[Downloadedfreefromhttp://www.sjkdt.orgonSunday,March29,2015,IP:114.125.43.

234]||ClickheretodownloadfreeAndroidapplicationforthisjournal

Saudi J Kidney Dis Transpl 2010;21(2):290-294

2010 Saudi Center for Organ Transplantation

Saudi Journal
of Kidney Diseases
and Transplantation

Original Article
Urinary Infection Before and After Prostatectomy
Gholamreza Pourmand1, Amir Reza Abedi1, Ali Akbar Karami1, Patricia Khashayar2,
Abdul Rasoul Mehrsai1
1

Urology Research Center, 2Research and Development Center, Sina Hospital,

Tehran University of Medical Sciences, Iran

ABSTRACT. To determine the prevalence of pre and post prostatectomy related urinary tract infection and its correlation with peri-operative events, we studied 120 patients who underwent prostatectomy due to benign prostatic hypertrophy from September 2005 to September 2006. Urine
cultures were performed before the operations, after a week, and three months later. Data including
prostate volume, prostatic specific antigen (PSA), post voiding residue (PVR) and histopathological
reports as well as the duration of urinary leak, bladder irrigation, hospitalization, and catheterization
were studied. The mean age of the studied patients was 70.5 8 years. Significant preoperative bacteriuria was revealed in 18 (15%) patients of whom 14(77%) patients developed negative cultures
following the operation. Postoperative bacteriuria was detected in 9(7.5%) patients who negative
urine cultures preoperatively. Pre and post operative micro-organisms were different in the majority
of the cases. The mean PSA was higher in patients with a positive history of infection. Following
prostatectomy, patients with positive urine cultures had significantly longer urinary leakage, catheterization, and hospital stays compared with those who remained culture negative. We conclude that
the incidence of positive urine culture pri-prostatectomy for BPH can be improved by appropriate
antibiotic therapy, and the risk factors for postoperative urinary infection include preoperative infection, prolonged urinary leakage, catheterization, and hospital stay. The elevated PSA may be a risk
factor.
Introduction
Benign prostatic hypertrophy (BPH) is a disease of aging men. The incidence increases to
Correspondence to:
Dr. Gholamreza Pourmand
Sina Hospital, Medical Sciences/University,
Imam Khomeini Street,
Tehran 11367, Iran
E-mail: gh_pourmand@yahoo.com

more than 70% in the individuals of 61 to 70

years old and 90% in those 81 to 90 years of
age.1,2 Lower urinary tract symptoms (LUTS)
are a common complaint among middle-aged
men and are believed to be secondary to benign
prostatic hyperplasia (BPH) in two third of
these patients.2 Inflammation has been found to
coexists with the hypertrophy, and its etiology
remains controversial.1-4
Prostatectomy is associated with acceptable
early postoperative outcomes; complications are

[Downloadedfreefromhttp://www.sjkdt.orgonSunday,March29,2015,IP:114.125.43.234]||ClickheretodownloadfreeAndroidapplicationforthisjournal

Urinary infection before and after prostatectomy

Table 1. The frequency of urinary complaints in
the study patients
Urinary Complaints
Frequency (%)
Retention
38 (31.7)
Obstructive symptoms
34 (28.3)
Irritative symptoms
4 (3.3)
Obstructive and irritative
21 (17.5)
symptoms
Massive hematuria
21 (17.5)
Urinary Incontinence
2 (1.7)

291

reported in 17.3% of the cases. Bleeding requiring transfusion (7.5%) and urinary tract infections (5.1%) comprise the most frequent postoperative events.5
We aim in this study to determine the prevalence of pre and post operative urinary tract infection (UTI) and its correlation with the peri
and postoperative course.

removing the urethral catheter.

