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MP20-15 FIBRINOGEN RELEASE AND DEPOSITION ON URINARY CATHETERS PLACED DURING UROLOGIC PROCEDURES
THE JOURNAL OF UROLOGYâ
e228
MP20-13 STENT COLONIZATION: DISCORDANCE WITH URINE CULTURE Jennifer Davila-Aponte*, Naveen Nandanan, Sean Corbett, Noah Schenkman, Tracey Krupski, Charlottesville, VA INTRODUCTION AND OBJECTIVES: Urologists are often asked to remove or exchange indwelling ureteral stents to obtain source control in patients with sepsis. In this situation, two approaches to managing patient care are brought into opposition. On the one hand, stent removal may provide source control. On the other, instrumenting an infected patient involves risks of anesthesia and of iatrogenic bacteremia. As part of an ongoing quality of care project, we sought to ascertain concordance between stent culture and urine culture. METHODS: We queried CPT code 52310 þ/- simultaneous 52332 from 2011 to present to compile a database of all pediatric and adult cases of stent removal. Stents were cultured in their entirety by pouring Schaedler broth over the stent, vortexing, and plating out on 4 different media. Stent culture was compared to preoperative urine culture. Patients on prophylactic antibiotics were excluded. Each instance was scored as “no growth in either culture”, “concordant” or “discordant” based on the organism(s) found at culture. RESULTS: A total of 68 cases were identified; 21 were excluded due to prophylactic antibiotic use. We analyzed the remaining 47 paired specimens and found that the average time difference between the stent and urine cultures was 2.0 days while the median stent dwell duration was 41 days. We found that only 17% (8/47) of the paired cases were concordant. In 49% (23/47) of paired cases, the organisms grown were discordant. In the remainder, there was no growth in either urine or stent culture. The organisms identified in positive stent cultures were Staphylococcus spp. (8), Enterococcus (7), Candida spp.(6), Proteus mirabilis (1) and Streptococcus spp.(1). CONCLUSIONS: We found that the vast majority of the time, the stent was not the source of the urine infection. These data suggest that immediate stent removal or exchange may not be necessary and that it is likely safe to treat the UTI and exchange any stent(s) as soon as feasible after completion of the treatment course. Source of Funding: None
MP20-14 ANTIMICROBIAL UTILIZATION PRIOR TO ENDOUROLOGICAL SURGERY FOR UROLITHIASIS: ENDOUROLOGICAL SOCIETY SURVEY RESULTS Adam Kaplan*, Durham, NC; Ramy Yacoub, Orange, CA; Richard Shin, Fernando Cabrera, Durham, NC; Andreas Neisius, Mainz, Germany; Charles Scales, Durham, NC; Roger Sur, San Diego, CA; Anicka Ackerman, Michael Ferrandino, Durham, NC; Brian Eisner, Boston, MA; Glenn Preminger, Michael Lipkin, Durham, NC INTRODUCTION AND OBJECTIVES: Guidelines and practice patterns regarding the use of antibiotic prophylaxis for endourologic stone surgery vary considerably. Our objective herein was to quantify the variations of antibiotic usage worldwide. METHODS: An online survey was distributed to members of the Endourologic Society. The survey used case scenarios to query the respondents’ proposed duration of antimicrobial therapy prior to uncomplicated ureteroscopy (URS) and percutaneous nephrolithotomy (PNL). Case scenarios include pre-operative cultures that were either negative or positive without symptoms of urinary tract infection. RESULTS: The response rate was 18.5% with 369 responders (40% from U.S., 61% academic and 64% endourology fellowship trained). The majority of respondents reported giving a single perioperative dose in patients with a negative urine culture (71% and 59% prior to URS and PNL; respectively). In patients with positive cultures, the responses were more heterogeneous. In the presence of a positive culture prior to URS the results were as follows: 13% preferred a single perioperative dose, 29% preferred 1e3 days, 46% preferred 4e7 days and 12% preferred > 7 days of antibiotics before the procedure. In
Vol. 193, No. 4S, Supplement, Saturday, May 16, 2015
presence of positive culture prior to PNL, 11% preferred single perioperative dose, 24% preferred 1e3 days, 49% preferred 4e7 days and 16 % preferred > 7 days. CONCLUSIONS: There are considerable variations in antimicrobial utilization prior to endourologic surgery for urolithiasis worldwide. According to current guidelines, nearly 1/3 of urologists are over-utilizing antibiotics prior to stone management in patients with negative cultures. Well-designed prospective randomized studies are needed to guide appropriate duration of prophlyactic antibiotics in patients with positive cultures.
