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With the improvement in anastomotic technique, it is rare to find anastomotic site leak after robot-assisted radical prostatectomy (RARP). It may not always be necessary to do regular check cystogram before catheter removal. We evaluated our 230 consecutive RARP patients and their cystograms to determine the indications for selective use of cystogram before catheter removal.
We reviewed our prospectively collected RARP database of 230 consecutive patients. Cystography was performed at low pressure by gravity instillation of diluted contrast through the catheter. Patients were observed under fluoroscopy in lateral oblique position for any contrast leak at the site of anastomosis. All patients were followed for a minimum of 6 months, and the longest follow-up was 5 years.
A total of 207 patients (90%) underwent catheter removal on postoperative day 7. Nine patients (3.9%) had extravasation on initial cystogram. Two patients with leak had a history of transurethral resection of prostate (TURP) and seven other had bladder neck reconstruction for wide bladder neck. Three patients with minimal leak did not require catheter replacement. In rest of the 6 patient with leak, continued catheter drainage was done. No significant difference in the intraoperative variables, blood loss, duration of drain, length of hospital stay, and continence outcomes was noted between the patients with leak compared to rest of the patients. None of the patient needed any procedure/intervention related to the surgery and none developed bladder neck stenosis.
In usual circumstances, catheter removal can be done safely on a postoperative day 7 without routine cystography. Selective use of check cystogram can be done in the case where bladder neck reconstruction is performed or those had a prior TURP and a wide bladder neck.
The optimal time of catheter removal following radical prostatectomy (RP) is not defined. From a patient's perspective, early removal of the urinary catheter is desirable due to catheter-related discomfort, penile pain, bladder irritation/spasm, pericatheter urine leaks, etc., However, the surgeon's concerns with early catheter removal are the possibility of anastomotic site leak and acute urinary retention. With experience and improvement in techniques, the duration of catheterization has decreased from an average of 21 days[1,2] in open RP era to 7–10 days in cases where robot-assisted RP (RARP) is performed. In fact, there are numerous reports about the feasibility and safety of even earlier (i.e. on the postoperative day 3–5) catheter removal after radical retropubic prostatectomy[4,5] or RARP. With early catheter removal, some concerns have been raised about increased risk of acute urinary retention. Therefore, in practice, the majority of the institutions perform catheter removal after 7 days of surgery.[7,8] However, there is a variation in the practice of performing cystograms before catheter removal which is done primarily to rule out anastomotic site leak. With the improvement in anastomotic technique, it is rare to find anastomotic site leak after RARP, and it may not always be necessary to obtain a routine check cystogram. We, therefore, evaluated our 230 consecutive RARP patients and the outcomes of their cystogram findings to determine the indications for cystogram before catheter removal.
We reviewed our prospectively collected RARP database of 230 consecutive patients who underwent robot-assisted RP by 2 surgeons from April 2010 to January 2015. All the patients underwent RARP through transperitoneal approach using 4 arm da Vinci(R) surgical system. Clinical characteristics included patient's age, biopsy Gleason score, clinical stage, and history of transurethral resection of prostate (TURP) or other urethral/bladder neck surgery. Intraoperative data recorded included: Estimated blood loss, operative time, bladder neck reconstruction, visible leak upon bladder irrigation at completion of anastomosis, and placement of pelvic drains. Bladder neck sparing was done whenever possible. In patients with a wide bladder neck, bladder neck reconstruction was performed by placing sutures at the 3 and 9 o’clock positions. Urethrovesical anastomosis was performed in 2 layers (described earlier). At the end of anastomosis, a “Bladder fill test” was performed (using 120 ml of saline) to assess intraoperative anastomotic leak. Any significant leak noted during the bladder fill test was repaired by interrupted sutures. Indwelling Foley's catheter was placed in all the cases.
Patients were called for office cystography and catheter removal, usually a week after surgery. Cystography was performed at low pressure by gravity instillation of 150–200 ml of diluted contrast through the catheter placed during RARP. Patients were observed under fluoroscopy in lateral oblique position for any contrast leak at the site of anastomosis. In the absence of extravasation, the catheter was removed. In patients with leakage, the catheter was left in place until a subsequent cystogram revealed resolution, typically 1 week later. In patients with retention of urine after catheter removal, placement of a 16Fr Foley catheter was done, without endoscopic assistance.
All patients were followed for a minimum of 6 months, and the longest follow-up was 5 years. Postoperative data included pathologic Gleason score and stage, hospitalization time, and catheterization time. Postoperative complications included urinary retention, urinary tract infection, bladder neck contracture, and urinary incontinence. Continence status was defined as the use of either “no pad” or just a security liner. Continence rate was assessed with the self-administered questionnaire during a visit in the outpatient department or by E-mail/postal mail at 6 week and at 3, 6, 9, 12, 18, and 24 months and then once a year. Statistical analysis was performed using SPSS (version 20, SPSS Inc., Chicago, IL, USA). Continuous parametric variables were reported as the mean ± standard deviations or as the median values and interquartile range.
230 patients underwent RARP during the study period. Their demographic details are given in Table 1. A total of 207 patients (90% patients) underwent catheter removal on the 7th postoperative day while 10% (23 patients) had catheter removal on the 10th day or later. A decision about delay in catheter removal was usually made by the operating surgeon, based upon satisfaction with bladder neck reconstruction or observation of minimal leak on bladder fill test during surgery. Four patients had an intraoperative leak on bladder fill test requiring additional interrupted sutures. Two of these patients had prior bladder neck reconstruction for the wide neck, and other two underwent standard anastomosis. A total of 21 patients (9.1%) underwent bladder neck reconstruction. As a routine, patients with bladder neck reconstruction and/or intraoperative leak (on bladder fill test) had their catheter removed on the day 10. Only one patient out of four with an intraoperative leak on bladder fill test had leak on postoperative cystogram.
