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Year : 2017  |  Volume : 50  |  Issue : 3  |  Page : 97-100

Prophylactic antibiotics for tubeless percutaneous nephrolithotomy

Department of Urology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan

Date of Submission20-Apr-2016
Date of Decision02-Jun-2016
Date of Acceptance14-Oct-2016
Date of Web Publication29-May-2017

Correspondence Address:
Yeong-Chin Jou
No. 539, Chung-Hsiao Road, Chia-Yi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/fjs.fjs_34_17

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Objective: The objective of this study was to investigate the efficacy of second-line versus first-line antibiotics in the prevention of postoperative fever after tubeless percutaneous nephrolithotomy (PCNL).
Methods: Three hundred consecutive tubeless PCNL procedures performed at our hospital between August 2010 and December 2013 were enrolled in this study. The efficacy of second-line antibiotics in the prevention PCNL-related urinary traction was reviewed by retrospective chart review.
Results: The overall postoperative fever rate was 12% (36 of 300 procedures). The second-line antibiotic prophylaxis was provided in 32 procedures according to preoperative urine culture data or physician's judgment. The first-line prophylactic antibiotic was used in 268 procedures with postoperative fever in 29 procedures (10.8%). The second-line prophylactic antibiotic was used in 32 procedures with postoperative fever in seven procedures (21.9%). No significance difference of postoperative fever rate between first-line or second-line prophylactic antibiotic was found (P = 0.069).
Conclusions: The second-line prophylactic antibiotic use for tubeless PCNL does not offer additional benefit over the first-line prophylactic antibiotic in the prevention of postoperative fever or shortening of the postoperative hospital stay.

Keywords: Antibiotic, percutaneous nephrolithotomy, tubeless

How to cite this article:
Yang CY, Chen PC, Lin CL, Cheng MC, Jou YC, Shen CH. Prophylactic antibiotics for tubeless percutaneous nephrolithotomy. Formos J Surg 2017;50:97-100

How to cite this URL:
Yang CY, Chen PC, Lin CL, Cheng MC, Jou YC, Shen CH. Prophylactic antibiotics for tubeless percutaneous nephrolithotomy. Formos J Surg [serial online] 2017 [cited 2020 Sep 23];50:97-100. Available from: http://www.e-fjs.org/text.asp?2017/50/3/97/207180

  Introduction Top

With the advances in endourology practice, most of the renal stones were treated by minimal invasive procedures now. Percutaneous nephrolithotomy (PCNL) remains the standard procedure for large renal stones, especially staghorn stones or stones, unsuccessfully treated by shock wave lithotripsy or other procedures. The European Association of Urology (EAU) guideline recommended PCNL as the first-line treatment for renal stones larger than 2 cm.[1]

The most common complications associated with PCNL are fever and bleeding. In contemporary series, post-PCNL fever rate was about 10% with sepsis rate about 1%.[2] The EAU guideline recommends preoperative urine culture and treatment of urinary tract infection (UTI) as well as perioperative prophylactic antibiotics for PCNL procedures.[1]

With the advantage of less analgesics requirement and shorter hospital stay, tubeless PCNL (without nephrostomy tube) gained popularity since the 2000s.[3],[4] There were some literatures comparing different prophylactic antibiotic for PCNL, but none of them was specific to tubeless PCNL.


We conducted this study to investigate the efficacy of second-line versus first-line antibiotics in the prevention of postoperative fever after tubeless PCNL.

  Methods Top

Three hundred consecutive tubeless PCNLs performed at our hospital between August 2010 and December 2013 were retrospectively reviewed in this study. All of the operations were performed by the same experienced team at our hospital utilizing a one-stage procedure. The access tract was created with ultrasound-guided puncture and dilated with serial coaxial metal dilators. Nephroscopy was performed under an open irrigation-drainage system. Holmium-yttrium-aluminum-garnet laser and/or pneumatic lithotripter were used for stone disintegration. At the end of the procedure, a double-J stent was placed. The bleeding points of the access tract were cauterized. The wound was closed without the placement of a nephrostomy tube.

