Abstract
Background:
Endoscopic surgery is now increasingly taking the place of open surgery in urology. Traditionally, endourological procedures are classified as clean-contaminated because the genitourinary tract is colonized by micro-flora, even in the case of sterile urine. The aim of this study was to determine whether a difference occurs in the infection rate after short endourological procedures using standard scrubbing and partial scrubbing techniques before the operations.
Patients and Methods:
This was a retrospective analysis of 397 patients who underwent a short endourological procedure, with all procedure durations lasting <30 min. Patients were divided into a first group who underwent operations using a full-scrub technique and a second group who underwent operations using a partial-scrub technique. All patients were followed up for the occurrence of urinary tract infections (UTIs). Both groups were compared for age, gender, and post-operative development of UTIs. Values of p < 0.05 were considered statistically significant.
Results:
Of the 397 patients, 200 and 197 underwent their procedures using the full-scrub and partial-scrub techniques, respectively. Females and males accounted for 142 (35.8%) and 255 (64.2%) patients, respectively. Only 18 (4.5%) patients developed documented UTIs and antibiotics were prescribed. Of the 18 patients diagnosed with post-operative UTIs, 10 (55.5%) had undergone partial-scrub operations and 8 (45.5%) had undergone full-scrub operations (p = 0.638).
Conclusion:
Our findings did not indicate any significant relationship between the risk of developing UTI after a short endourological procedure and the scrub technique used before the operation (partial or full scrub).
Endoscopic surgery is now increasingly taking the place of open surgery in urology. Endourological operations involve retrograde access to the urinary tract using specialized devices that are introduced into the urinary system through the urethra. No consensus presently exists regarding the risk of urinary tract infection (UTI) following endourological procedures or the need for antibiotic prophylaxis for these procedures. 1
The classification of transurethral surgery according to Cruise and Ford into clean, clean-contaminated, contaminated, and dirty is more complex compared with open urological surgical procedures (Table 1).3–6 Traditionally, endourological procedures are classified as clean-contaminated because the genitourinary tract is colonized by micro-flora, even in cases of sterile urine. 7
Contamination Classes 2
SSI, surgical site infection.
Over the past 20 years, the pre-operative use of antibiotic prophylaxis has undergone considerable change. The effectiveness of this tactic, in lowering post-operative wound infections has been made evident by advancements in the timing of the first administration, the optimal selection of antibiotic agents, and shorter administration periods. 2 Identifying the surgical class or category (i.e., the degree of contamination of the procedure) is important when planning surgery. The current surgical field contamination classifications were created during World War II and modified for use in military operations. They were later updated for open surgery and used in determining the relative risk of infection from a surgical wound. 8 However, urological interventions have not been classified, and the current definitions do not include endoscopic surgery. Nevertheless, opening or entering into the urinary tract, even in the presence of a negative urine culture, should automatically be classified as a clean-contaminated intervention. 9 As scrubbing before operation is an integral part in reducing surgical site infections (SSIs), the aim of our study was to determine whether a difference in infection rate after endourological procedures occurs when using standard scrubbing (cleaning hands to elbows and wearing sterile gown and gloves) versus partial scrubbing (cleaning hands only and wearing sterile gloves without a gown) techniques before the operations.
Patients and Methods
Study design and approval
After obtaining an Institutional Review Board approval number (IRB/2023/600), a retrospective analysis of 397 patients who underwent a short endourological procedure (flexible or rigid diagnostic cystoscopy, double J insertion, double J removal, optical urethrotomy, ureteroscopy and stone extraction, transurethral resection, or fulguration of a tumor <1 cm) with all procedure durations lasting <30 min (ranging from 15 to 30 min). None of the patients had UTI symptoms before their operations. Patients were divided into two groups (the decision made to do a full scrub versus partial scrub was done randomly by the surgeon). The first group underwent their operations using a full-scrub technique. The surgeons allowed water to run and covered the nail pick and brush with soap, using their elbows on the soap dispenser and then cleaning their nails and removing any gross debris from their hands. The surgeons then scrubbed their hands and forearms with soap down to their elbows for at least one minute. They then rinsed the soap from their hands and forearms by holding up their arms with their hands elevated under the tap, allowing the water to run off into the sink from their elbows. This procedure was repeated a further three times, each time lasting for at least one minute. The surgeons then donned sterile gowns and gloves.
The second patient group underwent their operations using a partial-scrub technique, in which the surgeons washed their hands with water and soap for one minute, followed by drying their hands and donning sterile gloves, but no gowns, before starting the procedure.
All patients were given prophylactic antibiotics pre-operatively. After the operation, the patients were followed for the occurrence of UTI symptoms, followed by oral or intravenous antibiotics if UTIs were confirmed by urine culture. The two groups were compared for age, gender, and development of post-operative UTIs. Values of p < 0.05 were considered statistically significant.
Inclusion and exclusion criteria
All patients who underwent endourological operations lasting <30 min between January 2021 and January 2023 were included in the study. Patients with operation durations lasting >30 min, patients with UTI symptoms before the operation, patients whose scrub type was not documented on their operative notes, and patients who were lost to follow-up were excluded from the analyses. Ultimately, 397 patients were included in the study.
Patient assessment
Patients were assessed for age, gender, operation duration, and medical (chronic kidney disease, DM, HTN, cancers) and surgical history, in addition to post-operative follow-up if they developed UTI post-procedurally and if they needed antibiotics. If a patient had UTI, the patient was administered oral or intravenous antibiotics according to the UTI severity.
Intervention
After being classified into two groups according to their scrub type, the patients were assessed for the development of UTIs. When a patient was confirmed to have a symptomatic and culture-documented UTI, the patient was given antibiotics (oral or intravenous) according to the severity of the infection.
