Urosepsis 30-day mortality, morbidity, and their risk factors: SERPENS study, a prospective, observational multi-center study.

PURPOSE: To provide a descriptive report of mortality and morbidity in the first 30 days of diagnosis of urosepsis. Secondary aim is to identify risk factors of unfavourable outcomes. METHODS: Prospective observational multicentre cohort study conducted from September 2014 to November 2018 in European hospitals. Adult patients (≥ 18 years) diagnosed with acute urosepsis according to Sepsis-2 criteria with confirmed microbiological infection were included. Outcomes were classified in one of four health states: death, multiple organ failure, single organ failure, and recovery at day 30 from onset of urosepsis. Descriptive statistics and ordinal logistic regression analysis was performed. RESULTS: Three hundred and fifty four patients were recruited, and 30-day mortality rate was 2.8%, rising to 4.6% for severe sepsis. All patients who died had a SOFA score of ≥ 2 at diagnosis. Upon initial diagnosis, 79% (n = 281) of patients presented with OF. Within 30 days, an additional 5% developed OF, resulting in a total of 84% affected. Charlson score (OR 1.14 CI 1.01-1.28), patients with respiratory failure at baseline (OR 2.35, CI 1.32-4.21), ICU admission within the past 12 months (OR 2.05, CI 1.00-4.19), obstruction causative of urosepsis (OR 1.76, CI 1.02-3.05), urosepsis with multi-drug-resistant(MDR) pathogens (OR 2.01, CI 1.15-3.53), and SOFA baseline score ≥ 2 (OR 2.74, CI 1.49-5.07) are significantly associated with day 30 outcomes (OF and death). CONCLUSIONS: Impact of comorbidities and MDR pathogens on outcomes highlights the existence of a distinct group of patients who are prone to mortality and morbidity. These findings underscore the need for the development of pragmatic classifications to better assess the severity of UTIs and guide management strategies. STUDY REGISTRATION: Clinicaltrials.gov registration number NCT02380170.

Condition-specific surveillance in health care-associated urinary tract infections as a strategy to improve empirical antibiotic treatment: an epidemiological modelling study.

BACKGROUND: Health care-associated urinary tract infection (HAUTI) consists of unique conditions (cystitis, pyelonephritis and urosepsis). These conditions could have different pathogen diversity and antibiotic resistance impacting on the empirical antibiotic choices. The aim of this study is to compare the estimated chances of coverage of empirical antibiotics between conditions (cystitis, pyelonephritis and urosepsis) in urology departments from Europe. METHODS: A mathematical modelling based on antibiotic susceptibility data from a point prevalence study was carried. Data were obtained for HAUTI patients from multiple urology departments in Europe from 2006 to 2017. The primary outcome of the study is the Bayesian weighted incidence syndromic antibiogram (WISCA) and Bayesian factor. Bayesian WISCA is the estimated chance of an antibiotic to cover the causative pathogens when used for first-line empirical treatment. Bayesian factor is used to compare if HAUTI conditions did or did not impact on empirical antibiotic choices. RESULTS: Bayesian WISCA of antibiotics in European urology departments from 2006 to 2017 ranged between 0.07 (cystitis, 2006, Amoxicillin) to 0.89 (pyelonephritis, 2009, Imipenem). Bayesian WISCA estimates were lowest in urosepsis. Clinical infective conditions had an impact on the Bayesian WISCA estimates (Bayesian factor > 3 in 81% of studied antibiotics). The main limitation of the study is the lack of local data. CONCLUSIONS: Our estimates illustrate that antibiotic choices can be different between HAUTI conditions. Findings can improve empirical antibiotic selection towards a personalized approach but should be validated in local surveillance studies.

Antibiotic resistance, hospitalizations, and mortality related to prostate biopsy: first report from the Norwegian Patient Registry.

