedures (often termed urosepsis) has a more favorable prognosis than septic shock from diseases of other organ systems because many urologic disorders are correctable. After correction of underlying urologic factors, the pathophysiology of urosepsis is often reversible. Urinary Tract Infection Risk Associated with Urologic Procedures Procedures performed by urologists vary widely and are associated with markedly different risks for infection. Therefore, we will consider the risks with common urologic procedures separately. Urethral Catheterization Urinary catheters represent an essential part of medical care that is widely employed to relieve structural or functional obstructions of the urinary tract. However, when used inappropriately or left in place too long, urethral catheters represent a significant risk factor for development of UTIandothercomplications.Catheter-associatedUTIsaccountforroughly40%ofallnosocomial infections that increase the duration of hospitalization, as well as morbidity and costs. Further, the use of antimicrobial therapy in the setting of indwelling urethral catheters often leads to selection of antibiotic-resistant microorganisms and nosocomial outbreaks of infection caused by multi-drug-resistant strains (5). Cystoscopy Traditionally, cystoscopy is considered a clean procedure that does not merit routine prophy- lactic antimicrobial therapy. Most reports indicate that symptomatic infections occur following fewer than 5% of procedures, provided the urine is sterile preoperatively (6). However, asympto- matic bacteriuria has been reported after as many as 35% of cystoscopy procedures in some series, with most series in the 10% range (7,8). In a randomized controlled trial of 162 patients undergoing office cystoscopy, Rane et al. compared preoperative, intramuscular gentamicin to no antimicrobial therapy. Only 4.9% of
16. 16. Infectious Complications of Urologic Surgery 3 the gentamicin group developed post-procedural bacteriuria compared to a 21.3% bacteriuria rate among untreated controls (P = 0.004) (8). Although there was no adverse reaction to gentamicin, this study did not evaluate the presence of symptoms, and results were based on a single urine specimen from each patient. Kortmann et al. addressed the question of symptomatic UTI in a study of 104 patients having office cystoscopy without prophylaxis. The outcomes included both urine culture and a follow-up symptom questionnaire. They found a 3% symptomatic UTI rate and a 9% asympto- matic bacteriuria rate (9). In contrast, Manson found an asymptomatic bacteriuria rate of only 2.2% among 138 patients who had cystoscopy without antimicrobials (10). Such low symptomatic UTI rates following cystoscopy led Kraklau et al. to conclude that low-risk patients undergoing cystoscopy do not require prophylactic antimicrobials (7). In our opinion, these and other studies suggest that patients with a history of UTI, voiding dysfunction, presence of a foreign body, or immunosuppression should be considered at high risk for symptomatic UTI. Such high-risk patients merit either a single dose or short course of antimicrobial prophylaxis. Ureteroscopy Ureteroscopy often represents the first-line approach for treating renal and ureteral calculi, as well as diagnosis and treatment of upper tract urothelial tumors. Thus, ureteroscopy has become one of the most common same day urologic procedures. In contrast to cystoscopy and other transurethral procedures, there are remarkably few data on the infectious complications of ureteroscopy. Following ureteroscopy, reported UTI rates range from 3.9% to 25%, and use of routine, perioperative, prophylactic antimicrobials is virtually ubiquitous. In one case series of 378 patients undergoing ureteroscopy, Puppo et al. reported post- operative fever after 3.9% of procedures for ureterolithiasis (11). Because the focus of this report was not on the infectious complications, routine postoperative urine cultures were not obtained. Further, this report did not describe the use of antimicrobials. In 1991, Rao et al. described a series of 117 patients undergoing endoscopic treatment of renal and ureteral stones (12). Bacteremia occurred in almost one-quarter of patients; however, this information is of limited use because they include many more invasive procedures such as percutaneous nephrolithotomy in this series. Although not the primary focus of their study, Hendrikx et al. collected infection data in a randomized trial comparing extracorporeal shock wave lithotripsy to ureteroscopy for treatment of mid-to-distal ureteral stones in 156 patients. Of patients undergoing ureteroscopy, 3.5% had signs of pyelonephritis with septicemia, including fever greater than 38.5C and symptomatic UTI in 3.5% and 4.5%, respectively (13). Details of prophylactic antimicrobial regimens were not provided. In 2003, Knopf et al. randomized 113 patients undergoing ureteros- copy for stone removal without clinical evidence of UTI to a