Postoperative Infectious Complications in Our Early Experience With Holmium Laser Enucleation of the Prostate for Benign Prostatic Hyperplasia

Lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) are one of the most common diseases in elderly males [1]. Patients in general are prescribed an alpha-blocker first and then, if necessary, are treated by transurethral resection of the prostate (TURP) if not enough response to the alpha-blocker is shown [2]. TURP has been accepted as the gold standard for the surgical management of symptomatic BPH [3]. Even though several excellent alpha-blockers are in use, some patients with severe LUTS require surgical therapy. Our county's guidelines recommend surgical management for patients with BPH with repeated urinary retention or bladder stone formation [4]. Recently, surgical therapy has come to include methods thought to be relatively less invasive than TURP [5]. These new methods have resulted in lower morbidity and excellent improvements in voiding and storage symptoms [6]. For example, holmium laser enucleation of the prostate (HoLEP) has become a widespread and well-accepted treatment modality with excellent outcomes compared to other conventional treatment modalities such as TURP and open prostatectomy [7, 8].

Because this surgical procedure is comparatively new, surgeons tend to concentrate on the completion of the surgery, and most previous reports regarding HoLEP have described the efficacy of the procedure for patients' urination. As a next step, surgeons need to consider whether this procedure can be performed safely with a comparatively lower rate of adverse events than TURP. This new technique should not only be less invasive and offer better efficacy for urination but also show a lower ratio of adverse events, especially in terms of postoperative infectious diseases [9].

In this study, we retrospectively examined the incidence of postoperative infectious complications (PICs) in our early experience with HoLEP for BPH with a particular focus on the kind and duration of prophylactic antibiotic administration (PAA).

HoLEP for BPH has become widespread in the urological field and has recently been performed at many institutions [11]. HoLEP may involve less stress to patients [12] and should offer a lower rate of surgical site infection and postsurgical complications than open surgery or TURP. This is beneficial to patients and has supported the spread and acceptance of HoLEP [13]. This surgery has the benefit of less extensive injury to prostatic tissue than TURP [14]; thus, postsurgical local inflammation may not be as severe as with TURP [15]. Inflammation could be one risk factor for PICs, such as prostatitis [16], and therefore HoLEP may also be beneficial for suppressing PICs [17]. Basically, HoLEP is thought to cause the patients less stress in addition to having higher efficacy for LUTS [18]. However, the present study had 7 cases of PICs, and this ratio may be comparatively higher than in other reports [9]. There are several possible reasons for this; 1) Our 90 cases were performed by 7 surgeons including beginners with less than 5 cases of experience with HoLEP. Even though it is not clear whether there is a significant relationship between longer surgical time and a higher ratio of PIC occurrence, beginners or less-experienced surgeons take more time to accomplish the surgery than experienced surgeons [9], both to finish the surgical procedures such as enucleation or tissue morcellation and to avoid surgery-related adverse events. 2) PAA may not have included the most appropriate kind of antibiotics or duration of dosing. This is because the CDC guidelines and Japanese guidelines recommend that first-generation cephalosporins be administered every 2 to 3 hours during surgery and that penicillins, first-generation or second-generation cephalosporins, and aminoglycosides be administered within 72 hours in TURP, respectively [19].

In addition, discrepancies may exist between PAA performance and guideline recommendations in individual cases. This is because, for instance, the Japanese guideline recommends first-generation or second-generation cephalosporins, penicillins, and aminoglycosides for TURP as mentioned above but has not yet established guidelines for HoLEP [19]. Our most often used PAA is SBT/ABPC and the duration of dosing is recommended to be within 72 hours. However, our cases tended to have a longer duration of dosing with a higher ratio of PIC occurrence than in other reports [20], even in preoperative nonpyuria cases. Our statistical data showed that PIC occurrence did not depend on the kind or duration of PAA, which suggests that we may be able to shorten the duration of PAA, which may lead to the control of unnecessary antibiotic use.

Regarding causative bacteria, the PIC cases included 2 cases of S. marcescens, 1 case of P. mirabilis, and 1 case of K. pneumonia. Other reports showed Escherichia coli to be the representative causative bacteria [21]. Our comparatively broader spectrum PAA than recommended in guidelines or other reports, or preoperative intervention against preoperative pyuria cases, might have accounted for this difference.

We would like to emphasize the study limitations. This was a retrospective study and the number of cases was not enough for making definitive conclusions. Second, some of our cases were performed by surgeons who were less experienced with HoLEP and showed a comparatively higher ratio of PIC. Third, our PAA duration of dosing tended to be longer and the kind of antibiotics tended to be broad spectrum, which could lead to the emergence and spread of resistant strains [22]. Future studies should be performed to address these problems.

The results of this retrospective study showed that PIC occurrence did not depend on the duration or the kind of PAA in our early experience with HoLEP. Further prospective study is necessary for the evaluation and establishment of prophylactic measures for PIC.