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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 2  |  Page : 290-294
Urinary infection before and after prostatectomy


1 Urology Research Center, Sina Hospital, Tehran University of Medical Sciences, Iran
2 Research and Development Center, Sina Hospital, Tehran University of Medical Sciences, Iran

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Date of Web Publication9-Mar-2010
 

   Abstract 

To determine the prevalence of pre and post prostatectomy related urinary tract in­fection and its correlation with peri-operative events, we studied 120 patients who underwent pros­tatectomy due to benign prostatic hypertrophy from September 2005 to September 2006. Urine cultures were performed before the operations, after a week, and three months later. Data including prostate volume, prostatic specific antigen (PSA), post voiding residue (PVR) and histopathological reports as well as the duration of urinary leak, bladder irrigation, hospitalization, and catheterization were studied. The mean age of the studied patients was 70.5 ± 8 years. Significant preoperative bac­teriuria was revealed in 18 (15%) patients of whom 14(77%) patients developed negative cultures following the operation. Postoperative bacteriuria was detected in 9(7.5%) patients who negative urine cultures preoperatively. Pre and post operative micro-organisms were different in the majority of the cases. The mean PSA was higher in patients with a positive history of infection. Following prostatectomy, patients with positive urine cultures had significantly longer urinary leakage, cathe­terization, and hospital stays compared with those who remained culture negative. We conclude that the incidence of positive urine culture pri-prostatectomy for BPH can be improved by appropriate antibiotic therapy, and the risk factors for postoperative urinary infection include preoperative infec­tion, prolonged urinary leakage, catheterization, and hospital stay. The elevated PSA may be a risk factor.

How to cite this article:
Pourmand G, Abedi AR, Karami AA, Khashayar P, Mehrsai AR. Urinary infection before and after prostatectomy. Saudi J Kidney Dis Transpl 2010;21:290-4

How to cite this URL:
Pourmand G, Abedi AR, Karami AA, Khashayar P, Mehrsai AR. Urinary infection before and after prostatectomy. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 Nov 18];21:290-4. Available from: http://www.sjkdt.org/text.asp?2010/21/2/290/60197

   Introduction Top


Benign prostatic hypertrophy (BPH) is a di­sease of aging men. The incidence increases to more than 70% in the individuals of 61 to 70 years old and 90% in those 81 to 90 years of age. [1],[2] Lower urinary tract symptoms (LUTS) are a common complaint among middle-aged men and are believed to be secondary to benign prostatic hyperplasia (BPH) in two third of these patients. [2] Inflammation has been found to coexists with the hypertrophy, and its etiology remains controversial. [1],[2],[3],[4]

Prostatectomy is associated with acceptable early postoperative outcomes; complications are reported in 17.3% of the cases. Bleeding requi­ring transfusion (7.5%) and urinary tract infec­tions (5.1%) comprise the most frequent post­operative events. [5]

We aim in this study to determine the preva­lence of pre and post operative urinary tract in­fection (UTI) and its correlation with the peri and postoperative course.


   Methods Top


After being approved by the ethic committee of Tehran University of Medical Sciences, this pros­pective study was conducted on BPH patients who underwent prostatectomy at the Sina Hos­pital from September 2005 to September 2006.

BPH patients with any history of refractory retention, bladder stone, bladder diverticula, recu­rrent urinary infection, gross hematuria, uremia and poor quality of life were enrolled in the study. An informed consent was obtained from all patients.

The patients were selected to undergo open transvesical prostatectomy and transurethral re­section prostatectomy (TURP) based on the in­dications of the operation as well as their pros­tate volume and preference. The same urolo­gists and operation team performed all operations.

Bladder irrigation started closely after the sur­gery in the operating room and continued for one or two days. Urethral catheter was removed on the 3rd-12th postoperative day.

We obtained serum prostatic specific antigen (PSA), creatinine, and blood urea nitrogen (BUN) on the day before the operation, in addition to urine samples for urinalysis and preoperative urine culture. Postoperative urine culture was re­peated in a week and then three months after removing the urethral catheter.

Ultrasound of kidney, bladder, and prostate was performed for all patients. The prostate volume was also determined for all the cases. Cystoure­theroscopy was done as indicated.

Peri-operative antibacterial regimen included a first-generation cephalosporin and gentamicine prophylactically if the preoperative urine cultures were negative. On the other hand, at least two doses of a broad-spectrum antibiotic against gram-negative micro-organisms were adminis­tered to patients with indwelling catheters; the patients were instructed to continue oral anti­biotics until the catheters were removed.

Data on each patient's prostatectomy type, prostate volume, post-voiding residue (PVR) vo­lume, prostatic histopathological reports, cathete­rization and hospitalization period were recorded.


   Statistical analysis Top


The gathered data were analyzed using the sta­tistical package SPSS version 13. Chi-square and student's t-test were used for analyzing quali­tative and quantitative variables. P value < 0.05 was considered significant.


   Results Top


We studied 120 patients with a mean age of 70.5 ± 8 years. [Table 1] demonstrates the fre­quency of the reported urinary complaints. The most common complaints were urine retention and obstructive symptoms.