BACKGROUND: A 68-year-old man died of cerebral arterial embolism 6 days after transrectal prostate biopsy with a single p.o. dose of trimethoprim sulfamethoxazole (TMP-SMX) as prophylaxis. The case precipitated analysis of local antibiotic resistance and complication rates. MATERIALS AND METHODS: Data on E. coli resistance from Oslo University Hospital and national data on hospitalizations and mortality after biopsy were retrieved from local microbiology files and the Norwegian Patient Registry (NPR) 2011-2017. RESULTS: Urine E. coli resistance against TMP-SMX increased from 35% in 2013 to more than 60% in 2015. For ciprofloxacin, the resistance increased from 15% in 2013 to about 45% in 2016. The highest annual E. coli resistance in blood cultures for TMP-SMX and ciprofloxacin was 37% and 28%, respectively. 10% of patients were hospitalized with a diagnosis of infection within the first 60 days after biopsy and there was a relative increase in mortality rate of 261% within the first 30 days. Due to the severity of the figures, the story and the NPR data were published in Norway's leading newspaper and were succeeded by a series of chronicles and commentaries. CONCLUSIONS: Several critical points of the biopsy procedure were not performed according to current standards. We believe that the patient might have died of septic embolism after biopsy. As a result of the findings and the debate, local practice was changed from transrectal to transperineal prostate biopsies.

Aspects of urinary tract infections and antimicrobial resistance in hospitalized urology patients in Asia: 10-Year results of the Global Prevalence Study of Infections in Urology (GPIU).

OBJECTIVES: To assess Asian data from Global Prevalence Study on Infections in Urology (GPIU study) which has been performed more than 10 years. METHODS: Seventeen Asian countries participated in the GPIU study between 2004 and 2013. Data for these countries were collected from the web-based GPIU database. The point prevalence of urinary tract infections (UTI) and antimicrobial susceptibility of representative pathogens were analysed for Asian geographic regions. RESULTS: A total of 6706 patients (5271 male, 1435 female) were assessed during the study period, and 659 patients were diagnosed with a UTI (9.8%). Of these UTI patients, 436 were male and 223 were female. Mean patient age was 54.9 ± 19.3 years. Pyelonephritis and cystitis were the most common clinical diagnoses, representing 30.7% and 29.9% of patients, respectively. Escherichia coli was the most frequently identified uropathogen (38.7%). For the patients with urinary tract infection, cephalosporins were the most frequently used antibiotics (34.4%), followed by fluoroquinolones (24.1%), aminoglycosides (16.8%). Fluoroquinolone resistance was relatively high (ciprofloxacin 54.9%, levofloxacin 39.0%), and cephalosporin resistance 42% (42.5-49.4%). Of the antibiotics evaluated, uropathogens had maintained the highest level of susceptibility to amikacin and imipenem (24.9% and 11.3% resistance rates, respectively). CONCLUSION: Uropathogens in many Asian countries had high resistance to broad-spectrum antibiotics. Knowledge of regional and local resistance data and prudent use of antibiotics are important for proper management of UTI in Asian countries.

Antimicrobial resistance in urosepsis: outcomes from the multinational, multicenter global prevalence of infections in urology (GPIU) study 2003-2013.

OBJECTIVE: Primary objective was to identify the (1) relationship of clinical severity of urosepsis with the pathogen spectrum and resistance and (2) appropriateness of using the pathogen spectrum and resistance rates of health-care-associated urinary tract infections (HAUTI) as representative of urosepsis. The secondary objective was to provide an overview of the pathogens and their resistance profile in patients with urosepsis. POPULATION AND METHODS: A point prevalence study carried out in 70 countries (2003-2013). Population studied included; 408 individuals with microbiologically proven urosepsis, 1606 individuals with microbiological proof of HAUTI and 27,542 individuals hospitalised in urology wards. Main outcomes are pathogens and resistance identified in HAUTIs and urosepsis including its clinical severity. A statistical model that included demographic factors (study year, geographical location, hospital setting) was used for analysis. RESULTS: Amongst urology practices, the prevalence of microbiologically proven HAUTI and urosepsis was 5.8 and 1.5 %, respectively. Frequent pathogens in urosepsis were E. coli (43 %), Enterococcus spp. (11 %), P. aeruginosa (10 %) and Klebsiella spp. (10 %). Resistance to commonly prescribed antibiotics was high and rates ranged from 8 % (imipenem) to 62 % (aminopenicillin/ß lactamase inhibitors); 45 % of Enterobacteriaceae and 21 % of P. aeruginosa were multidrug-resistant. Resistance rates in urosepsis were higher than in other clinical diagnosis of HAUTI (Likelihood ratio <0.05). CONCLUSIONS: It is not appropriate to use the pathogen spectrum and resistance rates of other HAUTIs as representative of urosepsis to decide on empirical treatment of urosepsis. Resistance rates in urosepsis are high, and precautions should be made to avoid further increase.

