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Shah M, Medina LG, Azhar RA, La Riva A, Ortega D, Sotelo R. Urine leak after robotic radical prostatectomy: not all urine leaks come from the anastomosis. J Robot Surg 2021; 16:247-255. [PMID: 33895942 DOI: 10.1007/s11701-021-01242-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 04/14/2021] [Indexed: 11/27/2022]
Abstract
Radical prostatectomy is the gold standard in patients that are surgical candidates with localized prostate cancer. While most postoperative urine leaks are from vesico-urethral anastomosis, urologists must be aware that a small percentage of patients may have a urine leak from other sites that may have been inadvertently injured during the procedure. We propose a systematic workup to evaluate the source of the urinary leak as well as appropriate management of such injuries. The mid-ureter can be injured during lymph node dissection. The distal ureter is at risk of injury when performing the Montsouris approach. The posterior bladder neck dissection can at times be challenging. If not careful, one can easily cause an injury to the trigone and/or ureteral orifices. The most common site of leak is at the vesico-urethral anastomosis due to a non-watertight closure. The management of intraoperatively detected ureteral injuries require placement of a ureteral stent. The location, severity and type of injury determine the reconstruction required to fix it. Postoperatively urine leak can be frequently detected when assessing the pelvic drain, and imaging such as CT Urogram with a cystogram phase may be helpful in the diagnosis. Urine leak after robotic-assisted laparoscopic radical prostatectomy remains a rare complication, sometimes the diagnosis can be challenging, and management varies depending on the site and severity of injury.
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Affiliation(s)
- Mihir Shah
- Christiana Care Urology, Wilmington, Delaware, USA
| | - Luis G Medina
- USC Institute of Urology, University of Southern California, 1441 Eastlake Ave., Suite 7416, Los Angeles, CA, 90089-9178, USA
| | - Raed A Azhar
- Department of Urology, King Abdul Aziz University, Jeddah, Saudi Arabia
| | - Anibal La Riva
- USC Institute of Urology, University of Southern California, 1441 Eastlake Ave., Suite 7416, Los Angeles, CA, 90089-9178, USA
| | - David Ortega
- USC Institute of Urology, University of Southern California, 1441 Eastlake Ave., Suite 7416, Los Angeles, CA, 90089-9178, USA
| | - Rene Sotelo
- USC Institute of Urology, University of Southern California, 1441 Eastlake Ave., Suite 7416, Los Angeles, CA, 90089-9178, USA.
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Siltari A, Riikonen J, Murtola TJ. Preservation of Endopelvic Fascia: Effects on Postoperative Incontinence and Sexual Function - A Randomized Clinical Trial. J Sex Med 2020; 18:327-338. [PMID: 33358241 DOI: 10.1016/j.jsxm.2020.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/17/2020] [Accepted: 11/20/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Urinary incontinence and sexual dysfunction are common after robot-assisted radical prostatectomy (RALP). New surgical techniques to improve these functions after the operation are under evaluation for example, preservation of endopelvic fascia during RALP. However, the benefits of this technique have not been critically scrutinized in a randomized setting. AIM In this study, we compared endopelvic fascia preserving operation with the standard surgical procedure in a randomized trial at the Tampere University Hospital, Finland. METHODS A total of 158 men with localized prostate cancer and scheduled for RALP were randomized 1:1 into endopelvic fascia-preserving RALP or a control group that is, standard operation. All operations were performed by a single surgeon. OUTCOMES Urinary and sexual function were evaluated by the Expanded Prostate Cancer Index Composite-26 questionnaire at baseline and 3, 6, and 12 months after the surgery. RESULTS There was no difference in urinary incontinence or sexual function between the groups at any time point (urinary incontinence domain at 12 months after RALP for fascia preserving and control group 73.6 ± 3 vs 78.9 ± 2.5 and sexual domain 43 ± 3.2 vs 40.3 ± 3, respectively). Clinical and pathologic tumor characteristics, duration of surgery, blood loss, rate of complications, and time to hospital discharge were similar between the study arms. Compliance of filling out the Expanded Prostate Cancer Index Composite-26 questionnaire varied from 91% to 98%, with no difference between study arms. CLINICAL IMPLICATIONS Based on our results, endopelvic fascia preservation alone during RALP is not recommended over the standard surgical method. STRENGTHS & LIMITATIONS This is a randomized clinical study with sufficient statistical power. As a limitation, only a minority of participants underwent magnetic resonance imaging before the operation, thus we could not evaluate the role of urethral length or shape of the prostate. Urinary and sexual function results are based on questionnaires filled out by the patients, however, participants completed the surveys independently unassisted by health care personnel. CONCLUSION Endopelvic fascia-preserving RALP does not improve urinary continence or sexual function as compared with the standard surgical technique. Future studies aiming to improve functional outcomes after RALP should focus on evaluating other technique modifications. Siltari A, Riikonen J, Murtola TJ. Preservation of Endopelvic Fascia: Effects on Postoperative Incontinence and Sexual Function - A Randomized Clinical Trial. J Sex Med 2021;18:327-338.
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Affiliation(s)
- Aino Siltari
- Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland; Department of Pharmacology, University of Helsinki, Faculty of Medicine, Helsinki, Finland
| | - Jarno Riikonen
- Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland; TAYS Cancer Center, Department of Urology, Tampere, Finland
| | - Teemu J Murtola
- Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland; TAYS Cancer Center, Department of Urology, Tampere, Finland; Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland.
