Transrectal contrast-enhanced (Levovist) ultrasonography in evaluation of urinary leakage after radical prostatectomy: A preliminary report

Microbubble-enhanced ultrasound to demonstrate urethral transection in a case of penile fracture

A 47-year-old man attended the emergency department following trauma during sexual intercourse after which he developed penile swelling and haematuria several hours later. A penile fracture was suspected but given the slightly atypical history, ultrasound was performed to look for a fracture. Given the history of haematuria, both a standard Doppler ultrasound and a microbubble-enhanced retrograde ultrasound urethrogram were performed. The Doppler confirmed the suspected diagnosis of penile fracture, and microbubble urethrogram demonstrated a urethral injury. This facilitated prompt surgical treatment and helped guide the surgical approach. Retrograde microbubble enhanced ultrasound urethrogram is a novel technique that can be used in conjunction with standard ultrasound to confirm the presence of a concurrent urethral rupture in penile fracture.

Outcome of vesicourethral anastomosis after robot-assisted laparoscopic radical prostatectomy: A 6-year experience in Taiwan

BACKGROUND/PURPOSE

The use of a da Vinci robotic system may improve the outcome of urological surgery. This study reports 6 years of experience with vesicourethral anastomosis (VUA) following robot-assisted laparoscopic radical prostatectomy (RALP) performed in Taichung Veterans General Hospital, Taichung, Taiwan.

METHODS

A total of 350 patients who underwent RALP by a single surgeon were reviewed. We followed Dr Patel's RALP procedure with minor modifications. VUA was checked with 120 mL and 200 mL saline in sequence. The urinary bladder was then pressed with endoscopic instruments. If a VUA leak was detected, it was sutured immediately. An 18-French silicon Foley's catheter was inserted and removed 7-14 days after RALP. Preoperative characteristics and perioperative complications were assessed.

RESULTS

Overall, 332 (94.85%) patients were without any leakage in the first step of the challenge, eight of whom had leakage in the second step. After repair, all were free from leakage. The other 18 patients had leakage in the first step of the challenge (5.14%). After repair, 12 patients were without leakage in the second step. However, one patient had urine leakage postoperatively. The other six patients had leakage in the second step. After repair, two patients were free from leakage, but the remaining four suffered from persistent minor urine leakage postoperatively. The urine leakage rate after RALP was 1.43% (5/350). The potential urine leakage after bladder challenge and endoscopic instruments pressing could be minimized to 0.29% (1/346).

CONCLUSION

VUA leakage after RALP is rare. Intraoperative VUA challenge is simple and feasible compared to postoperative retrograde cystography.

Transrectal contrast-enhanced ultrasonography, transrectal ultrasonography and retrograde cystography for the detection of vesicourethral anastomosis leakage after radical retropubic prostatectomy: a prospective comparative evaluation

OBJECTIVES

To evaluate the diagnostic accuracy of cystography (CG), transrectal ultrasonography (TRUS) and transrectal contrast-enhanced ultrasonography (CEUS) for the detection of vesicourethral extravasation (VE) after radical retropubic prostatectomy (RRP).

PATIENTS AND METHODS

In 80 consecutive patients who underwent RRP, the strength of the vesicourethral anastomosis (VUA) was assessed by CG, TRUS and transrectal CEUS. The investigation started with a conventional CG evaluated by an experienced uroradiologist. Following this, patients underwent TRUS which was performed by an experienced urologist who was blinded to the CG findings. The examination started with a conventional B-scan and, subsequently, a CEUS was performed by emptying and refilling the bladder with 90 ml of NaCl 0.9% + 10 ml suspension of 1:10 SonoVue and NaCl 0.9%.

RESULTS

26 patients (32.5%) presented urinary VE and 54 (67.5%) a watertight VUA. In 16 patients (61%) we observed a small leakage, 9 patients (35%) presented a moderate VE, and a large VE was detected in 1 patient (4%). No statistically significant difference in detection of VE was found among the three tests (p = 0.472).

