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Persistent Vesicourethral Anastomotic Leak After Radical Prostatectomy: A Novel Endoscopic Solution
Persistent Vesicourethral Anastomotic Leak After Radical Prostatectomy: A Novel Endoscopic Solution Ofer Yossepowitch* and Jack Baniel From the Institute of Urology, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Abbreviations and Acronyms RP ⫽ radical prostatectomy UVAL ⫽ urethrovesical anastomotic leak Submitted for publication March 18, 2010. Study received institutional review board approval. * Correspondence: Urologic Oncology Service, Institute of Urology, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel (telephone: 972-3-937-6553; FAX: 972-3-937-6569; e-mail: [email protected]).
Purpose: A vesicourethral anastomotic leak after radical prostatectomy is a common postoperative sequela. Rarely additional intervention is required for a persistent or high output urinary leak. We describe a novel solution to this uncommon complication. Materials and Methods: With the patient under general or spinal anesthesia the technique included 19Fr rigid cystoscopy in a partially distended bladder and insertion of 5Fr Single J® ureteral stents over a hydrophilic guidewire under fluoroscopic guidance. The 2 stents were exteriorized via the urethra beside an 18Fr Foley catheter. We monitored urine output and the relative amount of leak. The Jackson-Pratt drains were removed after leakage decreased to 50 ml or less per day. All patients underwent cystogram to ascertain leak resolution before stent removal. Time to continence was estimated using Kaplan-Meier analysis. Results: Seven of 1,480 patients (0.5%) required intervention for a prolonged or high output anastomotic leak after radical prostatectomy. Mean time from surgery to stent insertion was 6.2 days (range 2 to 12). Stents were retained an average of 9 days (range 6 to 11), enabling complete resolution of the leak within a mean ⫾ SD of 1.8 ⫾ 0.9 days. Median time to recovery of urinary continence was 20 ⫾ 1.7 weeks. Conclusions: Temporary urinary diversion with exteriorized ureteral stents via the urethra is a safe, effective solution for a prolonged or high output anastomotic leak after radical prostatectomy. Recovery of urinary continence may be delayed in this setting but long-term urinary function appears to be unaffected in most patients. Key Words: urinary diversion; prostate; prostatectomy; anastomosis, surgical; urinary incontinence
2452
www.jurology.com
IN men who undergo RP a common finding is UVAL, which can be detected in many patients by conventional or multidetector computerized tomography cystography.1,2 Although it is disconcerting to the patient and frustrating to the physician, UVAL is generally self-limiting and often resolves spontaneously without further intervention. Rarely persistent or high output UVAL is noted with almost all or most of the urine output extravasat-
ing through the pelvic drains. Several measures are advocated in this setting, including prolonged retropubic and bladder drainage, conversion of active (bulb suction) to passive (gravity) drainage, gentle catheter traction, adjustment of the drain position to ensure that its tip is not in close vicinity to the anastomosis, connecting the Foley catheter to intermittent needle vented suction3 and percutaneous placement of nephroureteral stents on suction.4
0022-5347/10/1846-2452/0 THE JOURNAL OF UROLOGY® © 2010 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
Vol. 184, 2452-2455, December 2010 Printed in U.S.A. DOI:10.1016/j.juro.2010.08.014
AND
RESEARCH, INC.
PERSISTENT VESICOURETHRAL ANASTOMOTIC LEAK AFTER RADICAL PROSTATECTOMY
When these maneuvers fail, cystogram is indicated to assess anastomotic integrity and the degree of extravasation. Complete anastomotic disruption mandates surgical repair by open or laparoscopic/robotic technique.5 However, a large anastomotic gap can still be managed by a more conservative approach. We present what is to our knowledge a novel endoscopic solution to this unusual clinical scenario.