Source of Funding: None
MP20-15 FIBRINOGEN RELEASE AND DEPOSITION ON URINARY CATHETERS PLACED DURING UROLOGIC PROCEDURES Jeffrey Larson*, Aaron Potretzke, Jennifer Walker, Ana Lidia FloresMireles, Scott Hultgren, Alana Desai, St. Louis, MO INTRODUCTION AND OBJECTIVES: Catheter-associated urinary tract infections are a common cause of hospital-associated infections. Previous animal models show that catheter placement induces inflammation and fibrinogen release, which accumulates on the catheter providing an environment for uropathogens such as Methicillin-Resistant Staph aureus (MRSA) and Enterococcus faecalis. The goal of this study was to examine urethral catheters placed for urologic procedures to test for fibrinogen deposition in humans and determine how long it takes for fibrinogen to become deposited on the catheter tip. METHODS: Urethral catheters placed for urologic procedures were collected and sent to the lab after removal. The dwell time and procedure type was recorded for each patient. Presence of fibrinogen deposition was studied by staining each catheter with fluorescent tagged anti-human antibody. RESULTS: A total of 23 catheters from different patients were studied of which 9 (39%) were removed in less than 24 hours (range 18 to 23 hours) and 14 were in place for a mean duration of 18.7 days. The catheters were placed for a variety of urologic procedures including 7 for retention, 6 after percutaneous nephrolithotomy, 4 after prostatectomy, 2 after partial nephrectomy and 1 after transurethral surgery. Fibrinogen deposition was present in all catheters in detectable levels as indicated by a representative sample in Figure 1. There was a correlation between the duration of catheter use and fibrinogen deposition although all catheters with a duration <24 hours had significant fibrinogen deposition indicating that the induced inflammatory response occurs within the first day of catheter placement. CONCLUSIONS: These findings indicate that the induced inflammatory response of the urinary tract to catheter placement is a rapid response that occurs within the first 24 hours of catheter placement creating an ideal microenvironment for urinary pathogens such as MRSA or E. faecalis. While our study is limited by the number of catheters with <24 hour dwell time and may be confounded by recent urologic surgery, these findings may explain why prolonged catheterization is associated with increased risk of urinary tract infections whereas intermittent catheterization continues to have a lower overall infection risk in patients with urinary retention.
THE JOURNAL OF UROLOGYâ
Vol. 193, No. 4S, Supplement, Saturday, May 16, 2015
e229
Table 1 The urodynamic parameters and urothelial dysfunction in patients with chronic kidneydisease and end - stage renal disease Normal (N¼20)
Source of Funding: None
REDUCED BLADDER CAPACITY AND INCREASED BLADDER SENSATION IS ASSOCIATED WITH UROTHELIAL DYSFUNCTION AND CHRONIC INFLAMMATION IN PATIENTS WITH CHRONIC KIDNEY DISEASE AND END-STAGE RENAL DISEASE
ESRD/ CKD + DU (N¼8)
38.419.2
27.126.0
14.725.5*
32.325.1
Mast-cell
3.02.83
8.456.88*
8.527.71
8.426.73*
TUNEL
0.490.99
1.961.86*
0.961.23
2.381.95*
ZO-1
8.234.99
4.733.01*
3.772.04*
5.143.29*
Age
57.911.7
59.115
54.811.1
61.016.29
FSF (mL)
180.165.8
140.294.2
63.531.8*
154.295.6
FS (mL)
322.181.7
178.3136.1*
66.349.6*
206.3137.3*
US (mL)
403.5104.0
195133.9*
79.362.4*
223.9132.4*
CBC (mL)
404.8113
204.5149.1*
79.362.4*
235.8149.2*
Pdet (cmH2O
24.415.7
26.920.0
10.59.19
29.720.2
Qmax (mL/s)
18.211.6
11.711.3
0
13.711.1
PVR (mL)
51.884.0
104.8164.5
9577.8
106.4177.3
363.9175.1
145.7130.1*
3.335.77*
181.3120.9*
32.417.1
32.820.8
28.516.3
33.522.0
Vol (mL)
CBC: cystometric bladder capacity; CKD: chronic kidney disease; DO: detruor overactivity; DU: detrusor underactivity; ESRD: end-stage renal disease; FS: full sensation; FSF: first sensation of filling; HSB: hypersensitive bladder; Pdet: detrusor pressure; Pves: intravesical pressure; PVR: post-void residual urine; Qmax: maximum flow rate; US: urgency sensation; Vol: volume; ZO-1: zonula occludens 1
