Can leakage at the vesico-urethral anastomosis be predicted after radical retropubic prostatectomy?

Omitting routine cystography after RARP: Analysis of complications and readmission rates in suprapubic and transurethral drained patients

OBJECTIVES

Robot-assisted radical prostatectomy (RARP) has become the therapy of choice for local treatment of prostate cancer. Postoperatively, urologists perform cystography before removing urinary catheters due to concerns about the integrity of the vesicourethral anastomosis. This study aims to evaluate the safety of waiving cystography before early catheter removal after RARP.

METHODS

A total of 514 patients from two tertiary referral centers who underwent RARP were retrospectively included. Patients received postoperative urinary drainage by transurethral (TUC) or suprapubic catheter (SPC). During the first year, both centers performed routine cystography before removing TUC or SPC on postoperative day 5. In the following year, management changed and catheters were removed without cystography unless indicated by the surgeon. Demographic and perioperative data were analyzed. Postoperative complications and readmission rates were compared between standard cystography (StCG), no cystography (NCG), and selective cystography (SCG).

RESULTS

Groups were comparable regarding demographic and oncological parameters. Analysis showed no significant difference regarding major complications and readmission rates between standard and no cystography (p = 0.155 and 0.998 respectively). Omitting routine cystography did not lead to inferior postoperative courses regardless of both urinary drainage used and tumor stage. Subgroup analysis showed an increase of major complications in SCG patients when compared with NCG (p = 0.003) while readmissions remained comparable (p = 0.554).

CONCLUSION

Waiving routine cystography before early catheter removal after RARP appears to be safe and feasible regardless of urinary drainage. However, the selective cystogram at the surgeon's request still plays a role in monitoring patients with an elevated risk profile.

Impact of the severity of urethrovesical anastomotic leakage on urinary continence following robot-assisted laparoscopic prostatectomy

We assessed whether the severity of anastomotic urinary leakage detected during routine cystourethrography after robot-assisted laparoscopic prostatectomy (RALP) affects urinary continence recovery. Around 302 patients who underwent RALP between August 2013 and May 2019 were included retrospectively. According to routine cystourethrographic findings obtained on the sixth or eighth postoperative day, which indicated leakage severity, patients were divided into three groups: no-leakage, grade 1 (linear shaped leakage, but not spreading), and grade 2 (spreading strip-shaped leakage). The preoperative factors and intraoperative factors were compared between no-leakage and leakage group (grade 1 and grade 2). Continence recovery was compared between the three groups. Continence recovery was defined as no pad used or one security pad used in a day. Cystourethrography revealed anastomotic urinary leakage in 44 patients (14.5%), of which 20 patients (6.6%) had grade 1 leakage and 24 patients (7.9%) had grade 2 leakage. On multivariate logistic regression analysis, the only significant predictor for urethrovesical anastomotic urinary leakage on cystourethrography following RALP was intraoperative anastomotic leakage (OR 5.306; 95% CI 1.530-18.398, p = 0.009). Continence recovery rates for no-leakage, grade 1 leakage, and grade 2 leakage groups were 11%, 20%, and 25% after 1 month (P = 0.131); 25%, 25%, and 45.8% after 3 months (P = 0.474); 44.6%, 55%, and 60.8% after 6 months (P = 0.184); and 63.1%, 87.5%, and 78.2% after 12 months (P = 0.095), respectively. In conclusion, urinary leakage in urethrovesical anastomosis, even at its severity, had no negative effects on continence recovery after RALP.