METHODS After obtaining institutional review board approval we queried our surgical database to identify all patients who underwent endoscopic surgical intervention for persistent or high output UVAL after RP. The technique included rigid cystoscopy using a 19Fr cystoscope with the patient under general or spinal anesthesia, and characterization of any anastomotic gap and its relative location to each ureteral orifice. Subsequently 5Fr Single J ureteral stents were inserted over a hydrophilic guidewire bilaterally under fluoroscopic control. Each stent was exteriorized via the urethra beside an 18Fr Foley catheter. To prevent inadvertent catheter passage through the hole in the anastomosis the Foley catheter was reintroduced into the bladder over a guidewire after puncturing its distal tip. Also, to avoid compromising any blood supply to the anastomosis we invariably avoided traction on the Foley catheter at this point. We monitored urine output and the relative amount of UVAL. The Jackson-Pratt drains were removed after leakage decreased to 50 ml or less per day. All patients underwent cystogram to ascertain complete leak resolution before stent removal. After the stents were removed the Foley catheter was left indwelling at treating surgeon discretion to facilitate further anastomotic healing. Postoperatively patients were followed routinely with questionnaires related to urinary and sexual function at 6 weeks, 3 months and every 3 months thereafter during the first 2 years. Urinary continence was defined as no protective pad use. Time to urinary continence was treated as a time dependent variable and estimated using KaplanMeier analysis.
2453
Clinical and pathological characteristics in 7 patients with persistent or massive urinary leak after RP Median age at surgery (IQR) Prostate vol (cc): Mean (range) Median (IQR) No. pathological stage (%): pT2b pT2c pT3a Mean ⫾ SD days (range): RP–stent insertion Stent insertion–drain removal Stent indwelling Foley catheter indwelling
64
(56, 69)
68 37
(35–165) (35, 70)
1 3 3
(14) (43) (43)
6.2 ⫾ 3.1 (2–12) 1.8 ⫾ 0.9 (1–3) 9 ⫾ 1.8 (6–11) 22.8 ⫾ 4.7 (19–29)
and were visualized more expediently in a partially distended bladder, allowing clear demarcation of the bladder neck trigone. Mean time from RP to cystoscopy was 6.2 days (range 2 to 12). The average drain output before stent placement on days ⫺3, ⫺2 and ⫺1 was 990 ml (46% of total urine output), 1,210 ml (46% of total urine output) and 1,320 ml (69% of total urine output), respectively. The mean ⫾ SD interval from stent insertion to pelvic drain removal at a daily drain output of 50 ml or less was 1.8 ⫾ 0.9 days (range 1 to 3). Stents were retained an average of 9 days (range 6 to 11) and removed after cystogram confirmed no urinary leakage (fig. 1). No patient required additional percutaneous intervention for pelvic collection and no other adverse sequela was noted during the remaining postoperative convalescence. The Foley catheter was removed an average of 3 weeks (range 19 to 29 days) after surgery. Median time to recovery of urinary continence was 20 ⫾ 1.7 weeks (fig. 2). At a median followup of 38 months 5 of the 7 patients had achieved complete recovery of urinary function while 1 still experienced moderate stress incontinence and used 3 or 4 pads daily 8 months postoperatively. One patient with anastomotic stricture who underwent bladder neck incision subsequently required artificial urinary sphincter placement for total urinary incontinence 14 months after prostatectomy.
RESULTS Endoscopic intervention was required for persistent UVAL in 7 of the 1,480 patients (0.5%) who underwent open retropubic RP between 1996 and 2007. The table lists patient characteristics. All men were clinically asymptomatic before the intervention. In 6 of the 7 patients (86%) endoscopy revealed a wide posterior gap, usually between the 5 and 7 o’clock positions. Undue proximity of the 2 ureteral orifices to the anastomosis was also observed in 5 of the 7 patients, rendering identification of the orifices somewhat cumbersome. The orifices were generally located more medial than expected
DISCUSSION The goals of RP are to eradicate cancer, minimize perioperative complications and optimize the recovery of potency and urinary continence. No surgeon uniformly achieves these results. Advances in technique and better understanding of the prostate and periprostatic anatomy have allowed surgeons to improve outcomes. However, whether RP is done laparoscopically, robotically or using a traditional open approach, it is still considered 1 of the most complex procedures in urology. As such, its unwarranted
2454
PERSISTENT VESICOURETHRAL ANASTOMOTIC LEAK AFTER RADICAL PROSTATECTOMY
Figure 1. A, filling cystogram on postoperative day 4 in patient with high output anastomotic leak after RP. B, repeat cystogram 7 days after urinary diversion with exteriorized ureteral stents reveals complete resolution of leakage.
morbidity remains inevitable. In this context UVAL is 1 of the most common complications. In the late 1990s we adopted an endoscopic approach to the rare case of persistent or high output UVAL after RP. When all conservative measures failed, patients were offered urinary diversion using cystoscopy and exteriorized ureteral stents via the urethra. Our data suggest that the technique is safe and effective, and allows rapid leakage resolution and complete anastomotic healing. Avoiding a fully distended bladder during cystoscopy is advocated to facilitate the rapid identification of the 2 ureteral orifices, which are generally located more medial than expected. This solution is appropriate in patients noted to have a wide anastomotic gap on cystoscopy. Those with complete anastomotic disruption are better served by surgical repair and reanastomosis.
