Long-Term Antibiotic Treatment Prior to Laparoscopic Nephrectomy for Xanthogranulomatous Pyelonephritis Improves Postoperative Outcomes: Results from a Multicenter Study.

PURPOSE: Xanthogranulomatous pyelonephritis is a destructive bacterial infection typically necessitating nephrectomy. We hypothesized that long-term preoperative antibiotics would facilitate laparoscopic nephrectomy by reducing the renal inflammation. MATERIALS AND METHODS: We reviewed the records of all patients with histologically confirmed xanthogranulomatous pyelonephritis at 3 University of California institutions between 2005 and 2018. Patients were stratified by antibiotic treatment duration and surgical approach. Patients treated with long-term preoperative antibiotics (28 days or more of continuous treatment until surgery) were compared to patients treated with short-term antibiotics (less than 28 days) and those who only received single-dose prophylactic antibiotics before surgery. Patient demographics and operative outcomes were analyzed. Complications were assigned by Clavien-Dindo classification. RESULTS: Among the 61 patients, 51 (84%) were female and mean age was 50 years. There were 21 (34%) open procedures and 40 (66%) laparoscopic procedures. Median duration of antibiotic treatment was 5 days in those who received a short-term treatment and 87 days in those who received long-term treatment. Eleven patients received only prophylactic single-dose antibiotics. Using multivariate analysis among patients undergoing laparoscopic nephrectomy, controlling for preoperative drainage, long-term antibiotics resulted in a 6.5-day shorter length of stay (p=0.023) and less overall as well as milder postoperative complications (p <0.001). CONCLUSIONS: Greater than or equal to 4 weeks of preoperative antibiotics before laparoscopic nephrectomy for xanthogranulomatous pyelonephritis was associated with shorter length of stay and fewer, less severe postoperative complications.

Nephrostomy tubes placed emergently prior to percutaneous renal stone surgery are practical for obtaining access. / La colocación de nefrostomía percutánea antes de la cirugía percutánea de la litiasis facilita la obtención del acceso.

OBJECTIVES: Renal access in percutaneous nephrolithotomy (PCNL) may be obtained via a pre-existing nephrostomy tube (NT) tract; however, emergent NTs are not always ideal for subsequent surgery. We sought to determine the rate of NT tract usability and assess factors related to the usability of emergently placed NTs. METHODS: A retrospective review was performed of UC San Diego subjects undergoing percutaneous renal surgery between January 2016 and October 2018. Demographics and peri-operative variables were collected. The primary outcome was the usability of NT tract for dilation and instrumentation. "Usable" indicated a tract in which PCNL could be completed; "unusable" indicated lack of dilation and the requirement of additional tract(s) for PCNL. RESULTS: 35 PCNL cases had previous emergently placed NT which were indwelling at time of percutaneous surgery. 51% of these NT tracts (18/35) were deemed usable and dilated for PCNL. No significant difference was seen between usable and unusable NT groups for number of dilated tracts during PCNL (p=0.13), or either the location of indwelling NT (p=0.96) or renal stones (p=0.95). In the usable NT tract cohort PCNL access was via the lower pole 56% of the time, where as when previous NT tracts were deemed unusable, a separate upper-pole access was obtained intra-operatively 53% of the time (p<0.01). CONCLUSIONS: Pre-existing, emergent NTs served a ssufficient PCNL access tracts in over half of recorded cases. Contrary to recently published reports, the utility of pre-existing NTs appears to vary among health systems. Other variables, including the desired location of PCNL appear to directly influence the like lihood of NT tract usability.