We routinely performed urine culture and urinalysis at admission. Prophylactic antibiotic was given from preoperative day to postoperative day 2 or 3. Our standard empirical antibiotic regimen was cefazolin 1.0 g every 6–8 h with gentamicin 80 mg every 12 h. Gentamicin may be omitted if insufficient renal function. We define the regimens mentioned above as the first-line prophylactic antibiotic. The second-line prophylactic antibiotics, defined as second-generation cephalosporin (cefuroxime) or levofloxacin or other advanced generation antibiotics, were given according to the sensitivity of preoperative urine culture or physician's choice occasionally. Postoperative fever was taken as PCNL-related UTI unless other source of infection was noted. The efficacy of the second-line prophylactic antibiotics for PCNL was compared to the first-line prophylactic antibiotics.

For statistical analysis of data from the study, we used IBM SPSS Statistics for Windows, Version 21.0 (IBM Corp. Released 2012. IBM Corp., Armonk, NY, USA). Student's t-test was used for comparison of numerical data. Chi-square test was used for comparison of qualitative data. Logistic regression was used for multivariate comparisons. Results were assessed within 95% confidence intervals (CIs) and P < 0.05 was taken as statistical significance level.

  Results Top

The mean age of patients was 51.0 ± 11.4 years old. The gender distribution was 192 (64%) males and 108 (36%) females. The mean body mass index (BMI) of patients was 26.5 ± 4.1 Kg/m 2. The classification of stones was renal stones in 140 (46.7%) procedures, ureteral stones in 67 (22.3%) procedures, renal and ureteral stones in 36 (12.0%) procedures, and staghorn stones in 57 (19.0%) procedures. The mean stone size, defined as the maximum diameter on the preoperative kidney ureter bladder film, was 3.4 ± 1.9 cm. The mean operative time was 63.6 ± 19.7 min. The overall stone-free rate was 75%. The overall post-PCNL fever rate was 12%. The mean postoperative hospital stay was 3.3 ± 1.4 days [Table 1].
Table 1: Characteristics of 300 consecutive patients underwent tubeless percutaneous nephrolithotomy

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The first-line prophylactic antibiotic was used in 268 procedures (Group 1), and the second-line prophylactic antibiotic was used in 32 procedures (Group 2). The age of patients was not statistically different between both groups (53.3 ± 12.1 years vs. 56.7 ± 10.0 years, P = 0.163). The BMI was not statistically different between both groups (26.5 ± 4.1 Kg/m 2 vs. 26.2 ± 3.9 Kg/m 2, P = 0.671). The mean stone size of both groups was not significantly different (3.36 ± 1.87 cm vs. 3.84 ± 2.16 cm, P = 0.239). The mean operative time was statistically shorter in Group 1 (69.2 ± 22.3 min vs. 84.0 ± 33.8 min, P = 0.002). The stone-free rate was significantly higher in Group 1 (210/268, 78.4% vs. 15/32, 46.9%, P = 0.000). The postoperative hospital stay was shorter in Group 1 (3.2 ± 1.3 days vs. 3.8 ± 1.8 days, P = 0.048). Post-PCNL fever rate was 10.8% (29 of 279 procedures) in Group 1 and 21.9% (7 of 32 procedures) in Group 2. There was no statistically significant difference between both groups [P = 0.069, [Table 2]. The risk factors of post-PCNL fever were analyzed by logistic regression. The odds ratio (OR) of post-PCNL fever between two groups was 2.31 (0.92–5.81, P = 0.076) and the adjusted OR was 1.05 (0.36–3.12, P = 0.924) [Table 3]. This result further confirmed that using the first-line or second-line prophylactic antibiotic for tubeless PCNL has similar fever rate.
Table 2: Comparison of percutaneous nephrolithotomy s using first-line and second-line prophylactic antibiotics

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Table 3: Risk factors of fever posttubeless percutaneous nephrolithotomy by logistic regression

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  Discussion Top

PCNL is a common used surgical procedure for renal stones. Fever or UTI is one of the most common complications after PCNL. Sepsis rate after a PCNL can be as high as 1%–2% which causes significant morbidity.[5] Renal stones are foreign bodies of the urinary tract that may host the bacteria inside and become the source of bacteriuria. In a global study of 5313 PCNL procedures, 16.1% had positive preoperative urine culture. The most frequent identified microorganisms in this study were Escherichia coli, Proteus, Klebsiella, Pseudomonas, and Entreococcus species.[6] Staghorn stones are the stones that fill the major part of the renal collecting system. Most staghorn stones are composed of struvite.[7] Struvite stones are infectious stones. They are formed in urine infected by urease-producing pathogens such as Proteus, Klebsiella, Pseudomonas, and Staphylococcus species.[8] At present, the standard treatment for staghorn renal stones is PCNL.