Figure 2. Kaplan-Meier estimated time to complete urinary continence.
While recovery of urinary continence in this setting may be delayed, the long-term urinary function outcome appears to be unaffected in most patients. The technical difficulty of completing a watertight anastomosis using the laparoscopic approach has been recognized by several investigators.6,7 Technical modifications to attain this have been offered, including using running vs interrupted sutures,6 decreasing the overall number of anastomotic sutures,8 using Lapra-Ty™ clips to avoid intracorporeal knot tying9 and ultimately introducing robotic prostatectomy. The widespread endorsement of minimally invasive surgery in urology has rekindled interest in the incidence and outcome of UVAL after laparoscopic or da Vinci® robotic prostatectomy. However, data remain sparse. Compared to historical series a recent study at 1 center of excellence revealed an overall decrease in the incidence of post-prostatectomy leaks.10 On postoperative day 8 slight and moderate urinary extravasation was noted in 12% and 11% of men, respectively, who underwent open RP. A similar UVAL incidence (13.6%) was observed in 490 consecutive patients who underwent robotic prostatectomy.2 While most of these leaks were clinically inconsequential, a major hazard when considering the transperitoneal rather than the extraperitoneal approach is the possibility of urine extending into the peritoneal cavity, resulting in significant abdominal discomfort and prolonged ileus. The latter was identified in 1.2% of all patients and in 9% of all those with a leak.2 To avoid unnecessary morbidity it is prudent that these large or intraperitoneal leaks be addressed expediently. We believe that temporary urinary diversion using bilateral Single J stents is a viable treatment alternative in these cases.
PERSISTENT VESICOURETHRAL ANASTOMOTIC LEAK AFTER RADICAL PROSTATECTOMY
CONCLUSIONS Temporary urinary diversion with exteriorized ureteral stents via the urethra is a safe, effective solution for a prolonged or high output anasto-
2455
motic leak after RP. While recovery of urinary continence may be delayed in this setting, longterm urinary function appears to be unaffected in most patients.
REFERENCES 1. Lee HJ, Shin CI, Hwang SI et al: MDCT cystography for detection of vesicourethral leak after prostatectomy. AJR Am J Roentgenol 2008; 191: 1847. 2. Williams TR, Longoria OJ, Asselmeier S et al: Incidence and imaging appearance of urethrovesical anastomotic urinary leaks following da Vinci robotic prostatectomy. Abdom Imaging 2008; 33: 367.
after robot-assisted laparoscopic radical prostatectomy. Urology 2009; 73: 1375. 5. Castillo OA, Alston C and Sanchez-Salas R: Persistent vesicourethral anastomotic leak after laparoscopic radical prostatectomy: laparoscopic solution. Urology 2009; 73: 124.
3. Moinzadeh A, Abouassaly R, Gill IS et al: Continuous needle vented Foley catheter suction for urinary leak after radical prostatectomy. J Urol 2004; 171: 2366.
6. Teber D, Erdogru T, Cresswell J et al: Analysis of three different vesicourethral anastomotic techniques in laparoscopic radical prostatectomy. World J Urol 2008; 26: 617.
4. Shah G, Vogel F and Moinzadeh A: Nephroureteral stent on suction for urethrovesical anastomotic leak
7. Ferguson GG, Ames CD, Weld KJ et al: Prospective evaluation of learning curve for laparoscopic
radical prostatectomy: identification of factors improving operative times. Urology 2005; 66: 840. 8. Mazaris EM, Chatzidarellis E, Varkarakis IM et al: Reducing the number of sutures for vesicourethral anastomosis in radical retropubic prostatectomy. Int Braz J Urol 2009; 35: 158. 9. Zorn KC: Robotic radical prostatectomy: assurance of water-tight vesicourethral anastomotic closure with the Lapra-Ty clip. J Endourol 2008; 22: 863. 10. Lepor H, Kozirovsky M, Laze J et al: Transabdominal sonocystography: a novel technique to assess vesicourethral extravasation following radical prostatectomy. J Urol 2008; 180: 2459.
