Endoscopic lithotripsy in patients with asymptomatic bacteriuria

Abstract

Introduction: Endoscopic surgery is a highly effective method for treating urolithiasis; however, it carries a risk of postoperative infectious complications. One of the main risk factors for these complications is a positive urine culture. The persistence of asymptomatic bacteriuria (ASB) in patients, combined with the absence of standardized guidelines for its managing prior to endoscopic procedures, highlights the need for further investigation. Thus, conducting a comparative analysis of infectious complications in patients with negative urine culture versus those with persistent ASB undergoing endoscopic surgery for renal and ureteral stones using different regimes of antibiotic prophylaxis seems clinically relevant issue.

Objective: To assess the safety of endoscopic stone surgery in patients with persistent asymptomatic bacteriuria and patients’ negative urine culture undergoing endoscopic surgery for renal and ureteral stones using different regimes of antibiotic prophylaxis.

Materials and Methods: We conducted a retrospective study analyzing data from patients who underwent endoscopic removal of renal and ureteral stones between January 2023 and July 2023. Of the 449 patient records reviewed, 211 patients meeting the inclusion and exclusion criteria were selected for further analysis. Antibacterial prophylaxis was administered as follows: a few hours prior to surgery for patients with an initially sterile urine culture, three days prior to surgery for those with clinically insignificant ASB, and seven days prior to surgery for patients with clinically significant ASB.

Results: A preoperative sterile urine culture was identified in 152 patients (72.0%), while 59 patients (28.0%) [95% CI: 22.0%; 34.5%] were diagnosed with bacteriuria. Among these, 28 patients (13.3%) [95% CI: 9.0%; 18.6%] had clinically significant bacteriuria, defined as a bacterial count of ≥10⁵ CFU/mL. Despite culture based antibiotic therapy prior to surgery persistent ASB was observed in six patients (22.0%). Consequently, 37 patients (17.5%) [95% CI: 12.79%; 23.4%] with clinically significant and insignificant ASB along with patients with sterile urine underwent endoscopic surgery. In the postoperative period, leukocytosis alone was observed in 54 patients (25.6%), fever in 17 patients (8.1%), and fever accompanied by leukocytosis in 11 patients (5.2%). Logistic regression analysis demonstrated a statistically significant association between bacteriuria and postoperative fever. A positive urine culture increased the odds of hyperthermia by 4,75 times (OR = 4,75, 95% CI: 1.256; 21.123, P = 0.022). Additional factors influencing leukocytosis included maximum stone size (P = 0.013), stone volume, and dwelling ureteral stent (P = 0.006). Specifically, an increase in stone volume by 1.0 cc raised the odds of leukocytosis by 1.54 times (OR = 1.543, 95% CI: 1.128; 2.158, P = 0.008).

Conclusion: Our study highlights that a positive urine culture is a significant risk factor for infectious complications following endoscopic surgery. Prolonged antibiotic prophylaxis for patients with clinically significant ASB appears to be an effective strategy to minimize the risk of postoperative infectious complications.

Keywords: Kidney stones, ureteral stones, asymptomatic bacteriuria, infection, complications, endoscopy