Resistance patterns of nosocomial urinary tract infections in urology departments: 8-year results of the global prevalence of infections in urology study.

OBJECTIVE: To present the worldwide antibiotic resistance rates of uropathogens reported in nosocomial urinary tract infections (NAUTI) during the period of 2003-2010. MATERIALS AND METHODS: Data from the Global Prevalence Study of Infections in Urology from the period of 2003-2010 were analyzed to evaluate the resistance rates of pathogens causing NAUTI. The web-based application was used to record data of investigators from urology departments participating in the study every year during the days allocated in November. Each center was allowed to enter data on a single day of the study. The point prevalence data was used to find differences among geographic regions and years by utilizing multiple logistic regression analysis. RESULTS: A total of 19,756 patients were hospitalized during the study period, and in 1,866 of them, NAUTI was reported. Proof of infection was reported in 1,395 patients. Resistance rates of all antibiotics tested other than imipenem against the total bacterial spectrum were higher than 10 % in all regions. Resistance to almost all pathogens was lowest in North Europe, and there is no single year where an outbreak of resistance has been detected. CONCLUSION: The resistance rates of most of the uropathogens against the antibiotics tested did not show significant trends of increase or decrease with Asia exhibiting the highest rates in general. The only antibiotic tested with an overall resistance rate below 10 % was imipenem. Knowledge of regional and local resistance data and prudent use of antibiotics are necessary to optimize antibiotic therapy in urological patients with NAUTI.

Healthcare-associated urinary tract infections in hospitalized urological patients--a global perspective: results from the GPIU studies 2003-2010.

INTRODUCTION: European Section for Infections in Urology has been conducting an annual prevalence survey investigating various aspects of healthcare-associated urinary tract infections (HAUTI) since 2003. MATERIAL AND METHODS: The data on various clinical categories of HAUTI, the contamination status of HAUTI patients who underwent any urological intervention with regard to microorganisms isolated, resistance status and antibiotics used to treat HAUTI will be presented. RESULTS: Of a total of 19,756 patients screened, 1,866 patients had HAUTI (9.4 %); 1,313 males (70.4 %) and 553 (29.6 %) females. Mean age was 59.9 ± 18.2. Asymptomatic bacteriuria (ASB) and cystitis were the most frequent clinical diagnoses representing 27.0 and 26 % of all HAUTI, respectively. Echerichia coli was found to be the most frequent uropathogen (544 of 1,371 isolates) (39.7 %). Fluoroquinolones were preferred in 26.6 % of cases followed by cephalosporins (23.3 %), aminoglycosides (14.1 %) and penicillins (13.8 %). High global resistance rates to ciprofloxacin (>50 %), cephalosporins (35-50 %) and penicillins (50 %) were found in the GPIU studies 2003-2010. DISCUSSION: We showed that around 10 % of hospitalized urological patients are at risk to develop HAUTI often caused by multiresistant uropathogens. Increased antibiotic use often with broad-spectrum antimicrobials will inevitably be followed by increasing bacterial resistance. To interrupt such a vicious cycle, our results suggest (1) there is still room for improvement in surgical prophylaxis in terms of limiting exposure to antibiotics and (2) far too many patients with ASB are being treated which shows that the new proposal of classification should be adopted where ABS is regarded as colonization and not as an infection to be treated.

The effect of smoking on spontaneous passage of distal ureteral stones.

