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International Journal of Antimicrobial Agents 38S (2011) 58–63
Contents lists available at SciVerse ScienceDirect
International Journal of Antimicrobial Agents
journal homepage: http://www.elsevier.com/locate/ijantimicag
Antibiotic prophylaxis in urological surgery, a European viewpoint夽
Magnus Grabe ∗
Department of Urology, Skåne University Hospital, University of Lund, S-20502 Malmö, Sweden
a r t i c l e
i n f o
Keywords:
Surgical site infection
Wound infection
Urinary tract infection
Antibiotic prophylaxis
a b s t r a c t
Surgical site infections (SSI) including urinary tract infections (UTI) cause a significant morbidity in urological surgery. Antibiotic prophylaxis is one of several factors impacting on infection rates. Antibiotic
prophylaxis is relevant only for clean and clean-contaminated operations and in the absence of bacterial
growth in the urine. Strict classification of urological procedures is lacking, but a proposal is presented
elsewhere. Only TURP and transrectal core prostate biopsy are well documented. The present review
confirms that there is a lack of hard data, insufficient consistency in classification and definitions, and
that new well-powered RCT and large multicentre quality cohort studies including risk factor analysis
are necessary to improve recommendations for antibiotic prophylaxis in urologic surgery.
© 2011 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.
1. Summary of recommendations
The summary of recommendations are given in Table 1. The
reader will find a paradox in the level of evidence and the policy recommended. The reasons are therefore explained for each
procedure in its respective section.
2. Introduction
This manuscript was published originally in Urogenital Infections
as a section of a chapter on prevention of infections associated
with urological surgery (ch 12), antibiotic prophylaxis being one
of several preventive measures. It has thus to be seen as an article integrated with the associated manuscript on preoperative
assessment of the patient giving a tentative classification of urological procedures. The present article focus on what is known
and evidence-based information on antibiotic prophylaxis in most
common urological procedures.
The use of antibiotics in urologic surgery has been controversial
for decades [1,2]. Over the same period of time, surgical procedures
and interventions have evolved remarkably from high-invasive
open to low-invasive surgery due to a fascinating improvement
of technologies and instruments. Also, medical treatment has
replaced surgery in a substantial number of situations and in this
way modified the profile of patients undergoing surgery.
The basic principle of antibiotic prophylaxis is to protect the
patient undergoing surgery against undesirable infectious complications by lowering the bacterial burden. Antibiotic prophylaxis is
applicable for clean and clean-contaminated operations. For the urinary tract, antibiotic prophylaxis implies the absence of detectable
bacterial growth in urine (<104 CFU/ml). In clean operations, the
urinary tract is not opened. In clean-contaminated operations, the
urinary tract is opened and, in case of urinary diversion, the intestinal tract, implying an increased bacterial burden. In the case of
bacterial growth and surgery associated with opening of the bowel
with spillage – contaminated operations – an individual treatment
strategy is prescribed [3].
Two types of infections dominate urologic surgery: (1) urinary
tract infection (UTI), a space or organ infection, associated with both
endoscopic, endoluminal interventions and open or laparoscopic
surgery, mostly coinciding with catheter and stent placement or
undetected harboured bacterial load and (2) wound infection after
open and laparoscopic surgery. Furthermore, a third form of infection is observed in terms of infection of the male genital system
(prostatitis, epididymitis and orchitis). A fourth form of infection,
blood-stream-borne sepsis, resulting from urologic instrumentation, is feared by patients and urologists, and is far from negligible
accounting for 10–12% of healthcare-associated infections (HAI) in
urologic wards [4].
3. Aim
夽 This manuscript was originally published in: Naber KG, Schaeffer AJ, Heyns CF,
Matsumoto T, Shoskes DA, Bjerklund Johansen TE, editors. Urogenital Infections.
European Association of Urology–International Consultation on Urological Diseases,
1st ed. Arnhem, The Netherlands; 2010, ISBN:978-90-79754-41-0.
∗ Tel.: +46 40 33 18 25; fax: +46 40 33 70 49.
E-mail address: magnus.grabe@skane.se
The present report focuses on the most frequent diagnostic and
therapeutic urologic interventions (Table 1) and results from a systematic review. It is out of range to be comprehensive and cover all
specific or special procedures as several of these have never been
studied. Also paediatric urologic surgery is not covered.
