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Horiguchi A, Shinchi M, Ojima K, Hirano Y, Ito K, Azuma R. Surgical and Patient-Reported Outcomes of Delayed Anastomotic Urethroplasty for Male Pelvic Fracture Urethral Injury at a Japanese Referral Center. J Clin Med 2022; 11:jcm11051225. [PMID: 35268315 PMCID: PMC8911321 DOI: 10.3390/jcm11051225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/16/2022] [Accepted: 02/22/2022] [Indexed: 12/28/2022] Open
Abstract
We aimed to assess the surgical and patient-reported outcomes of delayed anastomotic urethroplasty (DAU) for pelvic fracture urethral injury (PFUI). We included 211 male patients who underwent DAU for PFUI. DAU success was considered when the urethral lumen was sufficiently large for the passage of a flexible cystoscope, without additional treatment required. The patients completed the lower urinary tract symptoms (LUTS)-related quality of life (QOL) questionnaire (scores: 0, not at all; 1, a little; 2, somewhat; 3, a lot), EuroQol-5 dimensions (EQ-5D), and EQ-5D visual analog scale (EQ-VAS). Postoperative overall satisfaction was evaluated using the following responses: “very satisfied,” “satisfied,” “unsatisfied,” or “very unsatisfied.” DAU was successful in 95.3% cases, with a median postoperative follow-up duration of 48 months. Multivariate logistic regression analysis revealed that “greater blood loss” was an independent predictor of failed urethroplasty. Questionnaire responses were obtained from 80.1% patients. The mean LUTS-related QOL, EQ-5D score and EQ-VAS improved significantly from 2.8, 0.63 and 54.4 at baseline to 0.9, 0.81 and 76.6 postoperatively (p < 0.0001 for all parameters). Moreover, 35.5% and 59.2% of the patients responded being “satisfied” and “very satisfied,” respectively, with their DAU outcomes. DAU not only had a high surgical success rate, but also a significant beneficial effect on both LUTS-related QOL and overall health-related QOL.
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Affiliation(s)
- Akio Horiguchi
- Department of Urology, National Defense Medical College, Saitama 359-8513, Japan; (M.S.); (K.O.); (Y.H.); (K.I.)
- Correspondence: ; Tel.: +81-4-2995-1676
| | - Masayuki Shinchi
- Department of Urology, National Defense Medical College, Saitama 359-8513, Japan; (M.S.); (K.O.); (Y.H.); (K.I.)
| | - Kenichiro Ojima
- Department of Urology, National Defense Medical College, Saitama 359-8513, Japan; (M.S.); (K.O.); (Y.H.); (K.I.)
| | - Yusuke Hirano
- Department of Urology, National Defense Medical College, Saitama 359-8513, Japan; (M.S.); (K.O.); (Y.H.); (K.I.)
| | - Keiichi Ito
- Department of Urology, National Defense Medical College, Saitama 359-8513, Japan; (M.S.); (K.O.); (Y.H.); (K.I.)
| | - Ryuichi Azuma
- Department of Plastic Surgery, National Defense Medical College, Saitama 359-8513, Japan;
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Horiguchi A, Ojima K, Shinchi M, Hirano Y, Hamamoto K, Ito K, Asano T, Azuma R. Usefulness of a high-speed surgical air drill in pubectomy during delayed anastomotic urethroplasty for pelvic fracture urethral injury. Int J Urol 2020; 27:1002-1007. [PMID: 32776376 DOI: 10.1111/iju.14344] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/06/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Pubectomy is an ancillary technique used to increase exposure of the disrupted urethra and reduce anastomotic tension, which can be difficult for inexperienced surgeons. The objective of the present study was to illustrate the use of an air drill enabling delicate and precise bone resection in pubectomy for delayed anastomotic urethroplasty for pelvic fracture urethral injury. METHODS Between 2009 and 2019, 88 male patients underwent delayed anastomotic urethroplasty with pubectomy for pelvic fracture urethral injury. A total of 73 procedures used a high-speed surgical air drill (HiLAN HS; Aesculap, Tuttlingen, Germany) equipped with a short-hand piece. Operative time and blood loss in the air drill patient group (group 1) were compared with that of patients who underwent pubectomy using a rongeur and/or gouge (group 2, n = 15). RESULTS In 65 group 1 patients, urethroplasty was carried out using the perineal approach, with partial inferior pubectomy. Eight group 1 patients, whose proximal urethral end was displaced upward superior to the upper edge of pubis, underwent urethroplasty using the perineal and abdominal approach, with a superior partial pubectomy and supracrural urethral rerouting. No difficulty was encountered using the air drill in any of the cases. There was no significant difference in median operative time between the groups (group 1 256 min vs group 2 228 min; P = 0.31). The median blood loss in group 1 was significantly lower than group 2 (149 mL vs 453 mL; P < 0.0001). CONCLUSIONS Surgical air drills might facilitate pubectomy in patients undergoing delayed anastomotic urethroplasty for pelvic fracture urethral injury. This tool offers the advantage of a delicate bone resection with reduced blood loss.