Devastated Bladder Outlet in Pelvic Cancer Survivors: Issues on Surgical Reconstruction and Quality of Life

Bladder outlet obstruction following treatment of pelvic cancer, predominantly prostate cancer, occurs in 1-8% of patients. The high incidence of prostate cancer combined with the long-life expectancy after treatment has increased concerns with cancer survivorship care. However, despite increased oncological cure rates, these adverse events do occur, compromising patients' quality of life. Non-traumatic obstruction of the posterior urethra and bladder neck include membranous and prostatic urethral stenosis and bladder neck stenosis (also known as contracture). The devastated bladder outlet can result from benign conditions, such as neurogenic dysfunction, trauma, iatrogenic causes, or more frequently from complications of oncologic treatment, such as prostate, bladder and rectum. Most posterior urethral stenoses may respond to endoluminal treatments such as dilatation, direct vision internal urethrotomy, and occasionally urethral stents. Although surgical reconstruction offers the best chance of durable success, these reconstructive options are fraught with severe complications and, therefore, are far from being ideal. In patients with prior RT, failed reconstruction, densely fibrotic and/or necrotic and calcified posterior urethra, refractory incontinence or severe comorbidities, reconstruction may not be either feasible or recommended. In these cases, urinary diversion with or without cystectomy is usually required. This review aims to discuss the diagnostic evaluation and treatment options for patients with bladder outlet obstruction with a special emphasis on patients unsuitable for reconstruction of the posterior urethra and requiring urinary diversion.

Clinical significance and risk factors of urethrovesical anastomotic urinary leakage following robot-assisted radical prostatectomy: a multi-institutional study

Background

There has been a limited number of reports on the significance and risk factors of urethrovesical anastomotic urinary leakage (AUL) following robot-assisted radical prostatectomy (RARP). We aimed to analyze the clinical significance of AUL and evaluated its risk factors.

Methods

We conducted a multi-institutional study to review patients with prostate cancer undergoing RARP in three centers (The University of Tokyo Hospital, Mitsui Memorial Hospital, and Chiba Tokushukai Hospital). “Positive AUL” was defined as urinary extravasation at the anastomosis detected by post-operative cystogram and was further categorized into minor or major AUL. Univariate and multivariate analyses were performed to identify predictors of AUL. Postoperative continence rates and time to achieve continence were also analyzed.

Results

A total of 942 patients underwent RARP for prostate cancer in 3 centers. Of these patients, a cystogram after the RARP procedure was not performed in 26 patients leaving 916 patients for the final analysis. AUL was observed in 56 patients (6.1%); 34 patients (3.7%) with minor AUL and 22 patients (2.4%) with major AUL. Patients with major AUL exhibited a significantly longer time to achieve continence than those without major AUL. Multivariate analysis demonstrated that longer console time (≥ 184 min) was significantly associated with overall AUL, and higher body mass index (≥ 25 g/kg²) was a significant predictor of both major and overall AUL.

Conclusions

The presence of major AUL was associated with the achievement of urinary continence, suggesting clinical relevance of its diagnosis by postoperative cystogram. A selective cystogram has been proposed for high-risk cases. Furthermore, identification of the risk factors of AUL will lead to optimal application.

Association between cystographic anastomotic urinary leakage following retropubic radical prostatectomy and early urinary incontinence

Background

This study was performed to investigate the association between cystographic anastomotic urinary leakage (UL) after retropubic radical prostatectomy (RRP) and early urinary incontinence (UI).

Methods

The medical records of 53 patients who had undergone cystography after RRP at our institution between January 2015 and December 2018 were retrospectively analyzed. Cystography was performed 7 to 10 days after surgery. The duration of catheterization depended on the degree of UL, which was classified as mild, moderate, or severe. The study subjects were divided into the non-UL group and the UL group. Continence was defined as the use of no pads. The prostate was dissected in an antegrade fashion, and urethrovesical anastomosis was performed with a continuous suture.

Results

Incontinence rates at 1 and 3 months postoperatively were significantly higher in the UL group than the non-UL group (83.3% vs. 52.2%, p=0.014 and 76.7% vs. 47.8%, p=0.030, respectively); however, those at 6 and 12 months were not significantly different (23.3% vs. 17.4%, p=0.597 and 4.3% vs. 10.0%, p=0.440, respectively). The severity of UL was not found to influence the duration of incontinence. The presence of cystographic anastomotic UL was found to be predictive of UI during the first 3 postoperative months (odds ratio, 3.3; p=0.045).

