Usefulness of Cystography After Radical Retropubic Prostatectomy: a Prospective Comparison Between Cystography and Pericatheter Retrograde Urethrography

Korean J Urol Oncol 2011;9(1):17-22

Usefulness of Cystography after Radical Retropubic Prostatectomy: a Prospective Comparison between Cystography and Pericatheter Retrograde Urethrography

Jong Kil Nam, Chang Soo Park, Tae Nam Kim, Sung Woo Park, Wan Lee, Moon Kee Chung Department of Urology, Pusan National University Yangsan Hospital, Yangsan, Korea

Purpose: To evaluate the usefulness of cystography after radical retropubic prostatectomy and the appropriated period of indwelling catheter removal, we prospectively compared the usefulness of cystography and pericatheter RGU to assess the integrity of the anastomosis site. Materials and Methods: Between 2009 and 2010, cystography and pericatheter RGU was performed in 113 patients who underwent radical prostatectomy on POD 3 and 7 to reveal the presence of extravasation. If anastomotic extravasation was showed by both tests on POD 7, we performed the follow-up imaging study until there was no sign of the contrast extravasation. Results: The mean age of the study population was 66.0±6.1 years (range 51-82). The number of the patients who showed no extravasation on POD 3 and 7 were 81 and 96 patients, respectively. In cases of extravasation on POD 3, 2 patients showed only on cystography, 3 patients only on pericatheter RGU and 27 patients on both images. In cases of extravasation on POD 7, 3 patients showed only on cystography, 2 patients only on pericatheter RGU and 12 patients on both images. The 244 pairs of total 259 pairs (94.2%) showed concordant results on both imaging studies. There was no significant difference in extravasation rates between the two operation methods Conclusions: Our study showed that both tests provided similar results in all patients. However, because cystography is more simplicity, and less affected by technique, we suggest that cystography is more preferable. Because of the false negative results and the potential for disruption, we currently recommend delaying catheter removal until postoperative day 7 or later. (Korean J Urol Oncol 2011;9:17-22) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 Key Words: Prostatectomy, Catheterization, Urethra, Urinary bladder

technique of radical prostatectomy has undergone many refine- INTRODUCTION ments, including reduced blood loss through better control of the dorsal vein complex and preservation of erectile function One of the main therapeutic approaches for the treatment of by sparing the neurovascular bundles.1,2 The vesicourethral localized prostate cancer is radical prostatectomy. The surgical anastomosis can be effectively accomplished with either interrupted or running sutures.1-5 Received March 12, 2011, Revised April 9, 2011 (1st), April 11, 2011 (2nd), Accepted April 11, 2011 Leaving an indwelling urethral catheter is mandatory after Corresponding Author: Moon Kee Chung, Department of Urology, radical prostatectomy to allow anastomotic healing.1,2 In many Pusan National University Yangsan Hospital, Pusan National institutions, pericatheter retrograde urethrography (RGU) or University School of Medicine, Beomo-ri, Mulgeum-eup, Yangsan 626-770, Korea. Tel: 82-55-360-2134, Fax: 82-55- cystography is obtained routinely after radical retropubic prosta- 360-2164, E-mail: [email protected] tectomy to assess the integrity of the vesicourethral anastomosis This work was supported by Pusan National University Yangsan 6,7 Hospital Research Grant. before the removal of the catheter. When significant anasto- 17 18 대한비뇨기종양학회지：제9권 제1호 2011 motic extravasation is detected, the removal of the catheter is potential extravasation. Extravasation of the contrast at the ves- postponed until urinary leakage ceases. icourethral anastomosis and abnormalities of bladder shape To assess the usefulness of cystography after radical retro- were noted. pubic prostatectomy and the appropriated period of indwelling Correlations of cystography and pericatheter retrograde ure- catheter removal, to evaluate the distinction in leakage rates be- thrography were estimated using Cohen’s Kappa test. The dis- tween the laparoscopic and open methods, we prospectively tinction in leakage rates between the two operation methods compared the cystography and pericatheter RGU to assess the were evaluated using chi-square test and Fisher exact test. integrity of the anastomosis site. Statistical significance was defined as ＜0.05. Analysis was performed using the Statistical Package for Social Science MATERIALS AND METHODS (SPSS), version 12.0 for Windows.

