The risks for urinary tract infection (UTI) and urine leak do not increase in patients with early ureteral stent removal and shorter antibiotic prophylaxis after radical cystectomy. The findings were revealed in a poster presentation at the American Urological Association’s 2023 Annual Scientific Meeting in Chicago, Illinois.1
Jen‐Jane Liu, MD, Jessica Wenzel, MD, and colleagues from Oregon Health and Science University in Portland, conducted a retrospective chart review of 247 patients at their institution who underwent radical cystectomy during 2016-2022, of whom 43 patients had early and 204 patients had late stent removal, using 5 days after surgery as the threshold. Most surgeries (71%) were performed robotically with extracorporeal diversion. The institution changed their protocol in 2020 from a ureteral stent duration of at least 14 days and postoperative antibiotic prophylaxis for 30 days to stent removal prior to discharge and antibiotic discontinuation within 14 days.
Antibiotic exposure was significantly less in the early vs late stent removal group: 8 vs 21 days, Dr Liu reported. Rates of postoperative UTI (9.3% vs 10.8%) and urine leak (0% vs 0.9%) were comparable between the early and late groups. Mean operative time was significantly shorter for the early group (5.87 vs 6.84 hours). The 30-day hospital readmission rate (9.3% vs 11.3%), mean length of stay (5.5 vs 5.7 days), and 30-day mortality rate (both 0%) were similar.
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“Decreasing ureteral stent duration reduces postoperative antibiotic exposure without increasing adverse outcomes in patients undergoing radical cystectomy,” Dr Liu and Dr Wenzel stated in an interview. “Prophylactic antibiotics are effective in decreasing the rate of UTIs following radical cystectomy to around 10%, and can be safely discontinued the day after stent removal without an increased rate of UTI compared with 30 days of prophylaxis. This practice improves antibiotic stewardship while also minimizing infections. Ureteral stents can be safely removed at 4-5 days after radical cystectomy prior to discharge without an increased rate of clinically significant urine leak.”
Urologists are increasingly removing ureteral stents earlier or eliminating them altogether. A 2021 study published in The Journal of Urology2 found that ureteral stent use at radical cystectomy was associated with higher 30-day complications rates, including UTIs. That study compared open procedures using stents vs no stents.
“Radical cystectomy without intra-operative ureteral stents is feasible,” Dr Liu and Dr Wenzel stated. They noted, however, that prior studies found that stentless urinary diversion resulted in increased ileus and urine leak.3,4
The researchers suggested that their preliminary data can be used to plan future prospective studies to determine optimal stent duration and antibiotic exposure. Their team will be studying even earlier stent removal at 3-4 days after surgery and even shorter antibiotic prophylaxis.
References
1. Wenzel J, Bassale S, Jones P, et al. Early stent removal after radical cystectomy. Presented at: AUA 2023, Chicago, Illinois, April 28-May 1. Abstract MP32-06.
2. Donat SM, Tan KS, Jibara G, Dalbagni G, Arslan Carlon V, Sandhu J. Intraoperative ureteral stent use at radical cystectomy is associated with higher 30-day complication rates. J Urol. 2021 Feb;205(2):483-490. doi:10.1097/JU.0000000000001329
3. Mullins JK, Guzzo TJ, Ball MW, et al. Ureteral stents placed at the time of urinary diversion decreases postoperative morbidity. Urol Int. 2012;88(1):66-70.
4. Mattei A, Birkhaeuser FD, Baermann C, Warncke SH, Studer UE. To stent or not to stent perioperatively the ureteroileal anastomosis of ileal orthotopic bladder substitutes and ileal conduits? Results of a prospective randomized trial. J Urol. 2008 Feb;179(2):582-586.
