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Radiographic Assessment of the Vesicourethral Anastomosis Directing Early Decatheterization Following Nerve-Sparing Radical Retropubic Prostatectomy
0022-5347 /89/1411-0079$02.00/0 Vol. 141, January Printed in U.S.A.
THE 30URNAL OF UROLOGY
Copyright (c) 1989 by The Williams & Wilkins Co.
RADIOGRAPHIC ASSESSMENT OF THE VESICOURETHRAL ANASTOMOSIS DIRECTING EARLY DECATHETERIZATION FOLLOWING NERVE-SPARING RADICAL RETROPUBIC PROSTATECTOMY DANIEL P. DALTON, ANTHONY J. SCHAEFFER, JOHN E. GARNETT AND JOHN T. GRAYHACK From the Department of Urology, Northwestern University Medical School, Chicago, Illinois
ABSTRACT
Early decatheterization directed by postoperative gravity cystography in 55 consecutive radical prostatectomy patients is described. The catheter-free status was 22 per cent by postoperative day 8, 62 per cent by postoperative day 11 and 80 per cent by postoperative day 14. Cystograms performed beginning on postoperative day 7 identified 3 groups of patients and dictated their management: 1) no extravasation resulting in immediate catheter removal (36 patients), 2) moderate extravasation requiring repeat cystography leading to decatheterization by postoperative day 15 (9 patients) and 3) severe extravasation necessitating prolonged catheter drainage (8 patients). A decatheterization protocol is presented. (J. Ural., 141: 79-81, 1989) Recent technical modifications and data indicating improved survival free of disease have led to the resurgence of radical retropubic prostatectomy as the treatment of choice for clinically localized adenocarcinoma of the prostate. 1 - 4 Since the procedure has been standardized, it seems justifiable to concentrate on improving the postoperative management of these patients. We report our experience with early decatheterization as directed by postoperative gravity cystography in 55 consecutive radical prostatectomy patients.
until drainage ceased. The bladder was filled until the patient noticed a sense of fullness and/or discomfort (generally 150 to 200 cc). Oblique and post-void views were obtained in most patients. Urine cultures were obtained 24 hours before the cystogram and prophylactic antibiotics generally were used. If the initial cystogram revealed no or minimal extravasation the Foley catheter was removed within 24 hours. If significant extravasation was present the study was repeated in 3 to 4 days and the catheter was removed if extravasation was no longer evident. Presently, the information obtained from the initial cystogram is used to determine whether the repeat cystograms are performed as an inpatient or outpatient. All cystograms performed were reviewed retrospectively to determine the ability of the initial cystogram to predict the duration of anastomotic extravasation. Office and hospital charts were reviewed to evaluate long-term continence, incidence of post-decatheterization urinary retention and incidence of anastomotic stricture.
MATERIALS AND METHODS
A total of 55 patients with clinically localized, biopsy proved adenocarcinoma of the prostate underwent retroperitoneal pelvic lymphadenectomy and nerve-sparing radical retropubic prostatectomy from January 1984 to July 1987. All procedures were performed by a 4-man university group of urologists and house staff. Mean patient age was 62 years (range 40 to 73 years). Clinical stage was A2 in 12 patients, Bl in 28 and B2 in 15, whereas pathological stage was Bl in 9, B2 in 26, C in 19 and Dl in 1. The bladder neck closure and vesicourethral anastomosis were performed in a similar fashion by the 4 surgeons involved. When the bladder neck was greater than 2 cm. in diameter it was narrowed posteriorly with full thickness interrupted sutures of 2-zero chromic catgut. The bladder mucosa was not everted. The vesicourethral anastomosis was constructed using 1-zero chromic catgut with a 5/s gauge needle. Halsted mattress sutures were placed at the 6 and 12 o'clock positions, whereas simple through-and-through sutures were used at the 3 and 9 o'clock positions. Care was taken in the placement of the laterally situated sutures to avoid incorporating the neurovascular bundles.'' After placement of a 22F 5 cc balloon Foley catheter in the bladder the sutures were tied carefully beginning with the 6 o'clock position. The Foley catheter then was irrigated to assess anastomotic integrity. Following inflation of the balloon the catheter was secured to the glans penis with a single 3-zero nylon suture. Penrose drains were placed lateral to the anastomosis along the pelvic wall on each side to assure adequate drainage. Gravity cystograms were performed by the urology house staff beginning on postoperative day 7 (mean postoperative day 8.87 ± 1.96 standard deviation, range 7 to 16, see table). If significant Penrose drainage existed the cystogram was delayed