BACKGROUND: Animal studies have shown that nicotine affects the peristalsis of the ureter. The aim of the study is to analyze the effect of smoking on spontaneous passage of distal ureteral stones. METHODS: 88 patients in whom distal ureteral stone below 10 mm diameter diagnosed with helical computerized tomography enhanced images were reviewed. Patients were grouped as either smokers (n:33) or non smokers (n:50). Follow-up for spontaneous passage of stones was limited with 4 weeks. Patients did not receive any additional medical treatment other than non-steroid anti inflammatory drugs only during painful renal colic episodes.Two groups were compared with the chi-square test in terms of passing the stone or not. Stone passage was confirmed with either the patient collecting the stone during urination or by helical CT. RESULTS: Smoking habits was present in 30(34%) patients and the frequency in both groups were similar (smokers: 23(76%) vs non-smokers: 46(79%)). Spontaneous passage of the stone was observed in 69(78%) patients. The two groups were comparable in terms of patient age, male to female ratio and stone size. Stone passage decreased as stone diameter increased. Total stone passage rates were similar in both groups (smokers: 76% vs. non-smokers: 79%) (p > 0.05). Passage of stones > 4 mm was observed in 46% and 67% of smokers and non-smokers respectively. However passage of stones with a diameter ≤ 4 mm were similar in both groups (smokers: 100% vs non-smokers: 92%) (p > 0.05). CONCLUSION: Smoking has neither a favorable nor un-favorable effect on spontaneous passage of distal ureteral stones. However, spontaneous passage rates in patients with a stone diameter > 4 mm was lower in smokers. These results should be further confirmed with studies including larger numbers of patients.

Linguistic and clinical validation of the Turkish version of Acute Cystitis Symptom Score for the diagnosis and patient-reported outcome in acute uncomplicated cystitis.

PURPOSE: The Acute Cystitis Symptom Score (ACSS) was developed as a self-reporting questionnaire for diagnosing and monitoring acute uncomplicated cystitis (AC) in female patients. The study aims at the translation of the ACSS into Turkish from the original Uzbek including its linguistic, cognitive and clinical validation. MATERIALS AND METHODS: After forward and backward translation of the ACSS from Uzbek to Turkish and vice versa, the cognitive assessment of the Turkish ACSS was performed on 12 female subjects to achieve the final study version. RESULTS: The clinical validation was performed on a total of 120 female respondents including 64 Patients with AC and 56 controls without AC. For clinical diagnosis of AC, the predefined summary score of the typical symptoms of >6 showed high values (95% confidence interval) for sensitivity (0.88 [0.77-0.94]), specificity (0.98 [0.91-1.00]), and diagnostic accuracy (0.93 [0.86-0.97]). All patients were followed up between five to nine days after the baseline visit. Forty-four (68.75%) patients used antimicrobial treatment, whereas the rest (31.25%) preferred non-antimicrobial treatment. The severity scores of the typical symptoms and the quality of life were reduced significantly at follow-up. Using different (favored) thresholds for successful and non-successful treatment a clinical success rate between 54.7% and 64.1% (60.9%) was achieved. CONCLUSIONS: After translation from the original Uzbek and cognitive assessment, the Turkish ACSS showed similar good results for clinical diagnosis and patient-reported outcome as in other languages validated so far and could therefore now be used for clinical studies as well as in everyday practice.

Epidemiology, treatment and prevention of healthcare-associated urinary tract infections.

OBJECTIVES: Healthcare-associated urinary tract infections (HAUTIs) are the most frequent healthcare-associated infections in general hospitals. They are almost exclusively complicated UTIs, although complicating factors are very heterogenous. HAUTIs are mainly catheter associated. Most of them are asymptomatic and do not need antimicrobial therapy. However, cross-contamination and cross-infection may contribute to distribution of resistant uropathogens. The bacterial spectrum of HAUTI is broad, and antibiotic resistance is common. METHODS: The authors reviewed the literature from 2000 to 2010 to determine the epidemiology, prevention and best treatment strategies for HAUTI. The recommendations were summarized by determining the level of evidence and grading each recommendation. RESULTS: The treatment for HAUTI encompasses treatment for complicating factors as well as antimicrobial chemotherapy. At least in serious UTI, adequate initial antibiotic therapy results in lower mortality. Therefore, the initial antibiotic regimen must provide sufficient antibiotic coverage. This can only be achieved if the local or regional bacterial spectrum and antibiotic resistance patterns of uropathogens are followed continuously. Provisional microbiological findings, such as reports on Gram-stain or certain biochemical results, can lead to early stratification of pathogens and allow a more tailored empiric antibiotic therapy. Antibiotic therapy of HAUTI has to consider therapeutic success in the individual patient and prevention of emergence of antibiotic-resistant mutants. For both aspects, adequate drug selection and dosing are paramount. DISCUSSION: Antibiotic treatment for HAUTI should follow prudent antibiotic use to prevent emergence of antibiotic resistance.

