Objective:To evaluate the impact of a standardized antibiotic stewardship protocol on three subsequent endpoints in patients undergoing urethroplasty.Methods:Men undergoing bulbar substitution urethroplasty between Ja...Objective:To evaluate the impact of a standardized antibiotic stewardship protocol on three subsequent endpoints in patients undergoing urethroplasty.Methods:Men undergoing bulbar substitution urethroplasty between January 2009 and December 2016 were stratified by urine culture (UCx) at the time of surgery (sterile vs. non-sterile) and were subjected to a standardized algorithm for urinalysis and antimicrobial therapy. We performed quantitative and qualitative exploration of UCx results and the microbial spectrum. The ability of the algorithm to improve antibiotic stewardship was tested by three endpoints: (a) immediate (UCx 2 days postoperatively), (b) short-term (21-day infectious complications), and (c) long-term (retreatment-free survival [RFS]). Statistical analyses included bivariate comparisons. The Kaplan–Meier estimators were used to compare RFS between the groups. The multivariable Cox regression was used to evaluate the independent effect of UCx status at the time of surgery on RFS.Results:Of 374 men, 235 (63%) had a sterile and 139 (37%) a non-sterile culture at the time of surgery. The proportion of sterile cultures at the time of surgery (63%) was significantly improved to 82% 2 days postoperatively (p<0.001). There were 16 (4.3%) patients with infectious complications with no difference between patients with sterile versus non-sterile culture (p=0.6). At median follow-up of 29 months, there was no difference in RFS (84%) between patients with sterile versus non-sterile culture (p=0.3). Positive UCx was not a predictor of recurrence after multivariable adjustment (p=0.5).Conclusion:A standardized protocol such as the one introduced improves antibiotic stewardship through frequent testing and culture-specific treatment. This is crucial in avoiding unnecessary antimicrobial treatment, and reducing infectious events and adverse effects of a positive UCx on long-term stricture recurrence.展开更多
Iatrogenic ureteral injuries and strictures are relatively common complication of pelvic surgery and radiation treatment.Left untreated they are associated with severe shortand long-term complications such as urinoma,...Iatrogenic ureteral injuries and strictures are relatively common complication of pelvic surgery and radiation treatment.Left untreated they are associated with severe shortand long-term complications such as urinoma,septic state,renal failure,and loss of a renal unit.Treatment depends on timing of diagnosis,as well as extent of injury,and ranges from simple endoscopic management to complex surgical reconstruction under usage of pedicled grafts.While recent advances in ureteral tissue engineering are promising the topic is still underreported.Historically a domain of open surgery,laparoscopic and robotic-assisted approaches have proven their feasibility in small case series,and are increasingly being utilized as means of reconstructive surgery.This review aims to give an outline of incidence and treatment of ureteral injuries and strictures in light of the latest advances.展开更多
atients undergoing urologic surgery are at risk of acute kidney injury （AKI） and consequently long-term deterioration in renal function. AKI is further associated with signifcantly higher odds of perioperative compl...atients undergoing urologic surgery are at risk of acute kidney injury （AKI） and consequently long-term deterioration in renal function. AKI is further associated with signifcantly higher odds of perioperative complications, prolonged hospital stay, higher mortality and costs. Therefore, better awareness and detection of AKI, as well as identifcation of AKI determinants in the urological surgery setting is warranted to pre-empt and mitigate further deterioration of renal function in patients at special risk. New consensus criteria provide precise definitions of diagnosis and description of the severity of AKI. However, they rely on serum creatinine （SCr）, which is known to be an inaccurate marker of early changes in renal function. Therefore, several newurinary and serum biomarkers promise to address the gap associated with the use of SCr. Novel biomarkers may complement SCr measurement or most likely improve the diagnostic accuracy of AKI when used in combinations. However, novel biomarkers have to prove their clinical applicability, accuracy, and cost effectiveness prior to implementation into clinical practice. Most preferably, novel biomarkers should help to positively improve a patient’s long-term renal functional outcomes. The purpose of this review is to discuss currently available biomarkers and to review their clinical evidence within urologic surgery settings.展开更多
