Clinicopathological and etiological characteristics for urinary tract infection in cervical cancer patients with radical surgery with double J stents

doi:10.21203/rs.3.rs-3870117/v1

Background

To investigate the clinicopathological and etiological characteristics for urinary tract infection in cervical cancer radical surgery with indwelling ureteral stents.

Methods

A total of 24 patients who received cervical cancer radical surgery and retained with double J stent in Shanghai General Hospital from July 2018 to December 2022 were recruited as the study objects, the medical data were retrospectively analyzed, and the clinicopathological and etiological characteristics of the urinary tract infection were collected.

Results

Of the 24 cervical cancer patients with radical surgery patients with double J stent included in this study, 87.5% patients were locally advanced cervical cancer (LACC) and 73.91% patients received postoperative chemoradiotherapy. 58.33% patients had maximum diameter of cancer > 4cm and HPV 16 was present in 65% patients. Total 15 patients were complicated with urinary tract infection, with the infection rate reaching up to 62.5%. Postoperative adjuvant chemotherapy might be the risk factor for urinary tract infections, although no significant statistic difference was identified (P = 0.074). A total of 30 strains of pathogens were isolated from the patients with urinary tract infections. 10.00% were Gram-positive bacteria, 73.33% were Gram-negative bacteria, 16.67% were fungi. Escherichia coli were the most common pathogens of urinary tract infections. The Escherichia coli are resistant to ampicillin, ceftriaxone, cefotaxime, cefazolin and cefuroxime and sensitive to imipenem, meropenem, piperacillin/tazobactam, tigecycline and amikacin. Two strains of CRE (carbapenem resistant Enterobacteriaceae bacteria) were identified. 70.83% patients were inserted ureteral stents for 3 to 12 months. With the prolongation of ureteral stents placement, drug sensitivity for antibiotics targeting the same pathogen decreased and the pathogenic microbes changed from bacteria into fungi.

Conclusions

Ureteral tract infections were extremely high in LACC with radical surgery with ureteral stents insertion, with the rate reaching to 67.5%. Postoperative adjuvant chemotherapy might be the risk factor for urinary tract infections. The most common pathogens of urinary tract infections were Gram-positive bacteria, led by Escherichia coli. The Escherichia coli are relatively resistant to Penicillins and Cephalosporins and generally sensitive to Carbapenems and Glycylcyclines. This study could provide basis for clinicians to choose appropriate antibiotics for urinary tract infections during ureteral stents indwelling, preventing severe infections, reducing the burden of disease.

etiological characteristics

urinary tract infections

cervical cancer

radical surgery

double J stents

Despite the widespread promotion of early screening for cervical cancer and HPV vaccines, cervical cancer remains one of the most common malignancies in women(1). There were an estimated 604127 new cases and 341831 deaths of cervical cancer worldwide in 2020(2). It was estimated 13960 new cases and 4310 deaths with cervical cancer in the USA in 2023(3). Radical hysterectomy is standard management for cervical cancer in early stages, such as IB1, IB2 and selected IIA(1). The close anatomical relationship between genital and urinary tracts is a potential cause of injury of urinary tracts when performing gynecologic surgery. One study from China showed incidence of complications of radical hysterectomy with pelvic lymph node dissection for cervical cancer (IA2, IB1, IB2, IIA1, IIA2) was 34.41%, and 7.68% of patients with injury to adjacent tissues, the most common was ureteral injury, followed by the bladder injury(4). Another study from Netherlands reported occurrence of ureter and bladder injury in early cervical cancer (IB1 and IIA1) who underwent radical hysterectomy with pelvic lymphadenectomy was 4%(5). Ureter injuries cause pain and affect patients’ quality of life. Timely and adequate intervention is crucial in management of ureter injury. Early detection and treatment of urinary tract injury can prevent the deterioration of renal function, resulting in a satisfactory prognosis(6).