RESULTS
Duration of catheterization. The average duration of postoperative catheterization among all patients was 12.95 ± 7.54 days (range 8 to 46); 12 patients (22 per cent) were free of a catheter by postoperative day 8, 34 (62 per postoperative day 11, 44 (80 per cent) by postoperative day 14 and 46 (84 per cent) by postoperative day 16. Radiographic evidence of persistent anastomotic extravasation required prolonged catheterization in the remaining 9 patients (16 per cent). Of these patients 5 were decatheterized by postoperative day 21. The remaining 4 patients required 27, 30, 41 and 46 days of catheterization before anastomotic integrity was confirmed radiographically. Pelvic hematomas occurred postoperatively in 2 of these patients, undoubtedly contributing to the prolonged anastomotic extravasation. Cystogram results. All cystograms were reviewed. Inadequate oblique and post-void views contributed to the misinterpretation of a redundant bladder neck as extravasation in 1 patient, resulting in 7 unnecessary days of catheterization. Persistent urine drainage from the Penrose drains delayed the performance of the initial cystogram until postoperative day 16 in 1 patient. In the remaining 53 patients a direct relationship between the amount of extravasation on the initial cystogram and the over-all duration of extravasation was present. The initial cystogram identified 3 groups of patients and dictated
Accepted for publication May 12, 1988. 79
80
DALTON AND ASSOCIATES
the clinical management. Group 1 consisted of 36 patients (68 per cent) who had no or minimal extravasation on the initial cystogram allowing decatheterization in 12 patients by postoperative day 8, an additional 17 patients by postoperative day 11 and all 36 patients by postoperative day 14. The amount of extravasation in the remaining patients was quantified by measuring the distance between the anastomosis and the farthest extent of the contrast material on the oblique view of the cystogram. Group 2 consisted of 9 patients (17 per cent) with 4.2 cm. or less extravasation as measured on the oblique view of the initial cystogram (fig. 1, A and B). Repeat studies on these patients revealed radiographic resolution of the anastomotic extravasation in all patients by postoperative day 15 resulting in decatheterization in 5 patients by postoperative day 11 and all 9 patients by postoperative day 15. Group 3 consisted of 8 patients (15 per cent) with 5 cm. or greater extravasation (fig. 1, C). All 8 patients had prolonged anastomotic extravasation requiring 27.25 ± 11.13 days (range 16 to 46) for radiographic resolution and decatheterization. Ten patients (19 per cent) had positive cultures at the time of the initial cystogram, with Escherichia coli and Streptococcus faecalis being the most common organisms. Post-decatheterization urinary retention and anastomotic strictures. We observed immediate post-decatheterization urinary retention in 5 patients (9 per cent). In 4 patients bedside insertion of a 16 or 18F Foley catheter was performed easily and it was left in place for approximately 48 hours. One of these patients again experienced retention 8 days after he was discharged from the hospital and a suprapubic tube was placed elsewhere after unsuccessful urethral catheterization. In the remaining patient the catheter partially disrupted the anastomosis requiring endoscopic catheter placement and 17 days of catheterization. Of 5 patients with urinary retention 4 developed anastomotic strictures compared to 6 of 50 patients without urinary retention (p = 0.003, Fisher's exact test). Stricture occurred in the patient with partial anastomotic disruption and the patient who required suprapubic cystotomy. As a group, the 10 patients with anastomotic stricture (with Postoperative day initial cystogram actually done Postop. Day
No. initial cystograms performed (total 55)
7
8
9
10
11
12
13
12
22
6
4
5
2
3
16