Total of nine patients (3.9%) had extravasation on initial cystogram. Among the patient with anastomotic site leak, two patients had a history of TURP and seven other had wide bladder neck (resulting from wide margin due to basal tumor). Out of the total nine patients with leak, 3 patients had a minimal amount of contrast leak (which cleared on post void film); therefore, catheter was still not replaced [Flow Chart 1]. In rest of the 6 patient showing leak, continued catheter drainage was done for another week and repeat cystogram was done [Figure 1]. Four out of nine patient showing leak needed catheter for a total of 14 days while the two patients needed the catheter for a total of 21 days. Maximum catheter duration was 21 days. No significant difference in the intraoperative variables, blood loss, duration of drain, length of hospital stay, and continence outcomes was noted between the patients with anastomotic leak (noted on cystogram) when compared to rest of the patients. None of the patient needed any procedure/intervention related to the surgery. None of the patient developed bladder neck stenosis.
Acute urinary retention after catheter removal was noted in 3 patients. Only 1 out of 3 patients who had retention after catheter removal had bladder neck sparing surgery. None of the patient experienced immediate retention of urine. Out of those who developed retention (3 cases), one occurred after a week of catheter removal, and the other two developed after 48 h. The catheter was easily replaced in an emergency without any problem. These patients were started on alpha-blocker and catheter removed after 3 days with successful voiding.
At least 6 months follow-up was available in the majority of patients. “No pad” status at 3 months, 6 months, and 1 year was 76%, 86%, and 94%, respectively. All but one patient with urine leak was continent at 6 months (one patient became continent by 9 months of follow-up).
No significant difference in the intraoperative variables, blood loss, and duration of drain, length of hospital stay, prostate volume, grade or stage of the tumor, and continence outcomes was noted between the patients with leak compared to rest of the patients.
Cystogram at the time of catheter removal is an important tool that can help in documentation of healing at anastomotic site and identifying leak, if any. However, as noted in our study and also studied by other authors, the incidence of urine leak noted on cystogram done at day 7 is very low (2–5%). Therefore, instead of using cystogram in all the patients, selective use of cystogram can prove to be cost-effective. Compared to studies published from developed countries, our patients had a higher clinical stage and more cases of post-TURP status, thus requiring wide bladder neck dissection and subsequent reconstruction. We found that there is specific utility of cystogram in the patients who have had a history of TURP, wide bladder neck with intraoperative bladder neck reconstruction, or minimal leak noted on intraoperative bladder fill test. Although not supported by any evidence, it is our practice to delay catheter removal to postoperative day 10 (instead of day 7), in patients who undergo bladder neck reconstruction.
The optimal time for catheter removal (or indwelling catheter drainage) is still a point of scrutiny. Understandably, catheter-related symptoms and discomfort are less with shorter duration of indwelling catheter. However, the risk of anastomotic leak, acute urinary retention, and the impact of urine leak on long-term continence and bladder neck contracture are some of the concerns with early catheter removal. Most of the authors consider catheter removal after 7 days minimizes the risk of anastomotic leak as well as the chance of acute retention. Interestingly, there are studies that have suggested even earlier catheter removal (at 3–4 days) without any significant increase in complication. Khemees et al. have reported 1% cystogram leak rate after catheter removal at 2–4 days, but with a higher rate of acute retention.
It is considered that anastomotic site urine leak can potentially delay the time to continence, and adversely impact the overall continence rates. Several authors have studied the outcomes in their patients who had a varying degree of anastomotic site urine leak. All the studies based on robotic prostatectomy have concluded that urinary extravasation had no adverse impact on the long-term continence status. However, a slight delay in the achievement of continence may be seen. Patil et al. reported that those patients who had a leak, 70% were dry at 3 months, compared to 90% in those with no leaks. At the 12-month follow-up, 95.2% of the patients with no leak were dry, compared with 94% of those with a leak, thus concluding that at 12 months there was no difference. In our study, the number of patient with anastomotic site leak was too small to make a comparative statement about the impact on recovery pattern of continence. However, all but one patient with urine leak had zero pad status at 6 months (one patient became continent by 9 months).
It is also postulated that urine leak (especially prolonged duration) will lead to a sustained inflammatory reaction, hampering wound healing, thus increasing the risk of delayed complication such as bladder neck contracture. In a large series reporting urine leak eight of 287 (2.8%) patients subsequently developed bladder neck contracture. It was further clarified that bladder neck contracture developed in patients with higher grade leaks. None of our patients with urine leak developed the contracture.
Only three of our patient had retention of urine after few hour of catheter removal. It is likely that the cause of acute retention is mucosal edema or hematoma or increase bladder neck smooth muscle tone. No long-term morbidity or complications were seen in these patients. The reported risk of acute retention is reportedly higher (6.7–21%) with catheter removal at 4 days or less.[4,11,12]
Our study has some limitations. It is a nonrandomized study limited to a single-center. Therefore, results may not be generalizable. However, at the same time, constancy of anastomotic technique, operating surgeons and the follow-up methodology is the strength of this study.
The results of our study suggest that in usual circumstances, urinary catheter can be safely removed on the 7th postoperative day after RARP without a routine cystography. Selective use of check cystogram can be done in cases where bladder neck reconstruction is performed or those who have a history of TURP with wide bladder neck and when an intraoperative leak noted on the bladder fill test.
There are no conflicts of interest.