Risk of Recurrent UTIs Post Total Prostatectomy
The risk of recurrent UTIs after total (radical) prostatectomy is actually quite low, with postoperative UTI rates ranging from 2.5-3.2% in contemporary series, and the procedure itself may reduce long-term UTI risk by removing the chronically colonized prostate tissue that serves as a bacterial reservoir. 1
Understanding the UTI Risk Profile After Radical Prostatectomy
Acute Postoperative UTI Risk (First 30 Days)
The immediate postoperative UTI rate is 2.5-3.2% in modern robotic-assisted radical prostatectomy series, with no significant difference based on antibiotic prophylaxis type (cefazolin vs. ampicillin/sulbactam). 1
Neither the type nor duration of prophylactic antibiotic administration affects postoperative UTI/SSI/RI rates after radical prostatectomy, according to multivariate analysis of over 1,000 patients. 1
Surgical site infections and remote infections occur at comparable low rates (approximately 2-3% combined) regardless of antimicrobial prophylaxis regimen. 1
Long-Term Recurrent UTI Risk
Radical prostatectomy may actually reduce long-term UTI risk by eliminating the prostate as a bacterial reservoir—bacterial prostatic colonization occurs in 53.8% of men with BPH and significantly increases postoperative UTI risk in transurethral procedures. 2
The prostate itself serves as a source of persistent bacteriuria in men with BPH, with corresponding prostate and urine cultures found in approximately 50% of cases with positive prostate cultures. 2
Preoperative bacteriuria improves after prostatectomy in 77% (14/18) of patients who had positive cultures before surgery, suggesting the procedure eliminates a chronic infection source. 3
Critical Distinction: Radical vs. Transurethral Prostatectomy
Why This Matters for Your Patient
The evidence base primarily addresses TURP (transurethral resection), not radical prostatectomy—these are fundamentally different procedures with different UTI risk profiles. 4, 5, 2, 3
TURP leaves prostatic tissue behind and involves mucosal trauma in a contaminated field, while radical prostatectomy removes the entire gland and is performed in a sterile field. 6
Post-TURP persistent bacteriuria occurs in 15-18% of patients at 3 weeks, significantly higher than radical prostatectomy rates, because residual prostatic tissue remains colonized. 4
Risk Factors That Apply to Transurethral Procedures (Less Relevant to Radical Prostatectomy)
Age ≥75 years increases UTI risk 2.65-fold (OR 2.65,95% CI 1.06-7.52, p=0.036) after TURB, though this may not translate to radical prostatectomy. 6
Past pelvic radiotherapy increases UTI risk 6-fold (OR 6.00,95% CI 1.32-19.8, p=0.024) after transurethral procedures. 6
Preoperative bacteriuria increases postoperative UTI risk 2.97-fold (OR 2.97,95% CI 1.04-7.55, p=0.044) after TURB. 6
Preoperative pyuria increases UTI risk 2.54-fold (OR 2.54,95% CI 1.06-6.20, p=0.038) after transurethral procedures. 6
Practical Management Algorithm for Your Patient
Preoperative Screening (If Not Already Done)
Screen for and treat asymptomatic bacteriuria before radical prostatectomy using urine culture, as this is an endoscopic urologic procedure with potential mucosal trauma. 6
Prescribe targeted antimicrobial therapy based on culture results rather than empiric therapy, using short-course (1-2 doses) treatment initiated 30-60 minutes before the procedure. 6
Postoperative Monitoring
Obtain urine culture at catheter removal (typically 7-14 days post-radical prostatectomy) to detect early bacteriuria. 4, 3
Repeat urine culture at 1 week and 3 weeks post-catheter removal if the patient develops any urinary symptoms (frequency, urgency, dysuria, fever). 4
Monitor for prolonged urinary leakage or catheterization as these significantly increase UTI risk—patients with positive cultures have longer urinary leakage, catheterization, and hospital stays. 3
When to Treat vs. Observe
Do not treat asymptomatic bacteriuria after catheter removal unless the patient is undergoing another urologic procedure—the 2019 IDSA guidelines recommend against treatment in most scenarios. 6
Treat symptomatic UTI with culture-directed antibiotics for 7 days in men (trimethoprim-sulfamethoxazole 160/800 mg twice daily is first-line if susceptible). 6
Consider recurrent UTI prevention strategies only if the patient develops ≥2 symptomatic UTIs within 6 months or ≥3 within 12 months. 6
Recurrent UTI Prevention (If Needed)
Non-Antimicrobial Approaches (Try First)
Increase fluid intake to reduce recurrent UTI risk in all age groups. 6
Use immunoactive prophylaxis (such as OM-89) to reduce recurrent UTI episodes—this has strong evidence across all age groups. 6
Consider methenamine hippurate to reduce recurrent UTI episodes in men without urinary tract abnormalities (strong recommendation). 6
Advise D-mannose or cranberry products for recurrent UTI prevention, though patients should understand the evidence is weak and contradictory. 6
Antimicrobial Prophylaxis (Last Resort)
Use continuous or postcoital antimicrobial prophylaxis only when non-antimicrobial interventions have failed, with patient counseling regarding side effects. 6
Consider self-administered short-term antimicrobial therapy for patients with good compliance who can recognize UTI symptoms early. 6
Common Pitfalls to Avoid
Do not confuse radical prostatectomy UTI risk with TURP risk—the evidence base is predominantly TURP, which has higher rates due to residual prostatic tissue. 4, 5, 2
Do not treat asymptomatic bacteriuria post-prostatectomy—this exposes patients to unnecessary antimicrobial resistance and side effects without benefit. 6
Do not assume elevated PSA indicates infection risk—while mean PSA is higher in patients with infection history, this reflects prostatic inflammation, not post-prostatectomy risk. 3
Do not overlook catheter-related factors—prolonged catheterization, catheter events (blockage, displacement), and manual bladder irrigation significantly increase UTI risk. 4