Jia-Fong Jhang*, Jing-Liang Chen, Jia-Hui Chang, Hann-Chorng Kuo, Hualien, Taiwan INTRODUCTION AND OBJECTIVES: Patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD) may have reduced bladder capacity and compliance. Some patients also bother with severe frequency, urgency and frequent urinary tract infection (UTI). This study evaluated the urothelial dysfunction and chronic inflammation in the bladder mucosa from CKD or ESRD to clarify the pathophysiology of the bladder dysfunction in the bladder. METHODS: A total of 27 patients with CKD or ESRD with detrusor underactivity (DU) (n¼8), or with detrusor overactivity (DO) or hypersensitive bladder (HSB) (n¼19) were enrolled. Bladder mucosa specimens were obtained during transurethral procedures and were investigated for the adhesive protein E-cadherin, tight junction protein zonula occludens 1 (ZO-1), activated mast cell count by tryptase test, and urothelial apoptotic cell count by TUNEL. The urodynamic parameters were also evaluated and compared with a group of normal females without lower urinary tract symptoms. RESULTS: The bladder mucosa in CKD and ESRD showed significantly higher mast cell count and urothelial apoptosis and lower ZO-1 expression compared with the controls. E-cadherin was reduced in patients with ESRD/CKD with DU but not in ESRD/CKD with DO or HSB (Fig. 1). The expressions of ZO-1 and E-cadherin andmast cell activity were significantly associated with increased bladder sensation and small voided volume. Increased mast cell and apoptotic cell counts and decreased ZO-1 were more prominent in ESRD/CKD with DO or HSB (Table 1). CONCLUSIONS: Urothelial dysfunction and chronic inflammation are remarkable in the bladders of ESRD or CKD. Increased inflammation and defective barrier function are more prominent in ESRD/CKD bladder with DO of HSB. These urothelial pathophysiologies explain the bladder dysfunction and frequent UTI in the bladders of ESRD/CKD.
ESRD/CKD +DO/HSB (N¼19)
E-cadherin
Pves(cmH2O
MP20-16
ESRD/CKD Total (N¼27)
Source of Funding: none
e228
MP20-13 STENT COLONIZATION: DISCORDANCE WITH URINE CULTURE Jennifer Davila-Aponte*, Naveen Nandanan, Sean Corbett, Noah Schenkman, Tracey Krupski, Charlottesville, VA INTRODUCTION AND OBJECTIVES: Urologists are often asked to remove or exchange indwelling ureteral stents to obtain source control in patients with sepsis. In this situation, two approaches to managing patient care are brought into opposition. On the one hand, stent removal may provide source control. On the other, instrumenting an infected patient involves risks of anesthesia and of iatrogenic bacteremia. As part of an ongoing quality of care project, we sought to ascertain concordance between stent culture and urine culture. METHODS: We queried CPT code 52310 þ/- simultaneous 52332 from 2011 to present to compile a database of all pediatric and adult cases of stent removal. Stents were cultured in their entirety by pouring Schaedler broth over the stent, vortexing, and plating out on 4 different media. Stent culture was compared to preoperative urine culture. Patients on prophylactic antibiotics were excluded. Each instance was scored as “no growth in either culture”, “concordant” or “discordant” based on the organism(s) found at culture. RESULTS: A total of 68 cases were identified; 21 were excluded due to prophylactic antibiotic use. We analyzed the remaining 47 paired specimens and found that the average time difference between the stent and urine cultures was 2.0 days while the median stent dwell duration was 41 days. We found that only 17% (8/47) of the paired cases were concordant. In 49% (23/47) of paired cases, the organisms grown were discordant. In the remainder, there was no growth in either urine or stent culture. The organisms identified in positive stent cultures were Staphylococcus spp. (8), Enterococcus (7), Candida spp.(6), Proteus mirabilis (1) and Streptococcus spp.(1). CONCLUSIONS: We found that the vast majority of the time, the stent was not the source of the urine infection. These data suggest that immediate stent removal or exchange may not be necessary and that it is likely safe to treat the UTI and exchange any stent(s) as soon as feasible after completion of the treatment course. Source of Funding: None
