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Systematic Review: Bacterial Colonisation of Conduits and Neobladders - When to Test, Watch, and Treat - Beyond the Abstract

Bacterial colonization of diverted urinary tracts remains an understudied area of research. Outdated guideline recommendations prompted the publication of our review, where we have summarised the most up-to-date evidence in patients with urinary diversions. Of note, we highlight the need for streamlined definitions of bacteriuria, the benefits of monitoring bacteriuria over time, as well as the role of short-term antimicrobial therapy as part of management. However, an important area that must be further clarified is the relationship between asymptomatic bacteriuria, and subsequent urinary tract infection (UTI), in patients with urinary diversions.

Thus far, the differences between asymptomatic bacteriuria and symptomatic UTI are inconsistently reported and characterized. As expected, the classical symptoms of urinary frequency/dysuria may not be present for a patient with a reconstructed lower urinary tract. Nevertheless, some studies have still reportedly classified symptomatic UTIs as involving urgency, dysuria, malodorous urine, abdominal pain, and worsening incontinence.

Other studies have rather defined symptoms as being primarily abdominal pain and fevers. These two primary symptoms may more reasonably reflect the expected pathophysiology of a patient with a ‘pouchitis’, where inflammation of an intestinal pouch may cause abdominal pain, tenderness on palpation, as well as systemic inflammatory response, resulting in fevers. The use of these two symptoms as diagnosis, in addition to a positive urine culture, may be more appropriate in diagnosing a symptomatic UTI, in a patient with urinary diversions. Subsequent progression of the infection to the upper tract should present just as patients without urinary diversions, and their clinical features should not differ.
Until there is an addition of a recommended symptomatic UTI definition in urological guidelines for patients with diverted urinary tracts, there will continue to be confusion and inconsistency in its reporting. In addition to our main review recommendations, we suggest further clarification of diagnostic criteria to assist with research in this field.

Written by: Liang G Qu, MD, Department of Surgery, Austin Health, University of Melbourne, Melbourne, Australia and Nathan Lawrentschuk, MB, BS, PhD, FRACS, Associate Professor, University of Melbourne, Melbourne, Australia

References:

  1. Qu, Liang G., Ahmed Adam, Weranja Ranasinghe, and Nathan Lawrentschuk. "Systematic review: bacterial colonisation of conduits and neobladders—when to test, watch, and treat." World Journal of Urology (2019): 1-10.
  2. El-Assmy, Ahmed, Osama Mahmoud, Mohamed Kamal, Wafaa Soliman, Albeer Ashamallah, Niveen El-Wakeel, and Hassan Abol-Enein. "Characterization of standard urine properties in noncomplicated orthotopic ileal neobladders: a prospective controlled study." Urology 96 (2016): 80-84.
  3. Suriano, Francesca, Michele Gallucci, Gerardo Paolo Flammia, Stefania Musco, Antonio Alcini, Gregorio Imbalzano, and Giordano Dicuonzo. "Bacteriuria in patients with an orthotopic ileal neobladder: urinary tract infection or asymptomatic bacteriuria?." BJU international 101, no. 12 (2008): 1576-1579.
  4. Wood, David P., Fernando J. Bianco, J. Edson Pontes, Martha A. Heath, and Daniel dajusta. "Incidence and significance of positive urine cultures in patients with an orthotopic neobladder." The Journal of urology 169, no. 6 (2003): 2196-2199.
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