PCNL procedures break the natural barrier of renal collecting system and cause the translocation of bacteria from the urine or stone to the renal parenchyma, which may increase the risk of post-PCNL UTI or fever. Factors associated with post-PCNL UTI or fever vary in the reported series. Stone size, operative time, positive stone culture, and positive pelvic urine culture have been demonstrated as contributory factors to the development of post-PCNL UTI in a study of 61 PCNL procedures.[9] A global study of 5313 procedures demonstrated that positive urine culture, staghorn stone, preoperative presence of a nephrostomy, lower patient age, and diabetes were associated with an increased risk of postoperative fever.[6] The EAU guideline on urolithiasis recommended perioperative prophylactic antibiotic for PCNL.[1] Several studies demonstrated the effect of prophylactic antibiotics for PCNL. Charton et al. reported a series of 126 PCNL procedures. Among these cases, 107 had sterile urine preoperatively and did not receive prophylactic antibiotic. Thirty-seven cases (35%) developed bacteriuria postoperatively. Eleven cases (10%) presented with fever 38.5°C or more.[10] In a large database PCNL case–controlled study, despite negative preoperative urine culture, antibiotic prophylaxis significantly reduces the rate of postoperative fever (2.5% vs. 7.4%, P = 0.040).[11] In a meta-analysis of 1018 PCNL procedures with sterile preoperative urine, prophylactic antibiotic significantly decreased fever (risk ratio [RR] =0.71, 95% CI: 0.54–0.92, P = 0.009), bacteriuria (RR = 0.39, 95% CI: 0.23–0.67, P = 0.0006), and bacteremia incidence (RR = 0.43, 95% CI: 0.25–0.73, P = 0.002).[12]

Many studies had demonstrated that positive stone or pelvic urine cultures during PCNL are important risk factors for post-PCNL systemic inflammatory response syndrome (SIRS).[13],[14],[15],[16] In a series of 274 ureteroscopy and 54 PCNL procedures, the correlation rate of stone cultures and bladder urine cultures to the pathogen causing sepsis was 64% and 9%, respectively.[15] Many authors recommended routine collection of stone or pelvic urine culture during PCNL as they may be useful in directing postoperative antibiotic prescription.[13],[14] Despite prophylactic antibiotic use, the postoperative fever rate after tubeless PCNL was 12% in our study. Stone or pelvic urine culture offers a better chance to identify the pathogen related to the UTI after tubeless PCNL and directs proper antibiotic treatment. There were limited studies comparing different prophylactic antibiotic regimens for PCNL, and none of them was specific to tubeless PCNL. Demirtas et al.'s prospective randomized study of 90 PCNL procedures showed no statistically difference of post-PCNL SIRS rate between ciprofloxacin and ceftriaxone groups (15.5% vs. 8.8%, P = 0.52).[17] Seyrek et al.'s prospective randomized study of 198 PCNL procedures also demonstrated insignificant post-PCNL SIRS rate difference between sulbactam-ampicillin and cefuroxime groups (13.7% vs. 17.7%, P = 0.44).[18] In our study, the preoperative characteristics of both groups such as age, BMI, and stone size were not statistically different. The post-PCNL fever rate was higher in the second-line prophylactic antibiotic group compared to the first-line prophylactic antibiotic group, but it did not reach statistically significance (21.9% vs. 10.8%, P = 0.069). Our study demonstrated that the second-line prophylactic antibiotic use for tubeless PCNL does not offer additional benefit over the first-line prophylactic antibiotic in the prevention of postoperative fever or shortening of the postoperative hospital stay. The retrospective nature of our study and relatively small number of second-line prophylactic antibiotic group limited the power of study. Further prospective randomized study may be required to draw more powerful conclusions.

