Clinical Scorecard: Assessment of Urine Culture Utility During Stone Fragmentation in Patients Undergoing Percutaneous Nephrolithotomy and Retrograde Intrarenal Surgery: A Prospective Investigation

At a Glance

Key Highlights

• Infectious complications post-PCNL occur in 10–30% of patients with fever, 35% with SIRS, and up to 9.3% with sepsis; post-RIRS infections occur in 7.7% of patients.
• Preoperative bladder urine culture (BUC) is recommended but is an inaccurate predictor of postoperative infections compared to stone culture (SC) and renal pelvic urine culture (RPUC).
• Stone fragmentation during surgery may release colonizing bacteria into the renal collecting system, potentially increasing infection risk.

Guideline-Based Recommendations

Diagnosis

• Perform preoperative bladder urine culture (BUC) 2–3 weeks before surgery.
• Collect renal pelvic urine culture (RPUC) at the beginning of the procedure.
• Obtain stone culture (SC) and biochemical analysis of extracted stones.
• Collect urine sample during stone fragmentation (SFUC) to detect bacteria released intraoperatively.

Management

• Administer perioperative antibiotic prophylaxis, typically a first-generation cephalosporin for patients with negative BUC.
• Initiate targeted antibiotic therapy 48–72 hours before surgery in patients with asymptomatic bacteriuria.
• Postpone surgery in patients with leukocytosis, urinary symptoms, fever, or history of urosepsis until after full antibiotic course and negative BUC.
• Continue prophylactic antibiotics as full-course regimen if postoperative infectious complications occur; escalate to broad-spectrum antibiotics if no response.
• Tailor antibiotic therapy based on intraoperative culture results when available.

Monitoring & Follow-up

• Monitor for signs of systemic inflammatory response syndrome (SIRS) defined by at least two criteria: fever/hypothermia, tachypnea or low PCO2, tachycardia, leukocytosis or leukopenia.
• Assess for sepsis as SIRS with confirmed or suspected infection.
• Use Clavien–Dindo classification to analyze postoperative complications.

Risks

• High risk of postoperative infectious complications due to bacterial colonization of stones and intraoperative bacterial dissemination.
• Inaccurate prediction of infection risk by bladder urine culture alone, especially in obstructed or infected stones.
• Potential for systemic bacterial spread due to increased intrarenal pressure and vascular injury during procedures.

Patient & Prescribing Data

Adults undergoing PCNL and RIRS for stone removal with varying preoperative urine culture statuses.

Targeted antibiotic therapy based on preoperative and intraoperative cultures improves infection management; perioperative prophylaxis reduces infection rates but may not prevent infections from stone-colonizing bacteria.

Clinical Best Practices

• Obtain multiple culture samples including bladder urine, renal pelvic urine, stone culture, and irrigation fluid during stone fragmentation for comprehensive microbiological assessment.
• Use culture results to guide targeted antibiotic therapy rather than relying solely on preoperative bladder urine culture.
• Employ non-pressurized irrigation systems and holmium:YAG laser lithotripsy to minimize intrarenal pressure and bacterial dissemination.
• Postpone surgery in patients with active urinary infection or systemic signs until infection is controlled.
• Monitor patients closely postoperatively for signs of SIRS or sepsis and adjust antibiotic therapy accordingly.

References

• European Association of Urology Guidelines on Urolithiasis
• Clavien–Dindo Classification of Surgical Complications
• European Committee on Antimicrobial Susceptibility Testing (EUCAST)