文摘Objective:To evaluate the impact of a standardized antibiotic stewardship protocol on three subsequent endpoints in patients undergoing urethroplasty.Methods:Men undergoing bulbar substitution urethroplasty between January 2009 and December 2016 were stratified by urine culture (UCx) at the time of surgery (sterile vs. non-sterile) and were subjected to a standardized algorithm for urinalysis and antimicrobial therapy. We performed quantitative and qualitative exploration of UCx results and the microbial spectrum. The ability of the algorithm to improve antibiotic stewardship was tested by three endpoints: (a) immediate (UCx 2 days postoperatively), (b) short-term (21-day infectious complications), and (c) long-term (retreatment-free survival [RFS]). Statistical analyses included bivariate comparisons. The Kaplan–Meier estimators were used to compare RFS between the groups. The multivariable Cox regression was used to evaluate the independent effect of UCx status at the time of surgery on RFS.Results:Of 374 men, 235 (63%) had a sterile and 139 (37%) a non-sterile culture at the time of surgery. The proportion of sterile cultures at the time of surgery (63%) was significantly improved to 82% 2 days postoperatively (p<0.001). There were 16 (4.3%) patients with infectious complications with no difference between patients with sterile versus non-sterile culture (p=0.6). At median follow-up of 29 months, there was no difference in RFS (84%) between patients with sterile versus non-sterile culture (p=0.3). Positive UCx was not a predictor of recurrence after multivariable adjustment (p=0.5).Conclusion:A standardized protocol such as the one introduced improves antibiotic stewardship through frequent testing and culture-specific treatment. This is crucial in avoiding unnecessary antimicrobial treatment, and reducing infectious events and adverse effects of a positive UCx on long-term stricture recurrence.
文摘Iatrogenic ureteral injuries and strictures are relatively common complication of pelvic surgery and radiation treatment.Left untreated they are associated with severe shortand long-term complications such as urinoma,septic state,renal failure,and loss of a renal unit.Treatment depends on timing of diagnosis,as well as extent of injury,and ranges from simple endoscopic management to complex surgical reconstruction under usage of pedicled grafts.While recent advances in ureteral tissue engineering are promising the topic is still underreported.Historically a domain of open surgery,laparoscopic and robotic-assisted approaches have proven their feasibility in small case series,and are increasingly being utilized as means of reconstructive surgery.This review aims to give an outline of incidence and treatment of ureteral injuries and strictures in light of the latest advances.
基金supported by the Professor Walter Morris-Hale Distinguished Chair in Urologic Oncology at the Brigham and Women’s Hospital
文摘atients undergoing urologic surgery are at risk of acute kidney injury （AKI） and consequently long-term deterioration in renal function. AKI is further associated with signifcantly higher odds of perioperative complications, prolonged hospital stay, higher mortality and costs. Therefore, better awareness and detection of AKI, as well as identifcation of AKI determinants in the urological surgery setting is warranted to pre-empt and mitigate further deterioration of renal function in patients at special risk. New consensus criteria provide precise definitions of diagnosis and description of the severity of AKI. However, they rely on serum creatinine （SCr）, which is known to be an inaccurate marker of early changes in renal function. Therefore, several newurinary and serum biomarkers promise to address the gap associated with the use of SCr. Novel biomarkers may complement SCr measurement or most likely improve the diagnostic accuracy of AKI when used in combinations. However, novel biomarkers have to prove their clinical applicability, accuracy, and cost effectiveness prior to implementation into clinical practice. Most preferably, novel biomarkers should help to positively improve a patient’s long-term renal functional outcomes. The purpose of this review is to discuss currently available biomarkers and to review their clinical evidence within urologic surgery settings.