0924-8579/$ – see front matter © 2011 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.
doi:10.1016/j.ijantimicag.2011.09.008
M. Grabe / International Journal of Antimicrobial Agents 38S (2011) 58–63
59
Table 1
Summary of recommendations for antibiotic prophylaxis (ABP) per type of procedure.
Type of procedure
Level of recommendation
Remarks
Diagnostic procedures
Cystoscopy
No systematic ABP (GoR A)
Urodynamic study
No systematic ABP (GoR A)
Core prostate biopsy
To all patients (GoR A)
Low frequency of infections
Contradictory findings
Low frequency of infections
Contradictory findings
Single dose to all low-risk patients (GoR A) prolonged in
high-risk patients (GoR C)
No available studies
URS diagnostic
Therapeutic procedures
TURB
No systematic ABP (GoR C)
TURP
Shock-wave lithotripsy (ESWL)
As for cystoscopy in standard small TURB (GoR C)
Consider in large tumours (GoR C)
All patients (GoR A)
No systematic ABP (GoR A)
Ureteroscopic stone management
To all patients (GoR B)
Percutaneous stone management
To all patients (GoR B)
Open/lap nephrectomy
Open/lap nephroureterectomy
No systematic ABP (GoR C)
To all patients (GoR C)
PUJ repair
Open/lap bladder resection, ureteral repair
Open/lap prostatectomy
Cystectomy with urine deviation
To all patients (GoR C)
To all patients (GoR C)
To all patients (GoR B)
To all patients (GoR B)
Surgery for hydrocele and spermatocele
Prosthetic procedures
No systematic ABP (GoR B)
To all patients (GoR B)
No concern of tumour burden in studies
Well documented
Low frequency of infections
Contradictory findings
Simple mid and distal stones
Complex, proximal stones as for PCNL
Single dose to simple stones (GoR C)
Consider prolongation in complex stones (GoR C)
Catheter related BU/UTI
No available studies
Defined as clean-contaminated – single dose
Defined as clean-contaminated – single dose
Defined as clean-contaminated – single dose
Defined as clean-contaminated – single dose
Defined as clean-contaminated – single dose
Prolongation of ABP on individual basis
Review studies contradictory
Regimen not defined
4. Methods
5. Results per type of procedure
A systematic search was performed in Medline, Cochrane
Library and EMBASE and using the keywords antibiotic prophylaxis,
prophylaxis, antibiotics, urological surgery, urogenital surgery and the
procedures one by one. Approximately 200 abstracts were identified of which over 100 were not directly related to the topic. Of the
remaining 95 reports, a majority was related to transurethral resection of the prostate (TURP). As this procedure has been reviewed
by other authors by means of systematic review [5] and covered
more recently by two meta-analyses [6,7], the outcome was built
on these works. Also urodynamic studies were critically reviewed
[8] and the conclusions reported. For all other procedures, the articles were systematically reviewed and the conclusions compared
to those drawn by one other recent systematic review by a group
from the Netherlands [9] and the conclusions presented by a working group in the USA [10]. The quality of the studies was found to
vary largely, essentially in terms of design, description of randomisation, sample size, level of dropout, power, and strength of the
conclusion.
The procedures were divided between diagnostic procedures
(cystoscopy, urodynamic studies and transrectal core biopsy of the
prostate) and therapeutic endoscopic procedures (transurethral
resection of bladder tumours and of the prostate, endourological
interventions including shock wave lithotripsy), open and laparoscopic interventions (nephrectomy, pelvic junction surgery, total
prostatectomy, cystectomy with urinary diversion) and elective
surgery for benign scrotal surgery.
As far as possible, the expected natural history of infectious rates
is presented followed by the results of randomized placebo/no
antibiotic controlled studies (RCT). Thereafter, RCTs of different
antibiotic regimens are presented to detect the most rational one
(shortest, low cost and effective course) when applicable.
The studies were rated according to the level of evidence (LoE)
and the grade of recommendation (GoR) using ICUD standards (for
details see Preface) [11,12]. The LoE and GoR are given at the end of
each surgical procedure and the recommendation reported to the
summary table.
