Urinary tract infection prevention after midurethral slings in pelvic floor reconstructive surgery: A systematic review and meta‐analysis

Abstract

Introduction Synthetic midurethral slings are the most common procedures currently performed for stress urinary incontinence in women. Infection is a frequent complication of urogynecologic surgery. We performed a systematic review and meta‐analysis to identify interventions that successfully prevent infections, including urinary tract infection (UTI) and/or bacteriuria, compared with no intervention, in women undergoing midurethral sling surgery with or without concomitant pelvic reconstructive procedures for prolapse. Material and methods The primary outcome was the development of any infection post‐midurethral sling placement in women. MEDLINE, Embase, CINAHL and the Cochrane Library were searched for comparative studies from inception to July 2017, with no language restrictions. We used search terms related to midurethral sling, infections and infection‐reduction interventions. Two independent reviewers abstracted data and assessed study quality. Pooled effect size estimates were calculated. We conducted meta‐analysis of eligible studies. A protocol for this review has been registered and can be accessed online (http://hdl.handle.net/2429/64731). Results We identified seven eligible studies of infection risk‐reducing interventions; all focused on UTIs. Only one study assessed preoperative antibiotics with midurethral sling alone and was halted early because of low UTI rates. All other studies (three randomized control trials and three observational studies) examined whether postoperative antibiotics decrease UTI/bacteriuria rates after midurethral sling with or without reconstructive procedures for pelvic organ prolapse and using bladder catheterization postoperatively. Due to considerable clinical heterogeneity, we only combined four studies for meta‐analysis. Postoperative oral prophylactic nitrofurantoin showed no significant benefit in reducing UTI/bacteriuria in women post‐midurethral sling with or without concomitant reconstructive pelvic surgery and the need for bladder catheterization, when compared with the reference group (pooled relative risk 0.73, 95% confidence interval [CI] 0.42‐1.25). Conclusions Based on the best available evidence, postoperative oral nitrofurantoin is not effective at reducing UTI/bacteriuria rates in catheterized women after midurethral sling with or without concomitant pelvic reconstructive surgery for prolapse. For midurethral sling alone, preoperative antibiotic prophylaxis may not be needed for UTI prevention.

FIGO recommendations: Use of midurethral slings for the treatment of stress urinary incontinence

“…Retropubic MUS and urinary retention with postoperative PVR of 100 mL and above may increase the risk of UTI after a MUS (LOE 3, grade 1C) 134–137 . Antibiotic prophylaxis may not be required to prevent postoperative UTIs (LOE 2, grade 1B) 138 . Urinalysis should be performed at each postoperative visit after a MUS, especially if adverse symptoms are present.…”

“…[134][135][136][137] Antibiotic prophylaxis may not be required to prevent postoperative UTIs (LOE 2, grade 1B). 138 Urinalysis should be performed at each postoperative visit after a MUS, especially if adverse symptoms are present.…”

Midurethral sling position and surgical outcome: A meta-analysis

“…The postoperative continence status was compared using the suburethral sling position in 9 studies, [15][16][17][19][20][21][22][23][24] while postoperative lower urinary tract symptoms were assessed in 6 studies. [15][16][17]20,23,24,25] 3.1.1. Sling position and cure rate (retropubic approach).…”

Postoperative Complications After Sling Operations for Incontinence: Is Race a Factor?

“…6,7 Urinary tract infections contribute to lower quality metrics on surgical outcome data at a hospital system level, thus research has been undertaken to examine risk factors and implement prophylactic measures to decrease the incidence of complications. 8,9 Racial and ethnic minority groups experience higher rates of illness and death compared with their White counterparts in the United States, 10 and there is substantial evidence that this trend also exists in surgical outcomes. Broad multispecialty cohort studies of patients undergoing surgery demonstrate increased morbidity, mortality, and readmissions in patients of Black race.…”

“…Urinary tract infections account for more than 8 million office visits per year, longer hospital stays for inpatients, and increased antibiotic use 6,7 . Urinary tract infections contribute to lower quality metrics on surgical outcome data at a hospital system level, thus research has been undertaken to examine risk factors and implement prophylactic measures to decrease the incidence of complications 8,9 …”