Abbreviations and Acronyms RP ⫽ radical prostatectomy UVAL ⫽ urethrovesical anastomotic leak Submitted for publication March 18, 2010. Study received institutional review board approval. * Correspondence: Urologic Oncology Service, Institute of Urology, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel (telephone: 972-3-937-6553; FAX: 972-3-937-6569; e-mail: [email protected]).
Purpose: A vesicourethral anastomotic leak after radical prostatectomy is a common postoperative sequela. Rarely additional intervention is required for a persistent or high output urinary leak. We describe a novel solution to this uncommon complication. Materials and Methods: With the patient under general or spinal anesthesia the technique included 19Fr rigid cystoscopy in a partially distended bladder and insertion of 5Fr Single J® ureteral stents over a hydrophilic guidewire under fluoroscopic guidance. The 2 stents were exteriorized via the urethra beside an 18Fr Foley catheter. We monitored urine output and the relative amount of leak. The Jackson-Pratt drains were removed after leakage decreased to 50 ml or less per day. All patients underwent cystogram to ascertain leak resolution before stent removal. Time to continence was estimated using Kaplan-Meier analysis. Results: Seven of 1,480 patients (0.5%) required intervention for a prolonged or high output anastomotic leak after radical prostatectomy. Mean time from surgery to stent insertion was 6.2 days (range 2 to 12). Stents were retained an average of 9 days (range 6 to 11), enabling complete resolution of the leak within a mean ⫾ SD of 1.8 ⫾ 0.9 days. Median time to recovery of urinary continence was 20 ⫾ 1.7 weeks. Conclusions: Temporary urinary diversion with exteriorized ureteral stents via the urethra is a safe, effective solution for a prolonged or high output anastomotic leak after radical prostatectomy. Recovery of urinary continence may be delayed in this setting but long-term urinary function appears to be unaffected in most patients. Key Words: urinary diversion; prostate; prostatectomy; anastomosis, surgical; urinary incontinence
2452
www.jurology.com
IN men who undergo RP a common finding is UVAL, which can be detected in many patients by conventional or multidetector computerized tomography cystography.1,2 Although it is disconcerting to the patient and frustrating to the physician, UVAL is generally self-limiting and often resolves spontaneously without further intervention. Rarely persistent or high output UVAL is noted with almost all or most of the urine output extravasat-
ing through the pelvic drains. Several measures are advocated in this setting, including prolonged retropubic and bladder drainage, conversion of active (bulb suction) to passive (gravity) drainage, gentle catheter traction, adjustment of the drain position to ensure that its tip is not in close vicinity to the anastomosis, connecting the Foley catheter to intermittent needle vented suction3 and percutaneous placement of nephroureteral stents on suction.4
0022-5347/10/1846-2452/0 THE JOURNAL OF UROLOGY® © 2010 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
Vol. 184, 2452-2455, December 2010 Printed in U.S.A. DOI:10.1016/j.juro.2010.08.014
AND
RESEARCH, INC.
PERSISTENT VESICOURETHRAL ANASTOMOTIC LEAK AFTER RADICAL PROSTATECTOMY
When these maneuvers fail, cystogram is indicated to assess anastomotic integrity and the degree of extravasation. Complete anastomotic disruption mandates surgical repair by open or laparoscopic/robotic technique.5 However, a large anastomotic gap can still be managed by a more conservative approach. We present what is to our knowledge a novel endoscopic solution to this unusual clinical scenario.
METHODS After obtaining institutional review board approval we queried our surgical database to identify all patients who underwent endoscopic surgical intervention for persistent or high output UVAL after RP. The technique included rigid cystoscopy using a 19Fr cystoscope with the patient under general or spinal anesthesia, and characterization of any anastomotic gap and its relative location to each ureteral orifice. Subsequently 5Fr Single J ureteral stents were inserted over a hydrophilic guidewire bilaterally under fluoroscopic control. Each stent was exteriorized via the urethra beside an 18Fr Foley catheter. To prevent inadvertent catheter passage through the hole in the anastomosis the Foley catheter was reintroduced into the bladder over a guidewire after puncturing its distal tip. Also, to avoid compromising any blood supply to the anastomosis we invariably avoided traction on the Foley catheter at this point. We monitored urine output and the relative amount of UVAL. The Jackson-Pratt drains were removed after leakage decreased to 50 ml or less per day. All patients underwent cystogram to ascertain complete leak resolution before stent removal. After the stents were removed the Foley catheter was left indwelling at treating surgeon discretion to facilitate further anastomotic healing. Postoperatively patients were followed routinely with questionnaires related to urinary and sexual function at 6 weeks, 3 months and every 3 months thereafter during the first 2 years. Urinary continence was defined as no protective pad use. Time to urinary continence was treated as a time dependent variable and estimated using KaplanMeier analysis.
