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Assessment of the infectious factor in transurethral surgery of benign prostate hyperplasia

https://doi.org/10.21886/2308-6424-2021-9-3-79-91

Abstract

Performing surgical interventions for benign prostate hyperplasia against the background of chronic urinary tract infection or prostatitis can adversely affect the course of the postoperative period and mediate the development of complications. Therefore, it is important to understand the pre- and postoperative bacterial status of the patients in various endourological surgical techniques and its relationship with possible infectious complications. This review raises the problem of insufficient knowledge regarding the clinical structure of infections during transurethral surgery, assessment of their relationship with the course of the underlying pathology and the severity of symptoms.

For citation:


Kogan M.I., Naboka Yu.L., Ivanov S.N. Assessment of the infectious factor in transurethral surgery of benign prostate hyperplasia. Vestnik Urologii. 2021;9(3):79-91. (In Russ.) https://doi.org/10.21886/2308-6424-2021-9-3-79-91

Introduction

Surgical interventions in patients with benign prostate hyperplasia (BPH) associated with urinary tract infections (UTI) or prostatitis can affect the postoperative period unfavorably and become a risk for complications. Thus, it is important to understand the preoperative and postoperative bacterial status of patients who undergo various endourological surgeries and its association with the possible development of infectious complications. It is known that complicated UTI develops as secondary pathology to the structural and functional impairments of the urinary and reproductive systems [1]. BPH is one such condition. Urethral catheterization plays a certain role in the development of bacterial processes in patients with BPH. In this case, such complications are separated into a group of catheter-associated ones. Clinically, these patients experience recurrent UTI episodes. UTI associated with BPH results from the impairments in the process of urination, which creates favorable conditions for bacterial growth. The symptoms of infection can vary from light dysuria, increased micturition frequency, and urinary urgency to severe systemic infection, macrohematuria, and episodes of acute urine retention. They are often associated with the manifestation of the primary disease. Benign prostate obstruction is considered to be the main predisposing factor for the development of asymptomatic bacteriuria (ABU) [2]. Symptomatic UTI rarely takes place before the development of prostatic obstruction that provokes urination impairments [2][3][4].

Database search

The authors searched for publications in the following medical databases: The Cochrane Database, MEDLINE/ PubMed Database, and eLIBRARY. The most significant and representative publications were selected. They included 48 publications on the presented problem of infectious complications in patients that underwent transurethral prostate resection (TURP) and laser surgery for BPH (41 publications dated back 10 years and 31 publications dated back 5 years).

The evaluation of UTI before endourological surgery in patients with BPH

Retrospectively, the authors' opinions on the prevalence of bacteriuria (BU) among patients before surgical interventions for BPH seem to be similar. Thus, its incidence rate varies within 27.0 – 44.7% [2][3][4][5]. There are some differences in the bacterial spectrum. A well-known uropathogen E. coli was isolated in 8.9–20.0% of cases in some studies [3][6]. While in other studies, it was revealed in the preoperative microbiota in 47.6–48.1% of cases [2][4]. E. faecalis was also discussed by the authors competing for the leading role in the development of symptomatic and asymptomatic bacterial processes. Some authors revealed it in 8.2–14.5% [6], others, in 40.0% [3]. S. aureus was isolated in the urine in 3.7–20.4% of cases [3][4], and K. pneumoniae – in 12.0–25.0% of cases [2][6]. P. aeruginosa was reveled in 1.6–11.8% [6]. Apart from the above-mentioned microorganisms, the authors isolated S. epidermidis, S. viridans, K. oxytoca, A. baumannii, P. mirabilis, Citrobacter spp., Providencia spp., and S. marcencens. It should be mentioned that mixed culture was revealed in 22.4 – 24.2% of cases [6]. The spectrum of microorganisms of the distal urethra in patients before TURP is as follows: more often identified – S. epidermidis (23.0–52.0%), E. coli (9.5–15.0%), S. aureus (10.0–14.0%), E. faecalis (2.4–7.7%), less often identified – M. morganii, P. aeruginosa, P. mirabilis, K. pneumoniae, Citrobacter spp., S. viridans, A. calcareus, H. influenzae, Providencia spp., S. marcencens, Candida spp. The role of S. epidermidis (8.0–15.0%) was less significant in the bacterial spectrum of the species identified in the prostate tissues and the shares of Enterobacter spp. (16.0–33.0%), E. faecalis (15.0–16.0%), M. morganii (15.0–16.0%), and E. coli (11.0–12.0%) were higher. In some cases, this locus contained P. aeruginosa, P. mirabilis, Citrobacter spp., S. aureus, K. pneumoniae, and Providencia spp. [7][8]. The analysis of bacterial content of hyperplastic prostate tissue biopsies revealed dominating roles of some anaerobic microorganisms that included Peptostreptococcus spp. (24.1%), Propionibacterium spp. (18.2%), and Eubacterium spp. (14.6%) [9].