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Affiliation(s)
- Akio Horiguchi
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Kenichiro Ojima
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Masayuki Shinchi
- Department of Urology, Nishisaitama-chuo National Hospital, Tokorozawa, Saitama, Japan
| | - Yusuke Hirano
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Koetsu Hamamoto
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Keiichi Ito
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Tomohiko Asano
- Department of Urology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Ryuichi Azuma
- Department of Plastic Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
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Bugeja S, Frost A, Ivaz S, Campos F, Andrich DE, Mundy AR. Funneling of the bladder neck - radiological appearance after radical retropubic prostatectomy and clinical relevance. Asian J Androl 2020; 22:152-153. [PMID: 31290410 PMCID: PMC7155796 DOI: 10.4103/aja.aja_73_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 05/21/2019] [Indexed: 11/04/2022] Open
Affiliation(s)
- Simon Bugeja
- University College London Hospitals, NHS Foundation Trust, Reconstructive Urology Unit, London NW1 2PG, UK
| | - Anastasia Frost
- University College London Hospitals, NHS Foundation Trust, Reconstructive Urology Unit, London NW1 2PG, UK
| | - Stella Ivaz
- University College London Hospitals, NHS Foundation Trust, Reconstructive Urology Unit, London NW1 2PG, UK
| | - Felix Campos
- University College London Hospitals, NHS Foundation Trust, Reconstructive Urology Unit, London NW1 2PG, UK
| | - Daniela E Andrich
- University College London Hospitals, NHS Foundation Trust, Reconstructive Urology Unit, London NW1 2PG, UK
| | - Anthony R Mundy
- University College London Hospitals, NHS Foundation Trust, Reconstructive Urology Unit, London NW1 2PG, UK
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Giúdice CR, Lodi PE, Olivares AM, Tobia IP, Favre GA. Safety and effectiveness evaluation of open reanastomosis for obliterative or recalcitrant anastomotic stricture after radical retropubic prostatectomy. Int Braz J Urol 2019; 45:253-261. [PMID: 30325608 PMCID: PMC6541121 DOI: 10.1590/s1677-5538.ibju.2017.0681] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 06/17/2018] [Indexed: 11/24/2022] Open
Abstract
Purpose: To evaluate safety, efficacy and functional outcomes after open vesicourethral re - anastomosis using different approaches based on previous urinary continence. Materials and Methods: Retrospective study of patients treated from 2002 to 2017 due to vesicourethral anastomosis stricture (VUAS) post radical prostatectomy (RP) who failed endoscopic treatment with at least 3 months of follow-up. Continent and incontinent patients post RP were assigned to abdominal (AA) or perineal approach (PA), respectively. Demographic and perioperative variables were registered. Follow-up was completed with clinical interview, uroflowmetry and cystoscopy every 4 months. Success was defined as asymptomatic patients with urethral lumen that allows a 14 French flexible cystoscope. Results: Twenty patients underwent open re-anastomosis for VUAS after RP between 2002 and 2017. Mean age was 63.7 years (standard deviation 1.4) and median follow-up was 10 months (range 3 – 112). The approach distribution was PA 10 patients (50%) and AA 10 patients (50%). The mean surgery time and median hospital time were 246.2 ± 35.8 minutes and 4 days (range 2 – 10), respectively with no differences between approaches. No significant complication rate was found. Three patients in the AA group had gait disorder with favorable evolution and no sequels. Estimated 2 years primary success rate was 80%. After primary procedures 89.9% remained stenosis - free. All PA patients remained incontinent, and 90% AA remained continent during follow-up. Conclusion: Open vesicourethral re - anastomosis treatment is a reasonable treatment option for recurrent VUAS after RP. All patients with perineal approach remained incontinent while incontinence rate in abdominal approach was rather low.
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Affiliation(s)
- Carlos Roberto Giúdice
- Department of Urology, Reconstructive Surgery Area, Hospital Italiano de Buenos Aires, Argentina
| | - Patricio Esteban Lodi
- Department of Urology, Reconstructive Surgery Area, Hospital Italiano de Buenos Aires, Argentina
| | - Ana Milena Olivares
- Department of Urology, Reconstructive Surgery Area, Hospital Italiano de Buenos Aires, Argentina
| | - Ignacio Pablo Tobia
- Department of Urology, Reconstructive Surgery Area, Hospital Italiano de Buenos Aires, Argentina
| | - Gabriel Andrés Favre
- Department of Urology, Reconstructive Surgery Area, Hospital Italiano de Buenos Aires, Argentina
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Pfalzgraf D, Siegel FP, Kriegmair MC, Wagener N. Bladder Neck Contracture After Radical Prostatectomy: What Is the Reality of Care? J Endourol 2017; 31:50-56. [DOI: 10.1089/end.2016.0509] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Daniel Pfalzgraf
- Department of Urology, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Fabian P. Siegel
- Department of Urology, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Maximilian C. Kriegmair
- Department of Urology, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Nina Wagener
- Department of Urology, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
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Moltzahn F, Dal Pra A, Furrer M, Thalmann G, Spahn M. Urethral strictures after radiation therapy for prostate cancer. Investig Clin Urol 2016; 57:309-15. [PMID: 27617311 PMCID: PMC5017559 DOI: 10.4111/icu.2016.57.5.309] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/27/2016] [Indexed: 11/18/2022] Open
Abstract
Urethral stricture after radiation therapy for localized prostate cancer is a delicate problem as the decreased availability of tissue healing and the close relation to the sphincter complicates any surgical approach. We here review the pathophysiology, dosimetry, and the disease specific aspects of urethral strictures after radiotherapy. Moreover we discuss different treatment option such as direct vision internal urethrotomy as well as techniques for open reconstruction with and without tissue transfer.
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Affiliation(s)
- Felix Moltzahn
- Department of Urology, Inselspital Bern, Bern, Switzerland
| | - Alan Dal Pra
- Department of Radiation-Oncology, Inselspital Bern, Bern, Switzerland
| | - Marc Furrer
- Department of Urology, Inselspital Bern, Bern, Switzerland
| | | | - Martin Spahn
- Department of Urology, Inselspital Bern, Bern, Switzerland
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Cormio L, Di Fino G, Scavone C, Maroscia D, Mancini V, Ruocco N, Bellanti F, Selvaggio O, Sanguedolce F, Lucarelli G, Carrieri G. Prognostic Factors for Anastomotic Urinary Leakage Following Retropubic Radical Prostatectomy and Correlation With Voiding Outcomes. Medicine (Baltimore) 2016; 95:e3475. [PMID: 27100451 PMCID: PMC4845855 DOI: 10.1097/md.0000000000003475] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Luigi Cormio
- From the Department of Urology and Renal Transplantation (LC, GDF, VM, NR, OS, GC), University of Foggia, Foggia, Italy; Department of Radiology (CS, DM), San Carlo Hospital, Potenza, Italy; Department of Pathology (FS), University of Foggia, Foggia, Italy; Department of Internal Medicine (FB), University of Foggia, Foggia, Italy; and Department of Emergency and Organ Transplantation (GL), University of Bari, Bari, Italy
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Bladder neck contractures and the prostate cancer survivor. Curr Opin Urol 2014; 24:389-94. [PMID: 24901516 DOI: 10.1097/mou.0000000000000065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To summarize the cause and diagnostic and treatment concerns for bladder neck contractures (BNCs) in the prostate cancer survivor. RECENT FINDINGS BNC rates have decreased significantly in the last 2 decades, likely because of improvement in the surgical technique and increased utilization of laparoscopic and robotic surgery, which may allow better visualization of the vesicourethral anastomosis. Despite these improvements, risk factors such as smoking and coronary artery disease contribute to BNC development. Furthermore, although recent reports have questioned the classical tenets of anastomotic technique such as water-tight anastomoses, there is no evidence that these principles contribute to the risk of BNC development and should continue to be observed. The results of minimally invasive procedures such as urethral dilation and transurethral incision of the bladder neck may be improved with the use of injectable agents. SUMMARY There is little consensus regarding BNC therapy. Although several risk factors contributing to BNC development have been identified, strategies to reduce the risk are unclear. A number of therapeutic options are available, however. In the event of BNC development, treatment should be structured in a hierarchical fashion which minimizes the risk of urinary incontinence.