2453
Clinical and pathological characteristics in 7 patients with persistent or massive urinary leak after RP Median age at surgery (IQR) Prostate vol (cc): Mean (range) Median (IQR) No. pathological stage (%): pT2b pT2c pT3a Mean ⫾ SD days (range): RP–stent insertion Stent insertion–drain removal Stent indwelling Foley catheter indwelling
64
(56, 69)
68 37
(35–165) (35, 70)
1 3 3
(14) (43) (43)
6.2 ⫾ 3.1 (2–12) 1.8 ⫾ 0.9 (1–3) 9 ⫾ 1.8 (6–11) 22.8 ⫾ 4.7 (19–29)
and were visualized more expediently in a partially distended bladder, allowing clear demarcation of the bladder neck trigone. Mean time from RP to cystoscopy was 6.2 days (range 2 to 12). The average drain output before stent placement on days ⫺3, ⫺2 and ⫺1 was 990 ml (46% of total urine output), 1,210 ml (46% of total urine output) and 1,320 ml (69% of total urine output), respectively. The mean ⫾ SD interval from stent insertion to pelvic drain removal at a daily drain output of 50 ml or less was 1.8 ⫾ 0.9 days (range 1 to 3). Stents were retained an average of 9 days (range 6 to 11) and removed after cystogram confirmed no urinary leakage (fig. 1). No patient required additional percutaneous intervention for pelvic collection and no other adverse sequela was noted during the remaining postoperative convalescence. The Foley catheter was removed an average of 3 weeks (range 19 to 29 days) after surgery. Median time to recovery of urinary continence was 20 ⫾ 1.7 weeks (fig. 2). At a median followup of 38 months 5 of the 7 patients had achieved complete recovery of urinary function while 1 still experienced moderate stress incontinence and used 3 or 4 pads daily 8 months postoperatively. One patient with anastomotic stricture who underwent bladder neck incision subsequently required artificial urinary sphincter placement for total urinary incontinence 14 months after prostatectomy.
RESULTS Endoscopic intervention was required for persistent UVAL in 7 of the 1,480 patients (0.5%) who underwent open retropubic RP between 1996 and 2007. The table lists patient characteristics. All men were clinically asymptomatic before the intervention. In 6 of the 7 patients (86%) endoscopy revealed a wide posterior gap, usually between the 5 and 7 o’clock positions. Undue proximity of the 2 ureteral orifices to the anastomosis was also observed in 5 of the 7 patients, rendering identification of the orifices somewhat cumbersome. The orifices were generally located more medial than expected
DISCUSSION The goals of RP are to eradicate cancer, minimize perioperative complications and optimize the recovery of potency and urinary continence. No surgeon uniformly achieves these results. Advances in technique and better understanding of the prostate and periprostatic anatomy have allowed surgeons to improve outcomes. However, whether RP is done laparoscopically, robotically or using a traditional open approach, it is still considered 1 of the most complex procedures in urology. As such, its unwarranted
2454
PERSISTENT VESICOURETHRAL ANASTOMOTIC LEAK AFTER RADICAL PROSTATECTOMY
Figure 1. A, filling cystogram on postoperative day 4 in patient with high output anastomotic leak after RP. B, repeat cystogram 7 days after urinary diversion with exteriorized ureteral stents reveals complete resolution of leakage.
morbidity remains inevitable. In this context UVAL is 1 of the most common complications. In the late 1990s we adopted an endoscopic approach to the rare case of persistent or high output UVAL after RP. When all conservative measures failed, patients were offered urinary diversion using cystoscopy and exteriorized ureteral stents via the urethra. Our data suggest that the technique is safe and effective, and allows rapid leakage resolution and complete anastomotic healing. Avoiding a fully distended bladder during cystoscopy is advocated to facilitate the rapid identification of the 2 ureteral orifices, which are generally located more medial than expected. This solution is appropriate in patients noted to have a wide anastomotic gap on cystoscopy. Those with complete anastomotic disruption are better served by surgical repair and reanastomosis.
