Routine pelvic drainage not required after open or robotic radical prostatectomy

Perioperative outcomes, environmental impact and economic implications of pelvic drain discontinuation in prostate cancer patients undergoing robot-assisted radical prostatectomy

PURPOSE

The utility of a pelvic drain (PD) after robot-assisted radical prostatectomy (RARP) has been recently questioned. We investigated the impact of discontinuing PD placement after RARP on complications, pain, environmental benefits, and cost savings.

METHODS

We identified 1,199 patients who underwent RARP with or without extended pelvic lymph node dissection from 2016 to 2023 at a referral center. Starting in 2018, PD placement was discontinued in uncomplicated RARPs. Complications were collected following the European Association of Urology (EAU) recommendations on reporting and grading. Multivariable logistic regression models (MLR) evaluated the impact of PD use on perioperative outcomes and opioid usage. The PD life cycle-associated Carbon Dioxide Equivalent Emissions (CO2e) and its economic impact were estimated.

RESULTS

A PD was placed in a total of 555 (46%) patients, with a decreasing rate from 94% to 18% between 2016 and 2023. The rates of any and high-grade (HG) complications were similar between patients with and without PD (29 vs. 28% and 5% vs. 6%, respectively; all P ≥ 0.2). At MLR, the PD placement was not associated with the risk of any (OR:1.09, 95%CI:0.79-1.5) or HG complications (OR 1.45, 95%CI 0.80-2.63). PD placement was associated with greater postoperative opioid usage (OR:1.58, 95%CI:1.01-2.51, P = 0.045). The CO2e spared rose from 220 in 2016 to 2,180 in 2022 and cost savings per year increased from 1,855€ in 2016 to 18,506€ in 2022.

CONCLUSION

Unnecessary PD placement should be avoided in uncomplicated RARPs to obtain environmental benefits, reduce health-related costs, and improve patients' outcomes.

A review of enhanced recovery after surgery concept in perioperative radical prostatectomy for prostate cancer

Radical prostatectomy (RP) is the main treatment for early-stage localized prostate cancer. With the improvement of medical technology, radical prostatectomy is mainly performed under laparoscopy or robot assistance. With the continuous deepening of the Enhanced Recovery After Surgery (ERAS) concept in clinical practice, patients have increasingly high requirements for postoperative recovery. The ERAS concept is of great significance in the perioperative period and has been used in many surgical fields due to its ability to improve prognosis. ERAS has not yet been widely applied in urology and the research progress of other disciplines in ERAS has promoted its development in radical prostatectomy. This review summarizes the key elements of ERAS in the perioperative period of RP, aiming to demonstrate the superiority of ERAS and provide new references and inspirations for urologists.

Drains Are Not Necessary in the Majority of Robotic Urologic Procedures

Abdominal drain use is a common practice after urologic procedures involving urinary tract violation with the intention of externalizing potential urine leaks and preventing urinomas. Drains may alternatively be placed to detect bleeding or bowel injury, prevent hematomas or lymphoceles, or for other reasons equally lacking any evidence showing benefits. In general, the practice of placing abdominal drains in urology is based on dogma and learned habits.

Urine leak after robotic radical prostatectomy: not all urine leaks come from the anastomosis

Radical prostatectomy is the gold standard in patients that are surgical candidates with localized prostate cancer. While most postoperative urine leaks are from vesico-urethral anastomosis, urologists must be aware that a small percentage of patients may have a urine leak from other sites that may have been inadvertently injured during the procedure. We propose a systematic workup to evaluate the source of the urinary leak as well as appropriate management of such injuries. The mid-ureter can be injured during lymph node dissection. The distal ureter is at risk of injury when performing the Montsouris approach. The posterior bladder neck dissection can at times be challenging. If not careful, one can easily cause an injury to the trigone and/or ureteral orifices. The most common site of leak is at the vesico-urethral anastomosis due to a non-watertight closure. The management of intraoperatively detected ureteral injuries require placement of a ureteral stent. The location, severity and type of injury determine the reconstruction required to fix it. Postoperatively urine leak can be frequently detected when assessing the pelvic drain, and imaging such as CT Urogram with a cystogram phase may be helpful in the diagnosis. Urine leak after robotic-assisted laparoscopic radical prostatectomy remains a rare complication, sometimes the diagnosis can be challenging, and management varies depending on the site and severity of injury.