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Reiss CP, Pfalzgraf D, Kluth LA, Soave A, Fisch M, Dahlem R. Transperineal reanastomosis for the treatment for highly recurrent anastomotic strictures as a last option before urinary diversion. World J Urol 2013; 32:1185-90. [DOI: 10.1007/s00345-013-1180-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 10/05/2013] [Indexed: 11/27/2022] Open
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Kravchick S, Lobik L, Peled R, Cytron S. Transrectal Ultrasonography-Guided Injection of Long-Acting Steroids in the Treatment of Recurrent/Resistant Anastomotic Stenosis After Radical Prostatectomy. J Endourol 2013; 27:875-9. [DOI: 10.1089/end.2012.0661] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Cho HJ, Jung TY, Kim DY, Byun SS, Kwon DD, Oh TH, Ko WJ, Yoo TK. Prevalence and risk factors of bladder neck contracture after radical prostatectomy. Korean J Urol 2013; 54:297-302. [PMID: 23700494 PMCID: PMC3659222 DOI: 10.4111/kju.2013.54.5.297] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 01/22/2013] [Indexed: 11/18/2022] Open
Abstract
Purpose To evaluate the prevalence of bladder neck contracture (BNC) and its risk factors in patients undergoing radical prostatectomy in Korea. Materials and Methods We analyzed data from 488 patients with prostatic cancer who underwent radical prostatectomy performed by seven surgeons in seven hospitals, including 365 open radical prostatectomies (ORPs), 99 laparoscopic radical prostatectomies (LRPs), and 24 robot-assisted laparoscopic radical prostatectomies (RARPs). Patients with BNCs were compared with those without BNCs to identify the risk factors for BNC occurrence. Results Overall, BNCs occurred in 21 of 488 patients (4.3%): 17 patients (4.7%) who underwent ORP, 4 patients (4%) who underwent LRP, and no patients who underwent RARP. In the univariate analysis, men with BNCs had a longer length of time before drain removal (12 days vs. 6.8 days, p<0.001), which reflected urinary leakage through the vesicourethral anastomosis. In the multivariate analysis, the length of time before drain removal was the only predictor of BNC (odds ratio, 1.12; p=0.001). Intraoperative blood loss was higher in patients with BNC, but the difference was not statistically significant. Conclusions The most significant factor related to BNC occurrence after radical prostatectomy in our study was the length of time before drain removal, which reflects urinary leakage from the vesicourethral anastomosis. The proper formation of a watertight anastomosis to decrease urinary leakage may help to reduce the occurrence of BNC.
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Affiliation(s)
- Hee Ju Cho
- Department of Urology, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea
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Mucciardi G, Galì A, Inferrera A, Di Benedetto A, Macchione L, Mucciardi M, Magno C. Longitudinal observational cohort study about detrusor underactivity as a risk factor for bladder neck contracture after retropubic radical prostatectomy: preliminary results. Int Urol Nephrol 2013; 45:721-6. [DOI: 10.1007/s11255-013-0426-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 03/18/2013] [Indexed: 11/28/2022]
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Lim JH, You D, Jeong IG, Park HK, Ahn H, Kim CS. Cystoscopic injection of N-butyl-2-cyanoacrylate followed by fibrin glue for the treatment of persistent or massive vesicourethral anastomotic urine leak after radical prostatectomy. Int J Urol 2013; 20:980-5. [PMID: 23387512 DOI: 10.1111/iju.12094] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 12/26/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Vesicourethral anastomotic urine leak is a common postoperative complication of radical prostatectomy. Herein we describe a novel method for the treatment of this complication. METHODS Intervention for a prolonged or massive anastomotic urine leak was required in 10 out of 1828 patients (0.5%) submitted to radical prostatectomy between 2007 and 2011. N-butyl-2-cyanoacrylate (Histoacryl) followed by fibrin glue (Greenplast) were injected under local anesthesia into vesicourethral anastomotic gaps under fluoroscopic guidance using a 20-Fr rigid cystoscope. Cystograms were taken in all patients to confirm complete urine leak resolution before the removal of the urethral catheter. RESULTS Cystoscopic injection of Histoacryl followed by fibrin glue was technically successful and well tolerated in all patients. The mean time from radical prostatectomy to glue injection was 16.0 days (range 12-27 days). Urethral catheterization was required for an average of 7.7 days after cystoscopic injection of fibrin glue (range 3-13 days). These measures ultimately enabled complete resolution of the urine leak in all cases. At a mean follow up of 23.3 months, all 10 patients were fully continent. The mean time to recovery of urinary continence was 20.4 weeks (range 3.9-60.0 weeks). CONCLUSIONS Cystoscopic injection of N-butyl-2-cyanoacrylate followed by fibrin glue into the anastomotic gap is both a feasible and effective solution in patients with a persistent or massive vesicourethral anastomotic urine leak after radical prostatectomy.
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Affiliation(s)
- Ju Hyun Lim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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[Anastomotic stricture following radical retropubic prostatectomy: insights into incidence, management and factors predisposing for occurrence]. Nihon Hinyokika Gakkai Zasshi 2012; 103:604-9. [PMID: 23120994 DOI: 10.5980/jpnjurol.103.604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
PURPOSE Anastomotic stricture (AS) following radical prostatectomy (RP) decreases patients' quality of life. It occurs in 0.5% to 32% of men after open radical retropubic prostatectomy (RRP), although its etiology is poorly understood. In a series of patients who received RRP, we analyzed the incidence, possible predisposing factors, and management of AS after RP. MATERIALS & METHODS Between April 1997 and March 2006, 129 consecutive patients underwent RRP in our hospital. Anastomosis between the bladder neck and urethra was performed with interrupted anastomosis using four 2-0 absorbable sutures. AS was diagnosed when a 16Fr. panendoscope could not be passed. We assessed the relationship between the management method for AS and time interval between the surgical procedure and diagnosis of the stricture. The relationships between comorbidities identified preoperatively (hypertension [HT], diabetes mellitus [DM], cardiovascular disease [CVD], cerebral infarction [CI] and smoking history) and the incidence of AS were determined. Risk factors, including age, body mass index [BMI], preoperative PSA, total prostate volume, operative time, blood loss, Foley duration, amount of stress urinary incontinence (SUI) per day, amount of drain output, pathological T stage, Gleason sum and surgical margin status were also assessed. RESULTS The rate of AS after RRP was 10.9% (14/129). In 10 patients (72%), AS occurred within 3 months of surgery, in 2 (14%) it occurred at 4-12 months after surgery and in 2 (14%) more than 12 months after surgery. In univariate and multivariate analyses, intraoperative bleeding of 1,800 ml or more was independently the strongest predictor of AS. In two patients a urethral bougie was used and 11 underwent internal urethrotomy. Only 1 patient underwent transurethral resection. Of the 8 patients whose strictures were diagnosed within 3 months after surgery and underwent internal urethrotomy, 6 had recurrent anastomotic strictures. CONCLUSIONS Risk factors for AS are thought to be multifactorial. Intraoperative blood loss was significantly associated with the development of anastomotic stricture. We should understand that anastomotic stricture following radical retropubic prostatectomy is not a rare morbidity and should inform patients about the possibility of postoperative AS.