single oral dose of levofloxacin versus no prophylaxis (14). Although no patient in either group developed a symptomatic UTI, there was a significant reduction in postoperative bacteriuria from 12.5% to 1.8% in the antimi- crobial therapy group. Although limited, these data support the standard practice of prophylactic antimicrobial therapy for patients undergoing ureteroscopy and suggest that such treatment is associated with reduced rates of infectious complications. Nephroscopy Percutaneous access to the renal collecting system is necessary for treating large renal calculi, patients who fail shock-wave lithotripsy, and stones in anatomically abnormal kidneys. As with ureteroscopy, remarkably few data are available on the infectious risks of nephroscopy. Given the need to transverse the renal parenchyma, there is particular concern for causing bacteremia and sepsis syndrome. In the series of 27 patients undergoing percutaneous nephrolithotomy, nearly 40% devel- oped sepsis syndrome despite routine use of prophylactic antibiotics (12). The clinical impor- tanceofthiswasunderscoredbyOKeefeetal.inaseriesof700patientsundergoingpercutaneous procedures for upper tract stones. Sepsis syndrome occurred in 1.3%, with an associated mortality rate of 66% (15). Mariappan et al. described 54 patients who underwent percutaneous nephrolithotomy. Patients were monitored closely for sepsis syndrome defined using strict
17. 17. 4 DallEra et al. criteria. Despite routine perioperative therapy with intravenous gentamicin, 5.6% developed sepsis syndrome (16). The most accurate predictors of sepsis were culture-positive renal pelvis urine, and culture-positive stones. These limited observations support routine antimicrobial prophylaxis for patients under- going nephroscopy, especially for treatment of stones. Infectious complications occur com- monly. It may be difficult to identify patients with risk factors such as positive renal pelvis urine or culture-positive stones preoperatively. Transurethral Prostatic Resection Benign prostatic hypertrophy is one of the most common urologic problems among older men. With the development of selective alpha-antagonists and 5-alpha reductase inhibitors in the 1980s and 1990s, the need for surgical intervention has decreased drastically. Many minimally invasive techniques have been engineered to facilitate removal or destruction of obstructing prostatic adenomas. However, transurethral prostatic resection (TURP) remains the gold standard therapy for medically-refractory prostatic obstruction. Historically, TURP was considered an Altermeier class II (clean contaminated) proce- dure that did not merit routine perioperative antimicrobial therapy (17). However, postopera- tive bacteriuria rates up to 60% have been reported (18,19). The precise pathophysiology of infection following TURP is unknown, but most likely results from urethral abrasion and disruption of the prostatic bed (18). Potential sources of bacteria leading to infection include the prostatic adenoma, urethral flora, bladder colonization, or perioperative contamination (20). The clinical significance of asymptomatic bacteriuria following TURP is debatable. Reported rates of urosepsis from post-TURP bacteriuria range from 1% to 4%, with an associ- ated mortality rate of 13%. Mortality rates for post-TURP sepsis increase to more that 20% in men over 65 years old. Additionally, postoperative hospital stays may be prolonged by 0.6 to 5 days as a result of bacteriuria (21), based on studies from the older literature when hospital stays were much longer than in current practice. In 2002, Berry and Barratt reported a meta-analysis of 32 randomized controlled trials evaluating antimicrobial prophylaxis for TURP in patients with sterile preoperative urine (18). These studies included a total of 4260 patients, with 1914 randomized to receive no antimicrobials, and 2346 randomized to receive various perioperative regimens. The primary endpoints were development of bacteriuria, symptomatic infection, or sepsis syndrome. Antimicrobial prophy- laxis was associated with reduced rates of bacteriuria (9.1% vs. 26%, P < 0.01), and postoperative sepsis syndrome (0.7% vs. 4.4%, P < 0.01), corresponding to relative risk reductions of 65% and 77%, respectively. The effectiveness of various regimens was also analyzed, with aminoglycosides, co-trimoxazole, and cephalosporins all decreasing relative risks by 55% to 67%. Although evaluated in fewer studies, fluoroquinolone administration was associated with a relative risk reduction of 92%. Duration of prophylactic antimicrobial therapy appeared important, with short-course (75th percentile is considered high risk). Contaminated or dirty wounds are scored as one point, ASA score of III, IV, or V is scored as one point, and >75th percentile for procedure length is scored as one point. The total NNIS score predicts an individuals SSI risk (Table 3). Diagnosis of Surgical Site Infection The classical physical