Conclusion

The presence of anastomotic UL on cystography was associated with higher rates of UI in the early postoperative periods. However, incontinence rates in patients with or without anastomotic UL immediately after RRP equalized at 6 months and the severity of UL did not affect the duration of postoperative UI.

Urine colour as an indicator for anastomotic leakage after robot-assisted radical prostatectomy

Objectives: To determine whether macroscopic haematuria predicts urethrovesical anastomotic leakage after robot-assisted laparoscopic radical prostatectomy (RALP) as well as a cystogram.Patients and methods: Participants were recruited before cystogram and catheter removal 5-14 days after RALP surgery. Urine colour in the collection bag was classified according to a three-step scale (clear, light red and dark red) and leakages in cystogram were graded with a four-step scale (Grade 0-3). Diagnostic accuracy parameters were calculated for urine colour. A multivariate logistic regression model was used to evaluate other leakage risk factors.Results: Of 214 patients, 201 (94%) had clear, six (3%) had light red and seven (3%) had dark red coloured urine. In the cystogram, 20 (9%) patients had leakage; 14 had Grade 1, five Grade 2 and one Grade 3 leakage. Overall, specificity and sensitivity of urine colour in predicting anastomotic leakage were 0.97 (95% CI = 0.95-100) and 0.38 (95% CI = 0.17-0.59), respectively. Negative and positive predictive values were 94% and 62%, respectively. Other significant risk factors for anastomotic leakage were previous transurethral resection or radiation therapy to the prostate, non-waterproof anastomosis at surgery, postoperative pelvic haematoma, long catheterization and surgeon's inexperience. In patients with no other risk factors, test sensitivity improved to 0.80 (95% CI = 0.45-1.15) and negative and positive predictive values to 99% and 44%, respectively.Conclusion: This prospective single-arm trial indicates that in patients with clear urine and no other risk factors for anastomotic leakage, a cystogram examination before urethral catheter removal can be safely omitted.

Ideal timing of indwelling catheter removal after robot-assisted radical prostatectomy with a running barbed suture technique: a prospective analysis of 425 consecutive patients

Objective

To compare prospectively early outcome and complications of catheter removal after robot-assisted radical prostatectomy (RARP) on the 4th or 7th day with a standardized running barbed suture technique.

Introduction

The time point of removing the indwelling catheter after RARP mainly depends on institute’s/surgeon’s preferences. Removal should be late enough to avoid urinary leakage and complications such as acute urinary retention (AUR) but early enough to avoid unnecessary catheter indwelling.

Materials and methods

A consecutive single-institutional series of patients underwent RARP between July 2015 and August 2017 and were entered in a prospectively maintained data base. Between July 2015 and December 2016 a cystogram was performed on 7th postoperative day (group A), thereafter the cystogram was performed on 4th postoperative day (group B). Incidence of acute urinary retention (AUR), urinary tract infections (UTI) and adverse events between the two cohorts was compared.

Results

425 patients were analyzed (group A: n = 231; group B: n = 194). Both cohorts were comparable regarding demographic and oncological parameters. Watertight anastomosis was present in 84.8% in group A and in 82.5% in group B, respectively. AUR within 4 weeks after RARP occurred in 2.2% (n = 3) in A and 9.4% (n = 15) in B (p = 0.001). AUR within 72 h after catheter removal occurred in group A: 1% (n = 2) and in group B: 6.3% (n = 10) (p = 0.005). Symptomatic urinary tract infections occurred in 8.2% (n = 16) in group A and in 6.9% (n = 11) in group B. There were no differences in the rate of secondary anastomosis dehiscence. Age, BMI, prostate size, surgeon, or intraoperative bladder neck reconstruction were not correlated to the occurrence of AUR or UTI.

Conclusions

The removal of indwelling catheter on day 4 after a RARP with a running barbed suture shows similar anastomosis leakage rates as on the 7th postoperative day. However, AUR rates are higher for early removal. Patients scheduled for early removal should be carefully informed about the increased risk for AUR. Catheter indwelling time does not represent a risk factor for UTI.