A prospective comparative study of routine versus deferred pelvic drain placement after radical prostatectomy: impact on complications and opioid use

PURPOSE

To evaluate the association of post-RP drain placement with post-operative complications and opioid use at a high-volume institution.

METHODS

A prospective, comparative cohort study of patients undergoing robot-assisted or open RP was conducted. Patients for two surgeons did not routinely receive pelvic drains ("No Drain" arm), while the remainder routinely placed drains ("Drain" arm). Outcomes were evaluated at 30 days including Clavien-Dindo complications and opioid use. Intention-to-treat primary analysis and additional secondary analyses were performed using appropriate statistical tests and logistic regression.

RESULTS

Of 498 total patients, 144 (28.9%) were in the No Drain arm (all robot-assisted) and 354 (71.1%) in the Drain arm. In the No Drain arm, 19 (13.2%) intraoperatively were chosen to receive drains. There was no difference in overall or major (Clavien ≥ 3) complications between groups (p = 0.2 and 0.4, respectively). Drain deferral did not predict complications on multivariable analysis adjusted for age, BMI, comorbidities, clinical risk, surgical approach, operating time, lymphadenectomy, and number of nodes removed [OR 0.61, 95% CI 0.34-1.11, p = 0.10]; nor did it predict symptomatic fluid collection, adjusting for lymphadenectomy and nodes removed [OR 1.14, 95% CI 0.43-3.60, p = 0.8]. Drain deferral did not decrease opioid use (p = 0.5). Per protocol analysis and restriction to robot-assisted cases demonstrated similar results.

CONCLUSION

There was no difference in adverse events, complications, symptomatic collections, or opioid use with deferral of routine drain placement after RP. Experienced surgeons may safely defer drain placement in the majority of robot-assisted RP cases.

Review of the use of prophylactic drain tubes post‐robotic radical prostatectomy: Dogma or decent practice?

Objective

To assess the necessity of routine prophylactic drain tube use following robot‐assisted radical prostatectomy (RARP).

Method

We performed a literature review using the Medline, Scopus, and Web of Science databases with no restriction of language from January 1900 to January 2020. The following terms we used in the literature search: prostatectomy, radical prostatectomy, robot assisted, drainage, and drain tube.

Results

We identified six studies that examined the use of routine prophylactic drain tubes following RARP. One of these studies was a randomized study that included 189 patients, with 97 in the pelvic drain (PD) arm and 92 in the no pelvic drain (ND) arm. This non‐inferiority showed an early (90‐day) complication rate of 17.4% in the ND arm versus 26.8% in the PD arm (P < .001). Another non‐inferiority randomized control trial (RCT) showed a complication rate of 28.9% in the PD group versus 20.4% in the ND group (P = .254). Similarly, the other studies found no benefit of routine use of prophylactic drain tube after RARP.

Conclusion

Drain tubes play a role during robotic‐assisted radical prostatectomy, however, following a review of the current available literature, they can be safely omitted and we suggest that clinicians may be selective in their use.

Impact of enhanced recovery after surgery or fast track surgery pathways in minimally invasive radical prostatectomy: a systematic review and meta-analysis

Background

The enhanced recovery after surgery (ERAS) and fast track surgery (FTS) protocols have been applied to a variety of surgeries and have been proven to reduce complications, accelerate rehabilitation, and reduce medical costs. However, the effectiveness of these protocols in minimally invasive radical prostatectomy (miRP) is still unclear. Thus, this study aimed to evaluate the impact of ERAS and FTS protocols in miRP.

Methods

We searched PubMed, Cochrane Library, Embase, and Web of Science databases to collect randomized and observational studies comparing ERAS/FTS versus conventional care in miRP up to July 1, 2019. After screening for inclusion, data extraction, and quality assessment by two independent reviewers, the meta-analysis was performed with the RevMan 5.3 and STATA 15.1 software. Results were expressed as risk ratio (RR) and weighted mean difference (WMD) with 95% confidence intervals (CIs).

