Urethral catheter removal 3 days after radical retropubic prostatectomy is feasible and desirable

The purpose of this work was to assess the feasibility of urethral catheter removal 3 days after radical retropubic prostatectomy (RRP). Twenty-two patients who underwent RRP with a watertight eight-suture vesicourethral anastomosis had their urethral catheter removed usually on postoperative day (POD) 3. The average day of urethral catheter removal was POD 3.2. At 3 months, 56% of patients required no or one protective pad to stay dry and 68.4% of patients 'never leaked' or 'leaked occasionally'. Following RRP, the urethral catheter can be removed as early as POD 3 if the intraoperative anastomosis is watertight without compromising urinary continence.     

Initial results using a running vesicourethral anastomosis following open radical retropubic prostatectomy

PURPOSE: We assessed the results of early catheter removal following radical prostatectomy using a continuous suture vesicourethral anastomosis. MATERIALS AND METHODS: From March 2001 through December 2003, 76 patients underwent open radical prostatectomy, as performed by a single surgeon. A continuous 3-zero polyglactin suture was used for the vesicourethral anastomosis in 72 patients. Drain fluid creatinine on postoperative day 1 was used to assess anastomotic leakage. A cystogram was done before catheter removal in the initial 25 patients. Subsequently a cystogram was performed only if there was suspicion of urine leakage. RESULTS: Early catheter removal was possible in 63 of 72 patients (88%). Catheter removal occurred a mean of 3.4 days (range 1 to 6) postoperatively in this group. Ten of the 14 men who required catheter reinsertion for urinary retention had the catheter removed before postoperative day 4. In the remaining 9 patients early catheter removal was not attempted. Catheter removal occurred a mean of 10.1 days (range 7 to 14) postoperatively in this group. Overall the urethral catheter was successfully removed on or before postoperative day 6 (range 1 to 6) in 78% of patients. There was no incidence of urinoma, pelvic abscess or bladder neck contracture at a mean followup of 31 months (range 2 to 46). CONCLUSIONS: A running vesicourethral anastomosis following open radical retropubic prostatectomy allows reliable early catheter removal by postoperative days 4 to 6 in most patients with no increase in morbidity.     

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

Study Type – Diagnostic (exploratory cohort)
Level of Evidence 2b 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.     

Radical retropubic prostatectomy with running vesicourethral anastomosis and early catheter removal: Our experience

Objectives:   To assess the outcomes of patients undergoing radical retropubic prostatectomy (RRP) with a running vesicourethral anastomosis and catheter removal on postoperative day 3 or 5.
Methods:   From February 2006 through December 2007, 55 patients underwent RRP at our institution. All procedures were performed by a single surgeon using a running suture for the vesicourethral anastomosis. A cystogram was carried out before catheter removal in all patients. The initial 23 of 55 patients (Group 1; n  = 23) had the cystogram on postoperative day 5, the other 32 patients (Group 2; n  = 32) had the cystogram on postoperative day 3. Removal of the catheter was only carried out if there was no anastomotic extravasation.
Results:   The success rate of catheter removal in group 1 and 2 was 100% and 96.9%, respectively. Overall continence rates were 83.3%, 87% and 90.7% at 24, 48 and 72 h after removal of the catheter, respectively. There was no significant difference in terms of continence rate between groups 1 and 2. None of the patients had acute urinary retention and/or anastomotic stricture after catheter removal.
Conclusions:   These findings suggest that an advanced running vesicourethral anastomosis during RRP is technically feasible, allowing safe early catheter removal in most patients.     

