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Aseptic Management of the Obstructed Kidney
Vol. 112, Septern!Jer Printed in
THE -JOlR.~AL OF lTROLOCl
Copyri.S;ht © 19~4 h.v The \\'illic1 ms & \Vilkins C'o.
ASEP":''IC M,\I"J AGEIV!ENT
0}1'
THE OBSTRUCTED KIDNEY
ROBERT From the Departmf'rd o.f
Iiarcard 11:1edicai School, Srl:7hcm, ffosoita/. Bo,-:ton. Aiassachusetts
The aopearance of progresin a.septic
in cathetet
pas~; fro 1n 2.n e·valuation was made of with upper urinary trcecl obstruction who underwent an for this condition. Basic considerations include: l) bacterial invasion must be at the time of cystoscopy and catheterization of the lower and upper tract, 2) bacteria must be from entry either or around the ter and 3) bacteria must be from entering the wound or the urinary tract at the and course. In the latter instance the treated in the same catheter. METHODS
fibrosis or obstruction owing to calculus was selected for evaluation. In most imrtances antibiotics were not given. In 22 given prior to because of evidence of for publication ?vlarch 8, 1974. at annual meeting of New England Section, American Urological Whitefield, l\Jew September :iO-Octoher 19,:t W. T. and R. C .. Management ,J. Urol., , 1949. R. and Harrison. ,J_ H.: The mismanurethral catheter. Med. Clin. N. Amer., rtccer1ceu
of catheter 1960. Linton, B., of urinary infection 1960. G., Linton, K. B. and infection of urine in 1:3, 1962. VV .. Gra\"es, R. C. and Harrison, J. · Technical in the prevention of urinarv tract infection. J. Urol., 87: 487. 1962. 7 De°sautels, R. E.: The causes of catheter-induced urinary infections and their prevention. J. UroL HH: 757, 1969. 3 Beeson, P. B.: The case against the catheter. Amer. ,J. 241: 1, 1958. E. H. and Schneiderman, L. J.: bacteria the tracts of catheters. New Engl. J. 256:
cultures because of actual infection or conian1inaiion of latter cases antibiotics ~Nerf' infection. externa.l the area about the urethral n1eatus cidal soap, the urethra is l: 750 ber.zalkonium chloride and a well luhricoted instrument or catheter is taken not duced. The the area about the urethi·a, so that this can be
be
catheter. The catheter sys~ern can be kept free cf bacteria maintaining (l bacteriostatic field at the of the cc1tbetPr and urethra the area of the meatus and catheter with liberal amounts of konium chloride 1: 750 aqueous solution twice a in male and 2 or more in female so as to ensure cleanliness of the area. Disconnection of the catheter is but when it is done a germicidal solution used tc, clean off the junction and to fill the end of the catheter before it is reconnected. necessary, are done using a such as irrigant. system is used* and the bottom drain full of 1: 750 aqueous benzalkonium chloride, it each time the 1s 'I'he of catheter care have been weil worked and have been trained nPrQn,nn present a been for female been difficult to achieve standardized results duty staff. The of the meatmi in the female makes it more difficult to manage care of catheter,;_ this reason it is recommended that a stab totomy be considered for the catheter the bl.adder or ureter in female patients. µu,,::,,,ne to lead a ureteral catheter out tbi.,; urinary drainage system, Travenol LabornDeerfield, Illinois. 305
306
DESAUTELS
type of drainage site, thereby avoiding the more complicated problems of providing extremely careful perinea! care. Previous study has indicated that cystostomy sites rarely become infected with proper care. 3 The surgical wound and the dressing. To prevent contamination during the operation careful aseptic technique is essential, avoiding handling of the skin, especially the skin of the genitalia. The drain is treated in the same fashion as the catheter, the area about the drain being washed carefully with either 1: 750 aqueous benzalkonium chloride or a tincture of benzalkonium chloride once a day, cleaning off all crusts and blood that can inactivate the benzalkonium chloride. Again it is essential that an excess of the benzalkonium chloride be used so that there is an adequate amount remaining for antibacterial defense. The first layer of gauze applied over the drain is wet with benzalkonium chloride so as to provide additional antibacterial effects. This material adsorbs on any surface and will provide the desired effect if it is present in sufficient quantity. It is, of course, essential that the benzalkonium chloride be properly prepared in a completely sterile fashion. When the dressing becomes wet with urine or blood it is necessary to change it more frequently than once a day and with each dressing change the same procedure is followed. The application of a bag attached to the skin around a drain for the collection of urine is not advisable since it is likely that contamination of the drain will occur and that bacteria will eventually migrate into the incision and into the urinary tract.