Voiding cystourethrography after prostatectomy: spectrum of appearances

PURPOSE

This article reviews current prostatectomy techniques and then techniques for fluoroscopic voiding cystourethrography (VCUG) evaluation of the prostate and bladder after prostatectomy. Both normal post-prostatectomy appearances and complications will be reviewed.

CONCLUSION

VCUG is a useful evaluation for both common and uncommon post-prostatectomy complications and appropriate interpretation of the VCUG complications is important to aid the urologist's clinical decision making.

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.

Prognostic Factors for Anastomotic Urinary Leakage Following Retropubic Radical Prostatectomy and Correlation With Voiding Outcomes

This study aimed to determine the occurrence and grade of cystographically detected urinary leakage (UL) in a contemporary series of open retropubic radical prostatectomy (RP), whether patients' clinical variables predict occurrence of UL, and whether occurrence of UL correlates with patients' voiding outcomes in terms of urinary continence and anastomotic stricture (AS). Enrolled patients underwent cystography 7 days after retropubic RP; in case of UL, the catheter was left in situ and cystography repeated at 7 days intervals until demonstrating absence of UL. Leakage was classified as grade I = extraperitoneal leak <6 cm, grade II = extraperitoneal leak >6 cm, grade III = leak freely extending in the small pelvis. Voiding was evaluated at 3, 6, and 12 months after RP using the 24-hour pad test and uroflowmetry; in cases of maximum flow rate <10 mL/s, urethrocystoscopy was carried out to determine presence and location of an AS. The first postoperative cystogram showed UL in 52.6% of patients (grade I in 48.1%, grade II in 21.5%, and grade III in 30.4% of the cases). Multivariate analysis demonstrated that patients with UL had significantly greater prostate volume (64.5 vs 34.8 cc, P < 0.001), loss of serum hemoglobin (4.77 vs 4.19 g/dL, P < 0.001), lower postoperative serum total proteins (4.85 vs 5.4 g/dL, P < 0.001), and higher rate of AS (20.6% vs. 2.8%, p < 0.001) than those without UL. Continence rate at 3, 6, and 12 months postoperatively was 34.2%, 76%, and 90%, respectively, in patients with UL compared with 77.5%, 80.3%, and 93% in patients without UL; such difference was statistically significant (P < 0.001) only at 3 months follow-up. ROC curve analysis showed that prostate volume and postoperative serum total proteins had the best AUC (0.821 and 0.822, respectively) and when combined, their positive and negative predictive values for UL were 90% and 93%, respectively. In conclusion, half of the patients undergoing open retropubic RP may present, 7 days postoperatively, some degree of cystographically detected UL; prostate volume, loss of serum hemoglobin, and postoperative serum total proteins could be used to predict it. UL delayed return to urinary continence without affecting long-term results, but led to a significantly higher rate of AS.

Anastomotic complications after robot-assisted laparoscopic and open radical prostatectomy

Objective Anastomotic complications are well known after radical prostatectomy (RP). The vesicourethral anastomotic technique is handled differently between open and robotic RP. The aim of the study was to investigate whether the frequency of anastomotic leakages and strictures differed between patients undergoing retropubic radical prostatectomy (RRP) and robot-assisted radical prostatectomy (RARP) and to identify risk factors associated with these complications. Materials and methods The study included 735 consecutive patients who underwent RRP (n = 499) or RARP (236) at the Department of Urology, Rigshospitalet, Denmark, in a complete 3 year period from 2010 to 2012. Univariate and multivariate logistic regression analysis was used to analyse associations between surgical procedure (RRP vs RARP) and anastomotic complications. Analyses included age, smoking status, diabetes, hypertension, surgeon, prostate volume and anastomotic leakage as variables. Owing to a low number of events, multivariable analyses only included smoking status, diabetes and prostate volume for anastomotic leakage, and age, smoking status, prostate volume and anastomotic leakage for anastomotic strictures. Results The frequency of anastomotic leakage was 2.9%. Anastomotic stricture was seen in 4.9% of patients during follow-up. No differences were found in the frequency of anastomotic leakage (p = 0.35) or strictures (p = 0.35) between RRP and RARP. Univariate analysis demonstrated an association between surgeon and the risk of anastomotic strictures in RRP patients (p = 0.02). No other independent risk factors were identified. Conclusion Overall, the anastomotic complication rate in this cohort is similar to other published reports. No obvious risk factors for anastomotic complications could be identified, which in part was due to the low number of events.

