A Pelvic Drain May be Avoided After Radical Retropubic Prostatectomy

0022-5347/03/1701-0112/0 THE JOURNAL OF UROLOGY® Copyright © 2003 by AMERICAN UROLOGICAL ASSOCIATION

Vol. 170, 112–114, July 2003 Printed in U.S.A.

DOI: 10.1097/01.ju.0000068724.33478.2c

A PELVIC DRAIN MAY BE AVOIDED AFTER RADICAL RETROPUBIC PROSTATECTOMY MARC SAVOIE, MARK S. SOLOWAY,*, † SANDY S. KIM

AND

M. MANOHARAN

From the Departments of Urology, University of Miami School of Medicine, Miami, Florida

ABSTRACT

Purpose: We reassessed the role of routine pelvic cavity drainage to prevent complications after radical retropubic prostatectomy (RRP). Materials and Methods: RRP was performed in 116 consecutive patients with clinically localized adenocarcinoma of the prostate. Clinical and pathological information was recorded for each patient. After the prostate was removed and the anastomotic sutures were tied the bladder was filled with saline through the urethral catheter. If there was no significant leakage, a drain was not placed. Results: We did not place a drain in 85 of the 116 patients (73%). There were 3 immediate postoperative complications. In a patient without a drain a urinoma developed that required percutaneous placement of a drain on postoperative day 2. None of the 116 patients had clinical evidence of infection, lymphocele or hematoma. Two patients had hematuria 2 weeks after catheter removal and needed bladder irrigation. Neither patient had a drain. Three patients (drain and no drain in 1 each) were in urinary retention after catheter removal, which required catheter reinsertion for an additional week. None had an anastomotic stricture. Conclusions: The morbidity of RRP is low when performed by those who regularly perform this procedure. If the bladder neck is preserved or meticulously reconstructed, there may be little or no extravasation and, thus, routine drainage may be unnecessary. In properly selected cases morbidity is not increased by omitting a drain from the pelvic cavity after RRP. KEY WORDS: prostate, prostatic neoplasms, prostatectomy, drainage

Since the description of radical retropubic prostatectomy (RRP) for prostate cancer, the routine use of a drain for pelvic drainage has been considered essential. Although there have been several modifications in the surgical technique and indications for a pelvic lymphadenectomy, it is standard to leave a drain in the pelvis to provide a conduit for the removal of urine, blood, lymph and other fluid. Prior to the use of the closed suction drain passive drainage of the pelvic cavity with a Penrose drain was routine. Is a drain necessary in all cases? Does a pelvic drain prevent complications of RRP? Many groups in different fields have questioned the necessity of drainage after surgery.1⫺6 We assessed the role of routine pelvic cavity drainage in the prevention of complications after RRP.

MATERIALS AND METHODS

Radical retropubic prostatectomy was performed in 116 consecutive patients with clinically localized adenocarcinoma of the prostate. Complete data on patient age, clinical stage, prostate specific antigen (PSA), biopsy Gleason score, nerve sparing, pelvic lymph node dissection, bladder neck preservation, estimated blood loss and postoperative complications were recorded. All RRPs were performed by the same surgeon (MSS). Patients with a PSA of greater than 10 ng/ml, or cT2b or Gleason score 7 to 10 disease underwent bilateral pelvic node dissection. Sequential compression devices were used during and after the procedure as prophylaxis for thromboembolic

events. RRP was performed with modifications of the Walsh technique.7 The neurovascular bundles were identified and preserved or removed depending on several factors, including patient age, potency, Gleason score and clinical stage as well as ease of separation from the prostate.7 The bladder neck preservation technique with careful dissection and preservation of the circular bladder neck fibers8 was also performed when possible. The anastomosis was formed with 7 interrupted 2-zero chromic catgut or poliglecaprone 25 sutures. After the anastomosis was completed approximately 100 cc sterile saline were instilled through the urethral catheter and anastomosis integrity was assessed. A drain was placed in the pelvis if the anastomosis leaked, hemostasis was not adequate or there was injury to adjacent organs. The 20Fr urethral catheter was left in place postoperatively. When a drain was used, a 7 mm Jackson-Pratt closed suction drain was placed through a separate skin incision in the left lower quadrant. The drain was placed in proximity to the urethrovesical anastomosis. Most patients were discharged from the hospital on postoperative day 2. The drain was removed prior to discharge home in patients with a drain. The drain was removed when drainage was less than 30 cc for the 8 hours prior to removal. All patients received 10 days of an oral quinolone, that is 250 mg levofloxacin orally, for prophylactic antibiotic coverage. The first followup visit for catheter removal was around postoperative day 10. We did not evaluate the anastomosis by cystography before catheter removal. Routine pelvic imaging was not performed. Any surgical or interventional radiological procedures in the postoperative period were recorded. The primary end point of this study was the incidence of early postoperative complications. Differences in the bladder neck preservation drain and lymph node dissection groups were assessed using chi-square test, applying Yate’s correction.

