American Urological Association Best Research Articles

(242) Antimicrobial Prophylaxis for Inflatable Penile Prosthesis Surgery: Trends after Publication of the AUA Best Practice Statement

Abstract Introduction In April 2008, the American Urological Association (AUA) released a Best Practice Statement on antimicrobial use in urologic surgery, in which the combination of an aminoglycoside with either vancomycin or a 1st/2nd generation cephalosporin was recommended as the preferred antimicrobial regimen for inflatable penile prosthesis (IPP) implantation. This recommendation has come under scrutiny due to weak evidence supporting these combinations. Objective To assess changes in antibiotic prophylaxis for IPP surgery following publication of the AUA Best Practice Statement in April 2008. Methods The Premier Healthcare Database, an all-payer dataset that captures approximately 20% of hospital discharges in the United States, was queried for IPP surgeries from January 2000 to March 2020. The primary outcome was administration of an AUA-adherent antimicrobial regimen and secondary outcome was 90-day explant. Piecewise linear regression was used to compare antimicrobial trends before vs. after guideline publication. Multivariable logistic regression models were constructed for primary and secondary outcomes. Results A total of 26,574 patients who underwent IPP surgery were identified, of whom 17,754 (67%) received AUA-adherent antibiotics. After guideline publication, there was a 42% relative increase in AUA-adherent regimen usage, with an increase in the usage trend on piecewise linear regression (from 0.1% to 0.8% of encounters per quarter, R2=0.75, p<0.001). Increased usage trends were also observed for gentamicin (from 0.0% to 1.0% of encounters per quarter, R2=0.84, p<0.001) and vancomycin (0.1% to 0.7%, R2=0.77, p<0.001). On multivariable regression, odds of AUA-adherence increased after guideline publication (OR: 1.67, 95% CI: 1.54 – 1.80, p<0.001) and with surgery by a high-volume surgeon (OR: 2.21, 95% CI: 2.07 – 2.35, p<0.01). The risk of 90-day IPP explant was not associated with adherence to an AUA-recommended regimen (OR: 0.94, 95% CI: 0.75 – 1.18, p=0.6). Conclusions Publication of the AUA Best Practice Statement on Antimicrobial Prophylaxis was associated with a subsequent increase in the usage of AUA-recommended antibiotic regimens, with gentamicin and vancomycin being the most frequently used combination. No association was observed between AUA-adherent regimens and risk of 90-day explant. These findings suggest that the AUA Best Practice Statement, among other relevant communications on antimicrobial use at the time, led to significant changes in prophylactic antibiotic choice in IPP surgery, despite the absence of level-1 evidence regarding a superior choice. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Roman Health.

MP19-06 ANTIBIOTIC USE, BEST PRACTICE STATEMENT ADHERENCE, AND UTI RATE FOR INTRADETRUSOR ONABOTULINUMTOXIN A INJECTION FOR OVERACTIVE BLADDER: A MULTI-INSTITUTIONAL COLLABORATION FROM THE SUFU RESEARCH NETWORK