Ultrasound of kidney, bladder, and prostate was
performed for all patients. The prostate volume
was also determined for all the cases. Cystouretheroscopy was done as indicated.
Peri-operative antibacterial regimen included a
first-generation cephalosporin and gentamicine
prophylactically if the preoperative urine cultures
were negative. On the other hand, at least two
doses of a broad-spectrum antibiotic against
gram-negative micro-organisms were administered to patients with indwelling catheters; the
patients were instructed to continue oral antibiotics until the catheters were removed.
Data on each patients prostatectomy type,
prostate volume, post-voiding residue (PVR) volume, prostatic histopathological reports, catheterization and hospitalization period were recorded.

Methods

Statistical analysis

After being approved by the ethic committee of

Tehran University of Medical Sciences, this prospective study was conducted on BPH patients
who underwent prostatectomy at the Sina Hospital from September 2005 to September 2006.
BPH patients with any history of refractory
retention, bladder stone, bladder diverticula, recurrent urinary infection, gross hematuria, uremia
and poor quality of life were enrolled in the
study. An informed consent was obtained from
all patients.
The patients were selected to undergo open
transvesical prostatectomy and transurethral resection prostatectomy (TURP) based on the indications of the operation as well as their prostate volume and preference. The same urologists and operation team performed all operations.
Bladder irrigation started closely after the surgery in the operating room and continued for
one or two days. Urethral catheter was removed
on the 3rd-12th postoperative day.
We obtained serum prostatic specific antigen
(PSA), creatinine, and blood urea nitrogen (BUN)
on the day before the operation, in addition to
urine samples for urinalysis and preoperative
urine culture. Postoperative urine culture was repeated in a week and then three months after

The gathered data were analyzed using the statistical package SPSS version 13. Chi-square and
students t-test were used for analyzing qualitative and quantitative variables. P value < 0.05
was considered significant.
Results
We studied 120 patients with a mean age of
70.5 8 years. Table 1 demonstrates the frequency of the reported urinary complaints. The
most common complaints were urine retention
and obstructive symptoms.
Eighty-three (69.2%) of the patients underwent
TURP, whereas open transvesical prostatectomy
was performed in the remainder. The mean preoperative creatinine and hemoglobin levels were
1.23 0.52 mg/dL and 14.38 1.58 mg/dL,
respectively. The mean prostate volume was 55
23 mL; it was not statistically significantly correlated with the risk of urinary infection (P
value= 0.8).
Hydronephrosis and bladder stones were detected in 7 (5.8%) and 10 (8.3%) of the patients,
respectively; there was no statistically significant correlation between the presence of these
two risk factors and the development of urinary

[Downloadedfreefromhttp://www.sjkdt.orgonSunday,March29,2015,IP:114.125.43.234]||ClickheretodownloadfreeAndroidapplicationforthisjournal

292

Pourmand G, Abedi AR, Karami AA, et al

Table 2. The outcome in patients with postoperative urine cultures

Positive cultures
Negative cultures
Prostate volume (cc)
61 24
53 23
Catheterization time (days)
12
5
Urinary leak (days)
10 2
41
Pre op. bacteriuria
4
14
PVR (cc)
100 69
104 100
Post op. hospitalization (days)
10 2
41
Bladder irrigation (days)
6
2
*: Significant

infection (P= 0.76, 0.33, respectively).

Table 2 shows that the catheterization period
was significantly longer in patients with urinary
leak (12 days vs. 5 days; P value= 0.01). Longer
urinary leak significantly correlated with urinary
infection (P= 0.03).
Preoperative bacteriuria was revealed by positive urine cultures in 18 patients (15%), of whom
14 (77.7%) patients developed negative urine
cultures following the operation. Postoperative
bacteriuria was detected in the 4 other cases.
The pre and post operative micro-organisms
were different in the majority of cases (E. coli/
pseudomonas sp., E. coli/E. coli, E. coli/Klebsilla sp., Klebsilla sp./E .coli).
Postoperative bacteriuria developed a week after the catheter removal. Ten of the aforementioned patients had urinary catheters for eight
days while the catheter was removed after 3
days in the other 3 subjects (P = 0.001). Postoperative septicemia was reported in 2 of these
cases; pathologic evidence in accordance with
prostatic microabscess was reported in one of
these cases.
All the isolated bacteria were sensitive to quinolone antibiotics, and accordingly ciprofloxacin was included in the therapy.
Nine patients (8.8%) with negative preoperative urine-culture developed urinary infection
within a week following the operation; E.coli (5
cases) and klebsilla sp. (4 cases) were the 2 micro-organisms revealed by urine culture.
The mean PSA levels in the patients with positive urine culture was 6.2 3.6 ng/mL compared
to 4.8 5 ng/mL in the patients with negative cultures (P= 0.5). Post voiding residue was not statistically correlated with urinary infection (P= 0.37).
The means of postoperative hospitalization stay