CONCLUSIONS

TRUS and CEUS are able to provide information about the integrity of the VUA that is comparable with that of CG.

Urine colour after radical prostatectomy predicts urinary leakage at the vesicourethral anastomosis

OBJECTIVE

The aim of this investigation was to determine whether postoperative urine colour could be used as a predictor for the presence or absence of a urinary leakage at the vesicourethral anastomosis after open radical prostatectomy.

MATERIAL AND METHODS

In this prospective study, the urine colour of 223 patients who underwent open radical prostatectomy due to histologically proven localized prostate cancer was assessed macroscopically and microscopically on postoperative day (POD) 6, 7 and 8. All patients underwent evaluation of perianastomotic extravasation by retrograde cystography on POD 8. Baseline characteristics included age; prostate-specific antigen; prostate volume; tumour, node, metastasis classification; and Gleason score.

RESULTS

The urine colour was a highly significant predictor for perianastomotic extravasation in cystography when it was red on POD 6, 7 and 8. The sensitivity and specificity of urine colour as a predictor for extravasation were 71.4% and 83.2% on POD 6, 71.4% and 85.8% on POD 7, and 81.8% and 90.9% on POD 8, respectively, with a clear or slightly ensanguined urine colour. The negative and positive predictive values were 98.6% and 81.8%, respectively.

CONCLUSION

A cystography can be omitted if the patient demonstrates a clear urine colour on POD 8, without an increased risk of missing a perianastomotic extravasation.

New standardization of checking the vesicourethral anastomosis for tightness following radical prostatectomy with dynamic transrectal ultrasound: can this new technique replace the traditional postoperative cystogram?

PURPOSE

Urinary extravasation at the anastomosis is common after radical prostatectomies. Nevertheless, no data exist referring to the optimal date of catheter removal at the time of expected complete tightness of the leakage. Thus, we developed over the last 10 years a standardized concept to check the anastomosis, evaluating urinary extravasation using a dynamic transrectal ultrasound (dTRUS).

METHODS

From 1999 to 2008, 1,479 radical prostatectomies have been performed. For complete tightness, 752 could be evaluated using the standardized concept of checking the anastomosis. The first 250 patients have been evaluated by cystogram and dTRUS and the following 502 patients only by dTRUS postoperatively. The date of checking the anastomosis was determined by the urine color.

RESULTS

Urinary extravasation could be detected 4-8 days postoperatively in 41% (n = 308), 9-12 days in 16% (n = 120), 13-20 days in 8% (n = 60), and in no patient after 21 days. The coefficient of correlation comparing dTRUS versus cystogram was r = 0.99, P < 0.05. The measured volume of urinary extravasation after 4-8 days postoperatively was 15 ml (3-49 ml) using dTRUS and 16 ml (3-45 ml) using cystogram. After 9-20 days, the volume was determined as 9 ml (3-24 ml) by dTRUS and 9 ml (4-23 ml) by cystogram. The macroscopic evaluation of the urinary color was very well correlated with the likelihood of extravasation being still present. When the urine was cloudy or colored by old blood, extravasation was present in 96.9% of the patients. Microscopic evaluation like leukocyturia or hematuria of the urine on the same day shows specificity in only 34.3%.

CONCLUSIONS

Following radical prostatectomy, the urine color is essential to assess the chance of a persisting leakage at the anastomosis. The method of dTRUS can replace the cystogram in checking for complete healing of the anastomosis, thus decreasing the exposure to X-rays of the patient of about 60 cGy/cm(2).

Detection of urinary leakage after radical retropubic prostatectomy by contrast enhanced ultrasound - do we still need conventional retrograde cystography?

INTRODUCTION

To prospectively evaluate the accuracy of transvesical contrast-enhanced ultrasound (CEUS) as an alternative method for the detection of anastomotic leakage after radical retropubic prostatectomy (RRP) in comparison with the current standard method of conventional retrograde cystography (CG).

