CUA 2018: Do Common Urological Procedures Increase the Risk of an Infected Joint Prosthesis?

Halifax, Nova Scotia ( There has been concern of transient bacteremia during the course of urological procedures. Previously, on account of this concern, antibiotic prophylaxis was advocated for patients with structural heart disease and value replacements. However, guidelines have recently suggested that such prophylaxis is unnecessary. Similar concerns have also been raised regarding bacterial seeding of artificial joints. Notably, revision of knee and hip arthroplasty rates have been rising. In a podium presentation today at the Canadian Urologic Association Annual Meeting, Nahid Punjani, MD, and colleagues assessed the association between a prior cystoscopy or transurethral resection of the prostate (TURP) and the risk of infection of an infected total hip arthroplasty (THA) or total knee arthroplasty (TKA).

Using administrative data from the province of Ontario, the authors performed a retrospective, population-based cohort study of patients >66 years old in Ontario undergoing a first-time THA/TKA between April 1, 2003 and March 31, 2013. The authors looked back to identify patients who underwent cystoscopy or TURP within two years of a THA/TKA. Adjusting for relevant covariates, the authors performed Cox proportional hazard modeling to assess the association between prior urologic procedure and prosthetic joint infection requiring hospital admission.

The authors identified a total of 113 061 patients who met inclusion criteria (44 495 THA and 68 566 TKA). Median age was 74 years, and 40% were male. 

8426 (7.5%) patients had cystoscopy within two years of THA/TKA. In multivariate analysis, there was no significant association between cystoscopy and joint infection (hazard ratio [HR] 1.05; 95% confidence interval [CI] 0.85–1.30; p=0.66). The HR was still non–significant when considering only patients who underwent cystoscopy without antibiotic prophylaxis. 

A total of 1095 (2.5%) patients had a TURP within two years of THA/TKA. In multivariate analysis TURP was a significant risk factor for peri–prosthetic joint infection (HR 3.42; 95% CI 1.29–9.10; p=0.01).

The authors also assess the association between prior UTI and acute urinary retention. UTI was associated with an increased risk of joint infection (HR 1.21) while acute urinary retention was not associated with such a risk (HR 0.99).

The authors conclude that contemporary cystoscopy is a very non–invasive procedure and does not appear to be associated with a significant risk of a subsequent peri–prosthetic joint infection. This is contrasted with TURP, which is a more invasive procedure and does appear to be associated with an increased risk of peri–prosthetic joint infections. This has implications for the rational use of antibiotic prophylaxis and should be taken into account when updating societal antibiotic prophylaxis guidelines.

However, this study design and the resulting data are perhaps more informative for orthopedic surgeons who are operating on patients with a prior urologic history. Advice for urologists performing cystoscopy or TURP on patients with a prior history of joint arthroplasty cannot be drawn from these data and analysis considering this question would provide helpful guidance for urologists.

Presented by: Nahid Punjani, MD, Western University
Co-authors: Brent Lanting, Andrew McClure, Blayne Welk

Written by: Christopher J.D. Wallis, Urology Resident, University of Toronto, Twitter: @WallisCJD at the 73rd Canadian Urological Association Annual Meeting - June 23 - 26, 2018 - Halifax, Nova Scotia

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