signs of infection include redness, swelling, and pain over the incision, with purulent drainage or foul odor. Deeper infections may present initially with more systemic TABLE 2 Risk Factors for Surgical Site Infection Patient related Procedure related Bacteria related Hypothermia Seroma/hematoma Wound contamination Hyperglycemia Hair removal method Bacterial load Advanced age (>70 yr) Closed suction drains Antibiotic resistance Diabetes mellitus Foreign bodies Malnutrition Wound irrigation Immunosuppression Obesity Chronic alcohol use Malignancy Note: Documented univariate risk factors for surgical site infection risk. Estimating individual patient risk is based on the interaction between several risk factors. Source: From Refs. 3741, 4345. TABLE 3 NNIS Score and SSI Risk NNIS Score Risk of SSI (%) 0 1.5 1 2.9 2 6.8 3 13.0 Note: Because it is difficult to estimate an individual patients risk of SSI based on traditional risk fac- tors outlined in Table 2, the NNIS score was developed to consider the interaction between multiple risk factors and provide individualized SSI risk assessments. Estimates are based on over 84,000 procedures with 2376 documented SSIs. To calculate NNIS score, contaminated and dirty wounds are given 1 point, an ASA score of III or greater is given 1 point, and length of procedure >75th percentile is given 1 point. Abbreviations: NNIS, National Nosocomial Infection Surveillance System; SSI, surgical site infection. Source: From Ref. 35.
18. 22. Infectious Complications of Urologic Surgery 9 symptoms, such as fever, chills, and rigors. One must maintain a high index of suspicion for infection when a patient is not recovering as expected after a surgical procedure. Laboratory findings including leukocytosis, hyperglycemia, acidosis, C-reactive protein elevation, and procalcitonin elevation support the diagnosis of infection (48,49). If imaging is needed to document and localize an SSI (which is not necessary in a patient with a superficial infection), the most useful studies are ultrasound, computerized tomography, and magnetic resonance imaging (5052). All three imaging methods have equal sensitivity for detecting large, drainable abdominal and subcutaneous fluid collections (52). However, ultra- sound imaging is very operator-dependent and may be less accessible than computerized tom- ography in some practice settings. We prefer computerized tomography and magnetic resonance imaging. These methods have proved more sensitive for detecting small, deeper abscesses and provide far better anatomic detail for safe, percutaneous drain placement near vital structures (51,52). Because magnetic resonance imaging is significantly more expensive than other imaging methods, we reserve this approach for patients with contraindications to iodinated intravenous contrast. Management of Surgical Site Infection Superficial infections and cellulitis are treated with antimicrobial therapy and local wound care alone. Superficial abscesses should be drained by opening the surgical wound. Deeper fluid or abscess collections usually require drainage for diagnosis and management. In this situation, our preference is radiologically-guided percutaneous drainage, reserving traditional open surgical procedures for cases where percutaneous drainage is contraindicated or has failed. Up to 85% of intra-abdominal abscesses can be managed by percutaneous drainage and appropriate antimicrobial therapy (53). Purulent material should be carefully evaluated with Gram stain, culture, and antibiotic sensitivity testing. Empirical antimicrobial selection should be based on Gram stain results and the suspected pathogens based upon the wound type, and local sensitivity patterns. Such therapy may be modified, if needed, depending on subsequent culture and sensitivity results. Most patients respond rapidly to appropriate therapy. The clinical pearl is that subsequent clinical deterioration or nonprogression requires fur- ther evaluation. Such evaluation includes careful physical examination plus other measures such as repeated imaging, culturing, or a change in antimicrobial coverage. An undrained abscess and fungal or mycobacterial infections must also be considered when patients do not respond to therapy as expected. Prevention of Surgical Site Infection The NNIS guidelines recommend preoperative prophylactic antimicrobial therapy for proce- dures with an estimated SSI risk >1% based upon the NNIS score (54). Therefore, prophylactic antimicrobial therapy should be strongly considered for: (i) any clean-contaminated procedure, (ii) any clean procedure in a patient with an NNIS score >1, (iii) an immunocompromised patient, (iv) when any prosthetic material is inserted, or (v) when the operative area contains high bacterial counts, such as the axilla or scrotum. Timing of antimicrobial prophylaxis administration is critical. Alarge study by Stone et al. found that the lowest SSI risk occurred when therapy was initiated within one