and without urinary retention) were treated 3.80 ± 2.08 months postoperatively by a single dilation (6), intermittent dilation approximately every 3 months (1) and endoscopic incision (3). Of the latter 3 patients 2 still require intermittent dilation approximately every 3 months. Duration of catheterization and previous bladder neck surgery were not correlated statistically with the development of anastomotic stricture. Long-term continence was not affected by either the occurrence of urinary retention or the development and treatment of anastomotic stricture. Continence. The office charts of all patients were reviewed to determine their continence status with a minimum 8-month followup. Of the patients 46 (84 per cent) have excellent control. Mild stress incontinence not requiring pads is present in 8 patients (15 per cent). One patient requires 1 to 2 pads per day for moderate stress incontinence 8 months postoperatively. DISCUSSION
It is evident that gravity cystography can safely direct early decatheterization in the majority of patients following nervesparing radical retropubic prostatectomy. In our series of 55 patients 22 per cent were rendered free of a catheter by postoperative day 8, 62 per cent by postoperative day 11 and 80 per cent by postoperative day 14. A review of the literature on radical retropubic prostatectomy has revealed no detailed description on postoperative catheter management. The common practice appears to be to discharge the patient from the hospital with an indwelling Foley catheter and to have him return to the office for removal of the catheter 3 weeks postoperatively. Our data indicate that anastomotic integrity is intact in 92 per cent of the patients at 3 weeks, suggesting that this practice is, indeed, safe. However, our impression is that patients would prefer to be discharged from the hospital free of a catheter and our data indicate that they can be with safety. Furthermore, the method described allows one to replace personal prejudice with objective evidence in the decision-making process for decatheterization following radical prostatectomy. We observed that the amount of extravasation present on the oblique view of the initial cystogram predicted the duration of extravasation and, therefore, the duration of catheterization required. Therefore, we recommend the following decatheterization protocol ( fig. 2). The initial cystogram should be performed about 1 week postoperatively except in the presence of persistent drainage or compromised postoperative status. All patients should have urine cultures 24 hours before perform-
Fm. 1. A, typical group 2 patient with 2.6 crn. extravasation on initial crystograrn requiring 48 hours for resolution. Bilateral vesicoureteral reflux is noted. B, group 2 patient with slightly more severe extravasation (4.2 crn.) requiring 4 days to resolve. C, group 3 patient with severe extravasation (6 crn.) requiring 11 days for radiographic resolution.
RADIOGRAPHIC ASSESSMENT FOR DECATHETERIZATWN FOLLOWING PROSTATECTOMY GRAVITY CYSTUGRA>i ON PO!.l7 (OR WHEN D \lNAGE ~TOPS)
NO OK MINIMAL EXTRAVASATION
S::J"S'?AT_IO_N__ e,:::::::::t::O' WITH
cAI'"'
REPEAT YSTOGRAM AT 3 WEEKS
=ummo,
'"
C"'
REMOVE CATHETER
REMOVE CATHETER
FIG. 2. Proposed scheme for catheter management following radical prostatectomy. POD7, postoperative day 7.
ance of the cystogram and they should receive prophylactic antibiotics at the examination. At our institution the cost of performing a cystogram (in the office) preceded by a urine culture and prophylactic antibiotics is $117. If the cystogram reveals minimal or no extravasation the catheter may be removed safely. If a small amount of extravasation is evident defined as 4.2 cm. or less as measured on the oblique view of the initial cystogram, the catheter should be left in place and the cystogram should be repeated in 72 hours. In our study all such patients were free of a catheter by postoperative day 15. Patients otherwise able to be discharged from the hospital may undergo repeat cystography in the office as an outpatient. Those with a large amount of extravasation on the initial cystogram, defined as more than 5 cm. on the oblique view, should be discharged from the hospital with an indwelling Foley catheter if other factors permit, and they should return to the office for repeat cystography and probable catheter removal 3 weeks postoperatively. The reported incidence of anastomotic stricture ranges from 2.6 to 12 per cent. 6 The relatively high incidence of anastomotic stricture in our series, 18 per cent, may be due to several factors. We made no attempt to evert the bladder mucosa before constructing the vesicourethral anastomosis as suggested by Walsh. 