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.

Significance of the intraoperative methylene blue test for postoperative evaluation of the vesicourethral anastomosis

We prospectively investigated whether routine evaluation of the vesicourethral anastomosis (VUA) after radical prostatectomy can be waived. Primary integrity of the VUA was analysed by an intraoperative methylene-blue test (IMBT) and postoperatively by conventional cystography. Data on the IMBT, contrast extravasation and prostate volume as well as pad usage were collected prospectively. Significantly more patients with a primary watertight anastomosis demonstrated by the MBT had no leakage in the postoperative cystography (P < 0.001). In a multivariate logistic regression with adjustment for prostate size and surgeon, the positive correlation between IMBT and postoperative cystography remained statistically significant (P = 0.001). The IMBT is easy to perform, inexpensive, and timesaving. With it postoperative evaluation of VUA for integrity can be waived in a significant number of patients. Following our algorithm, the Foley can be removed without further testing of the VUA, whenever the IMBT detected no leakage.

All you need to know about urethrovesical anastomotic urinary leakage following radical prostatectomy

PURPOSE

Radical prostatectomy is a challenging operation demanding a high level of surgical expertise and experience. Urinary leakage at the urethrovesical anastomosis is one of the most common short-term complications of radical prostatectomy, reaching an incidence of 0.3% to 15.4%. In this review we investigate and discuss all matters directly related to urethrovesical anastomotic leak, specifically how to diagnose it properly, how to determine when it is clinically significant and when intervention is required, how to prevent or predict it and, finally, the possible long-term sequelae.

MATERIALS AND METHODS

We conducted a systematic analysis of the literature searching for English and nonEnglish language publications from a preidentified time frame (1985 to 2011) using primary search databases (PubMed®, Web of Science®). Manual selection was performed by 2 authors and the third reviewed the final common selection. We also created an algorithm for the diagnosis and management of urethrovesical anastomotic leak.

RESULTS

A total of 72 studies were finally selected, including 48 (67%) observational case series, 16 (22.2%) prospective trials, 1 letter to the editor, 1 review and 1 systematic review which was focused only on laparoscopic radical prostatectomy. We also found 2 experimental studies performed in animal models and 3 case reports. Of these studies 7 reported results from fewer than 20 patients. No consensus was recorded on a strict definition of urethrovesical anastomotic leak. The factors determining possible definitions included postoperative day of urethrovesical anastomotic leak, amount of extravasation on cystography and the need for intervention. Urethrovesical anastomotic leak should be classified according to the Clavien classification system, depending on severity and the need for intervention. To our knowledge the role of the open, laparoscopic or robotic approach in the incidence of urethrovesical anastomotic leak has not been systematically investigated. Risk factors for urethrovesical anastomotic leak include obesity, prostate size, previous prostatic surgery, type of anastomosis technique, suture number and type, eversion of the mucosa, a difficult anastomosis or an anastomosis under tension, reconstruction of the musculofascial plate, blood loss, intraoperative flush test result and postoperative urinary tract infection. Diagnosis can be determined primarily by establishing the nature of the drain output. Retrograde cystography, computerized tomography cystography, transrectal ultrasound, contrast enhanced ultrasound and excretory urography are the indicated imaging modalities, and are not always necessary. Finally, the development of anastomotic stricture and incontinence due to urethrovesical anastomotic leak are additional complications.

CONCLUSIONS

We gathered all relevant critical information concerning urethrovesical anastomotic leak to encourage standardization in the diagnosis and management of this common complication. Systematic meta-analysis of each debatable issue is required to provide definite answers.

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.

What is the long-term relevance of clinically detected postoperative anastomotic urine leakage after robotic-assisted laparoscopic prostatectomy?