The publications contained analysis on the combination of hyperplastic and infectious–inflammatory processes in the prostate. The role of BPH in the complicated development of UTI is hard to underestimate. The migration of bacteria in the prostate ducts in patients with BHP is promoted by intraprostatic urinary reflux [10]. In combination with an age-related decrease in the antibacterial properties of the prostate secret, this condition can lead to the accumulation of bacteria in the prostate and seminal vesicles and the development of infectious foci in these patients. Schneidewind et al. reported that in 52.9% of cases, the studied tissues collected after transurethral prostate resection contained the signs of chronic infectious-inflammatory processes in the prostate [11]. In 2011, Al-Hammouri et al. performed a histopathologic study of the samples collected after monopolar TURP and revealed chronic infection or prostate infarction in 96.5% of cases [12]. Umesha et al. noted that in patients with complicated pyelonephritis, BPH was risk factor and diabetes mellitus was the most common comorbid pathology [13]. The most important factors predisposing for bacterial accumulation and the further manifestation of infections included urine retention and hydronephrosis that were observed in the population of patients with indications for TURP in 40.0% and 8.9% of cases. Recurrent urine retention was revealed in around 28.0% of patients from this group [14][15]. Bacterial growth was observed in the urine samples in 27.0% of patients without symptoms. Among the verified microorganisms, E. coli (91.0%) prevailed. In patients with positive urine bacterial culture tests, the residual volume was around ≥ 150 ml. The analysis demonstrated that senior age, high IPSS, and residual volume positively correlated with bacteriuria. The lower was the volume of the retained urine, the higher was the possibility of a positive bacterial urine test. The volume of the residual urine with the highest sensitivity (87.0%) and specificity (98.5%) as a prognostic factor for the positive bacterial culture test was 180 ml. These data verify a well–known fact that one of the main methods of natural barrier from UTI is the complete emptying of the bladder [16]. Cai et al. [17] concluded that bacteriuria diagnosed in the preoperative period was not a predictor of UTI development in the postoperative period. However, this is disputed by other authors [18].

In the population of patients with BPH, researchers face episodes of periodic self-catheterization for acute or chronic urine retention. It is known that the application of urine diversion systems can affect qualitative and quantitative bacterial flora in the LUT. The that develop after catheterization are characterized by specific resistance and are included in a separate group [19]. Dybowski et al. analyzed catheter-associated bacterial flora among patients with BPH in the dynamics of three periods 1994–1996, 2004–2006, and 2011–2015 and revealed a more than ten-fold increase in the detection rate of mixed culture [20]. In comparison with a stable profile of gram-negative flora, the occurrence rate of gram-positive strains increased by nearly 4 times. According to the updated information, preoperative urine contains E. coli (27.0%), E. faecalis (19.0%), K. pneumoniae, P. aureginosa, E. cloacae (9.0% each), Coagulase-negative Staphylococci (CoNS), C. freundii, P. mirabilis (3.0% each), A. baumannii, K. oxytoca (2.0% each), E. faecium, S. aureus, S. marcensens (1.0% each) (Table 1).