Prophylactic ureteral stenting before major gynecologic surgery can prevent ureter injuries and reduce the risk for urologic complications; conversely, there has been great controversy over benefits from this procedure(6–10). During ureteral stent indwelling, bacterial adhesion onto the indwelling implant surfaces, encrustation and stone formation are risk factors associated with adverse effects(11, 12). Stent-related complications contained abdominal discomfort, urinary tract infection, stent displacement, and stent encrustation. Urinary tract infection was the most common complication of ureteral stent(11, 13). Most studies reported the incidence of urinary tract infections, but few studies deeply analyzed the pathogenic bacteria of urinary tract infections and antibiotic sensitivity of these pathogenic microbes. There was no consensus on the indications and removal time of prophylactic double J stent placement for patients with cervical cancer. Generally, the ureteral stents should be removed or replaced every 3 to 12 months based on different surface modification and materials of ureteral stents, which often caused urinary tract infections and had a negative impact on post-operative adjuvant therapy. This study retrospectively summarized the clinicopathological and etiological characteristics of patients with cervical cancer who had indwelling double J tubes and complicated with urinary tract infections.

Study setting and design

The study included patients who underwent radical hysterectomy with pelvic lymphadenectomy for cervical cancer with double-J ureteral stent placement between April 2019 and November 2022. The patients’ age, height, weight, diagnosis, clinical stage, pathologic stage, maximum diameter of cervical cancer, pathological type, SCC before surgery, HPV type, metastasis of lymph node, neoadjuvant chemotherapy, surgery time length, radiotherapy after surgery, chemotherapy after surgery, ureteral stent indwelling time, renal function during stent removal, occurrence of urinary tract infection during the stent indwelling time, pathogens isolated from urinary tract infection and drug sensitivity of these pathogens to common antibiotics were analyzed. All patients received prophylaxis antibiotic therapy for more than 2 days postoperatively. Urine analysis and urine culture were not performed in all patients, only in symptomatic patients during ureteral stent indwelling. All patients underwent KUB radiological examination to ascertain the position of the ureteral stent within 72 hours after surgery.

The patients were divided into two groups based on urinary tract infection or not: urinary tract infection group and no urinary tract infection group. Clinicopathological characteristics between the two groups were analyzed and compared thoroughly. Every strain pathogenic microbe for every patient during ureteral stents indwelling was investigated and summarized. Moreover, antibiotic sensitivity for these pathogenic microbes was also studied comprehensively.

Statistical analysis

The mean and standard deviation values were calculated for the patients’ ages, height, weight, BMI, numbers of lymph nodes removed, numbers of metastatic lymph nodes, surgery time length, SCC values pre-treatment, ureteral stent indwelling time, creatinine during stent removal, urea nitrogen during stent removal and GFR during stent removal. Independent t-test was implied to analyze the relationship between these characteristics above mentioned and the occurrence of urinary tract infection. Categorical variables, such as clinical stages, final pathological stages, pathological types, infected HPV types, neochemotherapy, postoperative adjuvant chemotherapy, postoperative adjuvant radiotherapy were computed as frequencies and percentages. Chi-square test and fisher exact test was applied to determine the relationship between these categorical variables above mentioned and he occurrence of urinary tract infection. P-value < 0.05 was considered statistically significant. Statistical analyses were performed using SPSS version 26.0.

Patients characteristics

A total of 24 cervical cancer radical surgery patients with JJ stent insertion were included and followed up. General characteristics were demonstrated in Table S1. The average maximum diameter of cancer was 4.68 cm, suggesting most patients included were locally advanced cervical cancer (LACC). Moreover, the average SCC value was 5.79 ng/ml, obviously higher than the normal, consistent with maximum diameter of cancer. Overview diagram of patients with ureteral stents indwelling complicated by urinary tract infections was demonstrated in Figure 1.

Characteristics associated with clinicopathology and indwelling JJ stent

Incidence of urinary tract infections reached in as high as 62.5%. 87.5% (21/24) patients included in this study were FIGO stage IB3-IVA, which were defined as LACC. 58.33% (14/24) patients had maximum diameter of cancer > 4cm. HPV 16 was present in 65% (13/24) patients included. More than half patients received postoperative chemotherapy and radiotherapy. JJ stent was inserted in 79.14% patients before and during surgery. Only 12.5% patients were placed JJ stent for less than 3 months. Most patients (70.83%) were inserted JJ stent for 3 to 12 months. During the stent removal, 40.91% patients had abnormal creatinine, 36% patients with abnormal urea nitrogen and 50% patients with abnormal GFR. Among all pathogens, 69.23% were Gram-positive bacteria and fungi accounted for 19.23% (Table 1).