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Schoeppler GM, Zaak D, Schuhmann P, Stief CG, Buchner A. Urine colour after radical prostatectomy predicts urinary leakage at the vesicourethral anastomosis. SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY 2012; 46:337-42. [PMID: 22607018 DOI: 10.3109/00365599.2012.689006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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.
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Affiliation(s)
- Gita M Schoeppler
- Department of Urology, University Hospitals - Grosshadern, Ludwig-Maximilians-University Munich, Germany.
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Schoeppler GM, Zaak D, Clevert DA, Schuhmann P, Reich O, Seitz M, Khoder WY, Staehler M, Stief CG, Buchner A. The impact of bladder neck mucosal eversion during open radical prostatectomy on bladder neck stricture and urinary extravasation. Int Urol Nephrol 2012; 44:1403-10. [PMID: 22585294 DOI: 10.1007/s11255-012-0186-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Accepted: 04/19/2012] [Indexed: 12/01/2022]
Abstract
PURPOSE To determine whether the bladder neck mucosal eversion (BNM-eversion) during radical retropubic prostatectomy (RRP) reduces the risk of bladder neck stricture (BNS) and of peri-anastomotic extravasation (PAE) in postoperative cystography. METHODS Two hundred and eleven patients with clinically localized prostate cancer underwent RRP and were prospectively randomized into patients with BNM-eversion (group I) and without BNM-eversion (group II). All patients underwent an evaluation of PAE by retrograde cystography on postoperative day 8. We assessed BNS after 6 months. RESULTS Ninety-two patients with and 113 patients without BNM-eversion were included. There was no significant difference in baseline characteristics, including age, TNM-classification, Gleason score, PSA, prostate volume, and blood loss in both groups. A complete follow-up of 6 months for BNS was available for 188 patients (89.1 %). Sixteen BNS out of 188 patients were recorded, 4.7 % (n = 4) in group I and 11.7 % (n = 12) in group II (p = 0.09). Data from 205 out of 211 patients were available for the evaluation of the extravasation by cystography. Peri-anastomotic extravasation was detectable in 11.96 %, (11/205) in group I and in 21.24 % (24/205) in group II (p = 0.08). CONCLUSION BNM-eversion does not have a positive influence on the prevention of bladder neck strictures. Peri-anastomotic extravasation detected by cystography does not correlate with a formation of bladder neck stricture.
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Affiliation(s)
- Gita M Schoeppler
- Department of Urology, University Hospitals Grosshadern, Ludwig-Maximilians-University, Munich, Germany.
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Ouzaid I, Xylinas E, Ploussard G, Hoznek A, Vordos D, Abbou CC, de la Taille A, Salomon L. Anastomotic stricture after minimally invasive radical prostatectomy: what should be expected from the Van Velthoven single-knot running suture? J Endourol 2012; 26:1020-5. [PMID: 22486229 DOI: 10.1089/end.2011.0650] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE Patients with localized prostate cancer (PCa) who are treated by radical prostatectomy (RP) have a good overall survival rate. Their quality of life, however, can deteriorate because of the incidence of bladder neck contracture (BNC). Our aim was to evaluate the incidence and the risk factors of BNC after minimally invasive radical prostatectomy (MIRP) with a single-knot running suture also known as the Van Velthoven technique (VVT). PATIENTS AND METHODS From 2003 to 2010, 2115 patients underwent extraperitoneal, transperitoneal, or robot-assisted RP for localized PCa. A single-knot running suture according to the VVT was performed for the vesicourethral anastomosis. Follow-up was scheduled and standardized for all patients and recorded into a prospective database. BNC was defined by a reduction of the lumen that does not allow the passage of an 18F fibroscope. RESULTS Mean follow-up of the patients was 43 (6-144) months. Of all, 1342, 241, and 532 had extraperitoneal, transperitoneal, and robot-assisted prostatectomy, respectively. BNC was diagnosed in 30 (1.4%) patients. Among them, 78% had the diagnosis within the first year of follow-up. Previous transurethral resection of the prostate (TURP) and external beam radiotherapy were independent risk factors of BNC. CONCLUSIONS BNC incidence after MIRP using the single-knot running suture for the vesicourethral anastomosis is low. Previous TURP and external beam radiotherapy are identified as risk factors. This technique showed satisfying results regardless of the classic laparoscopic or robot-assisted approach.
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Affiliation(s)
- Idir Ouzaid
- Department of Urology, Henri Mondor Hospital, Paris-Est University, Créteil, France.
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19
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Post-radical-prostatectomy urinary incontinence: the management of concomitant bladder neck contracture. Adv Urol 2012; 2012:295798. [PMID: 22611382 PMCID: PMC3349276 DOI: 10.1155/2012/295798] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 02/29/2012] [Indexed: 11/18/2022] Open
Abstract
Urinary incontinence postradical prostatectomy is a common problem which adversely affects quality of life. Concomitant bladder neck contracture in the setting of postprostatectomy incontinence represents a challenging clinical problem. Postprostatectomy bladder neck contracture is frequently recurrent and makes surgical management of incontinence difficult. The aetiology of bladder neck contracture and what constitutes the optimum management strategy are controversial. Here we review the literature and also present our approach.