Results

In total, 11 studies involving 1,207 patients were included. Pooled data showed that ERAS/FTS was associated with a significant reduction in length of stay (LOS) (WMD: -2.41 days, 95% CI: -4.00 to -0.82 days, P=0.003), time to first anus exhaust (WMD: -0.74 days, 95% CI: -1.14 to -0.34 days, P=0.0003), and lower incidence of postoperative complications (RR: 0.70, 95% CI: 0.53 to 0.92, P=0.01). No significant differences were found between groups for operation time, estimated blood loss, postoperative pain, blood transfusion rate, and readmission rate (P>0.01).

Conclusions

Our meta-analysis suggests that the ERAS/FTS protocol is safe and effective in miRP. However, more extensive, long-term, prospective, multicenter follow-up studies, and randomized controlled trials (RCTs) are required to validate our findings.

[Still no evidence for drains in bariatric surgery]

BACKGROUND

Registry data show that placement of a drain during bariatric surgery is still the normal practice in many surgical departments. Retrospective studies and a review article could show that the routine placement of a drain in bariatric surgery is useless and also potentially dangerous. Due to the lack of randomized controlled studies there is insufficient evidence on this topic in the literature.

OBJECTIVE

In order to further question the use of drains in bariatric interventions, the prospective in-house databank of patients who received a gastric sleeve (SG) or a Roux-en‑Y gastric bypass (RYGB) between January 2010 and June 2016 was retrospectively evaluated.

SETTING

A German university hospital.

METHODS

During the investigation period a total of 361 operations (219 gastric bypasses and 142 gastric sleeve operations) were carried out. A change in the internal treatment pathway with respect to the placement of drains in 2013 led to the formation of two groups: one where a drain was routinely placed in operations (n = 166) and a second group where a drain was not routinely placed (n = 195). The demographic data were statistically adjusted between the two groups using multiple regression analysis. The results of the operation and the 30-day morbidity were compared. Complications were evaluated according to the Clavien-Dindo classification.

RESULTS

In the group with no drain, complications occurred in seven patients. In the group with drainage there were 6 complications. The insufficiency and reoperation rates were not statistically significantly different between the two groups. The average postoperative hospital stay was 1.3 days longer in patients with a drain. Multivariate analysis showed that the placement of a drain was the greatest risk factor for a longer hospital stay.

CONCLUSION

Placement of a drain during bariatric interventions should only be considered on an individual basis. The routine placement should be discouraged.

Surgical Strategies for Lymphocele Prevention in Minimally Invasive Radical Prostatectomy and Lymph Node Dissection: A Systematic Review

Purpose: Pelvic lymph node dissection is an important step during robotic radical prostatectomy. The collection of lymphatic fluid (lymphocele) is the most common complication with potentially severe impact; therefore, different strategies have been proposed to reduce its incidence. Materials and Methods: In this systematic review, EMBASE, MEDLINE, Cochrane Library, and NIH Registry of Clinical Trials were searched for articles including the following interventions: transperitoneal vs extraperitoneal approach, any reconfiguration of the peritoneum, the use of pelvic drains, and the use of different sealing techniques and sealing agents. The outcome evaluated was the incidence of symptomatic lymphocele. Randomized, nonrandomized, and/or retrospective studies were included. Results: Twelve studies were included (including one ongoing randomized clinical trial). Because of heterogeneity of included studies, no meta-analysis was performed. No significant impact was reported by different sealing techniques and agents or by surgical approach. Three retrospective, nonrandomized studies showed a potential benefit of peritoneal reconfiguration to maximize the peritoneal surface of reabsorption. Conclusion: Lymphocele formation is a multistep and multifactorial event; high-quality literature analyzing risk factors and preventive measures is rather scarce. Peritoneal reconfiguration could represent a reasonable option that deserves further evaluation; no other preventive measure is supported by current evidence.

Regular vs. selective use of closed suction drains following robot-assisted radical prostatectomy: results from a regional quality improvement collaborative

BACKGROUND

Closed suction drain (CSD) placement is common in robot-assisted radical prostatectomy (RARP). Our goal is to quantify outcomes of RARP for patients undergoing RARP by surgeons who regularly or selectively use CSDs.

METHODS

Patients undergoing RARP (4/2014-7/2017) were prospectively entered into the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry. Outcomes included length of stay (LOS) >2 days, >16-day catheterization, 30-day readmission, and clinically significant urine leak or ileus. Retrospective analysis of each adverse event was performed comparing groups using chi-square tests.

