Endoscopic stone surgery in patients having asymptomatic bacteriuria

Introduction. Endoscopic surgery for the treatment of urolithiasis is highly effective but is associated with the risk of infectious complications. Nevertheless, endoscopy is also associated with the risk of postoperative infectious complications, the primary risk factor being positive urine culture. Considering the possibility of detecting persistent asymptomatic bacteriuria (ASB) in this patients amid the shortfall of clear algorithms and schemes of ASB management before endoscopy, a comparative analysis of infectious complications in patients with sterile urine and persistent ASB undergoing endoscopic surgery for renal and ureteral stones is an urgent task.

Оbjective. Analysis of the risk of infectious complications in patients undergoing endoscopic treatment of urinary stones, including those with preoperative evidence of asymptomatic bacteriuria.

Materials & methods. We conducted a cohort, retrospective study of data from eligible patients who underwent endoscopic removal of renal and ureteral stones between January 2023 and July 2023. From the 449 patient records selected, 211 patients fulfilling the established inclusion and non-inclusion criteria were enrolled in further analyses. Antibacterial prophylaxis was administered a few hours before surgery for initial sterile urine culture, three days before surgery for clinically insignificant ASB, and seven days before surgery for clinically significant ASB, followed by repeat control urine culture and determination of antibacterial prophylaxis according to the proposed methodology.

Results. A preoperative sterile urine culture was diagnosed in 152 patients (72.0%), while 59 patients 28% [22%; 34.5%] were found to have bacteriuria, of which 28 patients 13.3% [9%; 18.6%] had clinically significant bacteriuria at a titer of ≥ 10⁵ CFU/mL. After antibiotic therapy, ASB persisted in six patients (22.0%). Accordingly, 37 patients 17.5% [12.79%; 23.4%] with clinically significant and insignificant ASB underwent endoscopic surgery. In the postoperative period, 54 patients (25.6%) had leukocytosis, 17 patients (8.1%) had hyperthermia, and 11 patients (5.2%) had fever accompanied by leukocytosis One patient (0.5%) had an elevated procalcitonin level, which may indicate a systemic inflammatory response. Logistic regression analysis revealed statistically significant associations between the probability of hyperthermia and bacteriuria. A positive urine culture increased the odds of hyperthermia 4.75-fold (OR = 4,75, 95% CI [1.222; 18.803], p = 0.023). Maximum stone size (p = 0.013), stone volume, and ureteral stent drainage (p = 0.006) were the factors influencing the development of leukocytosis. Moreover, the volume of the stone increases the odds of leukocytosis by 1.54 times (OR = 1.543, 95% CI [1.128; 2.158], p = 0.008) for a 1.0 cc enlargement.

Conclusion. Our study shows that a positive urine culture is a significant risk factor for infectious complications after endoscopic surgery. Prolonged courses of antibiotic prophylaxis lasting seven and three days in patients having clinically significant and clinically insignificant ASB, respectively, seem adequate to minimize the risk of postoperative infectious complications. 

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