Evolution toward early stent removal and reduced antibiotic prophylaxis post-cystectomy.

Abstract

Background: The ideal duration of ureteral stents in cystectomy is unknown, with trends toward earlier removal or foregoing them altogether. To reduce the duration of indwelling stents and antibiotics, we modified the cystectomy pathway at our institution from ~2 weeks of stenting with 30 days of antibiotic prophylaxis to stent removal before discharge with prophylaxis ending one day after stent removal. We evaluated rates of urinary tract infection (UTI) and urine leak in cystectomy patients after these changes.

Methods: We performed a retrospective review of patients undergoing cystectomy with ileal conduit diversion at our institution from 2016-2022. Patients were stratified into early vs. late stent removal (postoperative day [POD] ≤5 or >5). Primary outcomes were the 30-day rate of UTI (positive urine culture with symptoms requiring antibiotics) and urine leak (postoperative drain creatinine measurement ≥2× serum creatinine).

Results: Of 228 patients, 19% had early stent removal. Mean stent removal was POD 4 vs. 18 days in the early vs. late group. The early stent removal group had shorter antibiotic exposure (8.2 vs. 21.9 days, p < 0.001). No differences between the early vs. late stent removal groups were seen for postoperative UTI (9.3 vs. 10.8%, p = 0.77), urine leak (2.3% vs. 2.2%, p = 0.96), or readmission rates (9.3 vs. 11.4%, p = 0.69). No difference in the rate of hydronephrosis on postoperative imaging was noted between the two groups.

Conclusions: Iterative decreases in ureteral stent duration as part of a quality improvement initiative enabled reduced postoperative antibiotic exposure without increasing adverse outcomes, including UTI, urine leak, or postoperative hydronephrosis.