Table 1. The microbial spectrum of urine in patients with benign prostate hyperplasia depending on the presence/absence of bladder catheterization episodes

Microorganisms

Urine microbiota of patients with BPH

Urine microbiota of patients with BPH and episodes of UT catheterization

R. Vennila et al. [4] (%)

M. Kikuchi et al. [3] (%)

J.O. Agbugui et al. [2] (%)

B.A. Dybowski et al. [20] (%)

E. coli

48.1

10.0

41.7

27.0

E. faecalis

39.7

19.0

S. aureus

3.7

1.2

14.6

⁓1.0

K. pneumonia

14.8

⁓1.3

25.0

⁓9.0

S. epiderimidis

⁓14.1

S. haemolyticus

⁓3.9

P. aeruginosa

7.4

⁓3.8

⁓4.2

⁓9.0

Enterobacter spp.

⁓6.3

E. cloacae

⁓9.0

P. mirabilis

3.7

⁓6.3

⁓3.0

C. freundii

⁓3.0

A. baumannii

7.4

⁓5.1

⁓2.0

M. morganii

⁓2.6

K. oxytoca

14.8

⁓2.0

Providencia spp.

⁓2.1

E. faecium

⁓2.0

S. mitis

⁓2.6

S. oralis

⁓2.6

Corynebacterium spp.

⁓2.6

Notes: BPH — benign prostate hyperplasia; UT — urinary tract.

A comparison of urine microbiota of the general population of patients with BPH and catheter-associated flora showed common tendencies. E. coli and E. faecalis were dominating uropathogens. K. pneumoniae and S. epiderimidis played significant roles but their differences were minimal.

The share of patients with manifested UTI before surgery varied from 10.0-20.0% [5][11], and the rate of recurrent UTI in the anamnesis was observed in 14.0% of cases [8]. At the same time, according to Shah et al, recurrent UTI, as well as epididymitis, determine the necessity in the surgical treatment only in 1.1% of cases [15].

Thus, the publications contain a critically low amount of detailed information on the structure of the infection observed in patients with transurethral interventions for BPH. This does not provide for an integral understanding of the influence of these associated pathological conditions on the quality of life of patients, effectiveness of these methods of correction and their indications, as well as the morbidity and mortality rates depending on the peculiarities of each type of UTI.

The evaluation of the infection after surgery

The studies conducted in the 20th century showed a significant rate of infectious complications after transurethral resection of BPH. In one of the largest studies by Vivien et al. (1998) that included 857 patients, the share of postoperative UTI was 19.3% and bacteriemia or septic complications were observed in 2.3% of cases [21]. Presently, there are various technological and methodological modifications of transurethral prostate surgeries. Thus, the population of patients that underwent such interventions is heterogeneous. After electrosurgery for BPH, the rate of postoperative infectious complications varies from 0.5 to 26.0% [22][23][24][25][26][27]. At the same time, the rate of postoperative bacteriuria reaches 36.0–42.0% [5][18]. This provides disputes on the classification of this event in the structure of early adverse events and sometimes remote adverse events in patients that underwent prostate surgery. Besides, a significant correlation between the rate of postoperative bacteriuria and the general rate of postoperative infectious complications was established [28].

 An issue of the bacteriological status of operated and related biotopes in patients with BPH is complicated and understudied. Some understanding was provided by a prospective multicenter comparative study conducted by Wagenlehner et al. The study included 400 patients from 14 urological centres in Germany. Bacteriuria was revealed within 5–7 days and 3–5 weeks of the postoperative periods in 22.0 and 26.0% of cases, respectively [28]. The authors reported that 38.0% of all episodes of bacteriuria were revealed after 4–6 weeks after TURP. A report provided by Huang et al. described a study that contained 121 patients after bipolar TURP. In 18.2% of them, postoperative bacteriuria was diagnosed. At the same time, in 27.0% of patients, it was revealed on day 6; in 64.0%, on day 7; and in 32.0%, in 4 weeks [23]. Osman et al. presented a similar study design on monopolar TURP. They analyzed urine and its cultivates three times (right after the removal of the catheter, one week, and three weeks after the surgery). This study was focused on the identification of persisting bacteriuria, which rate was 36.0% [18].