hour of surgery (55). Patients who received therapy after the incision had nearly the same risk as patients who did not receive prophylaxis. More recent data corroborate the conclusion that timely preopera- tive antimicrobial administration can reduce SSI rates (56). These and other observations demonstrate the importance of obtaining therapeutic serum antimicrobial levels before the sur- gical incision and exposure to bacteria. Current guidelines suggest that prophylactic antimicro- bials should be redosed appropriately for lengthy procedures and should stop within 24 hours of surgery (54). Recent data support prophylactic antimicrobial therapy for trans-scrotal surgery based on high bacterial counts on the scrotum and perineum. In a retrospective review of 131 outpatient scrotal procedures, Kiddoo et al. found a 9.3% overall SSI rate among patients who did not receive prophylactic therapy (57). In contrast, Swartz et al. found a 4% SSI rate in over 100 trans-scrotal
19. 23. 10 DallEra et al. procedures with a mean follow-up of 36 months (Swartz M, Urology, University of Washington). Although the precise benefit of prophylactic antimicrobials cannot be ascertained by comparing such retrospective studies, these data do suggest that scrotal wounds merit consideration as clean-contaminated wounds that may warrant prophylaxis. Prophylactic antimicrobial agents should be selected based on the most likely organisms encountered. Beta-lactam antibiotics, such as the cephalosporins, are the most common agents used for prophylaxis. Recommendations include cefazolin for clean abdominal procedures or cefotetan for clean-contaminated abdominal procedures involving the gastrointestinal tract (54). Clindamycin or vancomycin regimens are recommended alternatives for patients with documented beta-lactam allergies (54). Other possible regimens include combinations of either metronidazole or clindamycin with gentamicin or a floroquinolone. Currently, there is no evidence supporting the use of prophylactic vancomycin rather than other agents, even in hos- pitals with perceived high rates of bacterial resistance. Recommendations for specific urologic procedures are described next Special consideration must be given to preventing bacteremia in surgical patients with prosthetic joints who are at risk for joint infections or patients with certain cardiac anomalies who are at risk for life-threatening endocarditis. The American Urological Association (AUA) and the American Heart Association (AHA) have published specific guidelines for antibiotic prophylaxis in these patient populations (as outlined previously) (29,58). Transient bacteremia can occur after a variety of urologic procedures, especially if patients are instrumented during active UTI. Identification and treatment of active infections is strongly recommended prior to any elective procedure. Bacteremia is commonly associated with urologic procedures, with rates of 31% for patients undergoing TURP, 24% among patients undergoing urethral dilations, 44% in patients having prostate needle biopsy, and 7% in patients having office urodynamics (31,59,60). The AHA recommends endocarditis prophylaxis for patients undergoing prostatic surgery, urethral dilations, cystoscopy, or ureteroscopy (58). Prophylaxis is not necessary for urethral catheterization or circumcision in the absence of clinical infections (58). Perioperative ampicillin or vancomycin with gentamicin is recommended for high-risk patients while moderate-risk patients can be treated with single-agent ampicillin or vancomycin (58). High- risk patients are defined by having prosthetic heart valves, previous histories of endocarditis, or complex congenital anomalies. Currently, the AUA recommends assessing patients overall risk for artificial joint infection based on a combination of patient-related and procedure-related factors (as outlined previously) (29). Examples of Our Approach to Urologic Surgical Site Infection Problems Infected Artificial Urinary Sphincter The first consideration is prevention of infection, if possible. Perioperative antimicrobial administration is imperative. We favor broad-spectrum coverage with particular attention to assure coverage for Staphylococcus epidermidis employing either a cephalosporin or beta-lactam agent. As with surgery not involving insertion of prosthetics, therapy must be administered within one hour of surgery and prolonged administration postoperatively is not supported by the literature. Control of intraoperative risk factors to limit SSI risk is also important (as out- lined previously). Infections complicate 4% to 21% of artificial urinary sphincter (AUS) insertions and large series document no difference in infection rates between men and women (6164). Such infections represent some of the most difficult and frustrating complications in urology. S. aureus and coagulase-negative Staphylococcus species cause the vast majority of AUS infections (64,65). Multiple patient risk factors for infection have been identified including previ- ous sphincter insertion, previous radiotherapy, and previous procedures for bladder neck inser- tions (64). Recent series indicate that with modern focused radiotherapy, the risk for AUS infection is comparable to rates in the general population (64,66). Improper urethral catheteri- zation or endoscopy in patients with artificial sphincters also represent important risk factors for infection. There is considerable debate on the merits of simultaneous bladder augmentation and AUS insertion for patients with neurogenic bladders. After such combined procedures sphincter