MP20-14 ANTIMICROBIAL UTILIZATION PRIOR TO ENDOUROLOGICAL SURGERY FOR UROLITHIASIS: ENDOUROLOGICAL SOCIETY SURVEY RESULTS Adam Kaplan*, Durham, NC; Ramy Yacoub, Orange, CA; Richard Shin, Fernando Cabrera, Durham, NC; Andreas Neisius, Mainz, Germany; Charles Scales, Durham, NC; Roger Sur, San Diego, CA; Anicka Ackerman, Michael Ferrandino, Durham, NC; Brian Eisner, Boston, MA; Glenn Preminger, Michael Lipkin, Durham, NC INTRODUCTION AND OBJECTIVES: Guidelines and practice patterns regarding the use of antibiotic prophylaxis for endourologic stone surgery vary considerably. Our objective herein was to quantify the variations of antibiotic usage worldwide. METHODS: An online survey was distributed to members of the Endourologic Society. The survey used case scenarios to query the respondents’ proposed duration of antimicrobial therapy prior to uncomplicated ureteroscopy (URS) and percutaneous nephrolithotomy (PNL). Case scenarios include pre-operative cultures that were either negative or positive without symptoms of urinary tract infection. RESULTS: The response rate was 18.5% with 369 responders (40% from U.S., 61% academic and 64% endourology fellowship trained). The majority of respondents reported giving a single perioperative dose in patients with a negative urine culture (71% and 59% prior to URS and PNL; respectively). In patients with positive cultures, the responses were more heterogeneous. In the presence of a positive culture prior to URS the results were as follows: 13% preferred a single perioperative dose, 29% preferred 1e3 days, 46% preferred 4e7 days and 12% preferred > 7 days of antibiotics before the procedure. In
Vol. 193, No. 4S, Supplement, Saturday, May 16, 2015
presence of positive culture prior to PNL, 11% preferred single perioperative dose, 24% preferred 1e3 days, 49% preferred 4e7 days and 16 % preferred > 7 days. CONCLUSIONS: There are considerable variations in antimicrobial utilization prior to endourologic surgery for urolithiasis worldwide. According to current guidelines, nearly 1/3 of urologists are over-utilizing antibiotics prior to stone management in patients with negative cultures. Well-designed prospective randomized studies are needed to guide appropriate duration of prophlyactic antibiotics in patients with positive cultures.
Source of Funding: None
MP20-15 FIBRINOGEN RELEASE AND DEPOSITION ON URINARY CATHETERS PLACED DURING UROLOGIC PROCEDURES Jeffrey Larson*, Aaron Potretzke, Jennifer Walker, Ana Lidia FloresMireles, Scott Hultgren, Alana Desai, St. Louis, MO INTRODUCTION AND OBJECTIVES: Catheter-associated urinary tract infections are a common cause of hospital-associated infections. Previous animal models show that catheter placement induces inflammation and fibrinogen release, which accumulates on the catheter providing an environment for uropathogens such as Methicillin-Resistant Staph aureus (MRSA) and Enterococcus faecalis. The goal of this study was to examine urethral catheters placed for urologic procedures to test for fibrinogen deposition in humans and determine how long it takes for fibrinogen to become deposited on the catheter tip. METHODS: Urethral catheters placed for urologic procedures were collected and sent to the lab after removal. The dwell time and procedure type was recorded for each patient. Presence of fibrinogen deposition was studied by staining each catheter with fluorescent tagged anti-human antibody. RESULTS: A total of 23 catheters from different patients were studied of which 9 (39%) were removed in less than 24 hours (range 18 to 23 hours) and 14 were in place for a mean duration of 18.7 days. The catheters were placed for a variety of urologic procedures including 7 for retention, 6 after percutaneous nephrolithotomy, 4 after prostatectomy, 2 after partial nephrectomy and 1 after transurethral surgery. Fibrinogen deposition was present in all catheters in detectable levels as indicated by a representative sample in Figure 1. There was a correlation between the duration of catheter use and fibrinogen deposition although all catheters with a duration <24 hours had significant fibrinogen deposition indicating that the induced inflammatory response occurs within the first day of catheter placement. CONCLUSIONS: These findings indicate that the induced inflammatory response of the urinary tract to catheter placement is a rapid response that occurs within the first 24 hours of catheter placement creating an ideal microenvironment for urinary pathogens such as MRSA or E. faecalis. While our study is limited by the number of catheters with <24 hour dwell time and may be confounded by recent urologic surgery, these findings may explain why prolonged catheterization is associated with increased risk of urinary tract infections whereas intermittent catheterization continues to have a lower overall infection risk in patients with urinary retention.