OBJECTIVE

• To determine whether patients with postoperative clinically detected anastomotic urine leaks are at increased risk for poorer erectile function, urinary incontinence and bladder neck contracture (BNC) after robotic-assisted laparoscopic radical prostatectomy.

PATIENTS AND METHODS

• A retrospective review of all patients undergoing RALRP from October 2005 until December 2009 by a single surgeon (R.B.N.) was conducted. Clinically detected anastomotic urine leak was defined as drain output consistent with urine at more than 24 h postoperatively. The presence of BNC was identified on cystoscopy. • Erectile function was measured with the Sexual Healthy Inventory for Men (SHIM) questionnaire. Incontinence was measured by patient-reported daily pad use. • Univariate and multivariate analyses were performed. Outcomes were assessed at the most recent follow-up.

RESULTS

• Among 213 patients eligible for inclusion, 27 experienced an anastomotic urine leak (12.7%). • At a mean long-term follow-up of 24.2 months, there was no difference in SHIM scores (7.0 vs 13.1; P= 0.101), continence rates (87.5% vs 85.2%; P= 0.999) or risk of BNC (7.4% vs 3.2%; P= 0.268) between patients with and without postoperative anastomotic urine leaks, respectively. • The results did not change after controlling for covariates in a multivariate analysis.

CONCLUSION

• The present study suggests that patients with clinically detected postoperative anastomotic urine leaks do not necessarily have worse long-term outcomes of erectile function, continence and risk of BNC.

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.

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.

Para-anastomotic haematoma volume predicts the presence of anastomotic extravasation after radical retropubic prostatectomy

OBJECTIVE

To determine the mechanism for delayed healing of the urinary anastomosis after radical retropubic prostatectomy (RRP).

PATIENTS AND METHODS

The volumes of the para-anastomotic haematoma (PHV) and anastomotic extravasation were measured by ultrasonography in 95 men after RRP. The performance characteristics of PHV for predicting urinary extravasation were ascertained and compared with that of postoperative blood loss, measured as the difference between the haematocrit immediately after RRP and that at discharge.

RESULTS

The sensitivity and specificity of PHV for predicting urinary extravasation at a threshold of 37 mL was 100% and 96%, respectively. PHV was superior to postoperative blood loss in predicting anastomotic extravasation, as shown by an area under the receiver operating curve of 0.99 vs 0.91, respectively.

CONCLUSIONS

Our findings provide compelling evidence that delayed healing of the anastomosis after RRP is due to distraction forces secondary to a pelvic haematoma. The accuracy of PHV as a predictor of anastomotic extravasation suggests that this measurement might replace cystography for assessing anastomotic integrity after RRP.

MDCT cystography for detection of vesicourethral leak after prostatectomy

OBJECTIVE

The purpose of this study was to compare detection rates with MDCT cystography and conventional cystography in the evaluation of vesicourethral leakage after radical prostatectomy.

SUBJECTS AND METHODS

From September 2004 to May 2005, 51 sets of MDCT and conventional cystographic images of 46 patients who underwent retropubic radical prostatectomy were included in the study. The mean age of the patients was 65.3 +/- 2.1 years. The rates of detection of vesicourethral leakage at the anastomotic site were compared on conventional and MDCT cystographic images. In cases in which leakage was detected at MDCT cystography, the amount of contrast medium leaked was calculated with 3D volumetry. Correlation between leakage volume and hospital stay or indwelling time of a Foley catheter also was evaluated.

RESULTS

The rate of detection of vesicourethral leakage determined with MDCT cystography was 80.4% (37 of 46 cases), and that determined with conventional cystography was 54.3% (25 of 46 cases). The mean volume of leakage detected only with MDCT cystography was 2.2 +/- 2.1 mL, and that with both conventional and MDCT cystography was 19.3 +/- 14.1 mL. There was a moderate positive correlation between Foley catheter indwelling time and leakage volume.

CONCLUSION

MDCT cystography can be used for evaluation of leaks at the anastomotic site after prostatectomy and may have a better leak detection rate than conventional cystography.