Eighty-three (69.2%) of the patients underwent TURP, whereas open transvesical prostatectomy was performed in the remainder. The mean pre­operative creatinine and hemoglobin levels were 1.23 ± 0.52 mg/dL and 14.38 ± 1.58 mg/dL, respectively. The mean prostate volume was 55 ± 23 mL; it was not statistically significantly co­rrelated with the risk of urinary infection (P value= 0.8).

Hydronephrosis and bladder stones were de­tected in 7 (5.8%) and 10 (8.3%) of the patients, respectively; there was no statistically signifi­cant correlation between the presence of these two risk factors and the development of urinary infection (P= 0.76, 0.33, respectively).

[Table 2] shows that the catheterization period was significantly longer in patients with urinary leak (12 days vs. 5 days; P value= 0.01). Longer urinary leak significantly correlated with urinary infection (P= 0.03).

Preoperative bacteriuria was revealed by posi­tive urine cultures in 18 patients (15%), of whom 14 (77.7%) patients developed negative urine cultures following the operation. Postoperative bacteriuria was detected in the 4 other cases. The pre and post operative micro-organisms were different in the majority of cases (E. coli/ pseudomonas sp., E. coli/E. coli, E. coli/Kleb­silla sp., Klebsilla sp./E .coli).

Postoperative bacteriuria developed a week af­ter the catheter removal. Ten of the aforemen­tioned patients had urinary catheters for eight days while the catheter was removed after 3 days in the other 3 subjects (P = 0.001). Post­operative septicemia was reported in 2 of these cases; pathologic evidence in accordance with prostatic microabscess was reported in one of these cases.

All the isolated bacteria were sensitive to qui­nolone antibiotics, and accordingly ciprofloxa­cin was included in the therapy.

Nine patients (8.8%) with negative preopera­tive urine-culture developed urinary infection within a week following the operation; E.coli (5 cases) and klebsilla sp. (4 cases) were the 2 mi­cro-organisms revealed by urine culture.

The mean PSA levels in the patients with posi­tive urine culture was 6.2 ± 3.6 ng/mL compared to 4.8 ± 5 ng/mL in the patients with negative cul­tures (P= 0.5). Post voiding residue was not statis­tically correlated with urinary infection (P= 0.37).

The means of postoperative hospitalization stay and duration of bladder irrigation were longer in the patients with positive urine cultures (10 versus 5 days; P= 0.01), respectively (6 vs. 2 days; P= 0.01).


   Discussion Top


In our study, the incidence of bacteriuria fol­lowing prostatectomy was 10.8%. Only 1 patient developed bacteremia secondary to urinary tract infection. Our findings revealed that 18 (15%) of the 120 studied cases had significant preopera­tive bacteriuria; postoperative bacteriuria was confirmed only in 4 (3.3%) cases with appro­priate antibiotic therapy. Conversely, 9 (8.8%) patients with sterile preoperative urine culture developed urinary infection within a week fo­llowing their prostatectomy.

In a meta-analysis conducted by Qiang et al, bacterial contamination was detected in 44% of the BPH prostatic specimens. They reported satisfactory results and reduced infection rate following preoperative antibiotic prophylaxis in TURP patients. [6] Other studies found similar re­sults and the rate decreased shortly after the operation with antibiotic therapy. [7],[8],[9],[10],[11],[12]

Several risk factors have been identified for post- TURP infection; the major factors include preoperative bacteriuria, longer operating time (> 70 minutes), long preoperative hospitaliza­tions (more than 2 days), long indwelling post­operative urethral catheters (for more than 3 days), and open drainage systems. [7],[13],[14] four risk factors were significantly associated with the occurrence of bacteriuria in our study including long bladder irrigation phases, long hospitaliza­tions, long catheterization periods, and long uri­nary leaks.

Ohkawa et al found that 80.8% of the species isolated from blood specimens were similar to the reported preoperative species. [15] Our study similarly showed that preoperative bacteriuria was significantly related to the postoperative in­fection, but in contrast to Ohkawa's findings, we found in our study that the preoperative and postoperative species were different except for a single case.

Postoperative bacteriemia was found in 22.7% of the patients, one of whom developed septi­cemia, and prophylactic antimicrobial therapy did not influence the rate of bacteriemia. [16] The low prevalence of septicemia in our study could be due to the fact that all the patients with po­sitive preoperative cultures were treated with antibiotics prior to the operation.

Prophylactic continuous irrigation with various solutions, especially for 10 days or less following the indwelling catheter insertion, has been de­monstrated to be effective in reducing the risk of bacteriuria in open catheter drainage systems. Prophylactic antimicrobial irrigation in closed catheter systems is ineffective and is associated with the development of the species resistant to the irrigating solution. [17] Moreover, preoperative bladder instillation with povidone-iodine may re­duce the risk of post prostatectomy wound in­fection as well as bacteriuria in patients with in­dwelling catheters. [18] Chlorhexidine irrigation may also reduce the risk of infection in these cases. [19]

We conclude that the incidence of positive urine culture pri-prostatectomy for BPH can be improved by appropriate antibiotic therapy, and the risk factors for postoperative urinary infec­tion include preoperative infection, prolonged urinary leakage, catheterization, and hospital stay. The elevated PSA may be a risk factor.