You have accessJournal of UrologyCME1 Apr 2023MP19-06 ANTIBIOTIC USE, BEST PRACTICE STATEMENT ADHERENCE, AND UTI RATE FOR INTRADETRUSOR ONABOTULINUMTOXIN A INJECTION FOR OVERACTIVE BLADDER: A MULTI-INSTITUTIONAL COLLABORATION FROM THE SUFU RESEARCH NETWORK Katherine Shapiro, Monica van Til, Stephanie Daignault-Newton, Giulia Lane, Ariana Smith, Una Lee, Anne Suskind, Jennifer Anger, Doreen Chung, W. Stuart Reynolds, Anne Cameron, Christopher Tenggardjaja, Priya Padmanabhan, Benjamin Brucker, and Sufu Research Network Katherine ShapiroKatherine Shapiro More articles by this author , Monica van TilMonica van Til More articles by this author , Stephanie Daignault-NewtonStephanie Daignault-Newton More articles by this author , Giulia LaneGiulia Lane More articles by this author , Ariana SmithAriana Smith More articles by this author , Una LeeUna Lee More articles by this author , Anne SuskindAnne Suskind More articles by this author , Jennifer AngerJennifer Anger More articles by this author , Doreen ChungDoreen Chung More articles by this author , W. Stuart ReynoldsW. Stuart Reynolds More articles by this author , Anne CameronAnne Cameron More articles by this author , Christopher TenggardjajaChristopher Tenggardjaja More articles by this author , Priya PadmanabhanPriya Padmanabhan More articles by this author , Benjamin BruckerBenjamin Brucker More articles by this author , and Sufu Research Network More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003244.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Onabotulinumtoxin A (BTX-A) is a well-established treatment for overactive bladder (OAB). The American Urological Association (AUA) 2008 Antibiotic Best Practice Statement recommended trimethoprim-sulfamethoxazole or fluoroquinolone for cystoscopy with manipulation. The aim of the study was to evaluate concordance with antibiotic best practices at the time of BTX-A injection and urinary tract infection (UTI) rates based on antibiotic regimen. METHODS: We included men and women undergoing first-time BTX-A injection for idiopathic OAB with 100 units in 2016 within the SUFU Research Network multi-institutional retrospective database. Patients on suppressive antibiotics were excluded. The primary outcome was concordance of periprocedural antibiotic use with the AUA 2008 Best Practice Statement. As a secondary outcome we compared the incidence of UTI at 15 days and 30 days after BTX-A among women. 15 days was used as a cutoff for a UTI attributed to BTX-A injection procedure, whereas a UTI within 30 days was considered a chronic effect of BTX-A. We assumed that patients who were not seen in the first 15 days did not have a UTI within 15 days. Fisher’s exact tests were applied for categorical variables. RESULTS: Of the cohort of 216 patients (175 women, 41 men) undergoing BTX-A, 24 different periprocedural antibiotic regimens were utilized. Among patients who had in-office visits within 15 days of BTX-A, 87% received periprocedural antibiotics and 47% received best practice statement-concordant antibiotics. There was no significant difference in UTI events between patients who received any antibiotics and those that did not at 15 day follow up (N=173, 6% vs 9%, p=0.4). Of patients who received antibiotics, UTI rates did not vary significantly depending on concordance with recommendations or not (N=133, 5% vs 7%, p=0.7). 81% of the 216 patients with 30-day follow up received periprocedural antibiotics. Of those, 47% received best practice statement-concordant antibiotics. At 30 days, there was no significant difference in UTI events based on antibiotic use (N=173, 11% antibiotics vs 16% no antibiotics, p=0.5) or best practice statement concordance or not 8% vs 16% (N=133, p=0.13). CONCLUSIONS: This retrospective multi-institutional study demonstrates that antibiotic regimens and adherence to the AUA Best Practice Statement was variable among providers and that UTI rates at 15 or 30 days following BTX-A did not vary significantly regardless of antibiotic use or alignment with best practices. Source of Funding: SUFU Research Network © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e266 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Katherine Shapiro More articles by this author Monica van Til More articles by this author Stephanie Daignault-Newton More articles by this author Giulia Lane More articles by this author Ariana Smith More articles by this author Una Lee More articles by this author Anne Suskind More articles by this author Jennifer Anger More articles by this author Doreen Chung More articles by this author W. Stuart Reynolds More articles by this author Anne Cameron More articles by this author Christopher Tenggardjaja More articles by this author Priya Padmanabhan More articles by this author Benjamin Brucker More articles by this author Sufu Research Network More articles by this author Expand All Advertisement PDF downloadLoading ...

Trends in Antimicrobial Prophylaxis for Inflatable Penile Prosthesis Surgery From a Large National Cohort