TABLE
1. Obstructing lesions of the upper urinary tract Men
Women
Number of patients
42
40
Periureteral fibrosis Congenital ureteropelvic obstruction Ureteral calculus Renal calculus
0 10
2 19
20 17
9 11
TABLE
2. Non-calculous obstruction of the upper urinary
tract No. Pyeloplasty Operation for periureteral fibrosis Cystoscopy and catheterization of ureters Pre-existing infection Postoperative infection Antibiotic given Positive urine culture at discharge from hospital
TABLE
29
2
18 8 1 16 0
3. Calculous obstruction of the upper urinary tract No.
Ureterolithotomy Pyelolithotomy or nephrolithotomy Cystoscopy and catheterization of ureter or manipulation of calculus Pre-existing infection Postoperative infection: Wound Urinary Wound contamination from sigmoid tear Antibiotic given Positive urine culture at discharge from hospital
27 30 14 14
1 18
RESULTS
A group of 82 consecutive adult patients with obstruction of the upper urinary tract owing to periureteral fibrosis, calculus in the ureter or the renal pelvis and congenital narrowing of the ureteropelvic junction, all of whom underwent an operation for their underlying condition, was selected for study (table 1). All wounds were drained carefully with a Penrose drain. Cystoscopy and catheterization of the ureter were done in 15 (18 procedures) of the 31 patients with non-calculous obstruction of the upper urinary tract (table 2). In 8 of these patients there was evidence of pre-existing infection and they were, therefore, given antibacterial therapy prior to any manipulation. Their cultures remained sterile thereafter. In the remaining group antibacterial therapy was given to 7 patients either for supposed prophylactic benefit or suspected infection but the urine cultures failed to demonstrate any sign of infection at that time or subsequently. One woman had infection after catheterization postoperatively and had a rapid response to antibiotic therapy and 3 men had indwelling urethral catheters postoperatively, received no antibiotics and had sterile urine cultures throughout. None of the others received antibiotics or had evidence of infection either in the wound or in the urine. All patients in the group
TABLE 4.
Bacterial contamination related to procedures* Antibiotic Therapy No.
Cystoscopy and ureteral instrumentation Drainage of wound (Penrose drain) Urethral cat heterization (indwelling) Urethral catheterization (single) Ureterostomy and pyelostomy Contamination of wound Antibiotics given No antibiotics given
32
PreNo InInduced Existing feet ion Infec- (prophylnfection lactic) tion 4
0
2
7
0
0
0
:3
0
2
8
5
0
2
1
0 22
(1)
0
0
0 8 0
88
84 54
4
* 88 ope rat ions.
had a sterile urine at the time of discharge from the hospital. In 4 patients a catheter was used to drain the renal pelvis and in 1 of them a ureteral catheter was left as a stent. One patient received therapy for an infection, 2 received prophylactic therapy and 1 was given no drug.
