Effect of Intraoperative Regimen on Incidence of Symptomatic Postoperative UTI in a Urogynecology Practice

INTRODUCTION: Acute urinary tract infections (UTIs) are common after prolapse and anti-incontinence surgery, with incidence rates varying from 14% to 64%. OBJECTIVE: To decrease rates of symptomatic urinary tract infections in patients undergoing pelvic organ prolapse repair and/or anti-incontinence surgery with a change an intraoperative practice. METHODS: This change in practice was implemented January 19, 2024, to July 18, 2024, for all patients undergoing prolapse and/or anti-incontinence surgery within our division. Subjects from the same time range 1 year prior were used for comparison. The regimen consisted of re-prepping the urethra with 4% chlorhexidine swab before any instrumentation, including placement of the transurethral catheter or cystoscope. Any time the urethral catheter was temporarily removed, it was kept in a solution of 80 mg gentamicin/500 mL normal saline on the operative field. Counts for intraoperative urethral instrumentation were consistently tracked. No changes were made to our standard of care for prophylactic intraoperative antibiotics, and patients who were discharged with a Foley catheter received methenamine hippurate and cranberry per our usual practice. The primary outcome, incidence of symptomatic UTIs within 30 days postoperatively, was determined for pre- and post-regimen implementation subjects. Secondary analyses included the association between UTI rates and urethral instrumentation, specific surgeon, and procedure type. We also sought to determine if these interventions were associated with increasing resistance in bacterial isolates from urine cultures. RESULTS: The total 461 patients in pre- and post-practice change groups were similar in age, BMI, and race distribution with similar rates of baseline comorbidities of interest: diabetes, recurrent UTIs, and current smoking status (Table 1). For the primary outcome of symptomatic UTI within 30 days of surgery, there was a significant decrease from 18.1% to 10.9% (p 0.034). When analyzing the number of urethral instrumentations per case, the median number was 3, with no difference between those who developed UTI and those who did not. There was no difference in rates of failed voiding trial and no increase in resistant bacterial strains after the practice change implementation (Table 2). Approximately a 50% decrease in secondary postoperative urinary retention (POUR) was demonstrated in the post-implementation group, postulated to be related to the lower rate of UTIs. CONCLUSIONS: An intraoperative regimen that includes urethral re-prepping prior to all intraoperative instrumentation and leaving the Foley catheter in a gentamicin/saline solution when not in use, demonstrated a 40% decrease in symptomatic UTIs within 30 days of surgery. Given the low cost and ease of implementation of these interventions, surgeons may consider incorporating these measures to help minimize postoperative UTIs after prolapse and anti-incontinence surgery.