Preoperative assessment of the patient and risk factors for infectious complications and tentative classification of surgical field contamination of urological procedures.

PURPOSE: To assess the patient and identify the risk factors for infectious complications in conjunction with urological procedures and suggest a model for classification of the procedures. METHOD: Review of literature, critical analysis of data and tentative model for reducing infectious complications. RESULTS: Risk factors are bound to the patient and to the procedure itself and are associated with the environment where the healthcare is provided. Assuming a clean environment and sterile operation field, a five-level assessment ladder related to the patient and type of surgery is useful, considering: (1) the ASA score, (2) the general risk factors, (3) the individual endogenous and exogenous risk factors, (4) the class of surgery and the potential bacterial contamination burden and (5) the level of severity and difficulty of the surgical intervention. A cumulative approach will identify the level of risk for each patient and define preventive measures, such as the type of antibiotic prophylaxis or therapeutic measures before surgery. There are data suggesting that the higher the ASA score, the higher is the risk of infectious complication. Age, dysfunction of the immune system, hypo-albuminaemia/malnutrition and overweight, uncontrolled blood glucose level and smoking are independent general risk factors, whilst bacteriuria, indwelling catheter treatment, urinary tract stone disease, urinary tract obstruction and a history of urogenital infection are specific urological risk factors. There is inconclusive evidence for most other reported risk factors. The level of contamination of the surgical field is of utmost importance as are the procedure-related factors, and the sum of these have to be reflected on for the subsequent perioperative management of the patient. CONCLUSIONS: It is essential to identify and control risk factors to minimize infectious complications in conjunction with urological procedures. Our knowledge is limited and clinical research and quality registries analysing risk factors must be undertaken. We propose a working basis for assessment of patients' risk factors and classification of urological procedures.

Update on biofilm infections in the urinary tract.

PURPOSE: Biofilm infections have a major role in implants or devices placed in the human body. As part of the endourological development, a great variety of foreign bodies have been designed, and with the increasing number of biomaterial devices used in urology, biofilm formation and device infection is an issue of growing importance. METHODS: A literature search was performed in the Medline database regarding biofilm formation and the role of biofilms in urogenital infections using the following items in different combinations: "biofilm," "urinary tract infection," "bacteriuria," "catheter," "stent," and "encrustation." The studies were graded using the Oxford Centre for Evidence-based Medicine classification. RESULTS: The authors present an update on the mechanism of biofilm formation in the urinary tract with special emphasis on the role of biofilms in lower and upper urinary tract infections, as well as on biofilm formation on foreign bodies, such as catheters, ureteral stents, stones, implants, and artificial urinary sphincters. The authors also summarize the different methods developed to prevent biofilm formation on urinary foreign bodies. CONCLUSIONS: Several different approaches are being investigated for preventing biofilm formation, and some promising results have been obtained. However, an ideal method has not been developed. Future researches have to aim at identifying effective mechanisms for controlling biofilm formation and to develop antimicrobial agents effective against bacteria in biofilms.

Semirigid ureteroscopy: the effect of previous ipsilateral intraureteral manipulations on stone clearance.