ASEPTIC MANAGEMENT OF OBSTRUCTED KIDNEY
Urinary infection was present initially in 14 of the 51 patients with ureteral and renal calculi ( table 3). In all but 1 of these patients a sterile urine culture was achieved either by the time of the operation or in the postoperative period. In the 1 individual, who also had diabetes, chronic infection existed in relation to the presence of an ilea! conduit. In 1 patient antibiotic therapy was given for a pulmonary problem preoperatively. In all other patients therapy was given only when infection was demonstrated by culture. In the remaining group of 37 patients there was 1 patient with a wound culture of Staphylococcus aureus despite a negative urine culture, 1 patient with contamination of the wound from a sigmoid tear without evidence of subsequent infection and 1 woman in whom an infection developed after catheterization the night of the operation; 5 men had indwelling urethral catheters postoperatively, received no antibiotics and had sterile urine cultures. In 12 patients 14 cystoscopic procedures were done. In 2 patients with ureteral calculi and 2 with renal calculi with associated infection catheter drainage of the ureter and pelvis, was used. A summary of the entire group is presented in table 4. DISCUSSION
The results in this demonstrate that an appropriate plan of aseptic technique can be applied in a routine fashion to obstructive problems of the upper urinary tract. Catheters were not used in most of these patients because it was believed that they were not necessary and not because of fear of inducing infection. Previous studies have indicated that cystotomy and nephrostomy tubes can be maintained with complete sterility for significant periods, varying from several days to several weeks. The use of benzalkonium chloride as an antibacterial agent has been questioned by a number of authors. 10 - 13 From the evidence presented in this paper and others, 14 it is strongly indicated that the compound must have some antibacterial virtues when used properly in an adequate amount and adequate concentration. It would be unfortunate if this useful compound were abandoned and withdrawn from the market simply because of improper 10 Plotkin. S. A. and Austrian, R.: Bacteremia caused by Pseudomonas SP following the use of materials stored in solutions of a cationic surface-active agent. Amer. ,J. Med. Sci., 235: 621, 1958. 11 Malizia. W. F., Gangarosa, E. G. and Goley. A. F.: Benzalkonium chloride as a source of infection. :"-iew Engl. ,J. Med .. 263: 800. 1960. 12 Lee. J.C. and Fialkow. P. J.: Benzalkonium chloride-source of hospital infection with gram-negative bacteria. J.A.M.A., 177: 708, 1961. 13 Sanford, J.P.: Disinfectants that don't. Ann. Intern. Med., 72: 28:2, 1970. 14 Kundsin. R. B. and Walter, C. W.: Investigations on adsorption of benzalkonium chloride U.S.P. by skin, gloves, and sponges. Arch. Surg., 75: 10:36, 1957.
307
understanding of its physical Some British investigators have also adopted these ciples but have used chlorhexidine (hibitane) instead of benzalkonium chloride. 4 • 5 · 15 • 16 As in the case of the urethral the application of aseptic principles can sirmlar freedom from infection in those patients under going manipulation and an operation for various obstructive conditions in the upper urinary The obstructed kidney, although vulnerable lo infection, is usually free of infection, at least in the adult, when the patient is first seen the urologist. It is incumbent upon the physician to preserve this sterile condition during the process of treat ment. The comments that have been made abou\ benzalkonium chloride are not meant to exclude a trial of other antibacterial agents. is strong reason to reject the use of local since bacterial resistance can eventually occur. The ability of benzalkonium chloride to adsorb on a surface and render it antibacterial is a characteristic that is not shared by most other compounds which will be rubbed or washed away with time. Some of the iodine-containing antibac terial agents have been used but their trial has not been sufficient to justif'.y their substitution for benzalkonium chloride. Furthermore, benzalkonium chloride has been so acceptable that it is hard to believe that another compound would he even more successful. Aside from some of the problems described herein. there were no complications except for temporary persistence of drainage of urine the flank sinus and on 1 occasion temporary ureteral colic caused by secondary bleeding from ureterotomy site. In no case was there evidence postoperatively of significant or persistent obstruction either by x-ray or physical examination. SUMMARY
Obstruction of the upper urinary tract in 82 patients is evaluated herein. In 22 patients there was evidence of urinary infection and in 2 patients there was evidence of infection postoperatively. One patient had a minor staphylococcal infection at the Penrose drain site and 1 patient had contamination of the wound from a sigmoid tear without evidence of urinarv or significant wound infection. All but 1 patient had a sterile urine culture the time of discharge from the hospital. The application of rigid aseptic technique accounted for a striking lack of owing to infection. 15 Roberts, J. B. M., Linton. K. B., Pollard, B. Mitchell, J.P. and Gillespie, W. A.: Long-term catheter drainage in the male. Brit. J. lJrol.. 37: 6:3. 1965. 16 Webb. ,J. K. and Blandy, J. P.: Closed drainage into plastic bags containing antiseptic. Urol., 40: 585, 1968.
