Antimicrobial strategies for ureteral stent removal after radical cystectomy: a comparative cohort study.

INTRODUCTION

Patients undergoing radical cystectomy (RC) face a heightened risk of infectious complications around the time of ureteral stent removal. This study aimed to determine whether a culture-guided antimicrobial strategy reduces infectious complications after stent removal compared with an empirical nitrofurantoin regimen.

METHODS

We analyzed 200 patients who underwent RC with urinary diversion and ureteral stenting. Patients received either empirical nitrofurantoin or a culture-guided antimicrobial strategy based on pre-removal urine cultures for stent removal. The primary endpoint was the incidence of early systemic urinary tract infection (UTI) within 48 h after stent removal. Secondary endpoints included changes in inflammatory markers, hydronephrosis after stent removal, and UTI-related readmissions within 30 and 90 days.

RESULTS

Early systemic UTIs occurred in 4% of patients receiving empirical nitrofurantoin and 7% in the culture-guided group (OR 0.56, 95% CI 0.12-2.27; p = 0.54). UTI-related readmissions at 30 and 90 days were similar between regimens (1% vs. 2%, p = 0.99; 5% vs. 9%, p = 0.41). An early leukocyte rise was associated with early systemic UTI after stent removal (2.65 vs. 0.51 × 10⁹/L; p = 0.048). Pre-removal urine cultures frequently yielded non-classical uropathogens consistent with stent-associated colonization, potentially limiting the clinical utility of routine culture-guided escalation. The culture-guided strategy did not reduce early infectious complications despite the use of broader-spectrum agents.

CONCLUSION

Empirical nitrofurantoin and a culture-guided antimicrobial strategy showed similar rates of early systemic UTIs and UTI-related readmissions after ureteral stent removal in patients undergoing RC. Routine culture-guided escalation may therefore offer limited clinical benefit while increasing antimicrobial exposure. Prospective multicenter trials are warranted to define optimal procedure-specific strategies.

SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s10096-026-05514-4.