Accepted for publication January 17, 2003. * Corresponding author: Department of Urology, P. O. Box 016960 (M814), Miami, Florida 33101. † Financial interest and/or other relationship with Astra Zeneca, Matritech, Merck and TAP. 112

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PELVIC DRAIN MAY BE AVOIDED AFTER PROSTATECTOMY RESULTS

TABLE 2. Indications for pelvic drainage

The most recent 116 consecutive patients from a 10-year series of more than 1,000 RRPs are the basis of this report. Mean patient age was 60.4 years (median 61, range 43 to 73). Table 1 lists patient characteristics. Mean followup was 3 months (range 0.2 to 9.1). Estimated blood loss was 150 to 2,000 cc (mean 721, median 650). No patient received a homologous transfusion and 45% received 1 unit autologous blood. We did not place a drain in 85 of the 116 patients (73%). Table 2 lists indications for the pelvic drain. Bladder neck preservation was performed in 97 cases (84%) (table 3). Of the 97 patients who underwent bladder neck preservation 20 (21%) had a pelvic drain and 79% did not. Of the 19 patients without the bladder neck preserved 11 (58%) had a drain. Significant differences existed for drain insertion in patients who had bladder neck preservation (p ⫽ 0.002). Of the 16 patients 57 (49%) underwent pelvic lymph node dissection, of whom 16 (28%) had a drain and 41 (72%) did not. A total of 15 of the 59 patients (25%) without lymph node dissection had a drain. Differences were not significant for patients who had pelvic lymph node dissection and drain insertion (p ⫽ 0.91). Hospital stay was consistent with that of standard radical prostatectomy. All patients except 1 were discharged on postoperative day 2. The drain was removed prior to discharge home in all patients in who a Jackson-Pratt drain was placed. Three patients were in urinary retention after catheter removal, which required uneventful catheter reinsertion and bladder drainage for an additional week. Two of these patients had a drain and 1 did not. All 3 patients voided well after this episode. No specific reasons for urinary retention were identified. There were no patients with clinical evidence of infection, lymphocele or hematoma. There were 3 postoperative complications. A patient who did not have a drain had a urinoma prior to discharge home. This patient had undergone bladder neck preservation, nerve sparing and lymph node dissection. A drain was percutaneously inserted under computerized tomography guidance and left to straight drainage. Hospital discharge was delayed by 2 days. The drain was removed on postoperative day 7 and the catheter was removed on day 10. Two patients had hematuria 2 weeks after catheter removal, which required bladder irrigation. Neither patient had a drain following RRP. None had an anastomotic stricture during a mean followup of 3 months. DISCUSSION

RRP is an effective curative therapy for clinically localized prostate cancer.7 Since the initial description of RRP in the early 1980s, surgical placement of a pelvic drain has been a standard component of the procedure.9 The management of clinically localized prostate cancer has evolved in the last few years. With the advent of serial PSA monitoring and transrectal ultrasound biopsy the incidence of prostate cancer has increased and younger patients with pathologically organ confined disease are diagnosed and treated.10 Because there is a the low incidence of pelvic node metas-

TABLE 1. Characteristics of the most recent 116 consecutive patients in radical prostatectomy series No. pts Mean age ⫾ SD Mean PSA (ng/ml) No. clinical stage (%): T1 T2 T3 Mean biopsy Gleason score

Drain Present

Drain Absent

31 60.8 ⫾ 7.8 7.0

85 60.2 ⫾ 6.4 7.6

23 (27) 8 (26) 0 6.3

61 (73) 23 (74) 1 (100) 6.3

Totals 116 60.4 ⫾ 6.8 7.5 84 31 1 6.3

Indication

No. Pts

Anastomotic leakage Rectal injury Inadequate hemostasis

30 1 0

TABLE 3. Operative procedures and drain status

No. No. No. No.

pts bladder neck preservation (%) pelvic lymph node dissection (%) nerve sparing (%)

Drain Present

Drain Absent

Total No.