20. 24. Infectious Complications of Urologic Surgery 11 infection rates range from 5% to 50%, depending on the bowel segment used (6769). Miller et al. described an overall infection rate of 6.9% in 29 patients undergoing simultaneous procedures (67). Nineteen (66%) of the twenty-nine patients underwent gastrocystoplasty with no infections. In contrast, 2 (20%) of 10 patients had sphincter infections following ileal or colonic augmenta- tions (67). Other studies support these findings, suggesting that the relatively sterile stomach environment allows simultaneous procedures to be performed (68,70). Most patients with infected sphincters present with persistent pain over the prosthetic parts (65). Other symptoms, including dysuria, hematuria, or pump fixation against the scrotal wall, may represent the first indication of an infection. More obvious signs of infection include purulent drainage from the scrotum or exposed prosthetic parts. Other patients with infected sphincters may have few systemic symptoms, with only a mild leukocytosis or low-grade fever. Therefore, the clinician must have a high index of suspicion of infection when any patient with an AUS presents with vague symptoms of systemic infection or inflammation with no clear source. Initial management depends on the clinical presentation and extent of infection. Stable patients with suspected artificial sphincter infections may undergo a trial of oral or parenteral antimicrobial therapy. However, resolution of true prosthetic infections is rare with medical management alone. Persistent or progressive symptoms require surgical exploration and removal of the infected prosthesis. Regardless of the clinical presentation, more than half of patients have infections involving all three device components, supporting complete removal (61,62). Standard management includes removal of all parts with washout and debridement of any devitalized tissue. Selected patients may undergo AUS reinsertion several months later after the infection has completely resolved and all wounds have healed. Some investigators have described success with salvage protocols for removal and immediate replacement of an infected device similar to that outlined below for infected penile prostheses (65). Bryan et al. described eight patients with infected artificial sphincters who underwent a salvage protocol with removal of the entire device, extensive washout of the wound with multiple solutions, and immediate replacement (65). Most patients in this series had post-radical prostatectomy incontinence and all patients were given an oral fluoroqui- nolone for one month after reinsertion. Seven (88%) of eight patients did well with a mean follow-up of 33 months. These observations suggest that a salvage protocol for AUS infections might be feasible for highly selected patients. The advantages offered by immediate reinsertion following removal of an infected sphincter are not as pronounced as those for an infected penile prosthesis. Although patients enjoy immediate return of continence with simultaneous placement of a new sphincter, reinsertion once the infection has clearly resolved is often not much more difficult than primary insertions. Overall outcomes with regard to comfort and continence appear similar with primary and secondary insertions (71). Further data on optimal patient selection and long- term follow-up are needed to determine whether the risk of infection with reinsertion warrants general adoption of such salvage protocols for infected AUS. Infected Penile Prosthesis Consistent with our approach to management of infected urinary sphincters, we believe that the urologists first goal should be to prevent infection of penile prostheses. In 1978, Small reported a markedly decreased infection rate in men undergoing placement of penile prostheses with prophylactic antimicrobial therapy (72). The infection rate decreased from 5 (25%) of 20 patients without antimicrobial prophylaxis to 1 (5%) involve large fluid shifts and/or blood loss and include vascular (aortic and peripheral) surgeries and emergent procedures (particularly in elderly patients) (19). In contrast, low-risk procedures (cardiovascular event risk 2 9.1 (5.5, 13.8) a Cardiovascular event rates from the derivation patient cohort. Abbreviation: RCRI, revised cardiac risk index. Source: From Ref. 2.