OBJETIVOS: El acceso renal en la nefrolitotomía percutánea puede obtenerse a través de una nefrostomía pre-existente, aunque las nefrostomías urgentes no siempre son ideales para la posterior cirugía. Nosotros intentamos determinar la tasa de uso del tracto de nefrostomía y los factores de acceso relacionados con el uso de la nefrostomía urgente.MÉTODOS: Una revisión retrospectiva se realizó en UC San Diego de los pacientes que habían recibido cirugía renal percutánea entre enero 2016 y octubre 2018. Las variables demográficas y perioperatorias fueron recolectadas. El objetivo primario fue el uso del trayecto de nefrostomía después de dilatación e instrumentación.¨Usable"  indicó un trayecto en el que la nefrolitotomía percutánea se completo. "No usable" indicó falta de dilatación y el requerimiento de un nuevo trayecto para la cirugía percutánea. RESULTADOS: 35 casos de nefrolitotomía percutánea tenían nefrostomías urgentes previamente y presentes al empezar la cirugía. 51% de estos trayectos (18/35) fueron usados y dilatados para la nefrolitotomía percutánea. No hubo diferencias significativas entre los trayectos usables y no usables en el numero de trayectos dilatados durante la cirugía percutánea (p=0,13), ni en la localización de la sonda de nefrostomía (p=0,96) o las litiasis renales (p=0,95). En el grupo de pacientes con nefrostomía usable, en el 56% la nefrostomía accedía por el polo inferior. Cuando el trayecto de nefrostomía se considero no usable, un nuevo acceso intraoperatorio por el polo superior fue obtenido en el 53% de lo scasos (p<0,01). CONCLUSIONES: El trayecto de nefrostomía pre-existente fue suficiente para el acceso percutáneo en la mitad de los casos. Contrario a lo publicado recientemente, la utilidad de la nefrostomía pre-existente parece variar según el Sistema sanitario. Otras variables, incluyendo la localización deseada para la nefrostomía influencia el uso del trayecto.

Antibiotics are not necessary during routine cystoscopic stent removal: A randomized controlled trial at UC San Diego.

INTRODUCTION: Current American Urological Association (AUA) Best Practice Statement recommends antibiotic prophylaxis for cystoscopy with manipulation, including stent removal; although no Level 1b trials explicitly address prophylaxis for stent removal. We sought to determine the efficacy of prophylactic antibiotics to prevent infectious complications after stent removal. MATERIALS AND METHODS: Following institutional review board approval, patients undergoing removal of ureteral stent placed during stone surgery were recruited from July 2016 to March 2019. Patients were recruited at the time of stent removal and randomized to treatment (single dose 500 mg oral ciprofloxacin) or control group (no antibiotics). Telephone contact was attempted within 14 days of stent removal to assess for urinary tract infection (UTI) symptoms, antibiotic prescriptions, or Emergency Department visits. Primary outcome was UTI within 1 month of stent removal - defined by irritative voiding symptoms, fever or abdominal pain associated with positive urine culture (Ucx) (>100k colony-forming units/mL). RESULTS: Seventy-seven patients were enrolled, with 58 meeting final inclusion criteria for the analysis (33 treatment, 25 controls). No differences were seen with clinical and demographic variables, except a higher body mass index in the treatment group (P = 0.007). Positive Ucx rate before stone surgery (16.7% vs. 11.8%, P = 0.819) and at the time of stent removal (16.0% vs. 11.1%, P = 0.648) was not significantly different in treatment versus control groups, respectively. Primary outcome: No patients in either cohort developed symptomatic culture-diagnosed UTI within 1 month of stent removal. Of patients with documented phone follow-up (treatment n = 29, control n = 22), only one patient (control) reported any positive response on phone survey. CONCLUSIONS: We found a low infectious complication rate regardless of antibiotic prophylaxis use during cystoscopic stent removal. The necessity of antibiotics during routine cystoscopic stent removal warrants possible reevaluation of the AUA best practice statement.

Are Emergently Placed Nephrostomy Tubes Suitable for Subsequent Percutaneous Endoscopic Renal Surgery?

OBJECTIVE: To determine the percentage of emergently placed nephrostomy tubes (NT) that were subsequently deemed usable for definitive percutaneous nephrolithotomy or percutaneous antegrade ureteroscopy in patients presenting with nephrolithiasis. METHODS: A multi-institutional retrospective database review was completed to identify patients who underwent emergent NT placement and then subsequent percutaneous nephrolithotomy or percutaneous antegrade ureteroscopy. Demographic, operative, and postoperative data were collected. Complications were classified using the Clavien-Dindo system. RESULTS: A total of 36 patients with 41 NTs met inclusion criteria. Indications for emergent NT placement were: obstruction with evidence of urinary tract infection/pyelonephritis (61%) and obstruction with acute kidney injury (39%). After recovery from the acute event and NT placement and during subsequent percutaneous surgical procedures, 9 NTs (22%) were sufficient without need for additional percutaneous access, 2 NTs (5%) were partially sufficient and were used in conjunction with an additional percutaneous access tract, and 30 NTs (73%) were unusable. CONCLUSION: In this multi-institutional review, only 22% of NTs placed for emergent indications were sufficient for subsequent percutaneous surgery without the creation of additional percutaneous tracts. Urologists should be prepared to obtain additional access during definitive percutaneous renal surgery in patients who have had a tube placed under emergent conditions.