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20
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Open Retropubic Reanastomosis for Highly Recurrent and Complex Bladder Neck Stenosis. J Urol 2011; 186:1944-7. [DOI: 10.1016/j.juro.2011.07.040] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2011] [Indexed: 11/20/2022]
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Sandhu JS, Gotto GT, Herran LA, Scardino PT, Eastham JA, Rabbani F. Age, obesity, medical comorbidities and surgical technique are predictive of symptomatic anastomotic strictures after contemporary radical prostatectomy. J Urol 2011; 185:2148-52. [PMID: 21496848 DOI: 10.1016/j.juro.2011.02.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Indexed: 11/17/2022]
Abstract
PURPOSE Anastomotic strictures are relatively common after radical prostatectomy and are associated with significant morbidity, often requiring multiple surgical interventions. There is controversy in the literature regarding which factors predict the development of anastomotic strictures. In this study we determined predictors of symptomatic anastomotic strictures following contemporary radical prostatectomy. MATERIALS AND METHODS Between 1999 and 2007, 4,592 consecutive patients underwent radical prostatectomy without prior radiotherapy at our institution. Data were collected from prospective surgical and institutional morbidity databases, and retrospectively from inpatient and outpatient medical and billing records. Cases were assigned a Charlson score to account for comorbidities. Complications were graded according to the modified Clavien classification. RESULTS Open radical prostatectomy was performed in 3,458 men (75%) and laparoscopic radical prostatectomy was performed in 1,134 (25%). The laparoscopic radical prostatectomy group included 97 robotic-assisted cases. Median patient age was 59.5 years (IQR 54.7, 64.2). Symptomatic anastomotic strictures developed in 198 patients (4%) after a median postoperative followup of 3.5 months (IQR 2.1, 6.1). On multivariate analysis significant predictors included patient age, body mass index, Charlson score, renal insufficiency, individual surgeon, surgical approach and the presence of postoperative urine leak or hematoma. CONCLUSIONS Patient factors as well as technical factors influence the development of symptomatic anastomotic strictures following contemporary radical prostatectomy. The impact of these factors is influenced by the individual surgeon and the approach used.
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Affiliation(s)
- Jaspreet S Sandhu
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA.
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Mattei A, Z’Brun S, Stucki P, Di Pierro G, Danuser H. When and How Should We Test the Tightness of the Vesicourethral Anastomosis after Retropubic Radical Prostatectomy? Urol Int 2011; 86:388-92. [DOI: 10.1159/000323660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 11/25/2010] [Indexed: 11/19/2022]
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Tan G, Srivastava A, Grover S, Peters D, Dorsey P, Scott A, Jhaveri J, Tilki D, Te A, Tewari A. Optimizing Vesicourethral Anastomosis Healing After Robot-Assisted Laparoscopic Radical Prostatectomy: Lessons Learned from Three Techniques in 1900 Patients. J Endourol 2010; 24:1975-83. [DOI: 10.1089/end.2009.0630] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Gerald Tan
- LeFrak Center of Robotic Surgery and Institute of Prostate Cancer, James Buchanan Brady Foundation Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, New York
| | - Abhishek Srivastava
- LeFrak Center of Robotic Surgery and Institute of Prostate Cancer, James Buchanan Brady Foundation Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, New York
| | - Sonal Grover
- LeFrak Center of Robotic Surgery and Institute of Prostate Cancer, James Buchanan Brady Foundation Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, New York
| | - David Peters
- LeFrak Center of Robotic Surgery and Institute of Prostate Cancer, James Buchanan Brady Foundation Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, New York
| | - Philip Dorsey
- LeFrak Center of Robotic Surgery and Institute of Prostate Cancer, James Buchanan Brady Foundation Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, New York
| | - Ann Scott
- LeFrak Center of Robotic Surgery and Institute of Prostate Cancer, James Buchanan Brady Foundation Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, New York
| | - Jay Jhaveri
- LeFrak Center of Robotic Surgery and Institute of Prostate Cancer, James Buchanan Brady Foundation Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, New York
| | - Derya Tilki
- LeFrak Center of Robotic Surgery and Institute of Prostate Cancer, James Buchanan Brady Foundation Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, New York
| | - Alexis Te
- LeFrak Center of Robotic Surgery and Institute of Prostate Cancer, James Buchanan Brady Foundation Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, New York
| | - Ashutosh Tewari
- LeFrak Center of Robotic Surgery and Institute of Prostate Cancer, James Buchanan Brady Foundation Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, New York
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Yi JS, Kwak C, Kim HH, Ku JH. Surgical clip-related complications after radical prostatectomy. Korean J Urol 2010; 51:683-7. [PMID: 21031087 PMCID: PMC2963780 DOI: 10.4111/kju.2010.51.10.683] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Accepted: 08/26/2010] [Indexed: 11/26/2022] Open
Abstract
Purpose The aim of this study was to describe the surgical clip-related complications that can occur after open retropubic prostatectomy (RRP), pure laparoscopic prostatectomy (LRP), and robot-assisted laparoscopic radical prostatectomy (RALP). Materials and Methods A database of 641 patients who underwent RRP (n=439), LRP (n=49), and RALP (n=153) at our institution between January 2006 and April 2009 was reviewed to identify patients with complications related to the use of surgical clips. The median follow-up time for the entire cohort was 19.0 months (range, 1-42 months). Results Of the 641 patients, 25 (5.7%), 1 (2.0%), and 2 (1.3%) had a bladder neck contracture after RRP, LRP, and RALP, respectively. Two RRP patients had a bladder stone. In total, 6 patients had surgical clip-related complications. Metal clip migration was associated with 2 (8%) of the 25 RRP cases of bladder neck contracture and both (100%) of the RRP cases of bladder stone. Moreover, both (100%) of the RALP cases of bladder neck contractures were associated with Hem-o-lok clip migration into the anastomotic site. Conclusions Surgical clips are prone to migration and may cause, or significantly contribute to, bladder neck contracture or the formation of bladder stones after radical prostatectomy. These findings also suggest that because the incidence of bladder neck contracture after RALP is low, the migration of Hem-o-lok clips should be suspected when voiding difficulty occurs after RALP.
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Affiliation(s)
- Jun Seok Yi
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
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25
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[Anastomotic stricture after radical prostatectomy for prostate cancer]. Prog Urol 2010; 20:327-31. [PMID: 20471576 DOI: 10.1016/j.purol.2009.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Revised: 08/25/2009] [Accepted: 09/03/2009] [Indexed: 10/20/2022]
Abstract
The present paper intends to review diagnosis and treatment issues of bladder neck anastomosis stricture after radical prostatectomy for localised prostate cancer. Even though cancer control is not necessarily a concern, quality of life may be greatly altered. Patients may suffer from dysuria, urgency and the feeling of incomplete bladder emptying. Flowmetry, cystoscopy and cystography contribute to its diagnosis. Treatment should be graded according to the severity of the disease and the quality of life of the patient. Cold-Knife incisions and pneumatic dilatation are the first line treatments. Holmium laser shows good results on the stricture in a second line treatment. A two-stage strategy with an endoluminal stent followed by artificial urinary sphincter implant is the ultimate option to manage severe strictures, while maintaining acceptable quality of life. Continence sparing is the challenge of the treatment of this type of stricture.