P value
0.8
0.01*
0.03*
0.037*
0.37
0.01*
0.01*

and duration of bladder irrigation were longer

in the patients with positive urine cultures (10
versus 5 days; P= 0.01), respectively (6 vs. 2
days; P= 0.01).
Discussion
In our study, the incidence of bacteriuria following prostatectomy was 10.8%. Only 1 patient
developed bacteremia secondary to urinary tract
infection. Our findings revealed that 18 (15%) of
the 120 studied cases had significant preoperative bacteriuria; postoperative bacteriuria was
confirmed only in 4 (3.3%) cases with appropriate antibiotic therapy. Conversely, 9 (8.8%)
patients with sterile preoperative urine culture
developed urinary infection within a week following their prostatectomy.
In a meta-analysis conducted by Qiang et al,
bacterial contamination was detected in 44% of
the BPH prostatic specimens. They reported
satisfactory results and reduced infection rate
following preoperative antibiotic prophylaxis in
TURP patients.6 Other studies found similar results and the rate decreased shortly after the
operation with antibiotic therapy.7-12
Several risk factors have been identified for
post- TURP infection; the major factors include
preoperative bacteriuria, longer operating time
(> 70 minutes), long preoperative hospitalizations (more than 2 days), long indwelling postoperative urethral catheters (for more than 3
days), and open drainage systems.7,13,14 four risk
factors were significantly associated with the
occurrence of bacteriuria in our study including
long bladder irrigation phases, long hospitalizations, long catheterization periods, and long urinary leaks.

[Downloadedfreefromhttp://www.sjkdt.orgonSunday,March29,2015,IP:114.125.43.234]||ClickheretodownloadfreeAndroidapplicationforthisjournal

Urinary infection before and after prostatectomy

Ohkawa et al found that 80.8% of the species

isolated from blood specimens were similar to
the reported preoperative species.15 Our study
similarly showed that preoperative bacteriuria
was significantly related to the postoperative infection, but in contrast to Ohkawas findings,
we found in our study that the preoperative and
postoperative species were different except for
a single case.
Postoperative bacteriemia was found in 22.7%
of the patients, one of whom developed septicemia, and prophylactic antimicrobial therapy
did not influence the rate of bacteriemia.16 The
low prevalence of septicemia in our study could
be due to the fact that all the patients with positive preoperative cultures were treated with
antibiotics prior to the operation.
Prophylactic continuous irrigation with various
solutions, especially for 10 days or less following
the indwelling catheter insertion, has been demonstrated to be effective in reducing the risk
of bacteriuria in open catheter drainage systems.
Prophylactic antimicrobial irrigation in closed
catheter systems is ineffective and is associated
with the development of the species resistant to
the irrigating solution.17 Moreover, preoperative
bladder instillation with povidone-iodine may reduce the risk of post prostatectomy wound infection as well as bacteriuria in patients with indwelling catheters.18 Chlorhexidine irrigation may
also reduce the risk of infection in these cases.19
We conclude that the incidence of positive
urine culture pri-prostatectomy for BPH can be
improved by appropriate antibiotic therapy, and
the risk factors for postoperative urinary infection include preoperative infection, prolonged
urinary leakage, catheterization, and hospital
stay. The elevated PSA may be a risk factor.

293

2.
3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

Acknowledgement
The present study was performed, thanks to the
grant number 2433 offered by Tehran University of Medical Sciences.
References
1.

Nickel JC. Inflammation and benign prostatic

13.

