What is the management of sepsis following Transurethral Resection of Bladder Tumor (TURBT)?

Management of Sepsis Following TURBT

Treat post-TURBT sepsis with immediate broad-spectrum intravenous antibiotics, source control through urinary drainage, and aggressive hemodynamic support following standard sepsis protocols, while recognizing that antibiotic prophylaxis at the time of TURBT remains controversial and should be reserved for high-risk patients. 1, 2

Immediate Management of Established Sepsis

Recognition and Initial Resuscitation

• Sepsis represents life-threatening organ dysfunction from the body's response to infection and requires prompt recognition 2
• Initiate immediate broad-spectrum IV antibiotics within the first hour of recognition, targeting common urinary pathogens including gram-negative organisms and enterococci 2
• Provide careful hemodynamic support with IV fluids and vasopressors as needed to maintain adequate perfusion 2
• Obtain blood and urine cultures before antibiotic administration, but do not delay treatment 2

Source Control

• Ensure adequate urinary drainage with a large-caliber catheter (20-24 Fr) to facilitate drainage and prevent obstruction 3
• Consider imaging (CT scan) to evaluate for complications such as bladder perforation, which can occur after TURBT and contribute to sepsis 4
• If bladder perforation is identified (intraperitoneal or extraperitoneal), surgical consultation is mandatory as this represents a surgical emergency 4

Prevention: Antibiotic Prophylaxis Considerations

Current Evidence on Prophylaxis

• The evidence for routine antibiotic prophylaxis in TURBT is moderate to low-grade, suggesting it is not necessary for all patients 1
• The EAU guidelines provide a weak recommendation that antibiotic prophylaxis is appropriate only for patients at high risk of postoperative sepsis 1
• Research demonstrates that in patients without risk factors for infectious complications, symptomatic UTIs occur in only 3.4% without prophylaxis versus 2.3% with prophylaxis (not statistically significant, P=0.61) 5

High-Risk Patients Who Should Receive Prophylaxis

Antibiotic prophylaxis should be administered to patients with:

• Immunocompromised state 1
• Large tumor burden or prolonged surgical time (>2 hours) 1
• Pre-existing bacteriuria or positive urine culture 1
• History of recurrent UTIs 1
• Indwelling catheter or urinary retention 1

Prophylaxis Protocol When Indicated

• Administer perioperative antibiotics in adequate dose based on patient weight within 60 minutes of surgical incision 1
• Discontinue antibiotics within 24 hours after surgery 1
• Intraoperative redosing should occur after two antibiotic half-lives if surgery duration exceeds this timeframe 1
• Single oral dose of 200 mg levofloxacin is one effective option for low-risk patients when prophylaxis is chosen 5

Important Caveats and Pitfalls

Contraindications to Immediate Intravesical Chemotherapy

• Do not administer immediate postoperative intravesical chemotherapy if sepsis, perforation, or extensive resection occurred, as this can lead to severe complications including peritonitis 1, 6
• Immediate chemotherapy should only be given within 24 hours in uncomplicated cases without evidence of perforation 1

Bladder Perforation Risk

• TURBT on the anterior wall or dome carries higher perforation risk, particularly in patients with prior pelvic radiation, BCG therapy, or bladder outlet obstruction 4
• Perforation can occur days after discharge (up to 2 weeks post-procedure), presenting with abdominal pain, renal failure, or ascites 4
• Maintain high suspicion for delayed perforation in patients presenting with abdominal pain or urinary symptoms after discharge 4

Complication Rates

• Overall TURBT complication rate is approximately 8.1%, with most complications being Clavien-Dindo grade I or II 7
• Infection occurs in approximately 2.1% of cases 7
• Perforation occurs in 0.5% of cases 7
• Patients with prior complications are at higher risk for subsequent complications 7

Quality Indicators for Optimal Outcomes

Surgical Technique to Minimize Infection Risk

• Complete resection with detrusor muscle in specimen (except for Ta low-grade tumors) reduces residual disease and subsequent infection risk 1, 8
• Avoid bladder perforation through careful technique, as perforation significantly increases infection risk 1, 8
• Document tumor characteristics (number, location, size) using a bladder diagram 1
• Submit specimens in separate containers (exophytic portion, bladder wall with muscle, resection edges) for accurate pathological assessment 1, 8

Post-Operative Monitoring

• Monitor for signs of infection including fever, flank pain, urgency, frequency, or suprapubic pain within the first 2 weeks post-procedure 1, 7
• Maintain catheter drainage until bleeding is controlled, typically 24-48 hours 3
• Educate patients about delayed complications including perforation symptoms that may occur up to 2 weeks after discharge 4