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Gillitzer R, Thomas C, Wiesner C, Jones J, Schmidt F, Hampel C, Brenner W, Thüroff JW, Melchior SW. Single center comparison of anastomotic strictures after radical perineal and radical retropubic prostatectomy. Urology 2009; 76:417-22. [PMID: 19969328 DOI: 10.1016/j.urology.2009.10.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Revised: 10/04/2009] [Accepted: 10/07/2009] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To analyze the incidence and management of anastomotic strictures (ASs) after radical perineal prostatectomy (RPP) and retropubic prostatectomy (RRP) and to identify possible predisposing factors. METHODS Between 1997 and 2007, we performed 866 RPP and 2052 RRP for localized prostate cancer. Median follow-up was 52 months (12-136). We analyzed preoperative serum prostate-specific antigen, prostate size, clinical and pathologic tumor stage, neoadjuvant hormone deprivation, previous transurethral resection of the prostate, transfusion requirement, anastomotic insufficiency, and acute urinary retention (AUR) and its subsequent management to identify possible predisposing factors for AS formation. RESULTS The rate of AS after RPP and RRP was 3.8% (33/863) and 5.5% (113/2048), respectively (P = .067). In multivariate analysis, RRP was a statistically significant risk factor for AS (P = .0002). On survival analysis, the incidence of AS was lower for RPP as compared with RRP at median follow-up (P = .0229). Primary response to endoscopic AS incision or resection was 94% (31/33) and 72.6% (82/113) after RPP and RRP, respectively. On multivariate logistic regression analysis biopsy Gleason score, previous transurethral resection of the prostate, prostate volume, pathologic tumor stage and grade, transfusion requirement, AUR, and surgical technique were independent risk factors for the development of AS. An AS developed in 45.4% (20/44) and 10.9% (5/46) of the postoperative AUR cases treated with a suprapubic cystostomy tube and a transurethral Foley catheter, respectively (P <.05). CONCLUSIONS ASs occur more frequently after RRP in comparison with RPP. Primary endoscopic AS incision or resection are both highly successful. Treating postoperative AUR with a suprapubic cystostomy poses a high risk for AS formation and should be avoided.
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Affiliation(s)
- Rolf Gillitzer
- Department of Urology, Johannes Gutenberg-University Medical School, Mainz, Germany.
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27
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Neovesical-urethral anastomotic stricture due to external suture migration. Urology 2009; 73:1002. [PMID: 19394495 DOI: 10.1016/j.urology.2008.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2008] [Revised: 11/24/2008] [Accepted: 12/01/2008] [Indexed: 11/21/2022]
Abstract
We report on the endoscopic appearance and subsequent treatment of a neovesical-urethral anastomotic stricture caused by migration of a nonabsorbable suture originally placed for retropubic hemostasis.
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28
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Garg T, See WA. Bladder neck contracture after radical retropubic prostatectomy using an intussuscepted vesico-urethral anastomosis: incidence with long-term follow-up. BJU Int 2009; 104:925-8. [PMID: 19389011 DOI: 10.1111/j.1464-410x.2009.08544.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the incidence of bladder neck contracture (BNC), a known complication of radical retropubic prostatectomy (RRP), after a 9-year experience by one surgeon using a novel approach to lower urinary tract reconstruction, the intussuscepted vesico-urethral anastomosis (IVUA). PATIENTS AND METHODS After institutional review board approval, the charts of 406 patients who had RRP for clinically localized prostate cancer from March 1998 to July 2007 were reviewed retrospectively. All patients had lower urinary tract reconstruction using the IVUA technique, which involves a looped urethral suture using six double-armed sutures that are drawn 'inside-to-out' from staggered points on the urethral stump through the bladder neck opening. When the sutures are tied down, the urethra is intussuscepted into the bladder neck opening. RESULTS At a median follow-up of 48 months, three patients developed BNC: one was at increased risk secondary to a previous TURP; one had his catheter removed on the second day after RRP in the presence of a suprapubic tube and developed a BNC at his 'dry' anastomosis; and one with no risk factors developed a BNC. Balloon dilatation, laser incision and self obturation were successful in stabilizing the strictures while preserving continence. Overall, the incidence of BNC in this series was three of 406 (0.74%). CONCLUSIONS IVUA gives a lower incidence of BNC over a long-term follow-up than rates cited in previous reports. IVUA is a valuable technique for lower urinary tract reconstruction in patients undergoing RRP.
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Affiliation(s)
- Tullika Garg
- Department of Urology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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Sullivan L, Williams SG, Tai KH, Foroudi F, Cleeve L, Duchesne GM. Urethral stricture following high dose rate brachytherapy for prostate cancer. Radiother Oncol 2008; 91:232-6. [PMID: 19097660 DOI: 10.1016/j.radonc.2008.11.013] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2008] [Revised: 10/10/2008] [Accepted: 11/04/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE To evaluate the incidence, timing, nature and outcome of urethral strictures following high dose rate brachytherapy (HDRB) for prostate carcinoma. METHODS AND MATERIALS Data from 474 patients with clinically localised prostate cancer treated with HDRB were analysed. Ninety percent received HDRB as a boost to external beam radiotherapy (HDRBB) and the remainder as monotherapy (HDRBM). Urethral strictures were graded according to the Common Terminology Criteria for Adverse Events v3.0. RESULTS At a median follow-up of 41 months, 38 patients (8%) were diagnosed with a urethral stricture (6-year actuarial risk 12%). Stricture location was bulbo-membranous (BM) urethra in 92.1%. The overall actuarial rate of grade 2 or more BM urethral stricture was estimated at 10.8% (95% CI 7.0-14.9%), with a median time to diagnosis of 22 months (range 10-68 months). All strictures were initially managed with either dilatation (n=15) or optical urethrotomy (n=20). Second line therapy was required in 17 cases (49%), third line in three cases (9%) and 1 patient open urethroplasty (grade 3 toxicity). Predictive factors on multivariate analysis were prior trans-urethral resection of prostate (hazard ratio (HR) 2.81, 95% CI 1.15-6.85, p=0.023); hypertension (HR 2.83, 95% CI 1.37-5.85, p=0.005); and dose per fraction used in HDR (HR for 1 Gy increase per fraction 1.33, 95% CI 1.08-1.64, p=0.008). CONCLUSIONS BM urethral strictures are the most common late grade 2 or more urinary toxicity following HDR brachytherapy for prostate cancer. Most are manageable with minimally invasive procedures. Both clinical and dosimetric factors appear to influence the risk of stricture formation.