14.

hyperplasia. Urol Clin North Am 2008;35(1):

109-15.
Hirst GH, Ward JE. Clinical practice guidelines:
Reality bites. Med J Aust 2000;172:287-91.
Yi FX, Wei Q, Li H, et al. Risk factors for prostatic inflammation extent and infection in benign
prostatic hyperplasia. Asian J Andro1 2006;8(5):
621-7.
Roehrbom CG, Kaplan SA, Noble WD, et al.
The impact of acute or chronic inflammation in
baseline biopsy on the risk of clinical progresssion of BPH: Results from the MTOPS study.
2005 AUA meeting. J Uro1 2005;173(Suppl4):
346
Gratzke C, Schlenker B, Seitz M, et al. Complications and early postoperative outcome after
open prostatectomy in patients with benign
prostatic enlargement: Results of a prospective
multicenter study. J Urol 2007;177(4):1419-22.
Qiang W, Jianchen W, MacDonald R, et al.
Antibiotic prophylaxis for transurethral prostatic
resection in men with preoperative urine containing less than 100,000 bacteria per ml: A
systematic review. J Urol 2005;173:1175-81.
Colau A, Lucet JC, Rufat P, et al. Incidence and
risk factors of bacteriuria after transurethral
resection of the prostate. Eur Urol 2001;39(3):
272-6.
Fuiita K, Sayama T, Murayama T, Kawamura
M. Incidence of infection after transurethral
prostatectomy. Jpn J Antibiot 1986;39(4):905-8.
Collste LG, Torngvist H. Urinary infection and
transurethral prostatectomy. Scand J Urol Nephrol
1978;12(1):7-9.
Milcent S, Berlizot P, Palascak R, et al. Value
and justification of urine dipsticks in the diagnosis of postoperative urinary infections in urology. Frog Urol 2003;13(2):234-7.
Gordon DL, McDonald PI, Bune A, et al. Diagnostic criteria and natural history of catheterassociated urinary tract infections after prostatectomy. Lancet 1983;3(8362):1269-71.
Pestalozzi DM, Boss HP, Knonagel H. Infectious complications after transurethral resection.
Helv Chir Acta 1992;59(3):497-500.
Rassweiler J, Teber D, Kuntz R, Hofmann R.
Complications of Transurethral Resection of the
Prostate (TURP)-Incidence, Management, and
Prevention. Euro Urol 2006;50:969-80.
Vivien A, Lazard T, Rauss A, Laisne MJ,
Bonnet F. Infection after transurethral resection
of the prostate: variation among centers and
correlation with a longlasting surgical procedure.

[Downloadedfreefromhttp://www.sjkdt.orgonSunday,March29,2015,IP:114.125.43.234]||ClickheretodownloadfreeAndroidapplicationforthisjournal

294
Association pour la Recherche en AnesthesieReanimation. Eur Urol 1998;33(4):365-9.
15. Ohkawa M, Shimamura M, Tokunaga S, Nakashima T, Orito M. Bacteremia resulting from
prostatic surgery in patients with or without
preoperative bacteriuria under perioperative
antibiotic use. Chemotherapy 1993;39(2):140-6.
16. Tokunaga S, Ohkawa M, Oshinoya Y, et al.
Bacteremia from transurethral prostatic
resection under prophylactic use of antibiotics.
Kansen-shogaku Zasshi 1991;65(6):698-702.
17. Dudley MN, Barriere SL. Antimicrobial irrigations

Pourmand G, Abedi AR, Karami AA, et al

in the prevention and treatment of catheterrelated urinary tract infections. Am J Hosp
Pharm 1981;38(1):59-65.
18. Richter S, Kotliroff O, Nissenkom I. Single
preoperative bladder instillation of povidoneiodine for the prevention of post prostatectomy
bacteriuria and wound infection. Infect Control
Hosp Epidemiol 1991;12(10):579-82.
19. Bastable JR, Peel RN, Birch DM, Richards B.
Continuous irrigation of the bladder after
prostatectomy: its effect on post-prostatectomy
infection. Br J Urol 1977;49(7):689-93.