ObjectiveTo assess changes in antibiotic prophylaxis for inflatable penile prosthesis surgery following publication of the American Urological Association (AUA) Best Practice Statement in April 2008. Materials and MethodsThe Premier Healthcare Database was queried for inflatable penile prosthesis surgeries from January 2000 to March 2020. The primary outcome was administration of an AUA-adherent antimicrobial regimen and secondary outcome was 90-day explant. Piecewise linear regression was used to compare antimicrobial trends before vs after guideline publication. Multivariable logistic regression models were constructed for primary and secondary outcomes. ResultsA total of 26,574 patients who underwent inflatable penile prosthesis surgery were identified, of whom 17,754 (67%) received AUA-adherent antibiotics. After guideline publication, there was a 42% relative increase in AUA-adherent regimen usage, with an increase in the usage trend on piecewise linear regression (from 0.1% to 0.8% of encounters per quarter, R2 = 0.75, P < .001). Increased usage trends were also observed for gentamicin (from 0.0% to 1.0% of encounters per quarter, R2 = 0.84, P < .001) and vancomycin (0.1%-0.7%, R2 = 0.77, P < .001). On multivariable regression, odds of AUA-adherence increased after guideline publication (OR: 1.67, 95% CI: 1.54-1.80, P < .001) and with surgery by a high-volume surgeon (OR: 2.21, 95% CI: 2.07-2.35, P < .01). Nonadherence to an AUA-recommended regimen with use of nonstandard antibiotics (OR: 1.16, 95% CI: 0.78-1.71, P = .5) or excess antibiotics (OR: 0.91, 95% CI: 0.62-1.30, P = .6) was not independently associated with increased risk of 90-day explant. ConclusionsPublication of the AUA Best Practice Statement was associated with subsequent increases in the usage of guideline-adherent antibiotic regimens, particularly vancomycin and gentamicin, despite absence of level-1 evidence supporting this combination.

PD38-07 ANTIBIOTIC PROPHYLAXIS PRIOR TO OUTPATIENT UROLOGIC PROCEDURES: OUTCOMES FROM A DEPARTMENT-WIDE QUALITY IMPROVEMENT PROJECT

You have accessJournal of UrologyHealth Services Research: Quality Improvement & Patient Safety III (PD38)1 Sep 2021PD38-07 ANTIBIOTIC PROPHYLAXIS PRIOR TO OUTPATIENT UROLOGIC PROCEDURES: OUTCOMES FROM A DEPARTMENT-WIDE QUALITY IMPROVEMENT PROJECT Matthew Buck, Justin Nguyen, Alejandro Abello, Michael Leapman, Jaime Cavallo, and Patrick Kenney Matthew BuckMatthew Buck More articles by this author , Justin NguyenJustin Nguyen More articles by this author , Alejandro AbelloAlejandro Abello More articles by this author , Michael LeapmanMichael Leapman More articles by this author , Jaime CavalloJaime Cavallo More articles by this author , and Patrick KenneyPatrick Kenney More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002048.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urinary tract infections (UTI) are a common complication following office-based lower urinary tract procedures. While the American Urological Association Best Practice Statement provides guidelines on antibiotic prophylaxis in this setting, significant variability remains in practice. We assessed the effects of operationalizing a standardized approach to antibiotic use for outpatient lower tract procedures through a nursing-driven algorithm. METHODS: In February 2019, we implemented a clinical decision-support algorithm based on the Best Practice Statement within a regional healthcare network including five practice sites across two states. Covered procedures were outpatient cystourethroscopies with or without manipulation and urodynamic testing. Antibiotic selection was based on an algorithm consisting of established patient risk factors. Nursing staff assessed risk factors and administered single dose 3g oral fosfomycin for eligible patients. We evaluated the impact of our protocol in reducing site-level variation in antibiotic use, abnormal urinalysis, and rates of UTI. RESULTS: 12,909 patients were seen from January 2018 to December 2020, with 7,711 falling under the antibiotic protocol. We observed a reduction in the variation of antibiotic administration post-protocol (difference in SD = -10.55, p < 0.001), accompanied by an overall decrease in antibiotic use rate (- 9.4%, p < 0.001). Changes varied by site, with the pre-intervention highest utilizer experiencing a decrease (absolute percent change – 30.70%, relative percent change -60.99%) and the lowest utilizer experiencing an increase (absolute percentage change +14.92%, relative percentage change +46.83). Antibiotic use rate changes were not accompanied by a change in abnormal urinalysis (+2.69%, p = 0.437) or urinary tract infection ( +0.04%, p = 0.652). CONCLUSIONS: Operationalizing a standardized nurse-driven antibiotic prophylaxis pathway for office based cystoscopy reduced practice-level variation in antibiotic administration across a regional healthcare system. Changes in antibiotic practices were not associated with measurable changes in overall rates of UTI. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e664-e665 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Buck More articles by this author Justin Nguyen More articles by this author Alejandro Abello More articles by this author Michael Leapman More articles by this author Jaime Cavallo More articles by this author Patrick Kenney More articles by this author Expand All Advertisement Loading ...

Safety and effectiveness of zero antimicrobial prophylaxis protocol for outpatient cystourethroscopy.