Analysis of factors related to urinary tract infection

Factors such as age, height, weight, BMI, number of lymph node resection, number of lymph node metastasis, SCC before surgery, creatinine during stent removal, urea nitrogen during stent removal and GFR during stent removal were compared between patients with urinary tract infection and without urinary tract infection (Figure 2). However, no factor was determined as risk factor. In other words, these factors were not associated with urinary tract infections.

Furthermore, FIGO stage, pathological type, HPV type, neoadjuvant chemotherapy, radiotherapy and chemotherapy were also determined whether associated with urinary tract infection or not. It demonstrated that postoperative adjuvant chemotherapy might be more likely to cause urinary tract infections, although there was no significant statistical difference (P = 0.074), which might be related to the small amount of data included in this study. Other factors were confirmed to be not related with urinary tract infection (Table 2).

Distribution of pathogens of urinary tract infection in the patients

A total of 30 strains of pathogenic microbes were detected in 15 patients, including 3 strains of Gram-positive bacteria, including Enterococcus faecalis and Staphylococcus epidermidis, 22 strains of Gram-negative bacteria, mainly Escherichia coli and Klebsiella pneumoniae, and 5 strains of fungi, mainly Candida albicans. One thing to note were that two strains of CRE (carbapenem resistant Enterobacteriaceae bacteria) were identified (Table 3).

The pathogens of urinary tract infection varied during JJ stent indwelling. About 20.83% (5/24) patients experienced two different kinds of pathogens and 12.50% (3/24) patients experienced ≥ three kinds of pathogens (Table 3 & 4). Results from the antibiotic sensitivity analysis of Escherichia coli (Ecoli), the most common pathogen of urinary tract infections, demonstrated that Ecoli was resistant to Ampicillin, Ceftriaxone, Cefotaxime, Cefazolin and Cefuroxime. Escherichia coli was moderately sensitive towards Ciprofloxacin, Levofloxacin, Trimethoprim/Sulfamethoxazole, Aztreonam, Ceftazidime, Cefepime and Ampicillin/Sulbactam. Most Ecoli bacteria was sensitive to Imipenem, Meropenem, Piperacillin/Tazobactam, Tigecycline and Amikacin (Table S2 & Figure 3). Urine culture and antibiotic sensitivity test results demonstrated: with the prolonged time of JJ stent indwelling, pathogens of urinary tract infection became more complex and more difficult to control. The two most important features were: 1) infected pathogens changed from common type into rare type, and even turned into fungal infections; 2) antibiotic resistance significantly increased for the same pathogen.

Finally, 16.7% (4/24) patients underwent percutaneous nephrostomy due to refractory urinary tract infection or vesicovaginal fistula.

Cervical cancer is the most common gynecological malignancy. Surgical treatment (pelvic lymphadenectomy and radical hysterectomy) is the main treatment method for early cervical cancer. If there are high-risk factors, postoperative radiotherapy and chemotherapy are required. Currently, open radical hysterectomy (ORH) is one of the most commonly used methods for the treatment of early cervical cancer, with short postoperative hospital stay, fewer postoperative complications, and a 5-year disease-free survival rate of more than 90%(14–16).

In the surgical treatment of early cervical cancer patients, urinary system complications are common due to the proximity of the cervix to the bladder and other urologic structures(17). The complications of urinary system caused by gynecological surgery could bring great personal, economic, and social losses, seriously affecting life quality and cost-effectiveness. The double J stents play an important role in many urological procedures, such as ureteral strictures, or reno-ureteral stones treatment, iatrogenic injuries of the ureter in complex abdominal surgery(18, 19). Prophylactic ureteral stents to reduce injury and related complications in cervical cancer patients is controversial and the optimal indwelling time of double J stents is not well defined(20).

Surgery, radiotherapy and surgery combined with radiotherapy/ chemoradiotherapy are currently the three main treatment options for cervical cancer patients. These treatment options may damage the ureter and cause ureteral stricture. Thus, some physicians tend to insert ureteral stents pre-operation to prevent and reduce urinary related complications (21, 22). They believe that the preoperative stent is helpful for preventing and revealing the ureter intraoperative. Ureteral stents may reduce the incidence of ureteral stricture after radiotherapy. Furthermore, if the ureter was injured, the ureteral stent could be used for early diagnosis, prognosis and treatment monitoring(23).