7 In addition, we may have been overzealous in our attempt to construct a tight bladder neck to assure postoperative continence. While duration of catheterization was not correlated with stricture development, it is possible that extravasation occurring after decatheterization initiated a local tissue reaction resulting in stricture development. Indeed, early decatheterization itself may allow normal postoperative tissue reaction to proceed to stricture formation in the absence of the stenting function of the catheter, The local tissue effects of contrast material is another potential factor. It is evident that immediate post-decatheterization urinary retention portends development of anastomotic stricture. Whether retention results from stricture formation, or stricture results from the catheterization required to treat retention is a matter of conjecture, although each undoubtedly has a role in individual patients. Regardless, patients suffering post-decatheterization urinary retention should be followed closely for the development of anastomotic stricture. All strictures in our series became evident in the early postoperative period (mean 3.80 ± 2.08 months, range 1.5 to 8 months). Their presence usually was heralded by the development of obstructive voiding symp-
81
toms. Of 10 patients with anastomotic stricture 6 were managed easily in the office with a single dilation using either Van Buren sounds or filiforms and followers. A useful adjunct was endoscopic visualization of the anastomosis with an initial dilation performed with the cystoscope when possible. Exact visual placement of the filiform catheter via the cystoscope also was helpful. Four patients (7 per cent) have been more difficult to manage and have required intermittent dilation every 3 months (1), endoscopic incision (1) and endoscopic incision with continued 3-month dilations (2). More meticulous placement of the Penrose drains to avoid redundancy and/or contact with the anastomosis may reduce extravasation and perianastomotic tissue reaction. Total urinary incontinence appears to be a rare complication of radical retropubic prostatectomy. In the immediate post?ecath_eterization period mild to moderate stress and urgency mcontmence may be expected but in our experience almost all patients have discarded protective padding by 3 months postoperatively. Infrequent minimal stress urinary incontinence may persist in a minority of patients. The 4-suture anastomosis used in this series has several benefits. It is relatively easy to perform and the surgeon does not have multiple strands of suture to deal with in a space that is at times difficult to reach and see. Continence rates and anastomotic integrity have been excellent. In summary, gravity cystography safely directs early decatheterization in the majority of patients following radical retropubic prostatectomy. Findings on the initial cystogram predict which patients will require prolonged catheterization allowing their early discharge from the hospital with an indwelling catheter. The relatively high incidence of anastomotic stricture experienced in this series may be due to the perianastomotic reaction associated with early catheter removal, reaction to contrast material and/or excessive tightening of the bladder neck in an attempt to assure postoperative continence. The majority of patients in whom stricture developed were treated easily in the office with a single dilation. Postoperative urinary continence has been excellent. REFERENCES
1. Elder, J. S., Jewett, H. J. and Walsh, P. C.: Radical perinea! prostatectomy for clinical stage B2 carcinoma of the prostate. J. Urol., 127: 704, 1982. 2. Elder, J. S., Gibbons, R. P., Correa, R. J., Jr. and Brannen, G. E.: Efficacy of radical prostatectomy for stage A2 carcinoma of the prostate. Cancer, 56: 2151, 1985. 3. Reiner, VV. G. and Walsh, P. C.: An anatomical approach to the surgical management of the dorsal vein and Santorini's plexus during radical retropubic surgery. J. Urol., 121: 198, 1979. 4. Walsh, P. C., Lepor, H. and Eggleston, J.C.: Radical prostatectomy with preservation of sexual function: anatomical and pathological considerations. Prostate, 4: 4 73, 1983. 5. Kozlowski, J. M. and Grayhack, J. T.: Carcinoma of the prostate. In: Adult and Pediatric Urology. Edited by J. Y. Gillenwater, J. T. Grayhack, S. S. Howards and J. W. Duckett. Chicago: Year Book Medical Publishers, vol. 2, chapt. 34, pp. 1126-1219, 1987. 6. Walsh, P. C.: Radical retropubic prostatectomy. In: Campbell's Urology, 5th ed. Edited by P. C. Walsh, R. F. Gittes, A. D. Perlmutter and T. A. Stamey. Philadelphia: W. B. Saunders Co., vol. 3, sect. XV, chapt. 76, pp. 2754-2775, 1986. 7. Walsh, P. C.: Radical retropubic prostatectomy-an anatomic approach with preservation of sexual function. A pictorial review of urologic procedures. New York: Bristol Laboratories, 1986.