To examine compliance and clinical outcomes after implementation of a zero antimicrobial prophylaxis protocol for outpatient cystoscopy in an academic centre. Medical records of all patients who underwent diagnostic cystoscopy in the year preceding and year following protocol implementation were evaluated for urinary tract infection (UTI) diagnosis within 30days of cystoscopy. Variables compared between groups included age, sex, smoking history, benign prostatic hyperplasia (BPH) diagnosis, diabetes mellitus, immunosuppression, catheter use (indwelling, suprapubic, or intermittent), and previous lower urinary tract reconstruction (augmentation cystoplasty or neobladder). UTI was defined using the National Surgical Quality Improvement Program definition. Rates were compared between groups, and statistical analyses were performed using chi-squared and Fisher's exact tests and multivariable logistic regression, with significance defined as α < 0.05. In total, 941 patients were included in the analysis (72% men), 513 before protocol initiation, and 427 after. Groups were similar with regard to demographic variables and potential risk factors for infection. After protocol implementation, there was a significant reduction in patients receiving procedural antimicrobial prophylaxis (30% vs 15%; P < 0.001). The incidence of UTI after cystoscopy was slightly higher in the post-protocol group (2.9-3.7%), but the difference was not statistically significant (chi-squared = 0.56, P = 0.45). The incidence of UTI did not significantly differ with procedural antibiotic prophylaxis or with other antibiotic use at time of cystoscopy. Five out of a total of 31 UTIs (16%) over the study period resulted in fever, and four (13%) resulted in urosepsis. The probability of neither complication differed significantly between pre- and post-protocol groups. The only significant patient-level predictor of post-cystoscopy UTI was catheter use (odds ratio 1.48, 95% confidence interval 1.06-2.06). Protocol implementation led to a significant decrease in procedural antimicrobial prophylaxis, indicating protocols may be effective tools in promoting antibiotic stewardship. UTI incidence did not change significantly under the protocol, and antibiotic prophylaxis did not decrease infection rate. Our results support catheter use as a risk factor for post-cystoscopy infection, but other patient variables, including those present in the American Urological Association Best Practice statement, were not predictive. In total, this analysis suggests that decreasing antibiotic prophylaxis for cystourethroscopy is safe and can be effective in the outpatient setting.

A Randomized Controlled Trial of Preoperative Prophylactic Antibiotics Prior to Percutaneous Nephrolithotomy in a Low Infectious Risk Population: A Report from the EDGE Consortium

Single institution studies suggest a benefit of a week of preoperative antibiotics prior to percutaneous nephrolithotomy. These studies are limited by lower quality methodology, such as the inclusion of heterogeneous populations or nonstandard definitions of sepsis. The AUA (American Urological Association) Best Practice Statement recommends less than 24 hours of intravenous antibiotics but to our knowledge no other data exist on the duration or benefit of preoperative antibiotics. Using CONSORT (Consolidated Reporting of Trials) guidelines we sought to perform a rigorous multi-institutional trial to assess preoperative antibiotics in patients in whom percutaneous nephrolithotomy was planned and who were at low risk for infection. This randomized controlled trial enrolled patients undergoing percutaneous nephrolithotomy who were at low risk, defined as negative preoperative urine cultures and no urinary drain. Of the subjects 43 were randomized to nitrofurantoin 100 mg twice daily for 7 days preoperatively while a control arm of 43 received no oral antibiotics. All subjects received perioperative doses of ampicillin and gentamicin. Prone percutaneous nephrolithotomy was performed by urologists blinded to randomization. The primary outcome was the development of sepsis. A total of 86 subjects were enrolled. Preoperative patient characteristics were similar in the treatment and control cohorts with a stone size of 19 and 17 mm, respectively (p = 0.47). Intraoperative characteristics also did not differ. The sepsis rate was not statistically different between the treatment and control groups (12% and 14%, respectively, 95% CI -0.163-0.122, p = 1.0). Other infectious parameters and complications were similar, including intensive care admission, fever, hypotension and leukocytosis. Our study demonstrated no advantage to providing 1 week of preoperative oral antibiotics in patients at low risk for infectious complications who undergo percutaneous nephrolithotomy. Perioperative antibiotics according to the AUA Best Practice Statement appear sufficient.