It was reported that for patients with a history of previous pelvic surgery and strong suspicion of pelvic adhesion were recommended for preoperative stent placement(24). Many studies revealed that preoperative ureteral stenting has no statistical significance for urologic complications during and after pelvic surgery(8, 25). Hwang et al retrospectively reviewed medical records of 146 patients with cervical or endometrial cancer who underwent total laparoscopic radical hysterectomy with lymphadenectomy and found that double ureteral stents were inserted prophylactically in 13 patients (8.9%), 2 of whom had postoperative urologic complications. Nine patients (6.2%) had postoperative urologic complications(25). A 12-year randomized trial performed by Chou et al observed that a ureteral injury occurred in 1.20%( 19/1,583 ) patients with bilateral prophylactic ureteral catheterization versus 1.09% (17/1558) patients without prophylactic ureteral catheterization(8). No statistically significant difference identified in the incidence of ureteral injury between the different interventional groups (p = 0.774)(8). Another prospective randomized study by Kovachev et al showed urologic complications was observed in 2.6% patients with ureteral stenting compared to 10.5% without perioperative stenting; however, no statistical significance was observed between them(26). A retrospective study conducted by Redan and McCarus, including 151 patients received pelvic surgery and inserted lighted ureteral stents, revealed no ureteral injuries occurrence during and after surgery. Thus, they concluded that prophylactic placement of lighted ureteral stents was safe and cost-effective(27). However, another study revealed prophylactic ureteral stents insertion did not affect the rate of ureteral injury and had lower cost-effectiveness than expected(18).

Since the stent is a foreign body, it may cause patient discomfort, bacterial colonization, hematuria, irritative voiding symptoms, and deposition of urine constituents(28–30). These complications associated with stents may cause a significant increasement in burden and reduction in overall quality of life(17, 31, 32). Urinary tract infection is one of the most common and crucial complications related with indwelling ureteral stents. When ureteral stents inserted, bacterial rapidly adhered onto the indwelling implant surfaces and layers of biofilm formed, making it difficult to remove and leading to further morbidity and even urosepsis(12). It was reported that stents associated urinary tract infections were relatively high, ranging from 13–28%(33–35).

At present, most studies on double-J tubes insertion for cervical cancer focused on the adverse effects of urinary tract injury, while there were few researches on urinary tract infection. Thus, even fewer studies reported the pathogenic flora of urinary tract infection.

This study included 24 cervical cancer radical surgery patients with double J stent indwelling, 73.91% patients received postoperative chemoradiotherapy. Incidence of urinary tract infections reached in as high as 62.5%, obviously higher than previous literature reported(33–35). Factors such as age, height, weight, BMI, number of lymph node resection, number of lymph node metastasis, SCC before surgery, FIGO stage, pathological type, HPV type, neoadjuvant chemotherapy, radiotherapy these factors were confirmed to be not related with urinary tract infection. However, postoperative adjuvant chemotherapy was prone to associate with urinary tract infections, although no significant statistical difference identified. Reasons for these results might be smaller sample size and more LACC patients. Besides, ureteral stents placement for long time might the most important role in promoting and inducing urinary tract infections. The main pathogenic bacteria of these infections were identified as following: Escherichia coli, Klebsiella pneumoniae, Enterococcus faecalis, Staphylococcus epidermidis and Candida albicans. With the prolongation of ureteral stents placement, the drug sensitivity of the same pathogen decreased and the resistance of antibiotics increased. Also, the pathogenic microbes changed from bacteria into fungi with prolongation of ureteral stents placement. Furthermore, two cases of CRE were identified. It is worth noting that the urinary tract infections rate in this study was significantly higher than those reported in the literature. Main reasons for high rate of urinary tract infections are as follows: 1) Most patients included in this study were locally advanced cervical cancer (LACC), with large tumors and high surgical difficulty; 2) A high proportion of patients in this study received postoperative chemoradiotherapy, which increased the occurrence of ureteral complications; 3) The average duration of ureteral stents placement in this study was longer than 3 months.

There are several limitations within our study. First, the number of patients included was relatively small (n = 24). This may partly explain difference in the incidence of urinary tract infections compared to other reports. Second, the design of our study was retrospective and all operations were performed by a single surgeon. Thus, our results must be interpreted cautiously. Randomized studies are needed to establish the role of perioperative ureter stenting for urologic complications in LACC patients with radical pelvic surgery.