THE 30URNAL OF UROLOGY
Copyright (c) 1989 by The Williams & Wilkins Co.
RADIOGRAPHIC ASSESSMENT OF THE VESICOURETHRAL ANASTOMOSIS DIRECTING EARLY DECATHETERIZATION FOLLOWING NERVE-SPARING RADICAL RETROPUBIC PROSTATECTOMY DANIEL P. DALTON, ANTHONY J. SCHAEFFER, JOHN E. GARNETT AND JOHN T. GRAYHACK From the Department of Urology, Northwestern University Medical School, Chicago, Illinois
ABSTRACT
Early decatheterization directed by postoperative gravity cystography in 55 consecutive radical prostatectomy patients is described. The catheter-free status was 22 per cent by postoperative day 8, 62 per cent by postoperative day 11 and 80 per cent by postoperative day 14. Cystograms performed beginning on postoperative day 7 identified 3 groups of patients and dictated their management: 1) no extravasation resulting in immediate catheter removal (36 patients), 2) moderate extravasation requiring repeat cystography leading to decatheterization by postoperative day 15 (9 patients) and 3) severe extravasation necessitating prolonged catheter drainage (8 patients). A decatheterization protocol is presented. (J. Ural., 141: 79-81, 1989) Recent technical modifications and data indicating improved survival free of disease have led to the resurgence of radical retropubic prostatectomy as the treatment of choice for clinically localized adenocarcinoma of the prostate. 1 - 4 Since the procedure has been standardized, it seems justifiable to concentrate on improving the postoperative management of these patients. We report our experience with early decatheterization as directed by postoperative gravity cystography in 55 consecutive radical prostatectomy patients.
until drainage ceased. The bladder was filled until the patient noticed a sense of fullness and/or discomfort (generally 150 to 200 cc). Oblique and post-void views were obtained in most patients. Urine cultures were obtained 24 hours before the cystogram and prophylactic antibiotics generally were used. If the initial cystogram revealed no or minimal extravasation the Foley catheter was removed within 24 hours. If significant extravasation was present the study was repeated in 3 to 4 days and the catheter was removed if extravasation was no longer evident. Presently, the information obtained from the initial cystogram is used to determine whether the repeat cystograms are performed as an inpatient or outpatient. All cystograms performed were reviewed retrospectively to determine the ability of the initial cystogram to predict the duration of anastomotic extravasation. Office and hospital charts were reviewed to evaluate long-term continence, incidence of post-decatheterization urinary retention and incidence of anastomotic stricture.
MATERIALS AND METHODS
A total of 55 patients with clinically localized, biopsy proved adenocarcinoma of the prostate underwent retroperitoneal pelvic lymphadenectomy and nerve-sparing radical retropubic prostatectomy from January 1984 to July 1987. All procedures were performed by a 4-man university group of urologists and house staff. Mean patient age was 62 years (range 40 to 73 years). Clinical stage was A2 in 12 patients, Bl in 28 and B2 in 15, whereas pathological stage was Bl in 9, B2 in 26, C in 19 and Dl in 1. The bladder neck closure and vesicourethral anastomosis were performed in a similar fashion by the 4 surgeons involved. When the bladder neck was greater than 2 cm. in diameter it was narrowed posteriorly with full thickness interrupted sutures of 2-zero chromic catgut. The bladder mucosa was not everted. The vesicourethral anastomosis was constructed using 1-zero chromic catgut with a 5/s gauge needle. Halsted mattress sutures were placed at the 6 and 12 o'clock positions, whereas simple through-and-through sutures were used at the 3 and 9 o'clock positions. Care was taken in the placement of the laterally situated sutures to avoid incorporating the neurovascular bundles.'' After placement of a 22F 5 cc balloon Foley catheter in the bladder the sutures were tied carefully beginning with the 6 o'clock position. The Foley catheter then was irrigated to assess anastomotic integrity. Following inflation of the balloon the catheter was secured to the glans penis with a single 3-zero nylon suture. Penrose drains were placed lateral to the anastomosis along the pelvic wall on each side to assure adequate drainage. Gravity cystograms were performed by the urology house staff beginning on postoperative day 7 (mean postoperative day 8.87 ± 1.96 standard deviation, range 7 to 16, see table). If significant Penrose drainage existed the cystogram was delayed