A shift to laser technologies did not solve the issue of postoperative infections, which was shown by the studies on the effectiveness of new methods. Among patients that underwent transurethral thulium laser surgery, the rate of postoperative UTI varied within 6.9–15.0% in the resection group [29][30][31][32] and 3.1–8.5% in the enucleation group [27][31], which was significantly lower than after mono or bipolar TUR. The rate of severe UTI with signs of bacteriemia after laser TUR was around 1.6%, while after electrosurgery, the rate of the described febrile UTI was 4.9% and sepsis – 2.3% [11][33]. The authors that studied the outcomes of holmium laser prostate surgery revealed that the general rate of UTI varied within – 6.7%, which was comparable with thulium laser surgery. In this case, the rate of postoperative bacteriuria varied from 23.0% to 25.0% [3][28].

In the context of the discussed interventions, the infectious process affects not only the urinary but also reproductive tracts. There were episodes of epididymitis associated with prostate electrosurgery. Its rate varied from 0.2 to 2.0% in patients without vasectomy. This complication usually manifests several weeks or months after the surgery. In rare cases, it is dangerous for a patient that receives medical therapy. Epididymitis also occurs after laser surgery. Shigemura et al. conducted a study that included 9 patients after HoLEP. The inflammatory process developed in the epididymis in two patients, pyelonephritis developed in two patients, and prostatitis – in three patients. Shah et al. reported that the incidence rate of epididymitis was 0.4–1.3% after HoLEP depending on the prostate size [14][15].

Wagenlehner et al. presented the data on a one-month postoperative follow-up of 400 patients. It showed the prevalence of mono-infection (62.0%). Mixed infection was revealed in 38.0% of cases [28]. In this case, the bacterial spectrum had the following structure: CoNS (23.0%), Enterococcus spp. (19.0%), E. coli (15.0%), S. aureus (10.0%), Proteus spp. Klebsiella spp. (6.0% each), Pseudomonas (5.0%), Streptococcus spp. (4.0%), Enterobacter spp. (2.0%), and Serratia marcescens (1.0%). After standard TURP in 208 patients, the bacterial spectrum of the urine showed a prevalence of gram-positive flora (52%): E. faecalis (23.0%), CoNS (20%), S. aureus (7,0%), and Streptococci (2,0%). Gram-negative microorganisms were isolated only in 48.0% of cases. Their spectrum was presented by E. coli (23.0%), Klebsiella spp. (9.0%), Pseudomonas spp. (7.0%), Enterobacter spp. (5.0%), C. Diversus, and P. vulgaris (2.0% each) [34]. At the same time, Colau et al. evaluated the rate of identification of E. faecalis one month after the surgery in 28.6% among 101 patients. For E. coli, this rate reached 42.9%. In 11 patients, positive bacteriologic urine test results were obtained with the isolation of two bacteria after the catheter removal (E. faecalis + S. epidermidis; E. faecalis + P. aeruginosa; E. faecalis + E. coli) [22]. The evaluation of the data on more than 440 patients performed by Schneidewind et al. showed that in the structure of febrile UTI, E. coli as an etiological factor was revealed in 82.7% and E. faecalis – in 17.3% [11]. The study on postoperative infectious complications among 190 patients after HoLEP also revealed a dominating role of E. faecalis in the microbiological pattern of the urine (30.7%), E. coli was identified in 11.5%, E. cloacae, A. baumannii, MRSA (7.7% each), and S. epidermidis, S. hominis, S. haemolyticus, S. haemolyticus, S. caprae, Corynebacterium spp., E. coli, P. aeruginosa, and E. aerogenes – 3.8% each [3].