Author Reply

The present study suggests that the decision to use postoperative prophylactic oral antibiotics after artificial urinary sphincter or inflatable penile prosthesis is essentially a coin-flip, with roughly 60% choosing to do so. To this end, practices vary even between the authors' institutions, with some providers routinely prescribing up to 7 days of dual antibiotic coverage and others none at all. Who is right and who is rogue? One of these regimens (no postoperative oral antibiotics) adheres to the American Urological Association Best Practice Policy Statement, 1 Wolf J.S. Bennett C.J. Dmochowski R.R. et al. Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol. 2008; 179: 1379-1390https://doi.org/10.1016/j.juro.2008.01.068 Abstract Full Text Full Text PDF PubMed Scopus (608) Google Scholar whereas the other (7 days of dual antibiotic therapy) was developed in concordance with infectious disease specialists based on culture data from infections within the institution. As part of this collaboration with infectious disease specialists, prophylaxis for radical cystectomy was also broadened, with the result being significantly reduced rates of postoperative infection. 2 Pariser J.J. Anderson B.B. Pearce S.M. et al. The effect of broader, directed antimicrobial prophylaxis including fungal coverage on perioperative infectious complications after radical cystectomy. Urol Oncol. 2016; 34 (e9-e14): 121https://doi.org/10.1016/j.urolonc.2015.10.007 Abstract Full Text Full Text PDF Scopus (34) Google Scholar

Multidrug resistant bacteriuria before percutaneous nephrolithotomy predicts for postoperative infectious complications.

Multidrug resistant (MDR) uropathogens are increasing in prevalence and may contribute to significant morbidity after percutaneous nephrolithotomy (PCNL). We investigate the presence of MDR bacteriuria and occurrence of postoperative infectious complications in patients who underwent PCNL at our institution. Retrospective review was performed of 81 patients undergoing PCNL by a single surgeon (RLS) between 2009 and 2013. Patient demographics, comorbidities, stone parameters on imaging, and microbial data were compiled. MDR organisms were defined as resistant to three or more of the American Urological Association Best Practice Statement antimicrobial classes for PCNL. Postoperative complications were graded by Clavien score and European Association of Urology infection grade. Univariate comparisons were analyzed between patients with and without a postoperative infectious complication. Multivariate logistic regression was performed to determine significant predictor variables for postoperative infectious complications. Of the 81 patients undergoing PCNL, 41/81 (51%) had positive preoperative urine culture, 24/81 (30%) had positive MDR urine culture, and 16/81 (19%) had a postoperative infectious complication. Multivariate analysis revealed a positive preoperative MDR urine culture significantly increased the risk of postoperative infectious complication (odds ratio [OR]=4.89, 95% confidence interval [CI] 1.134-17.8, P=0.016). The presence of more than one access tract during PCNL also predicted for infectious complications (OR=7.5, 95% CI 2.13-26.4, P=0.003) Of the 16 patients with a postoperative infection 3 (18%) had postoperative urine cultures discordant with the preoperative urine cultures. Our institution demonstrated a relatively high prevalence of MDR bacteriuria in patients undergoing PCNL and that MDR is a significant risk factor for postoperative infectious complications despite appropriate preoperative antibiotics. Further investigations regarding prophylaxis modalities and infection prevention strategies are needed.

PD28-01 DOES PRE-OPERATIVE MULTI-DRUG RESISTANT URINE CULTURE PREDICT INFECTIOUS COMPLICATIONS AFTER PERCUTANEOUS NEPHROLITHOTOMY?