THE -JOlR.~AL OF lTROLOCl
Copyri.S;ht © 19~4 h.v The \\'illic1 ms & \Vilkins C'o.
ASEP":''IC M,\I"J AGEIV!ENT
0}1'
THE OBSTRUCTED KIDNEY
ROBERT From the Departmf'rd o.f
Iiarcard 11:1edicai School, Srl:7hcm, ffosoita/. Bo,-:ton. Aiassachusetts
The aopearance of progresin a.septic
in cathetet
pas~; fro 1n 2.n e·valuation was made of with upper urinary trcecl obstruction who underwent an for this condition. Basic considerations include: l) bacterial invasion must be at the time of cystoscopy and catheterization of the lower and upper tract, 2) bacteria must be from entry either or around the ter and 3) bacteria must be from entering the wound or the urinary tract at the and course. In the latter instance the treated in the same catheter. METHODS
fibrosis or obstruction owing to calculus was selected for evaluation. In most imrtances antibiotics were not given. In 22 given prior to because of evidence of for publication ?vlarch 8, 1974. at annual meeting of New England Section, American Urological Whitefield, l\Jew September :iO-Octoher 19,:t W. T. and R. C .. Management ,J. Urol., , 1949. R. and Harrison. ,J_ H.: The mismanurethral catheter. Med. Clin. N. Amer., rtccer1ceu
of catheter 1960. Linton, B., of urinary infection 1960. G., Linton, K. B. and infection of urine in 1:3, 1962. VV .. Gra\"es, R. C. and Harrison, J. · Technical in the prevention of urinarv tract infection. J. Urol., 87: 487. 1962. 7 De°sautels, R. E.: The causes of catheter-induced urinary infections and their prevention. J. UroL HH: 757, 1969. 3 Beeson, P. B.: The case against the catheter. Amer. ,J. 241: 1, 1958. E. H. and Schneiderman, L. J.: bacteria the tracts of catheters. New Engl. J. 256:
cultures because of actual infection or conian1inaiion of latter cases antibiotics ~Nerf' infection. externa.l the area about the urethral n1eatus cidal soap, the urethra is l: 750 ber.zalkonium chloride and a well luhricoted instrument or catheter is taken not duced. The the area about the urethi·a, so that this can be
be
catheter. The catheter sys~ern can be kept free cf bacteria maintaining (l bacteriostatic field at the of the cc1tbetPr and urethra the area of the meatus and catheter with liberal amounts of konium chloride 1: 750 aqueous solution twice a in male and 2 or more in female so as to ensure cleanliness of the area. Disconnection of the catheter is but when it is done a germicidal solution used tc, clean off the junction and to fill the end of the catheter before it is reconnected. necessary, are done using a such as irrigant. system is used* and the bottom drain full of 1: 750 aqueous benzalkonium chloride, it each time the 1s 'I'he of catheter care have been weil worked and have been trained nPrQn,nn present a been for female been difficult to achieve standardized results duty staff. The of the meatmi in the female makes it more difficult to manage care of catheter,;_ this reason it is recommended that a stab totomy be considered for the catheter the bl.adder or ureter in female patients. µu,,::,,,ne to lead a ureteral catheter out tbi.,; urinary drainage system, Travenol LabornDeerfield, Illinois. 305
306
DESAUTELS
type of drainage site, thereby avoiding the more complicated problems of providing extremely careful perinea! care. Previous study has indicated that cystostomy sites rarely become infected with proper care. 3 The surgical wound and the dressing. To prevent contamination during the operation careful aseptic technique is essential, avoiding handling of the skin, especially the skin of the genitalia. The drain is treated in the same fashion as the catheter, the area about the drain being washed carefully with either 1: 750 aqueous benzalkonium chloride or a tincture of benzalkonium chloride once a day, cleaning off all crusts and blood that can inactivate the benzalkonium chloride. Again it is essential that an excess of the benzalkonium chloride be used so that there is an adequate amount remaining for antibacterial defense. The first layer of gauze applied over the drain is wet with benzalkonium chloride so as to provide additional antibacterial effects. This material adsorbs on any surface and will provide the desired effect if it is present in sufficient quantity. It is, of course, essential that the benzalkonium chloride be properly prepared in a completely sterile fashion. When the dressing becomes wet with urine or blood it is necessary to change it more frequently than once a day and with each dressing change the same procedure is followed. The application of a bag attached to the skin around a drain for the collection of urine is not advisable since it is likely that contamination of the drain will occur and that bacteria will eventually migrate into the incision and into the urinary tract.
