Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Department of Urology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
Eur Urol Focus. 2024 Jul;10(4):612-619. doi: 10.1016/j.euf.2023.09.013. Epub 2023 Oct 12.
Enhanced recovery after surgery (ERAS) has significantly decreased the morbidity associated with radical cystectomy. However, infectious complications including sepsis, urinary tract (UTIs), wound (WIs), and intra-abdominal (AIs) infections remain common.
To assess whether intracorporeal urinary diversion (ICUD) and antibiogram-directed antimicrobial prophylaxis would decrease infections after robotic-assisted radical cystectomy (RARC).
DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis was performed of a prospectively maintained database of patients undergoing RARC between 2014 and 2022 at a tertiary care institution, identifying two groups based on adherence to a prospectively implemented modified ERAS protocol for RARC: modified-ERAS-ICUD and antibiogram-directed ampicillin-sulbactam, gentamicin, and fluconazole prophylaxis were utilized (from January 2019 to present time), and unmodified-ERAS-extracorporeal urinary diversion (UD) and guideline-recommended cephalosporin-based prophylaxis regimen were utilized (from November 2014 to June 2018). Patients receiving other prophylaxis regimens were excluded.
ICUD and antibiogram-directed infectious prophylaxis.
The primary outcome was UTIs within 30 and 90 d postoperatively. The secondary outcomes were WIs, AIs, and sepsis within 30 and 90 d postoperatively, and Clostridioides difficile infection (CDI) within 90 d postoperatively.
A total of 396 patients were studied (modified-ERAS: 258 [65.2%], unmodified-ERAS: 138 [34.8%]). UD via a neobladder was more common in the modified-ERAS cohort; all other intercohort demographic differences were not statistically different. Comparing cohorts, modified-ERAS had significantly reduced rates of 30-d (7.8% vs 15.9%, p = 0.027) and 90-d UTIs (11.2% vs 25.4%, p = 0.001), and 30-d WIs (1.2% vs. 8.7%, p < 0.001); neither group had a WI after 30 d. Rates of AIs, sepsis, and CDI did not differ between groups. On multivariate regression, the modified-ERAS protocol correlated with a reduced risk of UTIs and WIs (all p < 0.01). The primary limitation is the retrospective study design.
Utilization of ICUD and antibiogram-based prophylaxis correlates with significantly decreased UTIs and WIs after RARC.
In this study of infections after robotic radical cystectomy for bladder cancer, we found that intracorporeal (performed entirely inside the body) urinary diversion and an institution-specific antibiogram-directed antibiotic prophylaxis regimen led to fewer urinary tract infections and wound infections at our institution.
加速康复外科（ERAS）显著降低了根治性膀胱切除术相关的发病率。然而，包括脓毒症、尿路感染（UTIs）、伤口（WIs）和腹腔内（AIs）感染在内的感染性并发症仍然很常见。
评估在机器人辅助根治性膀胱切除术（RARC）中使用腔内尿流改道术（ICUD）和基于抗生素药敏试验的预防性抗菌药物是否会降低感染率。
设计、地点和参与者：对 2014 年至 2022 年在一家三级医疗机构接受 RARC 的患者前瞻性维护数据库进行回顾性分析，根据是否遵守前瞻性实施的 RARC 改良 ERAS 方案将患者分为两组：改良-ERAS-ICUD 和基于抗生素药敏试验的氨苄西林-舒巴坦、庆大霉素和氟康唑预防性治疗（自 2019 年 1 月至今），以及未改良-ERAS-腔外尿流改道（UD）和指南推荐的头孢菌素类为基础的预防方案（自 2014 年 11 月至 2018 年 6 月）。排除接受其他预防方案的患者。
ICUD 和基于抗生素药敏试验的感染预防。
主要观察指标是术后 30 天和 90 天的 UTIs。次要观察指标是术后 30 天和 90 天的 WIs、AIs 和脓毒症，以及术后 90 天的艰难梭菌感染（CDI）。
共研究了 396 例患者（改良-ERAS：258 例[65.2%]，未改良-ERAS：138 例[34.8%]）。改良-ERAS 组更常使用新膀胱的 UD；两组间其他组间人口统计学差异无统计学意义。与对照组相比，改良-ERAS 组 30 天（7.8% vs. 15.9%，p=0.027）和 90 天 UTIs （11.2% vs. 25.4%，p=0.001）和 30 天 WIs （1.2% vs. 8.7%，p<0.001）的发生率明显降低；两组均无 30 天后的 WI。两组间 AIs、脓毒症和 CDI 发生率无差异。多变量回归分析显示，改良-ERAS 方案与降低 UTIs 和 WIs 的风险相关（均 p<0.01）。主要限制是回顾性研究设计。
在 RARC 中使用 ICUD 和基于抗生素药敏试验的预防性抗菌药物与显著降低 RARC 术后 UTIs 和 WIs 相关。
在这项研究中，我们发现膀胱癌机器人根治性膀胱切除术后，使用腔内尿流改道术和基于机构的抗生素药敏试验指导的抗生素预防方案可导致尿路感染和伤口感染减少。