You have accessJournal of UrologyStone Disease: Evaluation I1 Apr 2014PD28-01 DOES PRE-OPERATIVE MULTI-DRUG RESISTANT URINE CULTURE PREDICT INFECTIOUS COMPLICATIONS AFTER PERCUTANEOUS NEPHROLITHOTOMY? Nishant Patel, MD Omer Raheem, MD Michael Liss, MD David Wenzler, MD William Shi, Craig Schallhorn, BS Charles Lakin, MD Michelle Ritter, andMD Roger L. SurMD Nishant PatelNishant Patel More articles by this author , Omer RaheemOmer Raheem More articles by this author , Michael LissMichael Liss More articles by this author , David WenzlerDavid Wenzler More articles by this author , William ShiWilliam Shi More articles by this author , Craig SchallhornCraig Schallhorn More articles by this author , Charles LakinCharles Lakin More articles by this author , Michelle RitterMichelle Ritter More articles by this author , and Roger L. SurRoger L. Sur More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2112AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES American Urological Association (AUA) Best Practice guidelines are in place to minimize infectious complications from percutaneous nephrolithotomy (PCNL). Multidrug resistant (MDR) uropathogens are increasing in prevalence and may contribute to significant morbidity following PCNL. We sought to document the prevalence of MDR baceteruria in patients whom underwent PCNL at our institution and evaluate whether presence of MDR bacteruria predicts for post-operative infectious complications. METHODS A retrospective review was performed of 83 patients undergoing PNCL by a single surgeon (RLS) between 2009-2013. Patient demographics, comorbidities, stone parameters on imaging, and microbial data was compiled. MDR organisms were defined as resistance to three or more of the AUA Best Practice Statement antimicrobial classes for PCNL (cephalosporin, aminoglycoside, fluoroquinolone, penicillin, clindamycin). Complications, Clavien score, and presence of post-operative infectious complications (EUA infection grade) were recorded. Univariate comparisons were analyzed between patients with and without a post-operative infectious complication. Multivariate logistic regression was performed to determine predicting variables for post-operative infectious complications. RESULTS Of the 83 patients undergoing PCNL, 49% had positive preoperative urine culture and 29% had positive MDR urine culture. Patients who had a post-operative infectious complication compared to those that did not, had an increased prevalence of staghorn calculus (50% vs. 18.6%, p=0.006) and an increased prevalence of pre-operative MDR urine culture (50% vs 20.3%, p=0.015). Controlling for age, stone size, and presence of renal structure abnormalities, multivariate analysis revealed presence of staghorn calculus increased the risk of a post-operative infectious complications by 4.15 times (95% CI 1.39-12.44, p=0.011). A positive pre-operative MDR urine culture increased the risk of post-operative infectious complication by 3.65 times (95% CI 1.23-10.87, p=0.02) despite appropriate culture-specific antibiotics. CONCLUSIONS Our institution demonstrated a relatively high prevalence of multi-drug resistant bacteruria in patients undergoing PCNL. The presence of a staghorn calculus and positive MDR urine culture predicted for a post-operative infectious complication. The higher risk of complications should be provided to patients undergoing PCNL and warrant extra attention to post-operative care by urologists. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e769 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Nishant Patel More articles by this author Omer Raheem More articles by this author Michael Liss More articles by this author David Wenzler More articles by this author William Shi More articles by this author Craig Schallhorn More articles by this author Charles Lakin More articles by this author Michelle Ritter More articles by this author Roger L. Sur More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Familiarity and Self-Reported Compliance with American Urological Association Best Practice Recommendations for Use of Thromboembolic Prophylaxis among American Urological Association Members

Thromboprophylaxis with subcutaneous heparin or low molecular weight heparin is now an integral part of national surgical quality and safety assessment efforts, and has been incorporated into the current AUA Best Practice Statement. We evaluated familiarity and compliance with the AUA Best Practice Statement, assessed practice patterns in terms of perioperative thromboprophylaxis and specifically examined self-reported compliance in high risk patients undergoing radical cystectomy. An electronic survey was sent to AUA members with valid e-mail addresses (10,966). Associations between AUA Best Practice Statement adherence and factors such as urological specialty, graduation year and guideline familiarity were assessed using chi-square analyses and generalized estimating equations. With 1,210 survey responses the largest group of respondents was urological oncologists and/or laparoscopic/robotic specialists (26.0%). This group was more likely to use thromboprophylaxis than nonurological oncologists and/or laparoscopic/robotic specialists in high risk patients (OR 1.3, CI 1.1-1.5). Respondents aware of the AUA Best Practice Statement guidelines (50.7%) were more likely to use thromboprophylaxis (OR 1.4, CI 1.2-1.6). Although 18.1% of urological oncologists and/or laparoscopic/robotic specialists and 34.2% of nonurological oncologists and/or laparoscopic/robotic specialists avoided routine thromboprophylaxis in patients undergoing radical cystectomy, the former were more likely to use thromboprophylaxis (p <0.0001) than other respondents. Urologists graduating after the year 2000 used thromboprophylaxis in high risk patients undergoing radical cystectomy more often than did earlier graduates (79.2% vs 63.4%, p <0.0001). Although younger age and self-reported urological oncologist and/or laparoscopic/robotic specialist status correlated strongly with thromboprophylaxis use, self-reported adherence to AUA Best Practice Statement was low, even in high risk cases with clear AUA Best Practice Statement recommendations such as radical cystectomy. These data identify opportunities for quality improvement in patients undergoing major urological surgery.