TABLE
1. Obstructing lesions of the upper urinary tract Men
Women
Number of patients
42
40
Periureteral fibrosis Congenital ureteropelvic obstruction Ureteral calculus Renal calculus
0 10
2 19
20 17
9 11
TABLE
2. Non-calculous obstruction of the upper urinary
tract No. Pyeloplasty Operation for periureteral fibrosis Cystoscopy and catheterization of ureters Pre-existing infection Postoperative infection Antibiotic given Positive urine culture at discharge from hospital
TABLE
29
2
18 8 1 16 0
3. Calculous obstruction of the upper urinary tract No.
Ureterolithotomy Pyelolithotomy or nephrolithotomy Cystoscopy and catheterization of ureter or manipulation of calculus Pre-existing infection Postoperative infection: Wound Urinary Wound contamination from sigmoid tear Antibiotic given Positive urine culture at discharge from hospital
27 30 14 14
1 18
RESULTS
A group of 82 consecutive adult patients with obstruction of the upper urinary tract owing to periureteral fibrosis, calculus in the ureter or the renal pelvis and congenital narrowing of the ureteropelvic junction, all of whom underwent an operation for their underlying condition, was selected for study (table 1). All wounds were drained carefully with a Penrose drain. Cystoscopy and catheterization of the ureter were done in 15 (18 procedures) of the 31 patients with non-calculous obstruction of the upper urinary tract (table 2). In 8 of these patients there was evidence of pre-existing infection and they were, therefore, given antibacterial therapy prior to any manipulation. Their cultures remained sterile thereafter. In the remaining group antibacterial therapy was given to 7 patients either for supposed prophylactic benefit or suspected infection but the urine cultures failed to demonstrate any sign of infection at that time or subsequently. One woman had infection after catheterization postoperatively and had a rapid response to antibiotic therapy and 3 men had indwelling urethral catheters postoperatively, received no antibiotics and had sterile urine cultures throughout. None of the others received antibiotics or had evidence of infection either in the wound or in the urine. All patients in the group
TABLE 4.
Bacterial contamination related to procedures* Antibiotic Therapy No.
Cystoscopy and ureteral instrumentation Drainage of wound (Penrose drain) Urethral cat heterization (indwelling) Urethral catheterization (single) Ureterostomy and pyelostomy Contamination of wound Antibiotics given No antibiotics given
32
PreNo InInduced Existing feet ion Infec- (prophylnfection lactic) tion 4
0
2
7
0
0
0
:3
0
2
8
5
0
2
1
0 22
(1)
0
0
0 8 0
88
84 54
4
* 88 ope rat ions.
had a sterile urine at the time of discharge from the hospital. In 4 patients a catheter was used to drain the renal pelvis and in 1 of them a ureteral catheter was left as a stent. One patient received therapy for an infection, 2 received prophylactic therapy and 1 was given no drug.