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Affiliation(s)
- Lisa Sullivan
- Division of Radiation Oncology, Peter MacCallum Cancer Centre and University of Melbourne, Australia
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30
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Webb DR, Sethi K, Gee K. An analysis of the causes of bladder neck contracture after open and robot-assisted laparoscopic radical prostatectomy. BJU Int 2008; 103:957-63. [PMID: 19076148 DOI: 10.1111/j.1464-410x.2008.08278.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate the difference in outcome of bladder neck contracture (BNC) and its causes between large groups of patients undergoing open radical prostatectomy (ORP) and robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS We analysed 200 consecutive RPs performed by one surgeon for prostate cancer, 100 by ORP and 100 by RALP, between March 2003 and September 2007. The operative techniques of bladder neck repair and urethro-vesical anastomosis were different. The ORP patients had a conventional stomatization and 'racquet handle' repair of the bladder if necessary, with mucosal eversion and a direct circular interrupted 'end-to-end' suture anastomosis between the bladder and urethra. The RALP patients had no bladder neck reconstruction or mucosal eversion and their anastomosis was by the continuous suture 'parachute' technique. RESULTS There was no BNC in the RALP group, whilst 9% of the ORP group developed a BNC (P < 0.005). Apart from surgical technique, other variables, including patient age, previous transurethral resection of the prostate, Gleason score, T stage, urine infection rate, urinary leakage, blood loss, drain tube removal, anastomotic suture material, catheter type and catheter removal times were statistically comparable in both groups. CONCLUSION This series suggests that the major factor involved in the cause of bladder neck contracture after ORP, relates to the stomatization or 'racquet handle' bladder neck repair, and the end-to-end anastomosis between the urethra and stomatized bladder. Mucosal eversion might also contribute. Normal postoperative urinary leakage when the anastomotic apposition is good seems unlikely to be a significant aetiological factor in the development of BNC. Prolonged urinary leakage results from an anastomotic gap, which heals by second intention, thereby causing scarring and BNC. The RALP 'parachute' technique, which expands the anastomosis towards the bladder, appears to protect against BNC. Mucosal eversion is not necessary in the parachute repair.
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Affiliation(s)
- David R Webb
- University of Melbourne, Surgery and Urology, Austin Hospital, Australia.
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Yazici S, Inci K, Yuksel S, Bilen CY, Ozen H. Radical prostatectomy after previous prostate surgery: effects on surgical difficulty and pathologic outcomes. Urology 2008; 73:856-9. [PMID: 19022487 DOI: 10.1016/j.urology.2008.09.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Revised: 08/17/2008] [Accepted: 09/12/2008] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To evaluate the surgical difficulty and pathologic outcomes of patients who had undergone radical prostatectomy after previous prostate surgery. METHODS A total of 45 patients with previous prostate surgery underwent radical retropubic prostatectomy for prostate cancer. The surgical difficulty and pathologic outcomes for this group of patients (group 1) were compared with those for 50 consecutive patients who had undergone radical retropubic prostatectomy as their only prostatic surgery (group 2). The estimated blood loss and operative time were accepted as surrogates for surgical difficulty. Surgical margin status, seminal vesicle invasion, and extracapsular extension were evaluated to determine the pathologic outcomes. Late complications, including urinary incontinence and anastomotic stricture, were also assessed. RESULTS Radical prostatectomy was technically more challenging in the patients after previous prostate surgery compared with surgery-naive patients, with significantly more estimated blood loss (P <.05) and a longer operative time (P <.001). A unilateral or bilateral nerve-sparing procedure was performed in only 9 patients in group 1 but in 35 patients in group 2, resulting in low potency rates in group 1. The mean hospital stay was significantly longer in group 1. The continence rate was significantly greater in surgery-naive patients. No difference was found between the groups with regard to the rate of seminal vesical invasion, extracapsular extension, and surgical margin status. CONCLUSIONS Although radical retropubic prostatectomy is technically more difficult after previous prostate surgery, it can be performed safely with no difference in pathologic outcomes from those seen in patients with no history of prostate surgery.
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Affiliation(s)
- Sertac Yazici
- Department of Urology, Hacettepe University School of Medicine, Ankara, Turkey
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Gaya sopena J, Palou redorta J, Arañó beltrán P, Caparrós sariol J, Villavicencio mavrich H. [Complex reconstructive surgery of cervico-urethral sclerosis after radical prostatectomy, due to endoscopic solution failure]. Actas Urol Esp 2008; 32:752-5. [PMID: 18788494 DOI: 10.1016/s0210-4806(08)73925-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The sclerosis of the cervico-urethral union is one of the complications that may arise after a radical prostatectomy, in most cases, the endoscopic treatment usually solves it. We introduce repair by open approach of a sclerosis cervico-urethral after radical prostatectomy that did not respond to endoscopic management. The surgical technique had two times, the first perineal and a second time with hypogastric approach. After six months of this complex surgery an artificial sphincter was placed to patient. The patient is asymptomatic and continent after three years of follow up surgery.
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Suardi N, Scattoni V, Briganti A, Salonia A, Naspro R, Gallina A, Cestari A, Colombo R, Karakiewicz PI, Guazzoni G, Rigatti P, Montorsi F. Nerve-Sparing Radical Retropubic Prostatectomy in Patients Previously Submitted to Holmium Laser Enucleation of the Prostate for Bladder Outlet Obstruction Due to Benign Prostatic Enlargement. Eur Urol 2008; 53:1180-5. [DOI: 10.1016/j.eururo.2007.07.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2007] [Accepted: 07/12/2007] [Indexed: 11/30/2022]
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[The revival of "uroscopy": an easy way to evaluate the anastomotic region after radical retropubic prostatectomy]. Urologe A 2008; 47:331-6. [PMID: 18210070 DOI: 10.1007/s00120-007-1615-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The cystogram after retropubic radical prostatovesiculectomy (RRP) examines the condition of the anastomosis region. There is no clear temporal recommendation for the determination of urine extravasation in cases of early removal of the catheter. This study investigates the macroscopic and microscopic examination of the bladder catheter urine after RRP. PATIENTS AND METHODS The catheter urine of 110 patients after RRP was macroscopically and microscopically examined and compared with the results of transrectal ultrasound and cystogram with regard to urine extravasation. RESULTS The examination of cloudy or bloody catheter urine indicated an extravasation in 32 of 33 cases (positive predictive value 97%; sensitivity 74%), for clear urine, there was sufficient anastomosis in 66 of 77 cases without any extravasation (negative predictive value 86%; specificity 99%). By performing a microscopic urine analysis unremarkable anastomosis was predicted only in 23 of 67 cases, which leads to a specificity of 34%. This shows that microscopic urine sediment is an inappropriate instrument to evaluate the anastomotic region. CONCLUSION In cases of macroscopic pathological urine findings, further diagnostics are not recommended; in 97% of the cases, extravasation is expected. The macroscopic urine examination sets a trend for other examinations like cystogram or dynamic transrectal ultrasound (dTRUS).