A comparison of the bacterial spectra in the postoperative period after electrosurgery and laser surgery revealed similar results (Table 2).

Table 2. The microbiota spectrum after electro- and laser surgery of benign prostate hyperplasia

Method

Electrical surgery

Laser surgery

TURP (%)

TURP (%)

HoLEP (%)

Year

2005

2011

2016

Study

F.M. Wagenlehner et al. [28]

X. Huang et al. [23]

M. Kikuchi et al. [3]

Grampositive microflora

E. faecalis

19.0

15.0

30.7

CoNS

23.0

11.0

19.2

MRSA

7.7

S. aureus

10.0

Streptococcus spp.

4.0

Corynebacterium spp.

3.8

Gramnegative microflora

E. coli

15.0

70.0

11.5

E. coli ESBL

3.8

Klebsiella spp.

6.0

4.0

Proteus spp.

6.0

Pseudomonas spp.

5.0

3.8

Enterobacter spp.

2.0

E. cloacae

7.7

E. aerogenes

3.8

A. baumannii

7.7

S. marcescens

1.0

Other

9.0

Notes: TURP — transurethral resection of the prostate, CoNS — Сoagulase-negative Ыtaphylococci, MRSA — methicillin-resistant Staphylococcus aureus. ESBL — extended-spectrum beta-lactamases. HoLEP — holmium enucleation of the prostate.

After electro- and laser surgery, dominating pathogens were E. coli, E. faecalis, and CoNS. However, few studies on the microbial spectrum of the urine after endosurgery for BPH do not allow the authors to perform a more detailed analysis on the bacterial status and the association of its variability with different factors and surgical techniques.

A comparison of approaches to the identification of infectious complications after prostate transurethral surgery

It is interesting to compare the guidelines used by researchers at different periods. Vivien et al. (1998) relied on the directives of the Centers for Disease Control and Prevention (CDC) for the identification of postoperative infections where symptomatic UTI was represented by a combination of fever (>38 °C) and 1) local symptoms (such as urinary urgency, frequent micturition, dysuria, or suprapubic soreness); 2) bacteriuria > 105 CFU/ml when not more than two species revealed or with positive results to leukocyte and neutrophil activity in the urine; 3) microorganisms revealed by Gram staining, two cultivations of urine samples with repeated isolation of the same uropathogen at the concentration >102 CFU/ml in the urine and bacteriuria at <105 CFU/ml with one uropathogen during an ongoing antimicrobial therapy; 4) diagnose verification and indication of the respective antimicrobial therapy [21]. In general, these criteria are similar to the relevant criteria of CDC dated 2020 [21][35]. The CDC criteria for asymptomatic bacteriuria in 1988 included the lack of the above–mentioned clinical symptoms of UTI, bacteriuria >105 CFU, and body temperature < 38 °C. While in 2020, the authors of the updated guidelines do not consider the presence of fever to be the criterion that excludes asymptomatic bacteriuria. The guidelines of this institution were also used by Shigemura et al. (2013). They performed the identification of postoperative infectious complications based on the prevention of infection during surgical interventions (1999), wherein the criteria of postoperative infection of UT included fever >38 °C and signs of UTI for 30 days after the surgery [14].

The European Association of Urology (EAU) uses the protocols of the European Centre for Disease Prevention and Control, wherein UTI is defined as а) microbiologically verified symptomatic UTI, at the same time, at least one sign or symptom should coincide with a positive bacteriological urine test (≥105 CFU/ml with the identification of not more than two taxa of microorganisms); or b) non-microbiologically verified symptomatic UTI with at least two signs or symptoms that coincide with other criteria, for example, positive test to leucocyte esterase and/or nitrates [19].