5.1. Cystoscopy
The natural history of the events following cystoscopy is important. In one study from 1990, Clark and Higgs [13] showed the
appearance of bacteriuria three days after instrumentation in
12/161 (7.5%). In two recent studies, a spontaneous acquired bacteriuria was observed in 2.7% and 4.5% [14,15]. The fate of this
bacterial contamination is not known and the spontaneous cure is
probably high. In a large British study with flexible cystoscopy [16],
a single dose of trimethoprim or ciprofloxacin reduced by more
than half, 2% and 3.2% respectively, the post-cystoscopy frequency
of bacteriuria as compared to placebo (6.8%). These results were in
accordance with an older study observing a significant reduction
of post-cystoscopy bacteriuria and clinical UTI [17]. Other studies were contradictory in their results, some advocating antibiotic
prophylaxis [18,19], others finding it no use [20–23]. The overall conclusions are that the frequency of bacteriuria is low and
that of clinical infections even lower, and that the frequencies of
these events are, globally, marginally reduced by antibiotic prophylaxis. Thus, the recommendation of giving systematically antibiotic
prophylaxis to all patients undergoing cystoscopy cannot be advocated in view of the lack of knowledge of the risk associated with
the bacterial contamination and its fate, the low frequency of
clinical infection, the recommendation and praxis in most European countries, the enormous amount of such instrumentation
and overtreatment, and the subsequent amount of antibiotics that
would be used (LoE 1b–2b, GoR A).
5.2. Urodynamic studies
Most studies are carried out on women investigated for incontinence. In a meta-analysis of 995 patients including eight RCT,
bacteriuria (>105 CFU/ml) was reduced by 40% by antibiotic prophylaxis [8]. The authors concluded that it was necessary to treat 13
individuals in order to avoid one episode of bacteriuria. In one other
study combining cystoscopy and urodynamic study in women,
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M. Grabe / International Journal of Antimicrobial Agents 38S (2011) 58–63
there was found to be no difference between one day of antibiotic
prophylaxis and no antibiotics [24]. In one Swedish study of 123
consecutive men undergoing a flow-pressure investigation, 4.1%
acquired bacteriuria and 2.5% fever [25]. The overall interpretation
is, as for cystoscopy, that the frequency of infectious events is low,
that the outcome and role of bacteriuria after urodynamic investigation is unknown and that there is a lack of support in the literature
for the systematic use of antibiotic prophylaxis in patients without
risk factors. For investigations of patients with other underlying
urological diseases such as neurological bladder dysfunction, refer
to the chapter on “UTI in patients with underlying urological diseases”
(LoE 1a, GoR A).
5.3. Transrectal core prostate biopsy
There are only very few studies on the natural history of infectious complications after transrectal prostate biopsy. In a few
cohort series, infectious complications such as febrile UTI, acute
prostatitis and sepsis are reported in frequencies between 2.9
and 10% [26–28]. In RCT, frequencies of 5–26% bacteriuria and up
to 10% febrile UTI are given in the control groups [29–31]. In older
studies, frequencies up to 48% have been reported [32,33]. There
is a consistent significant reduction of the frequencies of both bacteriuria and febrile urogenital infections by antibiotic prophylaxis,
below 5% in low-risk patients [29–34]. Recent studies have shown
that one day [35,36] and even one single dose [31,37,38] is appropriate to keep the infectious rate at 1% or below, including less
than 0.5% of sepsis. These low frequencies are confirmed by a few
consecutive cohort series with antibiotic prophylaxis [39,40]. The
antibiotic dose can be given in direct conjunction with instrumentation and there is now evidence for giving the medication 1–2 h
before the procedure [37]. Fluoroquinolones achieve the highest
concentrations in the prostate [41] and are best documented for
prophylaxis. However, new studies have to be done to avoid the
overuse of fluoroquinolones wherever possible due to the worldwide development of resistant strains in both community and
hospital settings. It is unknown how long prophylaxis should be
given to risk patients (risk factors are presented in the preceding
chapter). It is also unknown whether spontaneous acquired bacteriuria after core prostate biopsy can spontaneously cure (LoE 1b,
GoR A).
5.4. Transurethral resection of bladder tumour (TURB)
Although TURB is one of the most frequent urological procedures, there are no base-line data. Only three older, rather weak,
small-size studies covering antibiotic prophylaxis were disclosed
[18,42,43]. The data from the studies do not give any evidence
in favour of antibiotic prophylaxis in TURB. However, the studies focus only on smaller tumours or fulguration, an intervention
very similar to standard cystoscopy, and do not mirror the large
spectrum of resection of bladder cancer from the single minor
non-muscle-invasive bladder tumours (Ta, G1–2) to large muscleinvasive (T2, G3), sometimes necrotic, tumours that are part of daily
practice. Future studies covering all TURB procedures and breaking
them down according to the intervention’s level of severity and difficulty, duration and other risk factors has to be undertaken (LoE
2b, GoR C).