不同缝合方式对前列腺癌根治术后膀胱尿道吻合口狭窄发生率的影响

目的：评估在前列腺癌根治术中,以间断或连续缝合等2种不同的方法处理尿道膀胱吻合口后,远期尿道狭窄发生率的情况。方法：在2006～2010年间,国内3个临床中心共进行了549例开放或腹腔镜前列腺癌根治术。其中388例以问断缝合的方法处理膀胱尿道吻合口,161例以连续缝合的方法处理尿道膀胱吻合口,并评估术后吻合口狭窄发生率的情况。结果：45例（8．2％）患者m现术后尿道吻合口狭窄,发生的平均时间为术后4．1个月。在以间断缝合法处理吻合口的388例开放前列腺癌根治术患者中,10．1％（39例）的患者出现尿道狭窄;而在以连续吻合法处理的161例患者中,尿道狭窄发生率为3．7％（6例）,其中75例开放前列腺癌根治术后发生率为2．7％（2例）,86例腹腔镜前列腺癌根治术患者术后发生率为4．7％（4例）。结论：无论是以开放的或腹腔镜途径,用连续缝合法处理前列腺癌根治术中的尿道膀胱吻合口,术后吻合口狭窄的发生率低于间断缝合法。     

Vesicourethral anastomotic suture placement during radical prostatectomy using Maniceps

INTRODUCTION: A new method of using a semiautomatic device (Maniceps) for precise vesicourethral anastomosis during radical retropubic prostatectomy is described. METHODS: A total of 15 patients underwent radical retropubic prostatectomy with this technique. The follow-up period ranged from 6 to 16 months. The retrograde urethrocystography was performed at 2 weeks. Patients were evaluated specifically for anastomotic time, anastomotic obstruction and urinary continence. RESULTS: The average anastomotic time was 8.1 (range 5-12) min. The catheter of all patients could be removed at 2 weeks. Anastomotic obstruction occurred in 1 patient (6.7%), and 14 patients (93.3%) were completely continent of urine. CONCLUSION: Maniceps is a useful procedure to carry out vesicourethral anastomosis safely, easily and surely, and it has provided good surgical results in our experience.     

Introducing a novel technique to remove accidentally stitched or entrapped urethral catheters after radical prostatectomy

INTRODUCTION: A crucial step during radical prostatectomy is anastomosing the bladder neck to the urethral stump after specimen removal. For this purpose, a Foley catheter is inserted transurethrally to achieve a patent and watertight anastomosis. The catheter should be removed 6-10 days after the procedure to avoid ascending infection and stricture formation. On occasion, catheter removal is not possible due to fixation by one of the anastomotic sutures. In this case, a longer catheterization period may increase the risk of infection and formation of an anastomotic stricture. MATERIALS AND METHODS: In the present report, we suggest a technique to overcome this problem by using an endoscopic laser dissection of the anastomotic suture. In 2 patients, a 4.8-Fr pediatric ureteroscope was passed through the urethra along the fixated catheter. After carefully inspecting the anastomosis, a laser fiber was brought in direct contact with the responsible suture. RESULTS AND CONCLUSIONS: By activating the laser, the suture was cut immediately, and the catheter could be removed. Both patients showed no signs of anastomotic leakage or stricture on cystography. Fixation of the catheter after radical prostatectomy is a rare, but bothersome complication, which can compromise the functional outcome of the procedure. Using a pediatric ureteroscope and a laser fiber is an elegant, minimally invasive method to solve this problem. It can be easily and safely performed under local anesthesia in an outpatient setting.     

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

OBJECTIVES: To determine if low-risk patients can be identified in whom cystography is unnecessary to assess the integrity of the vesico-urethral anastomosis after radical retropubic prostatectomy (RRP), and thus who can have early catheter removal. PATIENTS AND METHODS: In all, 275 RRPs by one surgeon were analysed retrospectively; the surgical technique, blood loss and comorbidity were recorded. Cystograms were taken 8 days after RRP to assess vesico-urethral integrity before catheter removal. RESULTS: Of the 275 patients, 75% and 89% had cystography before 8 and 10 days after RRP, respectively; 71% of patients had no leak on cystography and were catheter-free at 8 days. Eighty-four leaks were identified, of which 25 (9.6%) were moderate or large. Previous transurethral prostatectomy, ischaemic heart disease, blood loss, mucosal eversion and preservation of the prostatic urethra were significant risk factors for developing a leak and were used to create a nomogram to assess the relative risk of leakage. However, none of the variables assessed, either alone or combined, could be used to predict which leaks were clinically significant. CONCLUSIONS: Leakage cannot be reliably predicted at the vesico-urethral anastomosis. Cystograms are necessary to identify clinically significant leaks at 8 days and should be taken if early catheter removal is being considered.     