The CDC protocols define catheter-associated infection (CAUTI) as a combination of ever or primarily diagnosed hypotension without alternative non-infectious cause, confusion of consciousness, intensification of pain or para-catheter purulent discharge, positive bacterial urine test that contains not more than two microorganisms, at least one microorganism should have 105 CFU/ml. The EAU guidelines (2020) have similar criteria. Still, they have certain differences in the evaluation of clinical manifestations of CAUTI in terms of characteristics of bacterial growth. Thus, the working group determines CAI after the identification of > 103 CFU/ml of one or several species of microorganisms in the urine sample collected from a catheterized patient or MSU within 48 hours after the removal of the catheter [19][35]. Unlike CDC, the EAU guidelines contain a description of catheter-associated asymptomatic bacteriuria (CA-ABU). In the 2020 revision, the EAU declares that patients with permanent and suprapubic catheters become the carriers of asymptomatic bacteriuria (ABU) resistant to antibacterial therapy. The differentiating criteria that distinguish CA-ABU from CAUTI include only UTI symptoms and not pyuria or specific urine smell.

The level of bacteriuria acknowledged by clinicians is defined by a high value of ≥ 105 CFU /ml. In rare cases, it can be lower. For example, Kikuchi et al. considered the results 104 CFU/ml as positive [3]. May et al. considered the concentration < 105 CFU/ml significant only when patients were receiving antibiotic therapy [6]. Thus, the methodology of identification of postoperative UTI does not have a uniform approach. Some authors consider the presence of uropathogens ≥ 104 or ≥ 105 CFU/ml in patients with and without a catheter, respectively [23][26]. Other authors classify any episode of clinical symptoms in the postoperative period as UTI or a combination of fever ≥ 38 °С or hypothermia ≤ 36.8 °С with positive bacterial urine test provided there are no other foci of clinical infection [6].

According to domestic guidelines “Bacteriological urine test” (2014), culture-based urine test should be made in case of “suspected UTI associated with medical manipulations (cystoscopy, catheterization) and medical care” and “increased body temperature in patients with permanent catheter”. During the interpretation of the urine test results, a diagnostically significant level of bacteriuria in patients with natural urination is ≥ 103 CFU/ml for primary infectious agents (E. coli, S. saprophyticus, etc.). For secondary pathogens (Enterobacter spp., Klebsiella spp., Proteus spp., P. aeruginosa, S. aureus, C. urealyticum, etc.) isolated as monoculture in men, it is 103 CFU/ml, in women – 104 CFU/ml. For the urine samples obtained via catheterization, it is ≥ 102 CFU/ml; for samples obtained via a permanent catheter from patients with UTI symptoms, it is ≥ 104 CFU/ml; in patients without clinical manifestations, it is ≥ 105 CFU/ml [36]. It can be seen that domestic, European, and American approaches are not identical.

The evaluation of the role of comorbidity in the development of infectious complications. The influence of an infectious factor on the development of other complications

During the evaluation of the association between comorbidity and infectious complications in surgical practice, Pokrzywa et al. revealed a statistically significant association between the development of UTI and any postoperative infectious and non-infectious complications [37]. A multifactor analysis that included initial differences between two groups also verified a high risk of postoperative complications in patients with UTI. According to these data, patients with UTI have a two-fold higher risk of postoperative complications in comparison with patients without preoperative UTI. The authors report that in the group of patients with UTI, the following concomitant diseases were observed more often: congestive heart failure (1.7% versus 0.6%), operative wound infection (10.8% versus 3.4%), and decrease in the body weight > 10% (6.5% versus 28.0%). A comparison of such individual complications as progressing renal injury, acute kidney injury, myocardial infarction, deep vein thrombosis, and thrombophlebitis showed that the share of patients with each of them was higher in patients with UTI. In particular, the difference in the risks of the development of complications between the two groups was the most significant in terms of respiratory complications, including unplanned intubation. It was noted that the urinary tract is the most common source of bacteriemia in senior people, which highlights the potential role of uropathogens in patients with systemic diseases.

