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
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organsSurgeryComplications. I. Loughlin, Kevin R. [DNLM: 1.
Urologic Surgical Proceduresadverse effects. 2. Intraoperative
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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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.
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
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
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.