   Acknowledgement Top


The present study was performed, thanks to the grant number 2433 offered by Tehran Univer­sity of Medical Sciences.

 
   References Top

1.Nickel JC. Inflammation and benign prostatic hyperplasia. Urol Clin North Am 2008;35(1): 109-15.  Back to cited text no. 1      
2.Hirst GH, Ward JE. Clinical practice guidelines: Reality bites. Med J Aust 2000;172:287-91.  Back to cited text no. 2  [PUBMED]    
3.Yi FX, Wei Q, Li H, et al. Risk factors for pros­tatic inflammation extent and infection in benign prostatic hyperplasia. Asian J Andro1 2006;8(5): 621-7.  Back to cited text no. 3      
4.Roehrbom CG, Kaplan SA, Noble WD, et al. The impact of acute or chronic inflammation in baseline biopsy on the risk of clinical progre­sssion of BPH: Results from the MTOPS study. 2005 AUA meeting. J Uro1 2005;173(Suppl4): 346  Back to cited text no. 4      
5.Gratzke C, Schlenker B, Seitz M, et al. Compli­cations and early postoperative outcome after open prostatectomy in patients with benign prostatic enlargement: Results of a prospective multicenter study. J Urol 2007;177(4):1419-22.  Back to cited text no. 5      
6.Qiang W, Jianchen W, MacDonald R, et al. Antibiotic prophylaxis for transurethral prostatic resection in men with preoperative urine con­taining less than 100,000 bacteria per ml: A systematic review. J Urol 2005;173:1175-81.  Back to cited text no. 6  [PUBMED]    
7.Colau A, Lucet JC, Rufat P, et al. Incidence and risk factors of bacteriuria after transurethral resection of the prostate. Eur Urol 2001;39(3): 272-6.  Back to cited text no. 7      
8.Fuiita K, Sayama T, Murayama T, Kawamura M. Incidence of infection after transurethral prostatectomy. Jpn J Antibiot 1986;39(4):905-8.  Back to cited text no. 8      
9.Collste LG, Torngvist H. Urinary infection and transurethral prostatectomy. Scand J Urol Nephrol 1978;12(1):7-9.  Back to cited text no. 9      
10.Milcent S, Berlizot P, Palascak R, et al. Value and justification of urine dipsticks in the diag­nosis of postoperative urinary infections in uro­logy. Frog Urol 2003;13(2):234-7.  Back to cited text no. 10      
11.Gordon DL, McDonald PI, Bune A, et al. Diag­nostic criteria and natural history of catheter­associated urinary tract infections after prosta­tectomy. Lancet 1983;3(8362):1269-71.  Back to cited text no. 11      
12.Pestalozzi DM, Boss HP, Knonagel H. Infec­tious complications after transurethral resection. Helv Chir Acta 1992;59(3):497-500.  Back to cited text no. 12      
13.Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of Transurethral Resection of the Prostate (TURP)-Incidence, Management, and Prevention. Euro Urol 2006;50:969-80.  Back to cited text no. 13      
14.Vivien A, Lazard T, Rauss A, Laisne MJ, Bonnet F. Infection after transurethral resection of the prostate: variation among centers and correlation with a longlasting surgical procedure. Association pour la Recherche en Anesthesie­Reanimation. Eur Urol 1998;33(4):365-9.  Back to cited text no. 14      
15.Ohkawa M, Shimamura M, Tokunaga S, Naka­shima T, Orito M. Bacteremia resulting from prostatic surgery in patients with or without preoperative bacteriuria under perioperative antibiotic use. Chemotherapy 1993;39(2):140-6.  Back to cited text no. 15      
16.Tokunaga S, Ohkawa M, Oshinoya Y, et al. Bacteremia from transurethral prostatic resection under prophylactic use of antibiotics. Kansen-shogaku Zasshi 1991;65(6):698-702.  Back to cited text no. 16      
17.Dudley MN, Barriere SL. Antimicrobial irrigations in the prevention and treatment of catheter­related urinary tract infections. Am J Hosp Pharm 1981;38(1):59-65.  Back to cited text no. 17      
18.Richter S, Kotliroff O, Nissenkom I. Single preoperative bladder instillation of povidone­iodine for the prevention of post prostatectomy bacteriuria and wound infection. Infect Control Hosp Epidemiol 1991;12(10):579-82.  Back to cited text no. 18      
19.Bastable JR, Peel RN, Birch DM, Richards B. Continuous irrigation of the bladder after prostatectomy: its effect on post-prostatectomy infection. Br J Urol 1977;49(7):689-93.  Back to cited text no. 19      

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Correspondence Address:
Gholamreza Pourmand
Sina Hospital, Medical Sciences/University, Imam Khomeini Street, Tehran 11367
Iran
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    Tables

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