Although numerous authors note that preoperative UTI is an independent predictor of infectious and non-infectious postoperative complications [37]. At the same time, it is still disputable if asymptomatic bacteriuria can increase the risk of postoperative complications. Salazar et al. evaluated the necessity for preoperative asymptomatic bacteriuria testing in patients with different profiles among more than 15 000 USA veterans. It was revealed that patients with asymptomatic bacteriuria developed operative wound infection 1.5 times more often within 30 days [38]. In the cohort of patients that underwent orthopedic and vascular interventions, postoperative UTI developed two times more often in patients with asymptomatic bacteriuria. In half cases, microorganisms isolated during the manifestation of the disease corresponded with the one isolated in the preoperative period. A similar tendency was observed in patients of traumatologic and neurologic surgery profiles [39, 40]. This discussion among authors and lack of a uniform opinion on the identification and therapy of this even suggest that ABU and UTI are potentially unfavorable factors for disease outcome and complications after surgical interventions, in particular, endourological treatment for BPH.

There are also data on certain associations between TURP outcomes and infectious episodes. Urethral stricture and bladder neck stenosis are common complications of this category. Huang et al. reported that it was observed more often in patients that underwent monopolar TURP with persisting positive results of bacteriological urine test for more than six weeks after the removal of a catheter [41]. Besides, according to Grechenkov et al. that also performed monopolar resection, this association was confirmed in patients with symptomatic UTI episodes and prostatitis [42]. Some authors consider UTI and prostatitis in the postoperative period to be risk factors for acute urine retention [43].

A heterogeneous group of patients with complicated general morbid backgrounds attracts the interest of researchers. Controversial views on the correction of perioperative variables can be explained by the lack of approved criteria of stratification of risks of complications and outcomes of transurethral interventions depending on the onset of certain associated and complicated conditions. The existing controversy of the available results of the studies is also associated with the lack of focus on the identification of initial characteristics of the groups in terms of systemic diseases and the indicated therapy in each case. Lv et al. reported a 1.5% rate of UTI in the group of patients older than 70 years old. The development of BPH in this group was complicated by one or more risk factors, including hydronephrosis, renal and/or heart failure, brain infarction, respiratory dysfunction, anemia, diabetes, and UT tumor [44]. At the same time, according to the study that included ~5000 patients (Taiwan National Research Database on Medical Insurance) that underwent TURP for BPH, patients with diabetes mellitus, who had a higher rate of concomitant diseases, demonstrated a lower rate of postoperative UTI and a higher rate of urine retention episodes that required catheterization within a month after TURP [26].

Hou et al. evaluated the initial and perioperative characteristics in the general population of patients with BPH and cerebrovascular disorders in the anamnesis [45]. In the second group of patients, the occurrence rate of such diseases as diabetes mellitus, hypertension, Parkinson's disease, chronic obstructive pulmonary disease, ischemic heart disease, and heart failure was 1.5-2.0 times higher than in the general group. The rate of UTI within 3 months was 18.4% in the control group and 27.7% in the group of cerebral strokes. It is interesting to note that within the first month after TUR, patients from the control and cerebral stroke group demonstrated a statistically similar occurrence rate of UTI within 21.0–26.0%. Within 1 month to 1 year after the surgery, the parameters in both groups restored a statistical difference and became around 20.0% in the control group and 30.0% in the group of patients with cerebral stroke.

It should be noted that patients from different groups of comorbidities often undergo therapy, which can influence the dynamics of perioperative parameters. Thus, a large group of patients with a high cardiovascular risk often undergo periodic or permanent therapy with anticoagulant, antiaggregant, and antiplatelet drugs. Clinical differences between this group of patients and the group of the general population after TURP were revealed by different authors. They noted a significantly larger weight of resected tissue in the group of patients that received oral anticoagulants and a lower rate of UTI development. The meta-analysis conducted in 2019 registered the following occurrence rates of UTI in the group of patients after HoLEP: 2.3–20.0% during antiplatelet therapy, 8.0–20.0% during anticoagulant therapy, and 2.0–5.0% during antiaggregant therapy [46]. At the same time, Becker et al. evaluated the data of more than 2000 patients that underwent similar intervention and revealed UTI in 24.0–25.0% of patients [32]. Tayeb et al. presented data on the development of urosepsis in 1.6% of patients after prostate laser surgery in the cases of indications to periodic or constant anticoagulant or antiaggregant therapy [47].