5.5. Transurethral resection of the prostate (TURP)
TURP is the most well studied of all urological studies. More
than 50 studies have been conducted, some of them of medium to
high quality. Postoperative bacteriuria has been reported in up to
70% of the patients. In a systematic review of subsequent studies
from the 1980s, it was shown that antibiotic prophylaxis reduced
the frequency of bacteriuria in men with pre-operative sterile urine
from an average of 34% to 10% [5]. In recent years, two high-quality
meta-analyses have been done including 32 and 28 participantcontrolled studies (respectively [6,7]). The conclusions are similar:
a short course of antimicrobial agents reduces the risk of bacteriuria
from an average of 26% to 9%. Berry and Barrat also analysed the
impact on sepsis: the impact was even more important, reducing
the risk from 4.4% to less than 1%. Both reviews show that a prolonged course (<72 h) is more effective than a single dose, but less
effective than one week [6]. Any antibiotic except nitrofurantoin
would do. In a recent high-quality multicentre study conducted in
Germany, Wagenlehner et al. [44] confirmed these results, although
the difference was less marked. Interestingly, they also showed that
the total amount of antibiotics used in the study was lower in the
antibiotic prophylaxis group, confirming data from one older similar analysis [45]. This observation is interesting in the argument for
antibiotic prophylaxis, as nowadays there is a high level of concern
about the total amount of antibiotics used in the community. Long
operation time, postoperative disconnection of drainage system
and longer catheterisation period were associated with increased
frequency of bacteriuria despite antibiotic prophylaxis [46] (LoE 1a,
GoR A).
Consequently, there is a scientifically high level of evidence
for the use of short regimens of antibiotic prophylaxis in TURP to
reduce the postoperative frequencies of both bacteriuria and, especially, severe febrile infections and sepsis. The conclusions are not
applicable to other prostate interventions such as adenoma enucleation, micro-wave thermotherapy or laser ablation, as there are
no quality RCT studies on these matters.
5.6. Extracorporeal shock-wave lithotripsy (ESWL)
A remarkably poor number of studies have been conducted for
such an enormous worldwide procedure. In a few follow-up studies, the frequency of post-ESWL bacteriuria has been shown to be
≤5% in patients without known risk factors [47–49]. In only one
[50] of five randomized placebo/non-antibiotic-controlled studies
was a significant reduction demonstrated [50–54]. In most studies,
the sample size or the frequencies of infections were low and no
clear-cut conclusions could be drawn. In a systematic review and
meta-analysis Pearle analysed eight prospective controlled studies
[55]. The frequencies of bacteriuria and/or symptomatic UTI were
reported to be 0–28% in the non-antibiotic control group and 0–7%
in the intervention group. They estimated the risk of acquiring a
UTI to be 5.7% and 2.1%, respectively.
The overall conclusion is that in patients with sterile urine,
uncomplicated kidney or ureteral stones and no known risk factors,
the risk of post-ESWL bacteriuria/UTI is low, that the reduction by antibiotic prophylaxis is marginal and that, subsequently,
there is no evidence for antibiotic prophylaxis in this category of
low-risk patients, which represents the majority of patients undergoing ESWL (LoE 1a–2b, GoR A).
5.7. Ureteroscopy (URS)
No studies on ureteroscopy as a diagnostic tool were found. Two
studies concerned with stone management were identified [56,57].
Both show a reduction of bacteriuria but not of symptomatic UTI.
One study comparing ESWL and URS for mid and distal ureteral
stones demonstrated a higher frequency of complications including infectious complications in the URS-treated group as compared
to the ESWL group [58]. The studies do not differentiate the degree
of invasiveness in terms of stone burden and localisation (impacted
proximal stone versus small mid and lower stones), surgical difficulty and complexity of the treatment, duration of operation,
experience of the surgeon; a weakness, as it is known that the
M. Grabe / International Journal of Antimicrobial Agents 38S (2011) 58–63
risk of infectious complications varies [59]. In conclusion, there is
only a weak level of evidence for antibiotic prophylaxis in URS,
although it is probably of value, especially in complex stone situations (diagnostic: LoE 2b, GoR C; stone management: LoE 2b,
GoR B).
