Letter: Postoperative Antibiotic Duration Affects Infectious Rates in High-Risk Patients Undergoing Holmium Laser Enucleation of the Prostate

Dear Editor,

I read with great interest the article entitled “Postoperative Antibiotic Duration Affects Infectious Rates in High-Risk Patients Undergoing Holmium Laser Enucleation of the Prostate (HoLEP),” which evaluates postoperative antibiotic use in patients at high risk of infection undergoing HoLEP for bladder outlet obstruction. ¹ While this study provides clinically relevant insights into preoperative infectious risk and postoperative antibiotic management in this population, I believe that certain methodological and analytical aspects warrant further clarification.

First, in the study, patients were classified as high risk based on the presence of preoperative asymptomatic bacteriuria, catheter dependency, immunosuppression, a history of pyelonephritis or urosepsis, and recurrent urinary tract infection. There are also studies that identify higher body mass index and a higher frailty score as risk factors for urinary tract infection following HoLEP. ² Another meta-analysis has shown that preoperative and intraoperative factors were not associated with the development of infection after HoLEP, whereas an increased amount of excised prostate tissue was associated with a higher risk of urinary tract infection. ³ Therefore, there is no standardized definition for identifying high-risk patients in the literature, and the heterogeneous criterion used in this study may complicate the interpretation of the results.

An important methodological consideration relates to the lack of standardization in the selection of postoperative antibiotic duration. Although all patients included in the study were classified as high risk for infectious complications, antibiotic prescribing appears to have been determined at the surgeon’s discretion rather than according to predefined criteria. This suggests that, even within a uniformly high-risk cohort, certain patients may have been perceived as having a relatively greater risk and therefore preferentially treated with longer antibiotic courses. The absence of clearly defined allocation criteria introduces the possibility of confounding by indication and selection bias, which may influence the observed differences in postoperative outcomes between groups.

In the present study, postoperative urinary tract infections were defined based on the initiation of antibiotic therapy in patients with clinical symptoms, without microbiological confirmation. Irritative lower urinary tract symptoms are commonly observed in the early postoperative period following HoLEP and may overlap with the clinical manifestations of urinary tract infection. ⁴ Postoperative urinary tract infection has been defined as the presence of a uropathogen in a urine culture within 90 days after surgery. ⁵ In contrast, defining urinary tract infection in the present study solely based on clinical symptoms and initiation of antibiotic therapy, without microbiological confirmation, may lead to an overestimation of infection rates and introduce bias in the interpretation of the results.

In conclusion, while this study addresses an important clinical question regarding postoperative antibiotic use in high-risk patients undergoing HoLEP, the findings should be interpreted with caution in light of the aforementioned methodological considerations. Well-designed prospective randomized studies with rigorous methodology are needed to better clarify the true impact of antibiotic duration on postoperative infectious complications.