Thus, these studies demonstrate a common opinion on the aggravating interrelation of general comorbid background and infectious processes in the perioperative period. It should be noted that studies on BPH do not contain enough information for the evaluation of the association between comorbidity and infectious factor in patients indicated endosurgery for BPH. Besides, the available reports do not provide a possibility to compare different approaches to the application of electro and laser surgery for BPH by this criterion.

Conclusion

In general, the analysis of worldwide publications showed that the issues of the clinical structure of UTI in patients with BPH, their association with BPH development, and expression of symptoms are understudied. At the same time, the identification of conditionally asymptomatic infection in patients with complaints associated with symptoms of lower urinary tract symptoms and observed in many patients with BPH provokes disputes.

The most authors apply standardized protocols for the evaluation of postoperative complications [6][8][14][23][26]. The described studies on the effectiveness of electro and laser technologies in transurethral surgery (more than 30 years) show that approaches to microbiological evaluation of a significant level of bacteriuria are stable and barely changeable. Still, there is a certain tendency to the revision of the paradigms in clinical and biological studies [48]. The EAU does not provide guidelines on this issue. According to the EAU, the verification of complicated UTI diagnosis should be based on diagnostically significant levels of bacteriuria but these values are not specified [19].

It must be mentioned that in many studies on catheterized patients, there are insufficient data on the parameters of catheterization (type, duration, frequency) associated with the developing infectious complications. Thus, there is no separation of the population of patients with UTI after endosurgery for BPH into subgroups by the mentioned conditions. Similar observations on CAUTI refer to the reports on any infectious complications in the population of patients after prostate transurethral surgery, clinical structure, and peculiarities of their development that are generally considered to be understudied by clinicians.

The issues of the differentiation of symptoms and their association with certain links of complex impairments in patients with positive bacteriological urine tests and BPH remain unsolved. A difficulty in the management of patients with existing BPH and the infectious processes is in the variability of clinical development of diseases and evolution of microbiologic characteristics of bacterial agents because of increasing antibiotic resistance, self-indicated treatment of patients, and lack of a uniform view on the identification and adequate treatment for BPH and UTI in combination with the comorbid background. Thus, patients with developing postoperative infectious complications of local and systemic character present a heterogeneous group, and the parameters of their postoperative period in terms of the influence of these peculiarities remain understudied.

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About the Authors

M. I. Kogan
Rostov State Medical University
Russian Federation

Mikhail I. Kogan – Honored Scientist of the Russian Federation, M.D., Dr.Sc.(M), Full Prof.; Head, Dept. of Urology and Human Reproductive Health (with Pediatric Urology and Andrology Course)

344022, Rostov-on-Don, 29 Nakhichevanskiy ln.


Competing Interests:

The authors declare no conflicts of interest.



Yu. L. Naboka
Rostov State Medical University
Russian Federation

Yulia L. Naboka – M.D., Dr.Sc. (M), Full Prof., Head, Dept. of Microbiology and Virology № 1

344022, Rostov-on-Don, 29 Nakhichevanskiy ln.


Competing Interests:

The authors declare no conflicts of interest.



S. N. Ivanov
Kuban State Medical University
Russian Federation

Sergey N. – Student

Krasnodar

tel.: +7 (928) 179-52-43


Competing Interests:

The authors declare no conflicts of interest.



For citation:


Kogan M.I., Naboka Yu.L., Ivanov S.N. Assessment of the infectious factor in transurethral surgery of benign prostate hyperplasia. Vestnik Urologii. 2021;9(3):79-91. (In Russ.) https://doi.org/10.21886/2308-6424-2021-9-3-79-91

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