The impact of urinary drainage on the development of anastomotic stricture after radical retropubic prostatectomy

OBJECTIVES

Anastomotic stricture (AS) is a well-described complication of radical retropubic prostatectomy (RRP) despite all the refinements in surgical technique. We aimed to define and discuss the role of postoperative urinary drainage on AS development.

PATIENTS AND METHODS

A total of 136 patients with localized prostate carcinoma underwent RRP. In all patients, urethral catheter was removed 3 weeks after RRP without a cystogram. We documented duration of drainage (<3 days, n=86; 3-5 days, n=36; and >5 days, n=14), volume of drainage (<300 ml, n=78; 300-500 ml, n=27; and >500 ml, n=31), and mean volume of drainage per day (<100 ml, n=85 and >100 ml, n=51), continence status, and clinical and histopathological characteristics of patients as risk factors related with AS.

RESULTS

AS was diagnosed in 28.6% of patients. The rate was found to be 35.9%, 41%, and 23.1%, consistent with duration, and 38.4%, 15.4%, and 46.2% according to volume of drainage, respectively (P=0.0001). AS occurred in 43.6% and 56.4% of patients concerning mean volume of drainage per day, respectively (P=0.007). Analysis showed that AS was significantly associated with duration (>3 days), total volume (>500 ml), and the mean volume (>100 ml) of urinary drainage among the variables. The rates of urinary incontinence were 30.7% in patients with AS and 6.2% in patients without AS.

CONCLUSIONS

Time and the amount of urinary drainage were significantly associated with stricture formation following RRP that might be caused by partial disruption of the anastomosis.

Cold-knife incision of anastomotic strictures after radical retropubic prostatectomy with bladder neck preservation: efficacy and impact on urinary continence status

OBJECTIVES

To evaluate the incidence and characteristics of anastomotic strictures (AS) after radical retropubic prostatectomy (RRP) with bladder-neck preservation (BNP), the efficacy of management with cold-knife incision (CKI), and its impact on urinary continence.

METHODS

Seven hundred five consecutive patients who underwent RRP with BNP were prospectively followed with uroflowmetry at postoperative months 1, 3, 6, 9, 12, and investigated for urinary incontinence with the 1-h pad test at AS diagnosis obtained with urethroscopy. If the instrument could not dilate the stricture, CKI was subsequently performed. Follow-up after treatment was performed with uroflowmetry and 1-h pad test at months 1, 3, 6, 9, 12. Recurrent AS was always treated with repeated CKI.

RESULTS

Six hundred forty-eight patients were assessable. After a median time of 3.8 mo from RRP, 46 (7.1%) patients developed AS. Urinary incontinence was present in 21 (46%) men at AS diagnosis. Three (7%) patients were successfully managed by urethroscopic dilation only, whereas 43 (93%) required CKI. Eleven (26%) of the latter had recurrent AS. After a median follow-up of 48 mo from the last AS treatment, all patients are stricture-free, de novo urinary incontinence was never documented, and of the 21 originally incontinent men, 11 became continent, 8 improved and 2 remained unchanged.

CONCLUSIONS

In our experience, BNP does not decrease the incidence of AS after RRP; however, AS can be effectively managed with repeated CKI with a final 100% success rate. CKI has a possible positive impact on urinary continence in 90% of patients, without causing de novo incontinence.

Outcomes with an alternative anastomotic technique after radical retropubic prostatectomy: 10-year experience

OBJECTIVES

To review 10-year outcomes of an alternative vesicourethral anastomotic technique performed after radical retropubic prostatectomy (RRP).

METHODS

With institutional review board approval, 307 consecutive RRPs performed by one surgeon (mean patient age, 63.5 years; range, 35 to 77 years) from November 1994 to December 2004 with an alternative anastomosis were reviewed. Cox proportional hazard models with forward selection were used to investigate associations with outcomes and operative parameters.

