When antibiotics fail: the role of trigonal electrofulguration in recurrent UTIs in women

Recurrent urinary tract infections (rUTIs) in women are frequently associated with significant morbidity, impaired quality of life, repeated antibiotic exposure, and increasing antimicrobial resistance. Experimental and translational evidence suggests that bacterial biofilms, intracellular bacterial communities (IBCs), and quiescent intracellular reservoirs (QIRs) within the bladder wall may contribute to persistence and recurrence. In selected women with antibiotic-refractory rUTIs and chronic trigonal inflammatory lesions, endoscopic electrofulguration (EF) has emerged as a potential therapeutic alternative. This systematic review evaluated the efficacy, safety, and limitations of EF for the treatment of refractory rUTIs. A systematic review was conducted according to PRISMA guidelines across 8 major electronic databases (PubMed, Embase, Web of Science, Scopus, ClinicalTrials.gov, EU Clinical Trials Register, LILACS, and SciELO). From 133 records screened, 22 eligible peer-reviewed studies met eligibility criteria and were included in the qualitative analysis. Two principal electrofulguration strategies were identified. Selective electrofulguration of cystoscopically visible lesions achieved infection-free rates ranging from 46% to 72%, with additional benefit observed following repeat procedures. Alternatively, complete electrofulguration of the trigone and bladder neck, with treatment of concomitant extratrigonal lesions when present, resulted in infection-free rates of up to 96% during the first postoperative year and 53% at two years. Reported complication rates ranged from 6% to 10% and were predominantly minor and self-limited, including transient dysuria, hematuria, and urinary retention. Severe complications were uncommon. Electrofulguration should be regarded as an experimental therapeutic option for highly selected women with antibiotic-refractory recurrent urinary tract infections and chronic trigonal inflammatory lesions. While preliminary data suggest it may reduce infection recurrence in carefully chosen patients, current evidence is limited to single-center, non-randomized studies. Prospective multicenter randomized trials are required before electrofulguration can be recommended as a standard treatment.