Between June 2009 and May 2010, 113 patients who under- RESULTS went radical prostatectomy were performed via the standard retropubic approach. Mucosal eversion of the bladder neck was The mean age of the study population was 66.1±6.1 years performed in all patients. Vesicourethral continuity was ach- (range, 51-82 years) and the mean prostate volume was ieved in all patients by a direct end-to-end anastomosis. The 36.8±12.6g. The mean catheterization period was 8.6 days 29 patients who underwent open surgery were performed six (range, 7-21 days) and the number of patient who had localized, full-thickness sutures and 84 patients who underwent laparo- locally advanced and advanced prostate cancer were 85, 26 and scopic surgery were continuous running sutures which were 2, respectively. 36 patients (31.9%) showed positive surgical used to reapproximate the urethral stump to the bladder neck margin and the number of patients who underwent open surgery over an 18 to 22 Fr hematuria Foley catheter. The retropubic and laparoscopic surgery were 29 and 84, respectively (Table 1). space was drained with a Penrose or closed suction device The number of the patients who showed no extravasation on (Hemovac). postoperative day 3 and 7 were 81 (71.7%) and 96 (85.6%), Cystography and pericatheter RGU were done in all patients respectively. In cases of extravasation on postoperative day 3, on postoperative day 3 and 7 to reveal the presence of 2 patients showed only on cystography, 3 patients only on peri- extravasation. If anastomotic extravasation was showed by cystography or pericatheter RGU on postoperative day 7, we performed the follow-up imaging study on postoperative day 10, Table 1. Clinicopathological characteristics of patients 14 and 21 days until there was no sign of the significant con- Variables n=113 trast extravasation. In order to standardize the technique of cys- Mean age (years) 66 (51-82) tography involved infusion of approximately 200cc of contrast Baseline PSA (ng/ml) 15.75±23.1 material by gravity into the bladder through the indwelling Prostate volume (g) 36.82±12.64 Foley catheter and stopped as soon as the patient felt some dis- Gleason score ≤6 41 comfort or the urge to void. During the cystographic procedure, 7 60 the catheter was advanced slightly (about 5cm) to avoid com- ≥8 12 pressing the bladder neck. Before the pericatheter RGU, the Pathologic stage Localized 85 contrast material in patient was completely emptied. The techni- Locally advanced 26 que of pericatheter RGU were obtained under fluoroscopic con- Advanced 2 trol by infusing 50ml of contrast material into the bladder Surgical margin through the side of indwelling catheter. Positive 36 Negative 77 Multiple films of bladder and vesicourethral junction were Operation method obtained in anteroposterior, lateral, and oblique projections. Open surgery 29 Films were also obtained after manipulation of the Foley bal- Laparoscopic surgery 84 loon and after bladder emptying in an attempt to demonstrate PSA: prostate-specific antigen. Jong Kil Nam, et al：Usefulness of Cystography after Radical Prostatectomy 19

Table 2. Cystography and pericatheter RGU results according to postoperative day POD 3 POD 7 POD 10 POD 14 POD 21 No leakage of both tests 81 96 6 6 5 Leakage of both tests 27 12 8 3 0 Cystography only leakage 2 3 1 1 0 Pericatheter RGU only leakage 3 2 2 1 0 Total 113 113 17 11 5 Cohen’s Kappa test (κ) 0.89* 0.80* - - - RGU: retrograde urethrography, POD: postoperative day. *p＜.001