Ureteral tract infections rate in our study was as high as 62.5%, which was extremely higher than other studies reported. High incidence of infections was mainly due to those reasons: 1) most patients included in were LACC with large tumors and high surgical difficulty; 2) high proportion of patients received postoperative chemoradiotherapy; 3) average duration of ureteral stents placement was relatively longer. Postoperative adjuvant chemotherapy might be the risk factor of urinary tract infections, although no significant statistical difference found. This study demonstrated that the most common pathogens of urinary tract infections were Gram-positive bacteria, led by Escherichia coli. The Escherichia coli were relatively resistant to Penicillins and Cephalosporins and generally sensitive to Carbapenems and Glycylcyclines. With the prolongation of ureteral stents placement, drug sensitivity towards corresponding antibiotics of the same pathogen decreased and drug resistance towards the same antibiotics increased gradually. Moreover, the pathogenic microbes for the same patient changed from weakly pathogenic bacteria to highly pathogenic bacteria, and finally to fungi. It means that pathogens of urinary tract infections became more complex and more difficult to control with the prolongation of ureteral stents indwelling.

LACC: Locally advanced cervical cancer

CRE: Carbapenem resistant Enterobacteriaceae bacteria

FIGO: Federation International of Gynecology and Obstetrics

HPV: Human papillomavirus

GFR: Glomerular filtration rate

SCC: Squamous cell carcinoma antigen

BMI: Body mass index

Data Availability

All data and materials are accessible in the supplementary information.

Patient data from this study are available upon request because there are ethical restrictions on sharing the data publicly. Approval to conduct the study was received from the Corresponding author (Dr. Chengjuan Jin, E-mail: [email protected]). Data requests can be sent to the department of Obstetrics and Gynecology, Shanghai General Hospital).

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This work was supported by the National Natural Science Foundation of China (grant NO. 82002736), Nosocomial Infection Management Project foundation of Shanghai General Hospital (grant NO. SYYG20221027).

Ethics approval and consent to participate

All clinical data and information were collected after informed consent was obtained from the patients or their guardians. Ethical approval of this study was obtained from the ethics committee of Shanghai General Hospital.

Authors’ contributions

Chengwen Jin: Data curation, Formal analysis, investigation, visualization, writing –original draft. Yingfeng Xue: project administration. Hualei Bu: Data curation, investigation, project administration. Jiangdong Xiang: Investigation, resources, project administration. Sufang Wu and Chengjuan Jin: Conceptualization, funding acquisition, investigation, methodology, project administration supervision, writing – review & editing. All authors had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Acknowledgements

Not applicable.

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Table 1 Characteristics associated with clinicopathology and indwelling JJ stent

Clinicopathological characteristics	n	%	Characteristics associated with JJ stent	n	%
FIGO stage			Time of JJ stent insertion
IB2	3	12.50	Before surgery	1	4.17
IB3	6	25.00	During surgery	18	75.00
IIA1	1	4.17	One week after surgery	1	4.17
IIA2	5	20.83	One week to one month after surgery	4	16.67
IIIA	1	4.17	Ureteral stent indwelling time
IIIC1	6	25.00	≤ 3 months	3	12.50
IIIC2	1	4.17	3-6 months	7	29.17
IVA	1	4.17	6-9 months	7	29.17
Pathological type			9-12 months	3	12.50
Squamous cell carcinoma	21	87.50	>12 months	4	16.67
Adenocarcinoma	3	12.50	Creatinine during stent removal
Maximum diameter of cancer			<73	13	59.09
<2cm	0	0	73-177	5	22.73
2-4cm	10	41.67	177-443	4	18.18
>4cm	14	58.33	443-707	0	0.00
Metastasis of lymphnode			>707	0	0.00
Yes	7	30.43	Urea nitrogen during stent removal
No	16	69.57	<7	14	63.64
HPV infection			7-17.9	8	36.36
Negative	4	20.00	17.9-21.4	0	0.00
HPV16/18	13	65.00	>21.4	0	0.00
Other type	3	15.00	GFR during stent removal
Neochemotherapy			≥90	10	50.00
Yes	6	25.00	60-89	1	5.00
No	18	75.00	30-59	4	20.00
Radiotherapy			15-29	2	10.00
Yes	17	73.91	<15	3	15.00
No	6	2.59	Urinary tract infection
Chemotherapy			Yes	15	71.43
Yes	16	66.67	No	6	28.57
No	8	33.33	Pathogens of urinary tract infection
Laparotomy or Laparoscopy			Gram-positive bacteria	18	69.23
Laparotomy	1	4.17	Gram-negative bacteria	3	11.54
Laparoscopy	23	95.83	Fungi	5	19.23