We investigated whether previous intraureteral manipulations had an effect on the stone-free rates (SFR) after semi-rigid ureteroscopy (URS) with pneumatic lithotripsy. A retrospective review of all patients who were treated for ureteral stones at two different institutions from June 2003 through January 2010 was performed. Data of 161 URS procedures were analyzed. Stone size, location (distal, mid and proximal) and number (single and multiple), patient demographics and previous intraureteral manipulations were recorded. Patients were grouped as having undergone a previous ipsilateral intraureteral manipulation (Group 1) or not (Group 2). Stone location and number, stone clearance and ancillary procedures were compared. There were no significant differences between Group 1 versus Group 2 for age (p > 0.05), gender (p > 0.05), stone site (p > 0.05) and stone size (p > 0.05). Stones with multiple locations were more frequent in Group 1 (18.5%); however, the difference did not reach statistical significance between the two groups. Similarly, the frequency of multiple stones was also higher in Group 1 (29.6%). Stone site, diameter and gender were comparable in both groups. Stone-free rate of all patients was 84.6% after the first intervention. This rate increased to 98.1% after secondary procedures. Univariate analysis revealed that SFR after URS were low in patients who underwent previous intraureteral manipulations (Group 1:55.6% vs. Group 2:89.1%). SFR after the first intervention were related with stone size, location and number. Additionally, multiple logistic regression analysis indicated a relationship between previous intraureteral manipulations and initial stone clearance rates. Spontaneous passage of stone fragments after URS was associated with stone burden, location, number and previous intraureteral manipulations. Further multiple logistic regression analysis showed that only previous intraureteral manipulations were associated with the expulsion of the stones left for passage.

Analysis of factors related with bleeding in percutaneous nephrolithotomy using balloon dilatation.

INTRODUCTION: The aim of the present study is to determine the preoperative and operative factors associated with bleeding in percutaneous nephrolithotomy (PNL) operations where tract dilatation was formed by balloon dilators. MATERIAL AND METHODS: A total of 378 patients underwent PNL in our department between 2003 and 2008. After excluding missing data 310 patients were included in the study in whom nephrostomy tract dilatation was performed using balloon dilators. The amount of blood loss was estimated by calculating the change in hemoglobin (Hgb). Preoperative and operative factors were assessed for association with the change in Hgb levels. The preoperative factors were age, sex, hypertension, diabetes mellitus (DM), smoking, ipsilateral pyelonephritis, body mass index, serum creatinine level, stone localization and burden, previous ipsilateral renal stone surgery and extracorporeal shock wave lithotripsy and degree of hydronephrosis. Operative factors were operation time, calyx of puncture and tract number. The possible effect of surgical experience was also taken into consideration. Univariate and stepwise multiple linear regression analysis were performed. RESULTS: The average Hgb drop was 1.9 g/dL (range: 0.1 g/dL-8.8 g/dL). Ancillary procedures were performed due to the residual calculi in 23% of patients. The stone free rates increased from 77% to 94% after the secondary interventions. Prolonged operation time and presence of diabetes mellitus (DM) had a significant association with the decrease in Hgb levels (p < 0.05). However the remaining factors analyzed did not have any association with the change in Hgb values (p > 0.05). Previous ipsilateral open renal stone surgery was not associated with a change in Hgb levels (p > 0.05). Staghorn stones and operation expertise were the factors related with operation time (p < 0.05). CONCLUSIONS: In patients where tract dilatation is gained by balloon dilators prolonged operation time and DM are the major risk factors related with a higher incidence of blood loss. Surgical expertise is highly related with operation time. It would be wise to operate staghorn stones when a high surgical experience is gained.

Comparison of prostate cancer detection rates between the Vienna nomogram and the 10-core biopsy protocol.