Incidence of Perioperative Urinary Tract Infection After Single-dose Antibiotic Therapy for Midurethal Slings

A recent Best Practice Statement published by the American Urological Association (AUA) recommends that antibiotic therapy in patients undergoing midurethral synthetic slings (MUS) should be 24 hours or less. Subjects at our institution are routinely administered a single dose of intravenous antibiotics before MUS surgery. We prospectively evaluated urinary tract infection (UTI) rates and risk factors for UTI in subjects undergoing MUS who receive single-dose antibiotic therapy. Adult female patients who were undergoing MUS for stress or mixed urinary incontinence were prospectively included and received a single-dose of an intravenous antibiotic in accordance with the AUA Best Practice Statement. Subjects requiring additional procedures for prolapse were excluded. Baseline characteristics and preoperative and postoperative postvoid residual (PVR) were documented. Subjects were contacted within 1 week of surgery, and seen in the office at 1 month, when a urinalysis was performed, and urine culture sent if subjects were symptomatic. A total of 101 subjects underwent solitary MUS and received a single dose of intravenous antibiotics. Overall, 6 (5.9%) subjects developed a UTI within 1 month of surgery. Patients who developed a UTI were more likely to have elevated PVRs at the preoperative office visit (62.2 vs 26.8 mL, P = .004). Our study has demonstrated that the rate of perioperative UTI after MUS with one perioperative dose of intravenous antibiotics is low. Patients with an elevated preoperative PVR may be at an increased risk of developing a UTI. Single-dose antibiotic administration is safe and effective at preventing perioperative UTI in subjects undergoing solitary MUS.

Editorial Comment

Asymptomatic microscopic hematuria (AMH) is a vexing problem for clinicians. Around 10%-15% of adults will have AMH during their lifetime and the American Urological Association Best Practice Policy recommends cystoscopy for all adults aged >40 years with microscopic hematuria and for those aged <40 years with risk factors for developing bladder cancer. 1 Grossfeld G.D. Litwin M.S. Wolf J.S. et al. Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association best practice policy—Part I: definition, detection, prevalence, and etiology. Urology. 2001; 57: 599-603 Abstract Full Text Full Text PDF PubMed Google Scholar , 2 Grossfeld G.D. Litwin M.S. Wolf Jr, J.S. et al. Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association best practice policy—Part II: patient evaluation, cytology, voided markers, imaging, cystoscopy, nephrology evaluation, and follow-up. Urology. 2001; 57: 604-610 Abstract Full Text Full Text PDF PubMed Google Scholar Despite these guidelines, many primary care physicians fail to refer patients with AMH for evaluation. 3 Nieder AM, Lotan Y, Nuss GR, et al. Are patients with hematuria appropriately referred to Urology? A multi-institutional questionnaire based survey. Urol Oncol, in press. Google Scholar One of the problems is the low risk of bladder cancer (2%-5%) and even lower risk of renal cancer, and the absence of tools to risk stratify patients based on likelihood for malignancy. The guidelines dictate the same evaluation strategy for all patients despite known differences in risk based on age, gender, ethnicity, smoking history, and environmental exposures. Utility of Urine Cytology in the Workup of Asymptomatic Microscopic Hematuria in Low-risk PatientsUrologyVol. 75Issue 6PreviewTo evaluate performance and cost-effectiveness of voided cytology in patients with pure asymptomatic microscopic hematuria (AMH). Although voided cytology has been validated for use in patients with a history of urothelial carcinoma (UC), its use in low-risk patients with AMH is controversial. Full-Text PDF ReplyUrologyVol. 75Issue 6PreviewThe commentary for our aforementioned article rightfully asserts the significant dilemma with which urologists are faced when evaluating low-risk patients with asymptomatic microscopic hematuria (AMH). Investigations used can have direct impacts on the sensitivity of cancer detection, as well as the overall cost of evaluation.1 Avoiding unnecessary investigation without affecting care is paramount. Although we support the use of AUA recommendations for AMH,2 which are designed to minimize under diagnosis, our series underscores the unproven nature of cytology in this specific population. Full-Text PDF