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Bachmann A. Editorial comment on: cold-knife incision of anastomotic strictures after radical retropubic prostatectomy with bladder neck preservation: efficacy and impact on urinary continence status. Eur Urol 2007; 54:654-5. [PMID: 18155823 DOI: 10.1016/j.eururo.2007.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Hakenberg OW. Editorial comment on: cold-knife incision of anastomotic strictures after radical retropubic prostatectomy with bladder neck preservation: efficacy and impact on urinary continence status. Eur Urol 2007; 54:656. [PMID: 18155827 DOI: 10.1016/j.eururo.2007.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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The impact of urinary drainage on the development of anastomotic stricture after radical retropubic prostatectomy. Int Urol Nephrol 2007; 40:667-73. [PMID: 18097770 DOI: 10.1007/s11255-007-9309-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2007] [Accepted: 11/07/2007] [Indexed: 10/22/2022]
Abstract
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.
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Giannarini G, Manassero F, Mogorovich A, Valent F, De Maria M, Pistolesi D, De Antoni P, Selli C. Cold-knife incision of anastomotic strictures after radical retropubic prostatectomy with bladder neck preservation: efficacy and impact on urinary continence status. Eur Urol 2007; 54:647-56. [PMID: 18155824 DOI: 10.1016/j.eururo.2007.12.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2007] [Accepted: 12/06/2007] [Indexed: 11/25/2022]
Abstract
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.
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Reply by Authors. J Urol 2007. [DOI: 10.1016/j.juro.2007.08.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Patel SG, Cookson MS, Clark PE, Smith JA, Chang SS. Neovesical-urethral anastomotic stricture after orthotopic urinary diversion: presentation and management. BJU Int 2007; 101:219-22. [PMID: 17941923 DOI: 10.1111/j.1464-410x.2007.07237.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the frequency, presentation, treatment, and outcomes of bladder neck contractures (BNCs) among patients who had an orthotopic urinary diversion after radical cystectomy. PATIENTS AND METHODS We retrospectively examined our single-institution database of 788 patients who had a radical cystectomy from 1 January 1996 to 4 January 2006 for BNC; variables evaluated included presentation, degree of stricture/contracture, clinical management, and outcomes after management. RESULTS Of the 374 patients who had an orthotopic urinary diversion, 11 (2.9%) men developed BNC; four BNCs were between 17 F and 22 F, six were <17 F, and one was pinhole-sized. Nine of the 11 patients presented with voiding difficulties, one in complete retention after complicated urinary tract infection, and one with new-onset nocturnal urinary incontinence. The treatment of BNC included cystoscopic dilatation in the clinic in six and under anaesthesia in three, and transurethral incision with a Collins knife or holmium laser in seven. After treatment, all patients were instructed to use continuous intermittent catheterization (CIC). Ten patients had follow-up data available after the intervention, with a mean (range) follow-up of 40.6 (10.6-98.0) months. Six patients were stricture-free for a mean period of 35.4 (10.6-98.0) months, while four patients had a recurrence within a mean of 7.4 (1.3-17.1) months. At the last follow-up, nine of the 10 patients were using CIC. No patient had significant daytime or night-time incontinence after treatment. CONCLUSION BNC develops in a small proportion of patients undergoing orthotopic urinary diversion, with most patients presenting with voiding difficulty. Most will require transurethral incision rather than an office-based dilatation. After endoscopic incision to correct BNC, we recommend CIC to ensure complete emptying and to maintain the patency of the anastomotic stricture.
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Affiliation(s)
- Sanjay G Patel
- Vanderbilt University Medical Center, Department of Urologic Surgery, Nashville, TN 37232-5770, USA
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Comparison of Open and Laparoscopic Radical Prostatectomy Outcomes from a Surgeon’s Early Experience. Urology 2007; 70:667-71. [DOI: 10.1016/j.urology.2007.06.1104] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2007] [Revised: 04/22/2007] [Accepted: 06/26/2007] [Indexed: 11/18/2022]
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Sultan R, Slova D, Thiel B, Lepor H. Time to Return to Work and Physical Activity Following Open Radical Retropubic Prostatectomy. J Urol 2006; 176:1420-3. [PMID: 16952648 DOI: 10.1016/j.juro.2006.06.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2005] [Indexed: 11/22/2022]
Abstract
PURPOSE We identified factors that predict return to part-time and full-time work and resumption of unlimited physical activity following open radical retropubic prostatectomy. MATERIALS AND METHODS Between July 1, 2002 and February 28, 2005, 537 men with clinically localized prostate cancer underwent open radical retropubic prostatectomy, as performed by a single surgeon. Intraoperative, perioperative and postoperative parameters were recorded in real time and entered into a database. An assessment was made 1 and 3 months postoperatively regarding time to return to work and unrestricted physical activity. RESULTS Of the men 50% returned to part-time and full-time work, and unrestricted activity within 14, 21 and 30 days after discharge home, respectively. Patient age and hematocrit at hospital discharge significantly predicted return to part-time and full-time work, and unlimited physical activity. The number of days that the urinary catheter was indwelling was also associated with return to part-time work. Occupation (blue vs white collar) and marital status were also associated with return to full-time work. In the multivariate model a unit increase in hematocrit decreased the time to return to part-time and full-time work, and unrestricted physical activity by 0.50, 0.60 and 0.59 days, respectively. Men with discharge hematocrit greater than 32% were 1.57 (p = 0.059), 1.65 (p = 0.041) and 2.03 (p = 0.002) times more likely to return to part-time and full-time work, and unlimited activity before 14, 21 and 30 days, respectively. Overall models were developed that accounted for 9.4%, 14.0% and 4.0% of the time to return to part-time work, full-time work and unrestricted physical activity, respectively. CONCLUSIONS Efforts to increase discharge hematocrit by minimizing intraoperative blood loss or using preoperative blood management strategies and earlier removal of the urinary catheter have a favorable impact on the return to work and physical activity.
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Affiliation(s)
- Raymond Sultan
- Department of Urology, New York University School of Medicine, New York, New York 10016, USA
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