Table 2 Several factors related to urinary tract infection

Clinical pathological factors	With urinary tract infection	Without urinary tract infection		p value
Clinical pathological factors	N	N		p value
FIGO stage
IB2	2	1	3.947	0.629
IB3	3	3
IIA1	1	0
IIA2	2	3
IIIA	1	0
IIIC1	4	2
IIIC2	1	0
IVA	1	0
Pathological type
Squamous cell carcinoma	13	8	0.025	0.872
Adenocarcinoma	2	1	0.025	0.872
HPV type
HPV16	7	6	0.277	0.869
Other HPV virus	2	1
Negative	2	1
Neochemotherapy
Yes	4	2	0.059	0.807
No	11	7	0.059	0.807
Radiotherapy
Yes	10	7	0.742	0.582
No	4	2	0.742	0.582
Chemotherapy
Yes	12	4	3.2	0.074
No	3	5	3.2	0.074

Table 3 Main pathogens of urinary tract infection in the patients

Pathogens related to urinary tract infection	n	%
Gram-positive bacteria	3	10.00
Enterococcus faecalis	2	6.67
Staphylococcus epidermidis	1	3.33
Gram-negative bacteria	22	73.33
Escherichia coli	14	46.67
Klebsiella pneumoniae	3	10.00
Streptococcus agalactiae	1	3.33
Pseudomonas aeruginosa	1	3.33
Enterobacter cloacae	1	3.33
Proteus mirabilis	1	3.33
flavobacterium indole-producing	1	3.33
Fungi	5	16.67
Candida albicans	4	13.33
Ommacta sp	1	3.33
Multiple infections during JJ stent indwelling
Infection of two pathogenic bacteria	5	20.83
Infection of ≥3 pathogenic bacteria	3	12.50
CRE	2	8.33

Table 4 Pathogens during ureteral stents placement and factors related with severe complication

Patient	Pathogens associated with urinary tract infeciton during ureteral stent indwelling	CRE or not	Renal fistula	Factors related renal fistula
Patient 1	Enterobacter cloacae - Klebsiella pneumoniae - Escherichia coli - Candida parapsilosis	/	/	/
Patient 2	Escherichia coli -Enterococcus faecalis	/	/	/
Patient 3	Escherichia coli-Streptococcus agalactiae-Enterococcus faecalis	/	/	/
Patient 4	Klebsiella pneumoniae - Staphylococcus epidermidis	/	Yes	Infection
Patient 5	Escherichia coli	/	/	/
Patient 6	Escherichia coli	/	/	/
Patient 7	Escherichia coli	/	/	/
Patient 8	Escherichia coli - Ommakodar	/	/	/
Patient 9	Escherichia coli - Flavobacterium indoligenes	Yes	Yes	Infection
Patient 10	Escherichia coli - Candida albicans	/	Yes	Infection
Patient 11	Candida pseudosmooth	/	/	/
Patient 12	Pseudomonas aeruginosa - Klebsiella pneumoniae - Candida albicans	/	/	/
Patient 13	No bacteria	/	/	/
Patient 14	No bacteria	/	/	/
Patient 15	Escherichia coli	/	/	/
Patient 16	Proteus mirabilis	/	/	/
Patient 17	No bacteria	/	/	/
Patient 18	Enterobacter aerogenes	Yes	/	/
Patient 19	No bacteria	/	Yes	Vesicovaginal fistula
Patient 20	No bacteria	/	/	/
Patient 21	Unknown	/	/	/
Patient 22	No bacteria	/	/	/
Patient 23	Unknown	/	/	/
Patient 24	Unknown	/	/	/

No competing interests reported.

Clinicopathological and etiological characteristics for urinary tract infection in cervical cancer patients with radical surgery with double J stents

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Background

Methods

Study setting and design

Statistical analysis

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1