AUA Best Practice Statement for the Prevention of Deep Vein Thrombosis in Patients Undergoing Urologic Surgery

Summary of VTE prophylaxis recommendations Level of risk Prophylactic treatmentLow Risk ● No prophylaxis other than early ambulationModerate Risk ● Heparin 5000 units every 12 hours subcutaneous starting after surgery ● OR *Enoxaparin 40 mg. (Cr Cl 30 ml/min. 30 mg.) subcutaneous daily ● OR Pneumatic compression device if risk of bleeding is highHigh Risk ● Heparin 5000 units every 8 hours subcutaneous starting after surgery ● OR *Enoxaparin 40 mg. (Cr Cl 30 ml/min. 30 mg.) subcutaneous daily ● OR Pneumatic compression device if risk of bleeding is highVery High Risk ● *Enoxaparin 40 mg. (Cr Cl 30 ml/min. 30 mg.) subcutaneous daily and adjuvant pneumatic compression device, or ● Heparin 5000 units every 8 hours subcutaneous starting after surgery and adjuvant pneumatic compression device* Guidelines and Cautions for Enoxaparin Use ● In patients with a body weight 150 Kg. consider increasing prophylaxis dose of Enoxaparin to 40 mg. subcutaneous every 12 hours. ● Withhold Enoxaparin generally for at least 2 to 3 days after major trauma, and then only consider use after review of current patient condition and risk benefit ratio.

Evidence-Based Medicine: A Survey of American Urological Association Members

We investigated the attitudes and opinions of urologists toward evidence-based medicine. In April of 2005 we contacted members of the American Urological Association listed with an e-mail address to participate in a web based survey. Participants were asked to characterize their level of agreement with statements referring to the role of evidence-based medicine in urology, to indicate their level of understanding of 15 evidence-based medicine related terms and to report their familiarity with 6 evidence-based medicine related resources. Of 8,100 American Urological Association members 714 (8.8%) responded to this survey. There was widespread agreement (median score 9) with the concept that evidence-based medicine improves patient care and that every urologist should be familiar with critical appraisal techniques. Select terms such as median/mean, selection bias and type I error were well understood ("understand and could explain to others") by 86%, 57% and 17%, respectively. The American Urological Association Best Practice Guidelines were the single best known resource that 91% of respondents reviewed or used regularly. To our knowledge this survey represents the first evidence-based medicine survey of a large international group of urologists. Its results indicate that evidence-based medicine is viewed favorably and that the American Urological Association Best Practice Guidelines present a well accepted instrument for the dissemination of evidence-based medicine in urology. However, given the low response rate and the potential for selection bias, interpretation of these results must be performed with caution. Future efforts should be directed toward providing increased opportunities for urologists to learn the principles of critical appraisal, facilitating the application of evidence-based medicine in the community and promoting high quality research.

Is Cytology Required for a Hematuria Evaluation?

The value of urine cytology in evaluating patients with hematuria remains controversial. The American Urological Association Best Practice Policy on Asymptomatic Microscopic Hematuria recommends cytology only in patients with risk factors for transitional cell carcinoma (TCC). This study evaluated how often urine cytology yielded supportive or unique information that led to the diagnosis of transitional cell carcinoma, the cost of that information and whether it would have been obtained using the current best practice policy. Between March 1976 and June 1985, 1,000 sequential patients with 1 episode of gross hematuria or microscopic hematuria, defined as greater than 3 red blood cells per high power field on 2 of 3 properly collected urinalyses, were evaluated according to a standard protocol in a closed panel health care system in the state of Hawaii. These records were reviewed to determine if urine cytology yielded supportive or unique information that led to the diagnosis of TCC. In 4 patients positive urine cytology was the sole finding supporting a TCC diagnosis. Urine cytology had a sensitivity of 55% and a specificity of 99.3%. The cost of a cytology result that yielded unique information was 8,367 US dollars using the 2002 Medicare reimbursement schedule. Urine cytology can have an important role in the evaluation of hematuria. The current American Urological Society Best Practice Policy using risk factors to select patients for urine cytology would have captured the 4 patients for whom cytology was the key to diagnosis. Urine cytology was comparable to excretory urography, creatinine and cystoscopy in terms of cost analysis.