RESULTS

In all, 6746 RARPs were performed by 115 MUSIC surgeons. CSDs were used in 4451 RARP (66.0%), with wide variation in surgeon CSD use (median: 94.7%, range: 0-100%, IQR: 45-100%). The cohorts of patients treated by surgeons with regular vs. selective CSD usage were similar. CSD use pattern was not associated with rates of prolonged catheterization (4.6% vs. 3.9%, p = 0.17) or readmission (4.5% vs. 4.0%, p = 0.35) and multivariable analysis confirmed these findings (each p > 0.10). Regular CSD use was associated with LOS >2 days (8.4% vs. 6.3%, p = 0.001) and multivariable analyses indicated an odds ratio (OR) of 1.42 (95% CI: 1.12-1.79; p = 0.017) and increased likelihood of clinically significant ileus (OR: 1.64; CI: 1.14-2.35; p = 0.008).

CONCLUSIONS

Although there are specific situations in which CSDs are beneficial, e.g. anastomotic leak or observed lymphatic drainage, regular CSD use during RARP was associated with a greater likelihood of LOS >2 days and clinically significant ileus. Our data suggest that CSD should be placed selectively rather than routinely after RARP.

Is a Drain Needed After Robotic Radical Prostatectomy With or Without Pelvic Lymph Node Dissection? Results of a Single-Center Randomized Clinical Trial

Objective: To investigate by means of a randomized clinical trial the safety of no drain in the pelvic cavity after robot-assisted radical prostatectomy (RARP) with or without extended pelvic lymph node dissection (ePLND). Materials and Methods: From May to December 2016, 112 consecutive patients who underwent RARP with or without ePLND were prospectively randomized into a control group (CG) and study group (SG). In the CG, a drain was placed in the pelvic cavity at the end of surgery and removed after 24 hours. The trial was designed to assess noninferiority. The primary endpoint was evaluated as complication rates graded by the Clavien-Dindo score (CDS). Secondary endpoints included length of hospital stay (LOHS) and hospital readmission (RAD). Results and Limitations: At final analysis, 56 patients were in the CG and 54 belonged to the SG. The groups were homogenous for all preoperative and perioperative variables and did not show any difference in CDS complication rates (28.9% in the CG and 20.4% in the SG; p = 0.254), LOHS (on average 4 days in each group; p = 0.689), and RAD rates (3.6% in the CG and 3.7% in the SG; p = 0.970). Conclusions: In a modern cohort of patients who underwent RARP with or without ePLND, a single-center randomized controlled trial showed that no-drain policy is equivalent to drain after RARP in terms of CDS complication rate, LOHS, and RAD rate. The option of placing a postoperative drain for the first 24 hours could be considered in cases of difficult urethrovesical anastomosis with uncertain watertightness.

Risk factors, complications and management of lymphocele formation after radical prostatectomy: A mini-review

Lymphocele formation is the most common adverse event of pelvic lymphadenectomy during radical prostatectomy for prostate cancer. Previous studies failed to favor one surgical technique over the other in terms of minimizing its rate. Data on risk factors for its development are still conflicting and warranting further research. In this mini-review, we aimed to scrutinize available evidence on these aspects and outline current achievements in lymphocele prevention approaches.

Exploring pathways towards improving patient experience of robot-assisted radical prostatectomy (RARP): assessing patient satisfaction and attitudes

OBJECTIVE

To determine patient satisfaction and experience after robot-assisted radical prostatectomy (RARP) for prostate cancer, using a convergent mixed-method qualitative analysis approach.

PATIENTS AND METHODS

412 patients who underwent RARP between January 2014 and June 2016 were mailed questionnaires and invited to participate in focus groups. Qualitative data was thematically analysed using NVivo. Descriptive statistics were obtained from the questionnaire using SPSS.

RESULTS

214 patients responded (52% of sample size) of whom 97.6% were satisfied and 91.1% would likely recommend RARP. Key themes from the qualitative data highlighted the psychosocial impacts of the diagnosis and RARP process. The importance of early recovery, the benefits of pelvic floor exercises and educational resources were emphasised.

CONCLUSION

Patients were overwhelmingly satisfied with RARP, largely due to relevance and timeliness of the information and support provided both before and after surgery. With an increased understanding of the factors and outcomes that are most important to patients regarding all aspects of hospital care, we can create more targeted care pathways. Key themes will help inform the implementation of an enhanced recovery after surgery (ERAS) protocol to further improve recovery and early return to function.