Early removal of the catheter after laparoscopic radical prostatectomy

PURPOSE: We prospectively tested the safety of routine removal of the catheter as early as 2 to 4 days after laparoscopic radical prostatectomy. MATERIALS AND METHODS: Between March 1998 and March 2001, 228 patients underwent laparoscopic radical prostatectomy for clinically organ confined prostate cancer. The last 113 consecutive patients were included in a prospective study according to gravitational cystography performed 2 to 4 days postoperatively. If no leak was seen the catheter was removed. If a leak was apparent the catheter was left indwelling for another 6 days and cystography was repeated. RESULTS: Cystography 2 to 4 days postoperatively showed an anastomosis without a leak in 96 (84.9%) patients who subsequently had the catheters removed. There were 28 patients who had the catheter removed on postoperative day 2, 28 day 3 and 40 day 4. In 17 (15.1%) patients an anastomotic leak was observed, and the catheter was not removed at that time. Of the 96 patients in whom the catheter was removed early 10 (10.4%) had urinary retention that necessitated re-catheterization. This procedure was performed without the need for cystoscopy. After the catheter was removed all patients were able to void 24 hours later. Median followup was 7 months (range 1 to 15) and showed continence rates greater than 93%. No anastomotic stricture, pelvic abscess or urinoma developed in any patient. CONCLUSIONS: Patients who undergo laparoscopic radical prostatectomy can have the catheter safely removed 2 to 4 days postoperatively without a higher risk of incontinence, stricture or leak related problems.     

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

Abstract 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.     

Early catheter removal and postoperative status of bladder outflow after retropubic radical prostatectomy

Cystography was performed on 35 patients 6 to 7 days after retropubic radical prostatectomy (RRP), to determine the feasibility of early removal of the urinary catheter. The urethral catheter was removed the same day if no extravasation was evident on cystography. Uroflowmetry was also performed both immediately after early catheter removal and at follow-up 4 to 20 months later. The urethral catheter could be removed on postoperative day 6 or 7 from all but one patient. Three patients developed acute urinary retention after catheter removal, requiring reinsertion of a Foly catheter. During a mean follow-up of 8.3 months (range 4 to 20 months), 25 patients (71.4%) reported excellent continence (requiring no pad) and seven patients (20%) good continence (requiring a single pad). Immediately after early catheter removal, 12 patients (34%) showed obstruction on a maximum flow nomogram. The number of patients with obstruction decreased to eight during follow-up, three of whom suffered anastomotic stricture and one anterior urethral stricture, all of which required urethrotomy. Our results show that early catheter removal can be accomplished safely, although some patients may have difficulty with urination or develop acute urinary retention immediately after catheter removal, probably due to anastomotic edema. On the other hand, if the patients develop difficulty in urination some time after the operation, the possibility of anastomotic or urethral stricture should be considered. Therefore we recommend uroflowmetry within one year after RRP to identify anastomotic or urethral stricture.     

Vesicourethral anastomotic strictures after radical retropubic prostatectomy: the experience of a single institution

OBJECTIVE: Stricture of the vesicourethral anastomosis remains a well-documented complication after radical retropubic prostatectomy. MATERIALS AND METHODS: We performed a retrospective study of 294 patients with prostate cancer who underwent radical retropubic prostatectomy. Possible correlations between anastomotic stricture formation, tumor stage, positive surgical margins, number of anastomotic sutures, bladder neck preservation, urine leakage, previous prostate surgery and/or intraoperative blood loss were examined. RESULTS: An anastomotic stricture was found in 18 cases (6%) requiring some kind of treatment. In 10 patients (56%), the bladder neck stricture occurred within 3 months after surgery, in 5 (28%) at 4-12 months after surgery and in 3 (16%) more than 12 months after surgery. Intraoperative blood loss (>1,000 ml) was found to be significantly correlated with urinary leakage (p < 0.001) and both correlated with anastomotic stricture formation (p < 0.005). CONCLUSION: Excessive intraoperative blood loss (>1,000 ml) and urine leakage was found to be significantly correlated to the formation of anastomotic stricture following radical retropubic prostatectomy.     