Figure 2. Kaplan-Meier estimated time to complete urinary continence.
While recovery of urinary continence in this setting may be delayed, the long-term urinary function outcome appears to be unaffected in most patients. The technical difficulty of completing a watertight anastomosis using the laparoscopic approach has been recognized by several investigators.6,7 Technical modifications to attain this have been offered, including using running vs interrupted sutures,6 decreasing the overall number of anastomotic sutures,8 using Lapra-Ty™ clips to avoid intracorporeal knot tying9 and ultimately introducing robotic prostatectomy. The widespread endorsement of minimally invasive surgery in urology has rekindled interest in the incidence and outcome of UVAL after laparoscopic or da Vinci® robotic prostatectomy. However, data remain sparse. Compared to historical series a recent study at 1 center of excellence revealed an overall decrease in the incidence of post-prostatectomy leaks.10 On postoperative day 8 slight and moderate urinary extravasation was noted in 12% and 11% of men, respectively, who underwent open RP. A similar UVAL incidence (13.6%) was observed in 490 consecutive patients who underwent robotic prostatectomy.2 While most of these leaks were clinically inconsequential, a major hazard when considering the transperitoneal rather than the extraperitoneal approach is the possibility of urine extending into the peritoneal cavity, resulting in significant abdominal discomfort and prolonged ileus. The latter was identified in 1.2% of all patients and in 9% of all those with a leak.2 To avoid unnecessary morbidity it is prudent that these large or intraperitoneal leaks be addressed expediently. We believe that temporary urinary diversion using bilateral Single J stents is a viable treatment alternative in these cases.
PERSISTENT VESICOURETHRAL ANASTOMOTIC LEAK AFTER RADICAL PROSTATECTOMY
CONCLUSIONS Temporary urinary diversion with exteriorized ureteral stents via the urethra is a safe, effective solution for a prolonged or high output anasto-
2455
motic leak after RP. While recovery of urinary continence may be delayed in this setting, longterm urinary function appears to be unaffected in most patients.
REFERENCES 1. Lee HJ, Shin CI, Hwang SI et al: MDCT cystography for detection of vesicourethral leak after prostatectomy. AJR Am J Roentgenol 2008; 191: 1847. 2. Williams TR, Longoria OJ, Asselmeier S et al: Incidence and imaging appearance of urethrovesical anastomotic urinary leaks following da Vinci robotic prostatectomy. Abdom Imaging 2008; 33: 367.
after robot-assisted laparoscopic radical prostatectomy. Urology 2009; 73: 1375. 5. Castillo OA, Alston C and Sanchez-Salas R: Persistent vesicourethral anastomotic leak after laparoscopic radical prostatectomy: laparoscopic solution. Urology 2009; 73: 124.
3. Moinzadeh A, Abouassaly R, Gill IS et al: Continuous needle vented Foley catheter suction for urinary leak after radical prostatectomy. J Urol 2004; 171: 2366.
6. Teber D, Erdogru T, Cresswell J et al: Analysis of three different vesicourethral anastomotic techniques in laparoscopic radical prostatectomy. World J Urol 2008; 26: 617.
4. Shah G, Vogel F and Moinzadeh A: Nephroureteral stent on suction for urethrovesical anastomotic leak
7. Ferguson GG, Ames CD, Weld KJ et al: Prospective evaluation of learning curve for laparoscopic
radical prostatectomy: identification of factors improving operative times. Urology 2005; 66: 840. 8. Mazaris EM, Chatzidarellis E, Varkarakis IM et al: Reducing the number of sutures for vesicourethral anastomosis in radical retropubic prostatectomy. Int Braz J Urol 2009; 35: 158. 9. Zorn KC: Robotic radical prostatectomy: assurance of water-tight vesicourethral anastomotic closure with the Lapra-Ty clip. J Endourol 2008; 22: 863. 10. Lepor H, Kozirovsky M, Laze J et al: Transabdominal sonocystography: a novel technique to assess vesicourethral extravasation following radical prostatectomy. J Urol 2008; 180: 2459.