General principles and indications

Preoperative treatment of bacteriuria does not negate the need for surgical antibiotic prophylaxis. An exception is when gentamicin is given preoperatively to treat bacteriuria and is also indicated as prophylaxis (eg for transurethral resection of the prostate). Additional prophylaxis will be required if adequate gentamicin plasma and tissue concentrations are not achieved at the time of surgical incision and for the duration of the procedure.

Note: Preoperative treatment of bacteriuria does not negate the need for surgical antibiotic prophylaxis.

Gentamicin is increasingly used for prophylaxis for urological surgery because of increased rates of cefazolin resistance in Enterobacteriaceae.

For catheterised patients, it may be necessary to seek advice on prophylactic antibiotic choice from a clinical microbiologist.

Prophylaxis against enterococcal endocarditis is indicated for patients with specific cardiac conditions (see here) who are undergoing urological surgery for which surgical antibiotic prophylaxis is required. If the surgical antibiotic prophylaxis regimen does not include an antibiotic active against enterococci (eg amoxicillin, ampicillin, vancomycin), see Endocarditis prophylaxis for genitourinary and gastrointestinal tract procedures for appropriate add-on recommendations.

Prophylaxis against enterococcal endocarditis may also be required for patients with specific cardiac conditions (see here) who are undergoing urological surgery for which surgical antibiotic prophylaxis is not required, if the patient has an established genitourinary infection—see Endocarditis prophylaxis for genitourinary and gastrointestinal tract procedures.

Urological procedures and their requirement for surgical antibiotic prophylaxis outlines the indications for surgical antibiotic prophylaxis for urological procedures. For prophylaxis for micturating cystourethrogram (MCUG), see Imaging to investigate urinary tract infection in children.

For a printable summary table of the indications and regimens for surgical antibiotic prophylaxis, see here.

Table 1. Urological procedures and their requirement for surgical antibiotic prophylaxis
Procedures	Is surgical antibiotic prophylaxis indicated?
urodynamic studies	NO
extracorporeal shock-wave lithotripsy	NO
prostate fiducial marker insertion	YES
ureteroscopy procedures	YES
endoscopic intrarenal and ureteric stone procedures (eg percutaneous nephrolithotomy or pyeloscopy for ureteric or kidney stones)	YES
other endoscopic procedures uncomplicated cystoscopic diagnostic procedures	ONLY IF there are risk factors for postoperative infection (eg urinary tract obstruction or abnormalities, urinary stones, indwelling or externalised catheters)
transurethral resection of the prostate	YES
transrectal prostate biopsy	YES
transperineal prostate biopsy	YES [NB1]
open or laparoscopic urological procedures in which the urinary tract is not entered (eg vasectomy, scrotal surgery, varicocele ligation) and prosthetic material is not implanted	NO
open or laparoscopic urological procedures involving implantation of prosthetic material (eg penile prostheses, artificial urinary sphincters, mesh)	YES
open or laparoscopic urological procedures where the urinary tract is entered	YES
Note: NB1: Transperineal prostate biopsy is associated with lower rates of postoperative infection than transrectal prostate biopsy. However, data are limited and it remains unclear whether antibiotic prophylaxis is required.