Outcome of precise vesicourethral anastomosis following retropubic radical prostatectomy using a Foley catheter

PURPOSE: In order to evaluate precise anastomosis using a Foley catheter, complications following radical retropubic prostatectomy were examined. METHODS: Twenty-one patients underwent radical retropubic prostatectomy. Precise vesicourethral anastomosis was performed, visualizing the urethral stump by raising up the urogenital diaphragm using a Foley catheter. Complications, such as prolonged urinary extravasation and temporary urinary retention, were checked when the catheter was removed. Incontinence was evaluated both within 6 weeks and more than 6 weeks after operation. Anastomotic and urethral strictures were also checked during follow up. RESULTS: The follow-up period ranged from 4 to 47 months (mean (+/- SD) 22.0 +/- 12.1 months). Eighteen of 21 patients (85.7%) achieved continence after the operation. However, two patients still had stress incontinence and one patient had mild incontinence. Neither prolonged urinary extravasation nor temporally urinary retention were observed. Anastomotic and urethral stricture were not experienced during follow up. CONCLUSIONS: Precise anastomosis using a Foley catheter is technically easy and useful, even for relatively inexperienced urologists, to perform. Patients can often achieve continence following this procedure.     

The single-knot method with Lapra-Ty clips is useful for training surgeons in vesicourethral anastomosis during laparoscopic radical prostatectomy

We determined the applicability of the running single-knotted suture with Lapra-Ty clips to locking the vesicourethra at the 6 o’clock position for teaching anastomosis during laparoscopic radical prostatectomy to trainee surgeons. Fifty consecutive patients underwent laparoscopic radical prostatectomy for prostate cancer conducted by five surgeons with no experience of this procedure. Twenty (group 1) and 30 (group 2) of the patients underwent vesicourethral anastomosis using the single-knot running technique without or with Lapra-Ty clips. Surgical data, duration of surgical anastomosis, extravasation rate, time until healing and catheter removal, and occurrence of anastomotic structures were evaluated. The duration of surgical anastomosis was significantly greater without than with the Lapra-Ty clips (56 ± 13 min versus 45 ± 10 min, P < 0.01). The extravasation rate on postoperative cystography was significantly higher without than with the Lapra-Ty clips (30.0% versus 10.0%, P < 0.05). Leakage occurred on the 6 o’clock side of the anastomosis in all of these patients and urinary retention occurred in one patient (5.0%) in group 1. The single-knot method with Lapra-Ty clips in vesicourethral anastomosis during laparoscopic radical prostatectomy is useful, safe, and efficient, especially for surgeons learning the technique.     

A case of further significant anastomotic rupture after gentle traction of urethral catheter for minimal anastomotic leakage after radical retropubic prostatectomy

A 76-year-old man with clinical stage T1c adenocarcinoma of the prostate underwent radical retropubic prostatectomy. After a cystography on postoperative day 7 demonstrated minimal contrast extravasation, gentle catheter traction was performed. However, a cystography on postoperative day 21 showed a displacement of the catheter out of the bladder due to more significant anastomotic rupture. The catheter was preserved without catheter traction for two months. A cystography revealed complete healing of anastomosis without extravasation. This case suggests that catheter traction for anastomotic leakage should be performed carefully because of a potential risk of further anastomotic leakage.     

Early catheter removal in 100 consecutive patients undergoing radical retropubic prostatectomy

