Figure. Postoperative rates of UTI or pyelonephritis (A), and sepsis or systemic inflammatory response syndrome (SIRS; B).

When asking urologists about their preoperative prophylactic antibiotic protocols, I am often met with a somewhat nervous, cautious glance as if trying to unravel a deeper intent to catch them in an indecent act. This is typically followed, quite surprisingly, by a vehement defense of their choice of antibiotic duration with corresponding rationale (usually citing long-standing clinical practices or dogma acquired during training). This quandary is perhaps best demonstrated in a survey sent out to fellowship-trained endourologists,¹ which found a variation in antibiotic durations prior to commonly performed endourologic procedures. As one of the few surgical specialties that routinely performs clean-contaminated cases in an era of multidrug-resistant bacteria and antibiotic stewardship, are we doing enough to optimize patient outcomes?

Every urologist has encountered these postoperative infectious complications, including UTI, pyelonephritis, and sepsis, which are uncommon but potentially devastating complications after many urologic procedures. With the rise of ureteroscopy as one of the most commonly performed stone surgeries worldwide, the importance of identifying strategies to mitigate the risk of these complications is becoming increasingly vital. The clinical guidance from the AUA and the European Association of Urology is to provide treatment for symptomatic UTIs; however, the management for asymptomatic patients with positive cultures or those patients who are otherwise at high risk of urinary tract colonization is not clearly defined.^2,3

This is a critical gap in our understanding of preoperative prophylactic antibiotic utilization. This is a population of patients not only at higher risk of harboring multidrug-resistant organisms, but also more susceptible to deleterious outcomes due to their frailty. Recent randomized trials by the Endourology Disease Group for Excellence consortium have demonstrated that short courses of preoperative antibiotics are no less protective than long courses in patients undergoing percutaneous nephrolithotomy for stone removal.^4,5 Establishing an evidence-based approach for antibiotic prophylaxis patients undergoing ureteroscopy would be impactful for a large number of patients.

We are excited to play a role in this effort through a randomized clinical trial of moderate- to high-risk patients undergoing ureteroscopy, where patients will be randomized to a short (2-day) or long (7-day) course of preoperative prophylactic antibiotics. In a review of our institutional experience using the Registry for Stones of the Kidney and Ureter, we found that antibiotic duration does not affect postoperative infectious complications (Figure). These data and the accompanying manuscript are currently under peer review.

If preoperative antibiotic prophylaxis is not a modifiable cause of postoperative infections, then what is? With recent advances in surgical technology, live monitoring of intrarenal pelvic pressures may further our understanding of pyelovenous backflow and the associated risk of infection. Could minimizing intrarenal pressure allow us to envision a future of minimal to no antibiotic prophylaxis even in high-risk patients?

Acknowledgments: We thank Drs Kaplan and Riordan for their stewardship of the AUA Research Council and the Urology Care Foundation™ grants. In addition, we thank the University of California, San Francisco Department of Urology for its continued support of our research endeavors.