PATIENTS AND METHODS

Forty-three patients underwent RRP for histologically proven localized prostate cancer. The vesico-urethral anastomosis was evaluated 8 days after RRP by CG and CEUS. Any peri-anastomotic leakage was assessed and determined in CG and CEUS as follows: no extravasation (EV), small leakage (≤0.5 cm), moderate leakage (>0.5 cm to ≤2 cm), large leakage (>2 cm diameter of EV seen).

RESULTS

In total, 21 (49%) patients showed a watertight anastomosis. Ten (23%), two (4.7%) and ten (23%) patients showed a small, intermediate and large EV, respectively. In 31 cases (72%) there was 100% agreement of CG and CEUS for detection of no, moderate and large EV, respectively. In nine cases a small and in two cases a moderate EV was categorized as watertight anastomosis by CEUS. Only in one case did CG detect a small EV where a large EV was detected in CEUS. The agreement between both methods was 95% for detecting absence or large leakages.

CONCLUSION

CEUS is a promising imaging modality that seems to be equivalent to CG for detecting the presence of a large anastomotic leakage that is clinically relevant for postoperative persistence of the indwelling catheter. CEUS could be a cheap and time-saving alternative to the CG without exposure of the patient to radiation.

Transperineal sonocystography: new standard for assessing anastomotic leaks after radical prostatectomy

OBJECTIVE

Fluorocystography (FC) is the reference standard for assessing the integrity of the vesicourethral anastomosis after radical prostatectomy (RP). We describe a new technique, transperineal sonocystography (TPSC), as a cost-effective alternative and more informative than FC.

METHODS

Between May 1, 2007, and October 1, 2008, 175 consecutive men underwent open or robotically assisted RP. Before Foley catheter removal, all men underwent both TPSC and FC, which were performed and interpreted by a single radiologist. Transperineal sonocystography was performed first with real-time imaging after gravity filling of the bladder with 150 mL of normal saline. Extravasation of saline was calculated by computer software after outlining the observed pooling of extravasated saline in the transverse and longitudinal views. Fluorocystography was performed after TPSC using our standard protocol, with qualitative classification of anastomotic leaks as none, slight, moderate, or severe.

RESULTS

The mean extravasation volume +/- SEM was 16.3 +/- 2.9 mL. Of the 175 patients, 142 (81.2%) showed no anastomotic leaks on TPSC. Of the remaining 33 patients (18.8%), TPSC identified 20 (11.4%), 13 (7.4%), and 0 patients with slight, moderate, and severe leaks, respectively. Excellent concordance was shown between TPSC and FC.

CONCLUSIONS

Transperineal sonocystography was equivalent to FC in detecting anastomotic leaks after RP. It provides a safe, inexpensive, and effective alternative to traditional FC for evaluating the integrity of the vesicourethral anastomosis after RP.

[Postoperative monitoring of anastomosis after radical retropubic prostatectomy Transrectal ultrasound can replace cystography?]

OBJECTIVE

We determined if transrectal ultrasound (TRUS) is as reliable as cystography in detecting vesicourethral extravasates after radical retropubic prostatectomy (RRP).

PATIENTS AND METHODS

Between October 2005 and February 2006 we prospectively investigated 100 consecutive patients undergoing RRP. The vesicourethral anastomosis was proven 6 days after operation by a combined investigation with TRUS and cystography.

RESULTS

In the majority of patients (79%) the vesicourethral anastomosis was watertight on postoperative day 6 (POD) or showed minimal leakage (8%) so that the urinary catheter was removed. Different degrees of paravasates were detected in 21 patients. Because of small, moderate, or marked paravasations the indwelling catheter was removed on POD 9, 14, and 21 in 5, 3, and 5 patients, respectively. Every paravasate documented by cystography had been detected by TRUS before. Therefore, TRUS showed no false-negative result in detecting insufficient anastomosis. In two patients paraurethral fluid was detected by TRUS mimicking anastomotic paravasation, without confirmation by cystography.

CONCLUSIONS

TRUS can safely replace cystography to detect anastomotic leakage after radical prostatectomy.