OBJECTIVE: To compare the Vienna nomogram and the 10-core prostate biopsy protocol regarding whether there is superiority in prostate cancer detection. METHODS: Between January and December 2012, a total of 215 patients applying to our outpatient clinic with lower urinary tract symptoms were evaluated, prospectively. Patients with a prostate-specific antigen level of 2.5-10 ng/mL and/or suspicious digital rectal examination were included in the study. Exclusion criteria were determined as recent pelvic radiotherapy, lower urinary tract surgery, history of acute urinary retention, or indwelling urinary catheter. Biopsies were taken systematically with at least 10 cores considering prostate volume and patient age. According to Vienna nomogram, in patients requiring 6- or 8-core biopsies, tissue sampling was completed to 10 cores (our standard protocol), whereas in patients requiring more than 10 cores additional tissue sampling was performed. RESULTS: After the determination of inclusion/exclusion criteria, 170 patients were enrolled in our study. The median (min-max) age, prostate-specific antigen value, and prostate volume were 65 (48-86) years, 7.6 ng/dL (2.5-10), and 55 cc (17-150), respectively. Prostate cancer was detected in 49 (28.8%) patients with transrectal ultrasound-guided prostate biopsy according to the Vienna nomogram. We found that our standard 10-core biopsy protocol would have diagnosed prostate cancer in 46 (27.1%) patients in the same study group showing no statistically significant difference (p > 0.005). CONCLUSION: The findings of this study suggest that considering cancer detection rates no statistically significant differences were found between both methods. Further prospective research in this aspect is needed to define the ultimate prostate biopsy protocol.

Perivesical inflammation and necrosis due to mitomycin C instillation after transurethral resection of bladder tumor: we must be vigilant!

The instillation of chemotherapeutic agents after transurethral resection of bladder tumor as an adjuvant treatment in bladder tumors is accepted as being safe if there is no associated bladder perforation. Mitomycin C (MMC) is a widely used agent for the adjuvant treatment of bladder tumors. A patient who developed MMC-induced bladder perforation and perivesical necrosis after an uneventful endoscopic tumor is presented. We suggest that the possible reason for such a complication could be deep resection at the anterior bladder wall. The treatment of the situation continued for an extended period, causing serious discomfort for the patient. Withholding immediate intravesical MMC instillation after resection of tumors on the anterior bladder wall ought to be considered in the early postoperative hours.

Transurethral Resection of the Prostate: are We Following the Guidelines? - Outcomes from the Global Prevalence of Infections in Urology (GPIU) Study.

Transurethral resection of the prostate (TURP) is one of the most common urological procedures. With the increasing rate of multiresistant infections including urosepsis, it is essential for all surgeons to adhere to the relevant international guidelines to prevent infectious complications. The aim of this prospective, multinational, multicentre study was to evaluate compliance with recommended infection control measures regarding TURP procedures. The study was performed as a side questionnaire to the annual Global Prevalence Study of Infections in Urology (GPIU) between 2006 and 2009. Patients that had undergone TURP were eligible. Baseline data about hospitals and patients were collected. The questionnaire contained questions regarding preoperative microbiological investigations, catheter care and performance of perioperative antibiotic prophylaxis. A total of 825 men were included from 138 participating centres from Africa, Asia, Europe and South America. Only 50.1% of the patients received perioperative antibiotic prophylaxis with a median duration of 3 days (interquartile range [IQR] = 1-7 days). Preoperative urine culture was taken in 59.2%. The catheter was replaced in 1 week prior to the surgery only in 38.3% of cases. Compliance with the recommended infection control measures regarding TURP were only moderate, despite high grade recommendations in relevant international Guidelines. Stronger guideline adherence is necessary to improve patient care decrease antibiotic consumption in line with antibiotic stewardship in surgical practices.

The effect of varicocele repair on experimental varicocele-induced testicular germ cell apoptosis.