ASEPTIC MANAGEMENT OF OBSTRUCTED KIDNEY
Urinary infection was present initially in 14 of the 51 patients with ureteral and renal calculi ( table 3). In all but 1 of these patients a sterile urine culture was achieved either by the time of the operation or in the postoperative period. In the 1 individual, who also had diabetes, chronic infection existed in relation to the presence of an ilea! conduit. In 1 patient antibiotic therapy was given for a pulmonary problem preoperatively. In all other patients therapy was given only when infection was demonstrated by culture. In the remaining group of 37 patients there was 1 patient with a wound culture of Staphylococcus aureus despite a negative urine culture, 1 patient with contamination of the wound from a sigmoid tear without evidence of subsequent infection and 1 woman in whom an infection developed after catheterization the night of the operation; 5 men had indwelling urethral catheters postoperatively, received no antibiotics and had sterile urine cultures. In 12 patients 14 cystoscopic procedures were done. In 2 patients with ureteral calculi and 2 with renal calculi with associated infection catheter drainage of the ureter and pelvis, was used. A summary of the entire group is presented in table 4. DISCUSSION
The results in this demonstrate that an appropriate plan of aseptic technique can be applied in a routine fashion to obstructive problems of the upper urinary tract. Catheters were not used in most of these patients because it was believed that they were not necessary and not because of fear of inducing infection. Previous studies have indicated that cystotomy and nephrostomy tubes can be maintained with complete sterility for significant periods, varying from several days to several weeks. The use of benzalkonium chloride as an antibacterial agent has been questioned by a number of authors. 10 - 13 From the evidence presented in this paper and others, 14 it is strongly indicated that the compound must have some antibacterial virtues when used properly in an adequate amount and adequate concentration. It would be unfortunate if this useful compound were abandoned and withdrawn from the market simply because of improper 10 Plotkin. S. A. and Austrian, R.: Bacteremia caused by Pseudomonas SP following the use of materials stored in solutions of a cationic surface-active agent. Amer. ,J. Med. Sci., 235: 621, 1958. 11 Malizia. W. F., Gangarosa, E. G. and Goley. A. F.: Benzalkonium chloride as a source of infection. :"-iew Engl. ,J. Med .. 263: 800. 1960. 12 Lee. J.C. and Fialkow. P. J.: Benzalkonium chloride-source of hospital infection with gram-negative bacteria. J.A.M.A., 177: 708, 1961. 13 Sanford, J.P.: Disinfectants that don't. Ann. Intern. Med., 72: 28:2, 1970. 14 Kundsin. R. B. and Walter, C. W.: Investigations on adsorption of benzalkonium chloride U.S.P. by skin, gloves, and sponges. Arch. Surg., 75: 10:36, 1957.
307
understanding of its physical Some British investigators have also adopted these ciples but have used chlorhexidine (hibitane) instead of benzalkonium chloride. 4 • 5 · 15 • 16 As in the case of the urethral the application of aseptic principles can sirmlar freedom from infection in those patients under going manipulation and an operation for various obstructive conditions in the upper urinary The obstructed kidney, although vulnerable lo infection, is usually free of infection, at least in the adult, when the patient is first seen the urologist. It is incumbent upon the physician to preserve this sterile condition during the process of treat ment. The comments that have been made abou\ benzalkonium chloride are not meant to exclude a trial of other antibacterial agents. is strong reason to reject the use of local since bacterial resistance can eventually occur. The ability of benzalkonium chloride to adsorb on a surface and render it antibacterial is a characteristic that is not shared by most other compounds which will be rubbed or washed away with time. Some of the iodine-containing antibac terial agents have been used but their trial has not been sufficient to justif'.y their substitution for benzalkonium chloride. Furthermore, benzalkonium chloride has been so acceptable that it is hard to believe that another compound would he even more successful. Aside from some of the problems described herein. there were no complications except for temporary persistence of drainage of urine the flank sinus and on 1 occasion temporary ureteral colic caused by secondary bleeding from ureterotomy site. In no case was there evidence postoperatively of significant or persistent obstruction either by x-ray or physical examination. SUMMARY
Obstruction of the upper urinary tract in 82 patients is evaluated herein. In 22 patients there was evidence of urinary infection and in 2 patients there was evidence of infection postoperatively. One patient had a minor staphylococcal infection at the Penrose drain site and 1 patient had contamination of the wound from a sigmoid tear without evidence of urinarv or significant wound infection. All but 1 patient had a sterile urine culture the time of discharge from the hospital. The application of rigid aseptic technique accounted for a striking lack of owing to infection. 15 Roberts, J. B. M., Linton. K. B., Pollard, B. Mitchell, J.P. and Gillespie, W. A.: Long-term catheter drainage in the male. Brit. J. lJrol.. 37: 6:3. 1965. 16 Webb. ,J. K. and Blandy, J. P.: Closed drainage into plastic bags containing antiseptic. Urol., 40: 585, 1968.