Clinical Report: Prophylactic Antibiotic Use in Urolithiasis Surgery
Overview
This systematic review evaluates the effectiveness of preoperative antibiotic prophylaxis in preventing postoperative infections in urolithiasis surgeries, including RIRS, URS, and PNL. Findings highlight variable infection rates and support guideline recommendations for antibiotic use tailored to surgical modality and patient risk factors.
Background
Urolithiasis affects up to 20% of the global population with rising incidence over recent decades. Minimally invasive surgeries such as ureteroscopy (URS), retrograde intrarenal surgery (RIRS), shock wave lithotripsy (SWL), and percutaneous nephrolithotomy (PNL) are common treatments. Postoperative infections, including sepsis, remain significant complications, with rates varying widely depending on procedure and patient factors. Current guidelines recommend antibiotic prophylaxis for URS and PNL but not for SWL.
Data Highlights
Procedure
Postoperative Fever (%)
Postoperative Sepsis (%)
Antibiotic Prophylaxis Recommendation
RIRS/URS
Variable
0.2 - 17.8
Recommended (weak strength)
PNL
10.8
0.5
Single-dose prophylaxis (strong strength)
SWL
Low
Low
Not recommended
Key Findings
Postoperative sepsis rates after RIRS range from 0.2% to 17.8%, with recent studies reporting 0.5% to 11.1%.
PNL is associated with a 10.8% incidence of postoperative fever and 0.5% sepsis rate.
EAU guidelines recommend single-dose antibiotic prophylaxis for PNL (strong recommendation) and prophylaxis for URS (weak recommendation), but not for SWL.
Preoperative urine cultures may not reliably predict pathogens found in renal pelvis or stone cultures, which can harbor multidrug-resistant organisms.
Systematic review included 13 studies (6 RCTs, 7 prospective), with varying risk of bias; five studies had low risk.
Targeted antibiotic therapy based on preoperative cultures may improve infection control but requires further validation.
Clinical Implications
Clinicians should adhere to guideline recommendations for antibiotic prophylaxis tailored to the type of urolithiasis surgery, emphasizing single-dose prophylaxis for PNL and considering prophylaxis for URS/RIRS. Routine prophylaxis is not advised for SWL. Preoperative urine cultures can guide targeted antibiotic use but may not fully capture resistant organisms present intraoperatively, underscoring the need for vigilant postoperative monitoring.
Conclusion
Antibiotic prophylaxis plays a critical role in reducing postoperative infections in urolithiasis surgeries, particularly PNL and URS/RIRS. Optimizing prophylactic strategies based on procedure type and microbiological data can improve patient outcomes and mitigate infection risks.
References
EAU Guidelines 2024 -- Antibiotic Prophylaxis in Urolithiasis Surgery
Walton et al. 2024 -- Concordance of Urine and Stone Cultures in PCNL
Systematic Review 2024 -- Prophylactic Antibiotic Use in Urolithiasis Surgery