5.8. Percutaneous stone extraction (PCNL)
Bacteriuria is reported in up to 35% and febrile UTI in around
10% of patients receiving no antibiotics [60,61]. Only one controlled
study comparing antibiotic prophylaxis with no antibiotics was
identified [56] and one comparing two different antibiotic regimens [62]. As for complicated URS, the danger of PCNL in terms of
severe, febrile UTI and sepsis has been underlined [59,63]. Antibiotic prophylaxis appears to reduce the frequencies of infectious
complications and there seems to be no difference between antibiotics. As mid-stream urine culture is not a good predictor for the
endogenous presence of pathogens [63], the urologist faces an
incertitude as to the real risk of infectious complications. Moreover, following the remarkable improvement of equipment, older
studies are not necessarily representative of the present profile of
renal stone management. Consequently, as for URS, there is a substantial lack of data on the use of antibiotics in PCNL and only very
limited evidence for antibiotic prophylaxis. Nonetheless, the infectious rates being high and the potential complications severe, there
are reasons to believe that antibiotic prophylaxis is of value. Large
multicentre controlled studies focusing on antibiotic regimens and
risk factor analysis are required (LoE 2b, GoR B).
5.9. Open and laparoscopic urologic surgery
An extensive search on open and laparoscopic surgery, nephrectomy, nephron-sparing surgery, pelvic junction reconstruction
bladder resection, cystectomy, total/radical prostatectomy and
scrotal surgery has revealed the lack of RCT and the weaknesses
of available data [9,10]. Expected data have to be extrapolated
from bottom-line data on type of surgery [3] and from colorectal and abdominal gynaecologic surgery. There are indications that
infectious complications are fewer after laparoscopic and robotic
surgery in abdominal surgery [64]. The issue has however not been
studied in RCT as far as urologic surgery is concerned. A few examples of common surgery by type of intervention follow.
5.9.1. Clean operations
Trans-abdominal open or laparoscopic nephrectomy is classed
as a clean operation. Only one RCT was identified [65]. Infectious
complications in terms of wound infection were 20.4% when no
antibiotics were given versus 0% for patients receiving one single
preoperative dose. The results indicate a marked impact of antibiotic prophylaxis but no other study confirms the data. In one report
on surgical site infections (SSI) in which antibiotic prophylaxis was
not in the protocol, Montgomery reports wound infections in 6.8%
(range 5.0–7.9%) in clean and clean-contaminated hand-assisted
kidney surgery, with no difference whether the urinary tract was
opened or not [66]. In one study of clean surgery in patients with or
without a risk factor for SSI, antibiotic prophylaxis had no impact
in low-risk patients whereas it reduced the frequency in patients
with at least one risk factor [67].
Scrotal surgery for elective benign conditions, mainly hydrocele and spermatocele, is a reasonably clean procedure. No RCT
was identified. In a few recent studies [68,69], including a Medline search review, infectious complications were reported in up
to 9%. In most reports, no antibiotic prophylaxis had been used.
A lower frequency of infections (3.6%) was observed in patients
61
receiving antibiotic prophylaxis [70]. Multicentre RCT have yet to
be undertaken to confirm this finding (LoE 3, GoR C).
5.9.2. Clean-contaminated operations
Nephroureterectomy, kidney resection and pelvic junction
surgery have, to the best of our knowledge, never been studied
in RCT. The searches have revealed no RCT on antibiotic prophylaxis versus placebo/no antibiotic in total prostatectomy. Thus,
there is a lack of baseline data on the infectious profile of this
nowadays so frequent operation. There are a few retrospective and
prospective cohort studies looking at SSI and catheter-associated
bacteriuria following different antibiotic regimens. The conclusion of this series of publications is that the frequency of wound
infections is low and that a single oral antibiotic dose is sufficient
[70–73]. The importance of the post-operative catheter-associated
bacteriuria, observed in the majority of the patients at catheter
removal, is unknown as is whether it has to be treated or not (LoE
3, GoR B).
