Urinary Tract Infections Following Radical Cystectomy and Urinary Diversion

Urinary tract infection (UTI) is one of the most common complications following radical cystectomy. Use of bowel in urinary diversion leads to high rates of bacteriuria (1-4). Thus, diagnosing UTI and deciding when to treat can be a bane for urologists. In spite of this, there are surprisingly few studies on postoperative UTI from high volume centers. Thus, we became interested in better characterizing early postoperative UTI by reviewing over 1100 patients who underwent radical cystectomy with urinary diversion during a ten-year period at our institution.

In our study, 123 of 1133 patients (11%) had a documented UTI within 90 days of surgery. Median time to first infection was 20 days. Over half (52%) led to readmission and 20% had urosepsis. 72% of our cohort underwent ONB, but there was no significant difference in rate of 90-day UTI and urosepsis between the three diversion types (ONB, IC, CCD). Gram-negative rods were found to be the most common etiology. Specifically, the most common pathogens were Escherichia coli (22%), Enterococcus faecalis (13%), and Klebsiella pneumoniae (12%). There was also a relatively high rate of fungal UTI (13%). Antimicrobial sensitivity was best to carbapenems and aminoglycosides and worst to quinolones. On multivariable analysis, CCI>2 was significantly associated with postoperative UTI.

The strengths of our study are its relatively large sample size, inclusion of three diversion types, and our characterization of pathogen incidence and antimicrobial sensitivities. Regardless of diversion type, UTI is common after radical cystectomy. Given that infections frequently occur at around three weeks postop, current efforts should be aimed towards evidenced based selection of antimicrobial prophylaxis such as with aminoglycosides and consideration of an anti-fungal. Recent (5) and ongoing studies are aimed at comparing antimicrobial prophylactic regimens to better serve our patients.

Written By:
Hooman Djaladat, MD, MS, Associate Professor of Clinical Urology, Institute of Urology, Norris Cancer Center, USC Los Angeles, CA

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References:

1. Abdel-Latif M, Mosbah A, El Bahnasawy MS, Elsawy E, Shaaban AA (2005) Asymptomatic bacteriuria in men with orthotopic ileal neobladders: possible relationship to nocturnal enuresis. BJU Int 96:391–396
2. Suriano F, Gallucci M, Flammia GP et al (2008) Bacteriuria in patients with an orthotopic ileal neobladder: urinary tract infection or asymptomatic bacteriuria? BJU Int 101:1576–1579
3. Wood DP Jr, Bianco FJ Jr, Pontes JE, Heath MA, DaJusta D (2003) Incidence and significance of positive urine cultures in patients with an orthotopic neobladder. J Urol 169:2196–2199
4. Wullt B, Agace W, Mansson W (2004) Bladder, bowel and bugs—bacteriuria in patients with intestinal urinary diversion. World J Urol 22:186–195
5. Pariser JJ, Anderson BB, Pearce SM et al (2016) The effect of broader, directed antimicrobial prophylaxis including fungal coverage on perioperative infectious complications after radical cystectomy. Urol Oncol 34:121.e9–121.e14

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