THE JOURNAL OF UROLOGYâ
Vol. 193, No. 4S, Supplement, Saturday, May 16, 2015
e229
Table 1 The urodynamic parameters and urothelial dysfunction in patients with chronic kidneydisease and end - stage renal disease Normal (N¼20)
Source of Funding: None
REDUCED BLADDER CAPACITY AND INCREASED BLADDER SENSATION IS ASSOCIATED WITH UROTHELIAL DYSFUNCTION AND CHRONIC INFLAMMATION IN PATIENTS WITH CHRONIC KIDNEY DISEASE AND END-STAGE RENAL DISEASE
ESRD/ CKD + DU (N¼8)
38.419.2
27.126.0
14.725.5*
32.325.1
Mast-cell
3.02.83
8.456.88*
8.527.71
8.426.73*
TUNEL
0.490.99
1.961.86*
0.961.23
2.381.95*
ZO-1
8.234.99
4.733.01*
3.772.04*
5.143.29*
Age
57.911.7
59.115
54.811.1
61.016.29
FSF (mL)
180.165.8
140.294.2
63.531.8*
154.295.6
FS (mL)
322.181.7
178.3136.1*
66.349.6*
206.3137.3*
US (mL)
403.5104.0
195133.9*
79.362.4*
223.9132.4*
CBC (mL)
404.8113
204.5149.1*
79.362.4*
235.8149.2*
Pdet (cmH2O
24.415.7
26.920.0
10.59.19
29.720.2
Qmax (mL/s)
18.211.6
11.711.3
0
13.711.1
PVR (mL)
51.884.0
104.8164.5
9577.8
106.4177.3
363.9175.1
145.7130.1*
3.335.77*
181.3120.9*
32.417.1
32.820.8
28.516.3
33.522.0
Vol (mL)
CBC: cystometric bladder capacity; CKD: chronic kidney disease; DO: detruor overactivity; DU: detrusor underactivity; ESRD: end-stage renal disease; FS: full sensation; FSF: first sensation of filling; HSB: hypersensitive bladder; Pdet: detrusor pressure; Pves: intravesical pressure; PVR: post-void residual urine; Qmax: maximum flow rate; US: urgency sensation; Vol: volume; ZO-1: zonula occludens 1
Jia-Fong Jhang*, Jing-Liang Chen, Jia-Hui Chang, Hann-Chorng Kuo, Hualien, Taiwan INTRODUCTION AND OBJECTIVES: Patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD) may have reduced bladder capacity and compliance. Some patients also bother with severe frequency, urgency and frequent urinary tract infection (UTI). This study evaluated the urothelial dysfunction and chronic inflammation in the bladder mucosa from CKD or ESRD to clarify the pathophysiology of the bladder dysfunction in the bladder. METHODS: A total of 27 patients with CKD or ESRD with detrusor underactivity (DU) (n¼8), or with detrusor overactivity (DO) or hypersensitive bladder (HSB) (n¼19) were enrolled. Bladder mucosa specimens were obtained during transurethral procedures and were investigated for the adhesive protein E-cadherin, tight junction protein zonula occludens 1 (ZO-1), activated mast cell count by tryptase test, and urothelial apoptotic cell count by TUNEL. The urodynamic parameters were also evaluated and compared with a group of normal females without lower urinary tract symptoms. RESULTS: The bladder mucosa in CKD and ESRD showed significantly higher mast cell count and urothelial apoptosis and lower ZO-1 expression compared with the controls. E-cadherin was reduced in patients with ESRD/CKD with DU but not in ESRD/CKD with DO or HSB (Fig. 1). The expressions of ZO-1 and E-cadherin andmast cell activity were significantly associated with increased bladder sensation and small voided volume. Increased mast cell and apoptotic cell counts and decreased ZO-1 were more prominent in ESRD/CKD with DO or HSB (Table 1). CONCLUSIONS: Urothelial dysfunction and chronic inflammation are remarkable in the bladders of ESRD or CKD. Increased inflammation and defective barrier function are more prominent in ESRD/CKD bladder with DO of HSB. These urothelial pathophysiologies explain the bladder dysfunction and frequent UTI in the bladders of ESRD/CKD.
ESRD/CKD +DO/HSB (N¼19)
E-cadherin
Pves(cmH2O
MP20-16
ESRD/CKD Total (N¼27)
Source of Funding: none