The purpose of this study was to evaluate the variance of apoptosis in rats in which experimental varicocele was induced and then treated by varicocelectomy. Forty adult male Wistar albino rats were used in this experimental study. Experimental varicocele was created in 30 rats. A total of 5 rats underwent a sham operation, and the remaining 5 rats were the control group. A total of 5 rats from the varicocele group were sacrificed on the 14th postoperative day, and 5 more were sacrificed on the 28th postoperative day to document the level of apoptosis due to varicocele. Varicocelectomy was performed on 20 rats with varicocele on the 14th postoperative day. These 20 rats were divided into 4 groups to evaluate the level of apoptosis in their testis after varicocelectomy. They were sacrificed on days 7, 14, 21, and 28 after varicocelectomy. The testes were fixated by perfusion with 10% formaldehyde and then placed in paraffin blocks. From each testis, 2 samples were stained with hematoxylin and eosin, and 2 samples were stained using the TUNEL method. In each specimen, apoptotic germ cells stained by TUNEL were counted in the cross section of 100 seminiferous tubules. The apoptotic index was defined by calculating the number of apoptotic cells per seminiferous tubule. Apoptotic index = total apoptotic germ cell count/100. In the adult rats on which experimental varicocele was performed, both in the second and fourth week, apoptosis in both left and right testes were significantly higher compared with the control group (with varicocele day 14: 0.25-0.26, with varicocele day 28: 0.28-0.32, control: 0.11-0.13). After varicocelectomy on the 7th and 14th days, the slight increase in the level of apoptosis continued (day 7 left testis: 0.30, day 7 right testis: 0.28; day 14 left testis: 0.25, day 14 right testis: 0.31). After varicocelectomy, apoptosis decreased significantly on day 21 (left testis: 0.16, right testis: 0,22), and on day 28 it was almost equal to the level of the control group (left testis: 0.14, right testis: 0.16). After the creation of unilateral varicocele, the level of apoptosis increased in both the left and right testes. Apoptosis in both testes decreased after surgical treatment.

Hospital acquired urinary tract infections in urology departments: pathogens, susceptibility and use of antibiotics. Data from the PEP and PEAP-studies.

Data from two internet-based studies on NAUTI in hospitalized urological patients are presented together: the Pan European Prevalence (PEP) study, which was a 1-day prevalence study in November 2003; and the Pan Euro-Asian Prevalence (PEAP) study, which was carried out in November 2004. Overall, 93 and 101 hospitals from the two studies, respectively, completed the hospital questionnaires and provided patient information for the present study. NAUTI was diagnosed according to the Centres for Disease Control and Prevention (CDC) criteria in 727 of the 6033 patients hospitalized on study days in urological departments. The most commonly reported pathogen was Escherichia coli (31%), followed by species of Pseudomonas (13%), Enterococcus (10%), Klebsiella (10%), Enterobacter (6%) and Proteus (6%). Candida spp. and Pseudomonas spp. occurred significantly more frequently as causative agents in urosepsis than in other types of infections. The resistance of E. coli, Klebsiella and Proteus spp. was below 45% for the most commonly used antibiotics. Enterococcus spp. and Pseudomonas spp. however, had resistance rates above 70% to most antibiotics. A total of 56% of the hospitalized urological patients were receiving antimicrobial therapy on the study day; 46% for prophylaxis, 26% for microbiologically proven UTI, 21% for only clinically suspected UTI and 7% for other infections. The most commonly used antibiotics were fluoroquinolones (35%), cephalosporins (27%), penicillins (16%), aminoglycosides (15%), and co-trimoxazole (9%). Differences between countries and regions were highly significant. There is an urgent need for continuous surveillance of NAUTI and improvement of antibiotic policy to counteract the widespread increase of antimicrobial resistance.

The Global Prevalence of Infections in Urology Study: A Long-Term, Worldwide Surveillance Study on Urological Infections.

The Global Prevalence of Infections in Urology (GPIU) study is a worldwide-performed point prevalence study intended to create surveillance data on antibiotic resistance, type of urogenital infections, risk factors and data on antibiotic consumption, specifically in patients at urological departments with healthcare-associated urogenital infections (HAUTI). Investigators registered data through a web-based application (http://gpiu.esiu.org/). Data collection includes the practice and characteristics of the hospital and urology ward. On a certain day in November, each year, all urological patients present in the urological department at 8:00 a.m. are screened for HAUTI encompassing their full hospital course from admission to discharge. Apart from the GPIU main study, several side studies are taking place, dealing with transurethral resection of the prostate, prostate biopsy, as well as urosepsis. The GPIU study has been annually performed since 2003. Eight-hundred fifty-six urology units from 70 countries have participated so far, including 27,542 patients. A proxy for antibiotic consumption is reflected by the application rates used for antibiotic prophylaxis for urological interventions. Resistance rates of most uropathogens against antibiotics were high, especially with a note of multidrug resistance. The severity of HAUTI is also increasing, 25% being urosepsis in recent years.