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Riikonen J, Pakarainen T, Siltari A, Pienimäki JP, Koskimäki J, Murtola TJ. Urine colour as an indicator for anastomotic leakage after robot-assisted radical prostatectomy. Scand J Urol 2020; 54:201-207. [PMID: 32308088 DOI: 10.1080/21681805.2020.1750474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objectives: To determine whether macroscopic haematuria predicts urethrovesical anastomotic leakage after robot-assisted laparoscopic radical prostatectomy (RALP) as well as a cystogram.Patients and methods: Participants were recruited before cystogram and catheter removal 5-14 days after RALP surgery. Urine colour in the collection bag was classified according to a three-step scale (clear, light red and dark red) and leakages in cystogram were graded with a four-step scale (Grade 0-3). Diagnostic accuracy parameters were calculated for urine colour. A multivariate logistic regression model was used to evaluate other leakage risk factors.Results: Of 214 patients, 201 (94%) had clear, six (3%) had light red and seven (3%) had dark red coloured urine. In the cystogram, 20 (9%) patients had leakage; 14 had Grade 1, five Grade 2 and one Grade 3 leakage. Overall, specificity and sensitivity of urine colour in predicting anastomotic leakage were 0.97 (95% CI = 0.95-100) and 0.38 (95% CI = 0.17-0.59), respectively. Negative and positive predictive values were 94% and 62%, respectively. Other significant risk factors for anastomotic leakage were previous transurethral resection or radiation therapy to the prostate, non-waterproof anastomosis at surgery, postoperative pelvic haematoma, long catheterization and surgeon's inexperience. In patients with no other risk factors, test sensitivity improved to 0.80 (95% CI = 0.45-1.15) and negative and positive predictive values to 99% and 44%, respectively.Conclusion: This prospective single-arm trial indicates that in patients with clear urine and no other risk factors for anastomotic leakage, a cystogram examination before urethral catheter removal can be safely omitted.
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Affiliation(s)
- Jarno Riikonen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,TAYS Cancer Center, Department of Urology, Tampere University Hospital, Tampere, Finland
| | - Tomi Pakarainen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,TAYS Cancer Center, Department of Urology, Tampere University Hospital, Tampere, Finland
| | - Aino Siltari
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Juha-Pekka Pienimäki
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Medical Imaging Center, Tampere University Hospital, Tampere, Finland
| | - Juha Koskimäki
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,TAYS Cancer Center, Department of Urology, Tampere University Hospital, Tampere, Finland
| | - Teemu J Murtola
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,TAYS Cancer Center, Department of Urology, Tampere University Hospital, Tampere, Finland.,Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
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Degheili JA, Malhas H, Yoo TK. Unorthodox cause of urinary leak post radical prostatectomy: Catheter balloon within a bladder diverticulum - Case report and highlights on various methods to overcome leaks. Int J Surg Case Rep 2020; 67:196-199. [PMID: 32062506 PMCID: PMC7025078 DOI: 10.1016/j.ijscr.2020.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 01/31/2020] [Accepted: 02/04/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Radical prostatectomy for prostate cancer has been increasingly adopted, especially for localized disease. Nevertheless, this has not been without any morbidities. Complications, such as urine leak, related to malpositioned or malfunctional indwelling catheters, are rarely reported. PRESENTATION OF CASE A 75-year-old male underwent an open radical prostatectomy for prostate cancer. Soon after surgery, he witnessed urine leak and extravasation. Imaging including a plain CT scan with a retrograde cystography, showed the tip of the indwelling catheter within a diverticular pouch of the bladder; itself possessing two anterior diverticular pouches, giving the shape of a "Mickey-Mouse" like bladder. The balloon was deflated, and the Foley catheter was repositioned within the bladder, under fluoroscopy. The urine leak from the surgical wound and through the urethra, completely vanished. DISCUSSION Urinary leak due to indwelling catheter malfunction or malposition, post radical prostatectomy, is very rare. Only one similar case has been reported so far. Vesicourethral anastomotic leak post prostatectomy is commonly seen, and mostly due to disruption in the posterior anastomosis. Risk factors for such leaks are various and may include: large prostate, previous transurethral resections, techniques adopted for anastomosis and bladder neck reconstruction, among others. Most leakage cases resolve spontaneously or using conservative measures. Those requiring more aggressive interventions are a minority. CONCLUSION Urethrovesical anastomotic leaks are commonly seen after radical prostatectomy. Although most cases are self-limited; others can be managed by various minimally-invasive procedures, diverting urine away from the anastomosis, giving it a chance to properly heal.
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Affiliation(s)
- Jad A Degheili
- Division of Urology, Department of Surgery, American University of Beirut - Medical Center, Riad El-Solh 1107 2020, Beirut, Lebanon.
| | - Haya Malhas
- Department of Medicine, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait city, Al Asimah, Kuwait.
| | - Tag Keun Yoo
- Department of Urology, Nowon Eulji Medical Center, Eulji University School of Medicine, 68, Hangeulbiseok-ro, Nowon-gu, Seoul, South Korea.
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Diamand R, Al Hajj Obeid W, Accarain A, Limani K, Hawaux E, van Velthoven R, Peltier A. Management of Anastomosis Leakage Post-RALP: A Simple Trick for a Complex Situation. Urol Case Rep 2017; 12:28-30. [PMID: 28280688 PMCID: PMC5342985 DOI: 10.1016/j.eucr.2017.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 02/06/2017] [Indexed: 11/30/2022] Open
Abstract
A case of 74 years old male patient who underwent RALP with bladder neck reconstruction. Persistent vesicourethral anastomotic leak was seen at cystography. A self-made side fenestrated Foley catheter was used and on the day after, a complete reversal in fluid output between the Foley catheter and the drain was seen.
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Affiliation(s)
- Romain Diamand
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - Walid Al Hajj Obeid
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - Anna Accarain
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - Ksenija Limani
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - Eric Hawaux
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - Roland van Velthoven
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Peltier
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
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