A Clinician's Guide to Avoiding and Managing Common Complications During and After Robot-assisted Laparoscopic Radical Prostatectomy

CONTEXT

Robot-assisted radical prostatectomy (RARP) is on the advance globally, and it is essential for surgeons and patients to know the rates of perioperative complications.

OBJECTIVE

To provide evidence-based clinical guidance on avoiding and managing common complications during and after RARP in the context of a comprehensive literature review.

EVIDENCE ACQUISITION

In concordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis 2015 statement guidelines, a literature search of the PubMed database from August 1, 2011, to August 31, 2015, using the predefined search terms robot* AND radical prostatectomy, was conducted. The search resulted in 653 unique results that were subsequently uploaded to DistillerSR (Evidence Partners, Ottawa, Canada) for team-based screening and processing of references.

EVIDENCE SYNTHESIS

Overall, 37 studies met the inclusion criteria and were included. Median rate of overall complication was 12.6% (range: 3.1-42%). Most of the complications were minor (Clavien-Dindo grades 1 and 2). Grade 3 complications comprised the bulk of the major complications with a median rate of 2.7%; grade IV and V complications were exceedingly rare in all reports.

CONCLUSIONS

Despite continued adoption of the RARP technique globally, rates of overall complication remain low. Many of the complications experienced during and after RARP can be mitigated and prevented by experience and the implementation of safe techniques.

PATIENT SUMMARY

Despite continued adoption of the robot-assisted radical prostatectomy (RARP) technique globally, rates of overall and major complications remain low at 12.6% and 2.7%, respectively. Complications can be minimized and successfully managed using established techniques. RARP is a safe and reproducible technique.

How to minimize lymphoceles and treat clinically symptomatic lymphoceles after radical prostatectomy

The development of a lymphocele after pelvic surgery is a well-documented complication, especially where pelvic lymph node dissection (PLND) is part of the operation. However, not all lymphoceles are symptomatic and require treatment. Most lymphoceles spontaneously resolve, and even lymphoceles that become symptomatic may resolve without any intervention. Robotic assisted radical prostatectomy (RARP) is a common operation in urology where PLND is likely to be performed in intermediate and high-risk prostate cancer patients. The rationale for performing a PLND in prostate cancer is for accurate staging and potential therapeutic benefits. However, due to potential intraoperative and postoperative complications there is still a debate regarding the value of PLND in prostate cancer. In this review, we will discuss the potential risk factors to be aware of in pelvic surgery in order to minimize the formation of a lymphocele, along with the management for clinically significant lymphoceles.

Impact of routine use of surgical drains on incidence of complications with robot-assisted radical prostatectomy

PURPOSE

To assess the impact of eliminating routine drain placement in patients undergoing robot-assisted laparoscopic prostatectomy (RALP) and pelvic lymph node dissection (PLND) on the risk of postoperative complications.

PATIENTS AND METHODS

An experienced single surgeon performed RALP on 651 consecutive patients at our institution from 2008 to 2012. Before August 2011, RALP with or without PLND included a routine peritoneal drain placed during surgery. Thereafter, routine intraoperative placement of drains was omitted, except for intraoperatively noted anastomotic leakage. We used multivariable logistic regression to compare complication rates between study periods and the actual drain placement status after adjusting for standard prespecified covariates.

RESULTS

Most patients (92%) did not have ≥grade 2 complications after surgery and only two patients (0.3%) experienced a grade 4 complication. The absolute adjusted risk of a grade 2-5 complication was 0.9% greater among those treated before August 2011 (95% confidence interval [CI] -3.3%-5.1%; p=0.7), while absolute adjusted risk of a grade 3-5 complication was 2.8% less (-2.8%; 95% CI-5.3%-0.1%; p=0.061). RESULTS based on drain status were similar.

CONCLUSIONS

Routine peritoneal drain placement following RALP with PLND did not confer a significant advantage in terms of postoperative complications. Further data are necessary to confirm that it is safe to omit drains in most patients.