OBJECTIVES: To investigate the outcome of 100 consecutive patients selected for early catheter removal after radical retropubic prostatectomy (RRP), where urethral catheter drainage is used routinely for 2-3 weeks. PATIENTS AND METHODS: The study included 129 consecutive patients with clinically localized prostate cancer who underwent RRP. Catheters were removed in the clinic (with no radiographic studies) 8-9 days after RRP provided there was no evidence of urine leak, pelvic haematoma, rectal injury or severe obesity. The follow-up (mean 21 months) results were available for 118 patients, 100 of whom were candidates for early catheter withdrawal. Their records were reviewed for evidence of complications, including urinary retention, anastomotic stricture formation and urinary incontinence. RESULTS: Urinary retention developed in two of the 100 patients, requiring simple catheter replacement. Nine patients developed bladder neck contracture requiring dilatation or incision. No patients developed anastomotic disruption, urinary tract infection or pelvic abscess. At the mean follow-up of 21 months, 76% of patients were continent and did not require pads; 19% of patients had mild stress urinary incontinence requiring the use of 4 pads/day. CONCLUSION: With appropriate patient selection as described, catheters can be removed in the clinic (with no radiographic studies) 8-9 days after RRP, with no increased incidence of complications, including anastomotic stricture, retention or incontinence.     

Neither alpha-blocker therapy nor cystography is required before early catheter removal after radical prostatectomy

OBJECTIVE: To evaluate the success of early catheter removal from men after radical retropubic prostatectomy (RRP) without using either cystography or giving an alpha-blocker. PATIENTS AND METHODS: We retrospectively analysed 156 consecutive patients who had RRPs between June 2003 and May 2004 to determine the incidence of urinary retention after early catheter removal, with no cystogram or using an alpha-blocker. RESULTS: The mean age of the men was 60 years and 99% were clinical stage T1 or T2; 74% had their catheters removed 8 days after RRP. The incidence of urinary retention was 1.3%, and of haematuria requiring catheter replacement 2.6%. Two patients (1.3%) developed a bladder neck contracture. CONCLUSIONS: In the present study removing an indwelling catheter 1 week after RRP was safe, with a minimal risk of urinary retention or bladder neck contracture. The addition of an alpha-blocker is unlikely to reduce the already low incidence of urinary retention.     

A pelvic drain may be avoided after radical retropubic prostatectomy

PURPOSE: We reassessed the role of routine pelvic cavity drainage to prevent complications after radical retropubic prostatectomy (RRP). MATERIALS AND METHODS: RRP was performed in 116 consecutive patients with clinically localized adenocarcinoma of the prostate. Clinical and pathological information was recorded for each patient. After the prostate was removed and the anastomotic sutures were tied the bladder was filled with saline through the urethral catheter. If there was no significant leakage, a drain was not placed. RESULTS: We did not place a drain in 85 of the 116 patients (73%). There were 3 immediate postoperative complications. In a patient without a drain, a urinoma developed that required percutaneous placement of a drain on postoperative day 2. None of the 116 patients had clinical evidence of infection, lymphocele or hematoma. Two patients had hematuria 2 weeks after catheter removal and needed bladder irrigation. Neither patient had a drain. Three patients (drain and no drain in 1 each) were in urinary retention after catheter removal, which required catheter reinsertion for an additional week. None had an anastomotic stricture. CONCLUSIONS: The morbidity of RRP is low when performed by those who regularly perform this procedure. If the bladder neck is preserved or meticulously reconstructed, there may be little or no extravasation and, thus, routine drainage may be unnecessary. In properly selected cases morbidity is not increased by omitting a drain from the pelvic cavity after RRP.     

Utility of extracorporeal traction with nylon thread for easier vesicourethral anastomosis in laparoscopic prostatectomy

PURPOSE: Vesicourethral anastomosis in laparoscopic prostatectomy is a very difficult procedure. Our purpose in this study was to evaluate a new method using extracorporeal bladder neck traction with nylon thread for vesicourethral anastomosis during laparoscopic radical prostatectomy. MATERIALS AND METHODS: A total of 10 patients underwent laparoscopic radical prostatectomy by this technique, and we evaluated anastomosis time, operative time, and postoperative status of vesicourethral anastomosis. RESULTS: It was possible to shorten both anastomosis time and operative time by this procedure, and to obtain a hermetic anastomosis without higher risk of incontinence, stricture, or leakage. CONCLUSIONS: Extracorporeal bladder neck traction with nylon thread is a very useful procedure to carry out easier vesicourethral anastomosis, especially for a surgeon's initial experience in laparoscopic radical prostatectomy.     

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

Study Type – Therapy (case series)
Level of Evidence 4

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.