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

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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 inter- rupted 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 ret- ropubic 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 cys- tography or pericatheter RGU on postoperative day 7, we per- formed 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.
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