Once may be enough.

Methods to prevent postprostatectomy wound infections in patients having open prostatectomy, and bacteriuria in those having open or transurethral prostatectomy, are legion and controversial. Virtually every new antibiotic or topical antiseptic has been subjected to a longor short-course study attempting to show prophylactic or treatment efficacy, all too often in poorly controlled studies. There are acceptable data in the literature to support the concepts that prophylactic perioperative systemic antibiotics, with spectra covering the common urinary pathogens, can significantly decrease bacteriuria, bacteremia, pyrexia, wound infections, and hospital stay in catheterized patients with sterile urine.1 The choice of prophylactic antibiotic is not absolutely critical, with many broad-spectrum agents providing similar results. This approach is not unanimously endorsed for such patients, although much more controversy exists regarding the need for any prophylaxis in noncatheterized patients with sterile urine.2 Patients with infected urine, however, require treatment with organism-susceptible systemic agents prior to surgical therapy to sterilize the urine and reduce the high rate of infectious complications.2,3 The concept of preoperative bladder irrigation with one of various antibacterial solutions is not new, and, in fact, the use of povidone-iodine has been reported previously to be useful if the concentration is 2% or greater and irrigations are done the night before and morning of surgery.4,5 The addition that the article by Richter et al in this issue makes is that one irrigation of povidone-iodine immediately prior to open prostatectomy produces similar results in terms of reducing b cteriuria wound infections. The study is not randomiz d, and all patients were treated with organismsensitive but differing systemic antibiotics. However, assuming, as best as can be determined from the data presen d, that the patient populations are comparable, the data in this study are compelling. Indeed, the addition of a povidone-iodine irrigation once preoperat v ly seems simple and effective. Relatively unnoticed, but perhaps the more importa t concept in this and other similar studies is the queue these patients must endure prior to definitive surgery. The patients themselves and/or the system delays car until they are in urinary retention. An indwelling ca heter is required, and then the patients wait an average of 50 days to have surgery. Whereas in some he lthcare systems, prostatectomy may be initiated too early-before a progressive natural history in the particular patient is established-in others it appear to be late-after the patient requires persistent bladder drainage. The data available clearly show that uninfec ed patients have fewer complications; us it seems intuitive that it would be in the patients' best interests to treat them surgically before they require constant drainage and thus become colonized, shortly after the necessity of catheter drainage b comes evi ent, or as part of a program of clean in ermittent catheterization in an attempt to prevent colonization in patients who do require long-term cat eterization prior to surgery. Perhaps the one-time povidone-iodine instillation advocated would be best used in thes patients.