A rare aetiology for increased drain output following a robotic-assisted prostatectomy

Robotic prostatectomies are being performed increasingly, with greater visualisation and improved precision, resulting in fewer postoperative complications. Despite advances in surgical techniques, drain output still remains one of the first signs of potential complications. We present the case of an iatrogenic cause for high drain output postoperatively, in order to highlight the potential problems of the drain itself. A 69-year-old man presented with a pelvic drain output of over 2 L a day as a result of the drain tip being placed at the site of the anastomosis. Here we discuss the rates of the three main causes of increased drain outputs following robotic prostatectomy, as well as highlighting the resulting complications. Overall, this case highlights the potential complications arising from the drain, which could potentially be avoided by either routine evaluation of the drain position postoperatively or by omitting the drain entirely if the anastomosis is performed well.

Clinical pathway after robotic nephroureterectomy: omission of pelvic drain with next-day catheter removal and discharge

OBJECTIVE

To determine the feasibility of applying a postoperative clinical pathway after robotic nephroureterectomy (RNU) targeting safe omission of a pelvic drain and removal of the bladder catheter on the day after surgery with hospital discharge on postoperative day 1 (POD#1).

METHODS

We reviewed a prospectively collected database of all RNUs performed by a single surgeon (R.A.) since institution of our clinical pathway in 2008 that includes pelvic drain omission, bladder catheter removal the morning after surgery, and discharge on POD#1. Patient demographics, and perioperative and postoperative outcomes were evaluated. Ability to adhere to the pathway and achieving the described parameters and whether any resulting complications occurred were determined.

RESULTS

RNU was performed in 29 patients with mean age and body mass index of 69 years (50-90 years) and 30 kg/m(2) (19-41 kg/m(2)), respectively. No patient required a pelvic drain, and 2 were discharged with a catheter. All but 2 patients (93%) were discharged on POD#1. Overall, successful pathway application was achieved in 26 of 29 patients (90%) including no drain, catheter removal on the morning after surgery, and discharge on POD#1. No patient developed urine leak or other complications related to early catheter removal.

CONCLUSION

Our clinical pathway after RNU allows safe omission of a pelvic drain with early discontinuation of the bladder catheter and discharge on the POD#1 in most patients. To our knowledge, similar pathways have not been previously achieved with nephroureterectomy by any approach, but should be considered by surgeons treating urothelial carcinoma of the upper urinary tract.

Advances in Robotic-Assisted Radical Prostatectomy over Time

Since the introduction of robot-assisted radical prostatectomy (RALP), robotics has become increasingly more commonplace in the armamentarium of the urologic surgeon. Robotic utilization has exploded across surgical disciplines well beyond the fields of urology and prostate surgery. The literature detailing technical steps, comparison of large surgical series, and even robotically focused randomized control trials are available for review. RALP, the first robot-assisted surgical procedure to achieve widespread use, has recently become the primary approach for the surgical management of localized prostate cancer. As a result, surgeons are constantly trying to refine and improve upon current technical aspects of the operation. Recent areas of published modifications include bladder neck anastomosis and reconstruction, bladder drainage, nerve sparing approaches and techniques, and perioperative and postoperative management including penile rehabilitation. In this review, we summarize recent advances in perioperative management and surgical technique for RALP.

Routine drain placement in Roux-en-Y gastric bypass: an expanded retrospective comparative study of 755 patients and review of the literature

Routine drain use after laparoscopic Roux-en-y gastric bypass (LRYGB) is still practiced by many bariatric surgeons. After a patient in our program experienced intestinal obstruction secondary to a drain, we reevaluated our practice and hypothesized drains would be of no benefit and potentially harmful after LRYGB. Retrospective record review of all patients undergoing LRYGB from August 2005 to August 2009 was performed. As we changed our practice in December 2006, we have two comparable groups: one with a drain placed at surgery and one without. All operations were otherwise performed in an identical fashion by three fellowship-trained university surgeons. We compared outcomes between the two groups, particularly regarding gastrojejunal (GJ) leaks. Jejunojejunal (JJ) leaks, unlikely to be captured by these drains, were not studied. A total of 755 LRYGBs were performed during the study period, the first 272 patients with routine drains and the subsequent 483 without. Demographics were statistically similar between the two groups. There were four GJ leaks in the drain group (1.47%) and three in the nondrain group (0.62%). Among the drain patients, two required operation and two were treated nonoperatively. Among the nondrain patients, two required operation and one was treated nonoperatively. The leak and reoperation rates between the groups were not statistically different (p = 0.154 and p = 0.514). Routine drains likely have no benefit after LRYGB. Clinical parameters such as tachycardia, fever, oliguria, and increasing abdominal pain should guide further investigation for and treatment of a leak.