Table 3. Cystography and pericatheter RGU results according to operation methods Postoperative day 3 Postoperative day 7 Laparoscopic Laparoscopic Open surgery Open surgery surgery p-value surgery p-value (n=29) (n=29) (n=84) (n=84) No leakage of both tests 22 59 0.17* 25 71 0.47* † † Leakage of both tests 5 22 0.49 3 9 0.59 Cystography only leakage 0 2 - 0 3 - Pericatheter RGU only leakage 2 1 - 1 1 - † RGU: retrograde urethrography. *Chi-square test, Fisher exact test. catheter RGU and 27 patients on both images. In cases of ex- the vesicourethral anastomosis before the removal of the travasation on postoperative day 7, 3 patients showed only on catheter.6,7 When significant anastomotic extravasation is de- cystography, 2 patients only on pericatheter RGU and 12 pa- tected, the removal of catheter is postponded until urinary leak- tients on both images (Table 2). age ceases. Urethral catheter was removed in the patients who showed The treatment of patients after radical prostatectomy has his- no extravasation on postoperative day 7. 108 patients (95.6%) torically been associated with a long period of catheteri- showed concordant results on both imaging studies on post- zation.1,2,8,10 An indwelling catheter is required to prevent uri- operative day 3 and 7. The 241 pairs of total 259 pairs’ imaging nary leakage and to allow the vesicourethral anastomosis to studies (94.2%) showed concordant results on both studies heal.8 However, during the last three decades, the surgical treat- (κ=0.833, p＜0.01) (Table 2). As shown in Table 3, there was ment of prostate cancer has changed remarkably, because of no significant difference in extravasation rates between the two both better knowledge of prostate anatomy and advances in sur- operation methods. Most patients who showed no leakage on gical techniques.2,3,11,12 Therefore, the duration of Foley cathe- postoperative day 3 also had no leakage on postoperative day terization after radical prostatectomy has decreased pro- 7, but there was delayed leakage in 3 cases. gressively. The average duration of catheterization is 10-15 days in many experienced urologic centers.12-15 However, this DISCUSSION recommendation regarding the timing of catheter removal has not been determined by evidence-based medicine. Approxi- Cystography and pericatheter RGU are a contrast radio- mately 40% of men who underwent radical prostatectomy re- graphic technique that can be used in evaluation of the ves- ported moderated-to-severe bother caused by the Foley catheter.6 icourethral anastomosis.8,9 These are relatively safe, inexpensive To reduce this bother, urologists have been removing the Foley and easy to perform, and does not require any special catheter earlier after radical prostatectomy. Leaving an in- equipment. In many institutions, these are obtained routinely af- dwelling catheter for a long period has not been supported by ter radical retropubic prostatectomy to assess the integrity of any objective data,16,17 but early catheter removal has been dis- 20 대한비뇨기종양학회지：제9권 제1호 2011 couraged on the assumption that early extravasation of urine edema of anastomotic site. Also possibly, early removal of would be associated with resulting formation of urinoma, pelvic catheter was the potential for disruption of the anastomosis or abscess, acute urinary retention and possibly bladder neck bladder neck reconstruction. Although, we believe that catheter- stricture.8,18 In some studies, the increased rate of acute urinary ization was unnecessary for greater than 3 to 4 days. Because retention, which is caused by edema at the anastomosis site, of the false negative results and the potential risks, we recom- has been reported. We believe that some modifications in surgi- mend delaying catheter removal until postoperative day 7. cal techniques have been suggested to improve postoperative Cystography and pericatheter RGU evaluated for removal of stricture or continence, including mucosa-to-mucosa apposition the urinary catheter after radical prostatectomy.6,8,9 However, of the bladder neck to the urethra, the need to avoid excessive these imaging techniques were different techniques. Although tightening and/or devascularization of the bladder neck, bladder both tests are known useful, the flow of contrast while perform- neck preservation and variation in techniques of apical ing cystography and pericatheter RGU are dissimilar and this dissection.19,20 Urinary catheterization is a source of infection, means that these imaging techniques does not have the same significant discomfort, and anxiety for the patient undergoing results. In our study, most patients showed concordant results radical prostatectomy.21-23 In our institution, if extravasation of on both imaging studies. However, in some cases of discordant anastomosis site was not showed by cystography and peri- results, Fig. 1A and B shows normal cystography with abnor- catheter RGU on postoperative day 7, whether there was no ex- mal (positive urine leakage) pericatheter RGU and Fig. 1C and travasation on postoperative day 3, we performed the catheter D shows abnormal cystography with normal pericatheter RGU. removal. In this study, we performed the imaging study until Cystography and pericatheter RGU have been used to eval- there was no sign of the contrast extravasation. Because Koch uate anastomotic integrity and as a tool for removing catheters et al showed that it is safe to remove catheter in most patients earlier after post-radical prostatectomy.6,9 In this study, we 3 to 4 days in 72%,24 and Lepor et al reported on a series of found the same results between the leakage detection rate with 184 patients and found that the catheter could be successfully cystography and pericatheter RGU (κ=0.83). Therefore, we sug- removed on postoperative day 7 in 71%.6 In Korean literatures, gest that both imaging techniques can be useful in evaluation Kang et al. showed that the catheter can be safely removed, with of the vesicourethral anastomosis after radical prostatectomy. caution, on postoperative day 6 days after radical prostatectomy.25 However, we think that cystography was more simple and In our study, 81 patients showed no extravasation of contrast more physiologic technique because the flow of urine while on postoperative day 3 but, 3 cases showed extravasation of voiding and contrast while performing cystography are similar contrast on postoperative day 7. These results suggest that it and it is easy to standardize. Moreover, venous intravasation is possible to false negative findings due to blood clot or tissue of contrast material in the corpus spongiosum and surrounding