  Conclusions Top

The second-line prophylactic antibiotic use for tubeless PCNL does not offer additional benefit over the first-line prophylactic antibiotic in the prevention of postoperative fever or shortening of the postoperative hospital stay.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Türk C, Petřík A, Sarica K, Seitz C, Skolarikos A, Straub M, et al: EAU guidelines on interventional treatment for urolithiasis. Eur urol, 2016;69:475-82.  Back to cited text no. 1
Seitz C, Desai M, Häcker A, Hakenberg OW, Liatsikos E, Nagele U, et al. Incidence, prevention, and management of complications following percutaneous nephrolitholapaxy. Eur Urol 2012;61:146-58.  Back to cited text no. 2
Limb J, Bellman GC. Tubeless percutaneous renal surgery: Review of first 112 patients. Urology 2002;59:527-31.  Back to cited text no. 3
Crook TJ, Lockyer CR, Keoghane SR, Walmsley BH. A randomized controlled trial of nephrostomy placement versus tubeless percutaneous nephrolithotomy. J Urol 2008;180:612-4.  Back to cited text no. 4
Jou YC, Lu CL, Chen FH, Shen CH, Cheng MC, Lin SH, et al. Contributing factors for fever after tubeless percutaneous nephrolithotomy. Urology 2015;85:527-30.  Back to cited text no. 5
Gutierrez J, Smith A, Geavlete P, Shah H, Kural AR, de Sio M, et al. Urinary tract infections and post-operative fever in percutaneous nephrolithotomy. World J Urol 2013;31:1135-40.  Back to cited text no. 6
Segura JW, Preminger GM, Assimos DG, Dretler SP, Kahn RI, Lingeman JE, et al. Nephrolithiasis clinical guidelines panel summary report on the management of staghorn calculi. The American Urological Association Nephrolithiasis Clinical Guidelines Panel. J Urol 1994;151:1648-51.  Back to cited text no. 7
Griffith DP, Osborne CA. Infection (urease) stones. Miner Electrolyte Metab 1987;13:278-85.  Back to cited text no. 8
Gonen M, Turan H, Ozturk B, Ozkardes H. Factors affecting fever following percutaneous nephrolithotomy: A prospective clinical study. J Endourol 2008;22:2135-8.  Back to cited text no. 9
Charton M, Vallancien G, Veillon B, Brisset JM. Urinary tract infection in percutaneous surgery for renal calculi. J Urol 1986;135:15-7.  Back to cited text no. 10
Gravas S, Montanari E, Geavlete P, Onal B, Skolarikos A, Pearle M, et al. Postoperative infection rates in low risk patients undergoing percutaneous nephrolithotomy with and without antibiotic prophylaxis: A matched case control study. J Urol 2012;188:843-7.  Back to cited text no. 11
Yang MG, Zheng ZD, Xu ZQ, Lin HL, Zhuang ZM, Zhang CX. Prophylatic antibiotic use in percutaneous nephrolithotomy: A meta-analysis. Zhonghua Wai Ke Za Zhi 2013;51:922-7.  Back to cited text no. 12
Mariappan P, Smith G, Bariol SV, Moussa SA, Tolley DA. Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy: A prospective clinical study. J Urol 2005;173:1610-4.  Back to cited text no. 13
Ma K, Xu QQ, Huang XB, Wang XF, Li JX, Xiong LL, et al. Clinical implication of stone culture in percutaneous nephrolithotomy. Zhonghua Yi Xue Za Zhi 2010;90:222-4.  Back to cited text no. 14
Eswara JR, Shariftabrizi A, Sacco D. Positive stone culture is associated with a higher rate of sepsis after endourological procedures. Urolithiasis 2013;41:411-4.  Back to cited text no. 15
Shoshany O, Margel D, Finz C, Ben-Yehuda O, Livne PM, Holand R, et al. Percutaneous nephrolithotomy for infection stones: What is the risk for postoperative sepsis? A retrospective cohort study. Urolithiasis 2015;43:237-42.  Back to cited text no. 16
Demirtas A, Yildirim YE, Sofikerim M, Kaya EG, Akinsal EC, Tombul ST, et al. Comparison of infection and urosepsis rates of ciprofloxacin and ceftriaxone prophylaxis before percutaneous nephrolithotomy: A prospective and randomised study. ScientificWorldJournal 2012;2012:916381.  Back to cited text no. 17
Seyrek M, Binbay M, Yuruk E, Akman T, Aslan R, Yazici O, et al. Perioperative prophylaxis for percutaneous nephrolithotomy: Randomized study concerning the drug and dosage. J Endourol 2012;26:1431-6.  Back to cited text no. 18


  [Table 1], [Table 2], [Table 3]


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