There are no RCT on antibiotic prophylaxis in urologic surgery
including urine deviation and the use of bowel. Postoperative
wound infection is reported in up to one-third of cases, usually
10–15%, even when using antibiotic prophylaxis [74–76]. Also UTI,
pyelonephritis and sepsis are added to the burden of infections.
5.9.3. Penile prosthesis
Implantation of penile prosthetic devices is a special case.
Infection of the prosthetic device remains the most troublesome
complication. Infection may lead to more surgery, loss of penile
tissue and even the inability to replace penile prosthesis. Antibiotic prophylaxis in addition to standard sterility and good surgical
technique reduces the risk of infection [77,78].
6. Discussion
The present review requires a certain number of remarks on the
validity and relevance of the references revealed by an in-depth
search of the literature. Firstly, the remarkable technical development and medical achievements in urology during the past 25–30
years mean that older studies from the 1970s and 1980s have partly
lost their relevance. Secondly, the quality of older studies in the
present view of good clinical practice is usually poor in terms of
sample size, consistency in definitions, statistical estimates and
power. Thirdly, risk factors for infectious complications are rarely
debated and, as shown in the preceding section about preparation
of the patient for surgery, our knowledge of the relative importance
of individual risk factors and their cumulative impact is limited.
Fourthly, numerous reports have given results on a mixture of procedures and the breakdown has shown so low a sample size per
procedure that it is difficult to draw a conclusion. Fifthly, the lack
of consistency in definitions of infectious complications, especially
UTI, the level of bacterial growth and the relation between clinical
symptoms and bacterial growth weakens the possibility of comparison. Clear definitions are often lacking. The results are therefore
more indicative, than proof. Against this background, large cohort
studies and historical controls gain indicative importance by giving a “natural history” of the events after a defined intervention and
therefore have also been used to some extent.
It is remarkable that there are so few studies on very frequent
interventions such as transurethral resection of bladder tumours
and endoscopic stone management including ESWL. It is thus not
astonishing that Bootsma et al. stated that “except for TURP and
prostate biopsy, there is a lack of well performed studies investigating the need for antibiotic prophylaxis in urologic interventions”.
On the other hand, urologists need a working hypothesis for antibiotic prophylaxis.
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M. Grabe / International Journal of Antimicrobial Agents 38S (2011) 58–63
One approach is to stick to the classification of surgical interventions in clean, clean-contaminated and contaminated classes and
follow the experience of other surgical practices such as general,
orthopaedic and gynaecologic surgery. Theoretically, there should
be no need for antibiotic prophylaxis in clean operations, whilst
a single dose should be advocated for clean-contaminated procedures. In case of contaminated procedures (i.e. urine deviation with
bowel, presence of asymptomatic bacteriuria in urine), the antibiotic regimen’s start and length is less obvious and documentation
is insufficient. In standard colorectal surgery, usually a single dose
or very short regimen is advocated. Bacteriuria is a known risk
factor and, in conjunction with urological procedures should therefore, reasonably, be treated. Thus, individual adjustment has to be
suggested depending on patient susceptibility, bacterial load and
the development of the procedure in terms of spillage and duration. However this approach is not totally satisfactory; it is only
indicative and usually no strong recommendations can be given in
guidelines, such as those of the European Association of Urology,
except in a few situations [79]. Therefore, there is an inevitable
discrepancy between the level of evidence and the grade of recommendation in Table 1.
The role of antibiotics is to reduce the bacterial burden, not
necessarily to cover all potential strains. Also, antibiotics for prophylaxis should ideally be limited to a few and usually different
from those used for therapeutics to avoid an overload of drug doses
and local environmental pressure. Recommendations should be set
in cooperation with specialists in infectious diseases and hospital
environmental hygiene.
7. Further research
This review underlines the absolute need for serious, wellconducted studies and large, multicentre quality registries per
type of procedure including breakdowns in the level of severity
of surgery and the reporting of potential risk factors.
8. Conclusions
An extensive search of the literature and systemic reviews has
revealed a lack of well-built data for antibiotic prophylaxis in urological surgery. Strong recommendations can only be given for
transrectal core biopsy of the prostate and transurethral resection
of the prostate. As surgery has markedly changed over the decades
and because older studies vary so much in quality, it is mandatory to
initiate new large industry-independent, prospective, randomised
controlled studies and to set up large prospective quality registries
and infectious control materials.
Funding: No funding sources.
Competing interests: None declared.
Ethical approval: Not required.
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