RESULTS

Mean estimated blood loss (EBL) was 550 mL. Sixty-three patients (20.5%) required blood transfusion. Mean anastomotic time ranged from 8 to 22 minutes (median, 11 minutes). Nine patients (2.9%) required surgical drain for more than 2 days. A total of 246 patients were available for at least 1-year continence follow-up (mean, 51 months). Of these, 160 patients (65.0%) never leaked or required a pad at point of last follow-up; 25 patients (10.2%) required 1 non-insurance pad or more per day. Only 3 patients (1.2%) have had incontinence interventions (one artificial sphincter and two collagen injections). Operative parameters statistically associated with wearing 1 pad per day or more were EBL (P = 0.035) and time to continence (P <0.001). Forty-three patients (17.5%) required stricture dilation, with a mean time to intervention of 6 months (range, 1 to 33 months). No patient required incision of bladder neck contracture. The only statistically associated factors with stricture formation were increased age and increased EBL.

CONCLUSIONS

The alternative anastomotic technique is efficient and provides proper urethral alignment with a minimal rate of prolonged urinary extravasation. Long-term urinary continence is excellent, and stricture rates are acceptable compared with other anastomotic techniques.

Postoperative Blood Loss Predicts the Development of Urinary Extravasation on Cystogram Following Radical Retropubic Prostatectomy

PURPOSE

We determined if the degree of postoperative bleeding predicts the extent of urinary extravasation on initial postoperative cystogram.

MATERIALS AND METHODS

Between October 2000 to June 2004, 879 men underwent radical retropubic prostatectomy performed by a single surgeon. Of these men 97% underwent the initial postoperative cystogram 3 to 8 days following radical prostatectomy. Postoperative bleeding was expressed as the absolute change in hematocrit between hematocrit values measured immediately upon arrival into the recovery room and hospital discharge. Three hematocrit points were added to the change in postoperative hematocrit for every unit of blood transfused postoperatively. The relationship between the change in postoperative hematocrit and the extent of extravasation was examined.

RESULTS

None, mild, moderate and marked extravasation was observed on the initial cystogram in 82.7%, 7.9%, 8.8% and 0.6% of cases, respectively. A significant relationship was observed between changes in postoperative hematocrit and the extent of extravasation on initial cystography (p <0.001). Postoperative changes in absolute hematocrit points of less than 2, 2 to 6 and greater than 6 identified clinically meaningful risk groups for urinary extravasation. The degree of extravasation was not significantly related to risk of anastomotic stricture or urinary incontinence.

CONCLUSIONS

The extent of postoperative bleeding predicts the extent of urinary extravasation on initial cystography. It may be a useful measurement for identifying men who can safely undergo early catheter removal without cystography.

Identification and validation of risk factors for vesicourethral leaks following radical retropubic prostatectomy

AIMS

To identify risk factors for anastomotic leaks at cystography following radical retropubic prostatectomy (RRP).

METHODS

In phase 1 the records of a 107 RRP patients were reviewed. Data collected included comorbidity, pathological factors and intra- and postoperative complications. From these, risk factors were identified that were associated with a leak at cystography. In phase 2 (n = 46) we prospectively tested if the risk factors identified could predict an anastomotic leak.

RESULTS

In phase 1 the only identifiable risk factors were that of a difficult anastamosis, an unsatisfactory intraoperative test flush and the presence of a urinary tract infection. One or more of these events were found in 17/25 (68%) of the patients who leaked (P < 0.0001). Of the eight leaks missed, five were classed as minimal and did not require repeat cystography. Within the prospective phase 2 cohort one or more risk factors were present in 7/10 (70%) of the patients who leaked. In contrast, the identified risk factors were present in only 5/36 (13.8%) of the patients who did not leak (P < 0.001). The specificity of the test was 86.1% with a sensitivity of 70%. This gave a positive predictive value of 58.3% and a negative predictive value of 91.1%. Three leaks (two minimal and one moderate) would have been missed but 31 (67.3%) patients would have avoided an unnecessary radiological study.

CONCLUSION

Using a retrospective and prospective cohort of patients we have shown that a cystogram following RRP can be safely avoided in the absence of the identified risk factors.