Outcome measures and assessment tools
The primary outcome was an assessment of the effect of the scrub technique used in the short endourological operation on the development of a post-operative UTI.
Statistical analysis
The statistical analysis was performed using IBM SPSS 25.0 software. The dependent variable was the occurrence of UTIs. For independent samples, a t-test was used for numerical variables (age), whereas a chi-square test was used for categorical variables (scrub technique, medical illness, and gender). Differences were considered statistically significant at p < 0.05.
Results
The study population included 397 individuals who underwent short endourological procedures in our center from January 2021 to January 2023. Overall, 200 patients (50.4%) underwent their procedure using full scrubbing (cleaning hands to elbows and wearing sterile gown and gloves), whereas 197 patients (49.6%) underwent partial scrubbing (cleaning hands only and wearing sterile gloves without gown). Among the 397 patients, 142 (35.8%) were female and 255 (64.2%) were male. The mean patient age was 38.98 years old (range 17–75 y). Most of the patients (91.4%) had no significant medical history. The duration of the operations ranged from 15 to 30 min. All patients were followed for two weeks post operation and when UTI symptoms (dysuria, frequency, and fever) developed, urine analysis and culture were done. Only 18 patients (4.5%) developed documented UTIs (7 patients have infection post urethroscopy, and 6 patients have infection post TURBT, 2 have infection post diagnostic rigid cystoscopy, 2 patients have infection post diagnostic flexible cystoscopy, and 1 patient has infection post double J insertion), and antibiotics were prescribed. Of the 18 patients diagnosed with post-operative UTIs, 10 (55.5%) had undergone partial scrub procedures, whereas 8 (45.5%) had undergone full scrub operations. All patients diagnosed with UTIs were treated with oral antibiotics except for one patient who was admitted because of a high-grade fever, hypotension, and vomiting (see Table 2). When studying the relation between risk of developing a post-operative UTI and age, body mass index (BMI), gender, and scrub technique, we found no significant relation between post-operative UTI risk and any of the above variables (p values were 0.205, 0.15, 1, and 0.638, respectively). This indicated that no significant relation existed between the risk of developing UTI following short endourological procedures and the scrub techniques used before the operation (partial or full) (see Table 3).
Illustration for Demographics, Scrubbing Type, Medical History, and Development of Urinary Tract Infection Post Operation
BMI, body mass index; UTI, urinary tract infection.
Different Variables and Their p Values
BMI, body mass index.
Discussion
Prevention of post-operative infections, especially SSIs, depends on the use of sterile sutures, gloves, gowns, drapes, and surgical hats, increased cleanliness of operating rooms, and improvements in sterilization techniques for surgical instruments,10,11 in addition to disinfection technology for surgical instruments. Endourological surgery is a minimally invasive type of surgery used to diagnose and treat conditions of the urinary tract. It represents a huge advancement in the field of urology because it is less invasive and offers a quicker recovery time than traditional open surgeries. Nevertheless, one of the concerns about endourological surgery is the risk of UTIs. The reduced invasiveness of endourological surgery, characterized by the absence of large incisions, minimizes direct surgeon–surgical site contact, inherently reducing infection risk. 12 In contrast to open surgeries, in endourological surgery, such as cystoscopy or ureteroscopy, we take into consideration febrile UTIs rather than SSIs. 13 Some studies show that not applying surgical hand hygiene increases time efficacy and cost effectiveness without affecting the post-operative infection rate.14,15
Unno et al. included 477 patients in their study and suggested that regular hand hygiene may be sufficient to prevent infection in patients undergoing endourological surgery and that double gloves may not be necessary. 12 Some studies have also reported that the operation time, rather than the scrubbing technique, has the most effect in reducing the post-operative infection rate.16,17 Moreover, other research has shown that hand-scrubbing materials are not as effective after three hours, but the actual duration of hand cleanliness is unknown during a long operation. 18 However, knowledge of the duration of hand cleanliness would allow the development of better protocols for hand hygiene during long operations. This could help reduce the risk of UTIs and improve patient outcomes after endourological surgeries.
Few studies have investigated whether surgical hand hygiene plays a role in reducing post-operative infection rates. 19 For example, an investigation of how pre-operative scrubbing before surgery affects different groups of patients identified a significant difference in infection rates. When surgeons performed pre-operative scrubbing before surgery, the risk of infection in their patients was very low, at 9.09%. By contrast, when surgeons did not perform pre-operative scrubbing, their patients had a much higher infection rate of 48%. In scenarios with clean-contaminated wounds (as in endourological surgeries), the SSI rate dropped to 16% with the execution of scrubbing, whereas the group without scrubbing experienced a markedly higher rate of 60%. 20 Overall, the findings of the present study highlight how a short pre-operative scrubbing before surgery can significantly decrease the risk of post-operative infections. Another study showed that performing a pre-operative surgical scrubbing for 2–3 min using an appropriate antiseptic material can decrease the possibility of SSIs. 21 The retrospective nature of this study and its relatively small sample size are major limitations of our study. Therefore, further larger studies are needed to confirm this relationship.
Conclusion
Although scrubbing is an important step before operations to reduce the risk of infection after the operation, our study showed no significant relation between the risk of developing a UTI after a short endourological procedure and the scrub technique (partial or full) used before the operation. However, further research with larger numbers of patients is needed in this field.
Footnotes
Data Availability
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.
Authors’ Contributions
All authors made a significant contribution to the work reported and took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agreed to be accountable for all aspects of the work.
Author Disclosure Statement
The authors declare that they have no competing interests.
Funding Information
This study was not funded.