Urinary tract infections affect up to 50% of women each year. Some have recurrent urinary tract infections (RUTIs; >3 UTI/year) and require repeated and/or prophylactic antibiotic courses[1] which can lead to development of antibiotic resistance without UTI resolution. Prior cystoscopic studies have noted areas of chronic inflammation (trigonitis when limited to trigone) that can house bacterial persistence.[2] Electrofulguration (EF) is an outpatient endoscopic cauterizing technique which eliminates these superficial areas of inflammation to eradicate these bacterial niches.[3] A previous study of EF in management of RUTIs in women with a variety of cystitis lesions involving the trigone and beyond reported 75% resolution of inflammatory lesions and over 80% improvement in UTI rates.[3] Our hypothesis is that given the lesser burden of disease in women with limited trigonitis compared to those with advanced cystitis lesions, they should respond the best to EF. Therefore, the goal of this study was to evaluate the response to EF for trigonitis alone in women with antibiotic-recalcitrant RUTIs.

Following IRB approval, a retrospective chart review of women who underwent EF of limited trigonitis to treat their antibiotic-recalcitrant RUTIs and had a minimum 1 year follow-up was undertaken. RUTIs were classified as antibiotic-recalcitrant secondary to high rates of antibiotic-resistance, antibiotic allergies or no durable response to long-term antibiotic suppression. EF was performed on an outpatient basis by an FPMRS faculty. A 17.5-Fr urethrocystoscope with a fine tip monopolar Bugbee electrocautery on a setting of 20 was used to superficially fulgurate the inflammatory lesions over the trigone. Most patients were discharged home after a voiding trial with some electing to keep a catheter overnight due to distance from home. Primary outcome was number of symptomatic UTI episodes requiring antibiotics post-EF, leading to definitions of cure (0/year), improvement (1-2 UTI/year) and failure (>3 UTI/year). Secondary outcome was endoscopic success based on complete resolution of trigonitis during an office cystoscopy at 6 months after EF.

From 2008-2018, 40 women met study criteria (Group 1: 34 (85%) endoscopic success, Group 2: 6 (15%) endoscopic failure) (Table 1). There was no statistically significant difference in patient characteristics or pre-operative UTI management in the two groups. Median follow-up in group 1 was 3.7 years (IQR 2-6.1) and 2.3 years (IQR 1.7-7.5) in group 2 (p=0.71). Median urinary tract infections/year post-EF were 0.6 in group 1 and 0.9 in group 2 (p=0.89). The groups showed comparable procedure times (p=0.19), with almost all procedures lasting less than 25 minutes. No intra-operative or post-operative complications were noted. Clinical outcomes between groups were not statistically different, with overall 9 (23%) cured, 29 (73%) improved and 2 (5%) failed. In the clinically improved group, 19 (66%) had <1 UTI/year in the follow-up period starting 6 months post-EF. No patients remained on long term, continuous antibiotic suppressive therapy after the follow-up 6 months cystoscopy.

During the follow-up period, trigonitis resolved in most, and many had substantial clinical improvement or cure of their UTI’s. Endoscopic success was greater than 85%, with few undergoing repeat EF, providing merit to the goal of the procedure of mechanically removing bacteria residing in the inflamed trigone. The length of procedure was very short in all patients with no complications seen in this study. Most patients with endoscopic success and some with endoscopic failure had significant clinical improvement (<1 UTI/year) or cure (0 UTI/year). Since endoscopic success was defined as complete resolution of lesions, it is possible that patients may have had a few residual lesions, but a lesser burden of disease than originally observed and still benefited from EF. Although some patients continued to utilize post-coital prophylaxis or self-start antibiotic therapy, no patients required continuous suppressive antibiotics after 6 months from EF, decreasing their antibiotic use that could have led to additional antibiotic resistances or adverse effects.

EF resulted in endoscopic resolution of trigonitis alone in 86% of women with antibiotic-recalcitrant RUTIs, with durable clinical cure or improvement of RUTI in most patients.

Anger et al. J Urol 2019
De Nisco, N. et al. JMB 2019
Crivelli, J et al. IJU 2019