Laparoscopic radical prostatectomy: omitting a pelvic drain

PURPOSE

Our goal was to assess outcomes of a selective drain placement strategy during laparoscopic radical prostatectomy (LRP) with a running urethrovesical anastomosis (RUVA) using cystographic imaging in all patients.

MATERIALS AND METHODS

A retrospective chart review was performed for all patients undergoing LRP between January 2003 and December 2004. The anastomosis was performed using a modified van Velthoven technique. A drain was placed at the discretion of the senior surgeon when a urinary leak was demonstrated with bladder irrigation, clinical suspicion for a urinary leak was high, or a complex bladder neck reconstruction was performed. Routine postoperative cystograms were obtained.

RESULTS

208 patients underwent LRP with a RUVA. Data including cystogram was available for 206 patients. The overall rate of cystographic urine leak was 5.8%. A drain was placed in 51 patients. Of these, 8 (15.6%) had a postoperative leak on cystogram. Of the 157 undrained patients, urine leak was radiographically visible in 4 (2.5%). The higher leak rate in the drained vs. undrained cohort was statistically significant (p = 0.002). Twenty-four patients underwent pelvic lymph node dissection (8 drained, 16 undrained). Three undrained patients developed lymphoceles, which presented clinically on average 3 weeks postoperatively. There were no urinomas or hematomas in either group.

CONCLUSIONS

Routine placement of a pelvic drain after LRP with a RUVA is not necessary, unless the anastomotic integrity is suboptimal intraoperatively. Experienced clinical judgment is essential and accurate in identifying patients at risk for postoperative leakage. When suspicion is low, omitting a drain does not increase morbidity.

Advances in bioadhesives, tissue sealants, and hemostatic agents

The use of bioadhesives, tissue sealants, and hemostatic agents has allowed for increased use of minimally invasive techniques for complex reconstructive urologic procedures. Hemostatic agents can facilitate clot formation through enzymatic reactions with host factors, mechanical compression, or a combination of the two. Tissue sealants and bioadhesives act through polymerization between themselves and adjacent tissues. This article reviews the unique features, mechanism of action, safety profile, and prototypical applications of the agents most commonly used in urologic surgery.

Robotic-assisted laparoscopic extended pelvic lymph node dissection for prostate cancer: surgical technique and experience with the first 99 cases

BACKGROUND

To date, there is still a paucity of data in the literature on robotic-assisted laparoscopic extended pelvic lymph node dissection (RALEPLND) in patients with prostate cancer.

OBJECTIVE

To assess the technical feasibility of RALEPLND and to present our surgical technique.

DESIGN, SETTING, AND PARTICIPANTS

From April 2006 to March 2008, we performed RALEPLND in 99 patients prior to robotic-assisted laparoscopic radical prostatectomy. Indications for RALEPLND were a prostate-specific antigen (PSA) > or = 10 ng/ml or a preoperative Gleason score > or = 7. The data were evaluated retrospectively.

SURGICAL PROCEDURE

The transperitoneal approach was used in all cases. In order to gain optimal access to the common iliac bifurcation, the five trocars were placed in a more cephalad position than in patients undergoing radical prostatectomy without RALEPLND. After identification of important landmarks, the lymphatics covering the external iliac vein, the obturator lymphatic packet, and the lymphatics overlying the internal iliac artery were removed on both sides.

MEASUREMENTS

The total lymph node yield, the frequency of lymph node metastases, and the complication rate.

RESULTS AND LIMITATIONS

The median patient age was 64 yr (range: 45-78). The median preoperative PSA level was 7.7 ng/ml (range: 1.5-84.6). The median number of lymph nodes harvested was 19 (range: 8-53). In 16 patients (16%), we found lymph node metastasis. Complications occurred in seven patients (7%).

CONCLUSIONS

RALEPLND is feasible, and its lymph node yield is well in the range of open series. The robotic-assisted laparoscopic approach in itself does not seem to limit a surgeon's ability to perform a complete extended pelvic lymph node dissection.