Fig. 1. Some cases of discordant results. (A) and (B) shows normal cystography with abnormal(open arrow) pericatheter RGU. (C) and (D) shows abnormal (arrow) cystography with normal pericatheter RGU. Jong Kil Nam, et al：Usefulness of Cystography after Radical Prostatectomy 21 veins, indicating excessive pressure or speed of contrast in- dicts the development of urinary extravasation on cystogram jection is possible in pericatheter RGU. Despite the limitations, following radical retropubic prostatectomy. J Urol 2006;175: 146-50 Pericatheter RGU may be useful in some cases of clinically 8. Leibovitch I, Rowland RG, Little JS Jr, Foster RS, Bihrle R, suspected vesicourethral leakage in which the findings of cys- Donohue JP. Cystography after radical retropubic prostatec- tography are negative. tomy: clinical implications of abnormal findings. Urology There are several limitations to our study. The number of en- 1995;46:78-80 rolled cases was relatively small in sample size and the fol- 9. Gnanapragasam VJ, Baker P, Naisby GP, Chadwick D. low-up period was short. Therefore, additional confirmatory Identification and validation of risk factors for vesicourethral leaks following radical retropubic prostatectomy. Int J Urol studies are required in the near future. 2005;12:948-52 10. Little JS Jr, Bihrle R, Foster RS. Early urethral catheter re- CONCLUSIONS moval following radical prostatectomy: a pilot study. Urology 1995;46:429-31 Our study showed that cystography and pericatheter RGU 11.Walz J, Burnett AL, Costello AJ, Eastham JA, Graefen M, Guillonneau B, et al. A critical analysis of the current knowl- provided similar results in all patients who underwent open and edge of surgical anatomy related to optimization of cancer con- laparoscopic surgery. However, because cystography is more trol and preservation of continence and erection in candidates simplicity and it is less affected by technique, we suggest that for radical prostatectomy. Eur Urol 2010;57:179-92 cystography is more preferable. Moreover, most patients had a 12. Walsh PC. Anatomic radical prostatectomy: evolution of the no leakage of anastomotic site on postoperative day 3. surgical technique. J Urol 1998;160:2418-24 13. Souto CA, Rhoden EL, De Conti R, Chammas M Jr, Laste However, because of the false negative results and the potential SE, Fornari A, et al. Urethral catheter removal 7 or 14 days for disruption of the anastomosis or bladder neck re- after radical retropubic prostatectomy: clinical implications and construction, we recommend delaying catheter removal until complications in a randomized study. Rev Hosp Clin Fac Med postoperative day 7. Sao Paulo 2004;59:262-5 14. Souto CA, Telöken C, Souto JC, Rhoden EL, Ting HY. 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