31 20 (21) 16 (28) 22 (23)

85 77 (79) 41 (72) 73 (77)

116 97 57 95

tases in patients with low grade tumors, low serum PSA and small tumor volume, pelvic lymph node dissection is often omitted in those with favorable tumor characteristics11, 12 Consequently it eliminates the risk of lymphocele in these patients. In our experience with 1,000 consecutive RRPs less than 1% have shown lymph node metastasis. The morbidity of RRP is low when performed by those who regularly perform this procedure. The most common complications are wound related. Anastomotic leakage, prolonged lymph drainage, rectal injury, symptomatic lymphocele, pelvic abscess or hematoma occur in less then 1% to 2% of cases.13, 14 In a single surgeon (MSS) 10-year experience there was only 1 lymphocele and 1 urinoma, and no patients had a pelvic abscess or hematoma requiring drainage. The prophylactic value of drains in abdominal or pelvic surgery is not routine. Many prospective studies of various intra-abdominal procedures in fields other than urology have not indicated a statistical difference in the rate of complications between patients with and without drainage.1, 2, 5, 6 Routine placement of intraperitoneal drains has been shown to be unnecessary after colon resection for cancer on prepared bowel,2, 4 perforated duodenum closure, open or laparoscopic cholecystectomy, radical hysterectomy, pelvic lymphadenectomy5 and retroperitoneal lymphadenectomy.6 Conservative management of extraperitoneal bladder perforation with urethral catheter drainage is safe.15, 16 Routine drainage of the pelvic cavity is not required and not associated with a higher incidence of complications. To our knowledge the incidence of complications directly attributable to the Jackson-Pratt drain is unknown. However, breaking a drain during removal or retention of a piece of drain has been reported.17, 18 One of us (MSS) has returned 4 patients to the operating room to locate and cut sutures that entrapped the Jackson-Pratt drain, preventing its removal. Niesel et al investigated postoperative pain after RRP and found that pain was attributable to the drain site in 42 of 179 patients (24%).19 Other potential complications of drain placement include injury to the inferior epigastric vessels and abdominal wall hematoma.5, 6 The cost of the JacksonPratt drain is approximately $20. We recognize that placement of a pelvic drain is indicated when hemostasis is not excellent, when there is leakage at the anastomotic site after irrigation or when there is injury to adjacent organs. A recent report indicates that a pelvic drain may not be necessary following simple retropubic prostatectomy performed for benign prostatic hyperplasia.20 In that series Morey et al applied fibrin sealant over the closed prostatic capsule in 5 patients and did not place a pelvic drain. A 3-way urethral catheter was used for continuous bladder irrigation. There were no complications. Only 1 of our patients had a complication related to the absence of a pelvic drain. This complication would have been avoided by routine drainage of the pelvic cavity. Despite this single incident we believe that routine placement of a pelvic drain in noncomplicated RRP with a watertight anastomosis

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PELVIC DRAIN MAY BE AVOIDED AFTER PROSTATECTOMY

is not mandatory. The benefit of not having a drain may outweigh the slight risk of requiring later placement. The surgeon must carefully evaluate the anastomosis and weigh the benefit and potential risk of not leaving a drain. We recognize that there are several limitations to this study. This study was nonrandomized and retrospective. The number of patients was relatively small and only half were treated with lymph node dissection. Our assessment of early complications was based on clinical symptoms. We did not routinely perform objective investigations such as pelvic ultrasound or cystography. Mean followup was short (3 months). Our intent was to assess early postoperative complications following RRP when routine pelvic drainage was avoided. CONCLUSIONS

Our results are consistent with those of recent studies in different surgical specialties indicating that routine drain use may not be necessary. Following RRP if the bladder neck is preserved or meticulously reconstructed and there is little or no extravasation, the routine use of a drain may be unnecessary. In properly selected cases morbidity is not increased by omitting a drain from the pelvic cavity after RRP. REFERENCES

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