RESULTS
Duration of catheterization. The average duration of postoperative catheterization among all patients was 12.95 ± 7.54 days (range 8 to 46); 12 patients (22 per cent) were free of a catheter by postoperative day 8, 34 (62 per postoperative day 11, 44 (80 per cent) by postoperative day 14 and 46 (84 per cent) by postoperative day 16. Radiographic evidence of persistent anastomotic extravasation required prolonged catheterization in the remaining 9 patients (16 per cent). Of these patients 5 were decatheterized by postoperative day 21. The remaining 4 patients required 27, 30, 41 and 46 days of catheterization before anastomotic integrity was confirmed radiographically. Pelvic hematomas occurred postoperatively in 2 of these patients, undoubtedly contributing to the prolonged anastomotic extravasation. Cystogram results. All cystograms were reviewed. Inadequate oblique and post-void views contributed to the misinterpretation of a redundant bladder neck as extravasation in 1 patient, resulting in 7 unnecessary days of catheterization. Persistent urine drainage from the Penrose drains delayed the performance of the initial cystogram until postoperative day 16 in 1 patient. In the remaining 53 patients a direct relationship between the amount of extravasation on the initial cystogram and the over-all duration of extravasation was present. The initial cystogram identified 3 groups of patients and dictated
Accepted for publication May 12, 1988. 79
80
DALTON AND ASSOCIATES
the clinical management. Group 1 consisted of 36 patients (68 per cent) who had no or minimal extravasation on the initial cystogram allowing decatheterization in 12 patients by postoperative day 8, an additional 17 patients by postoperative day 11 and all 36 patients by postoperative day 14. The amount of extravasation in the remaining patients was quantified by measuring the distance between the anastomosis and the farthest extent of the contrast material on the oblique view of the cystogram. Group 2 consisted of 9 patients (17 per cent) with 4.2 cm. or less extravasation as measured on the oblique view of the initial cystogram (fig. 1, A and B). Repeat studies on these patients revealed radiographic resolution of the anastomotic extravasation in all patients by postoperative day 15 resulting in decatheterization in 5 patients by postoperative day 11 and all 9 patients by postoperative day 15. Group 3 consisted of 8 patients (15 per cent) with 5 cm. or greater extravasation (fig. 1, C). All 8 patients had prolonged anastomotic extravasation requiring 27.25 ± 11.13 days (range 16 to 46) for radiographic resolution and decatheterization. Ten patients (19 per cent) had positive cultures at the time of the initial cystogram, with Escherichia coli and Streptococcus faecalis being the most common organisms. Post-decatheterization urinary retention and anastomotic strictures. We observed immediate post-decatheterization urinary retention in 5 patients (9 per cent). In 4 patients bedside insertion of a 16 or 18F Foley catheter was performed easily and it was left in place for approximately 48 hours. One of these patients again experienced retention 8 days after he was discharged from the hospital and a suprapubic tube was placed elsewhere after unsuccessful urethral catheterization. In the remaining patient the catheter partially disrupted the anastomosis requiring endoscopic catheter placement and 17 days of catheterization. Of 5 patients with urinary retention 4 developed anastomotic strictures compared to 6 of 50 patients without urinary retention (p = 0.003, Fisher's exact test). Stricture occurred in the patient with partial anastomotic disruption and the patient who required suprapubic cystotomy. As a group, the 10 patients with anastomotic stricture (with Postoperative day initial cystogram actually done Postop. Day
No. initial cystograms performed (total 55)
7
8
9
10
11
12
13
12
22
6
4
5
2
3
16
and without urinary retention) were treated 3.80 ± 2.08 months postoperatively by a single dilation (6), intermittent dilation approximately every 3 months (1) and endoscopic incision (3). Of the latter 3 patients 2 still require intermittent dilation approximately every 3 months. Duration of catheterization and previous bladder neck surgery were not correlated statistically with the development of anastomotic stricture. Long-term continence was not affected by either the occurrence of urinary retention or the development and treatment of anastomotic stricture. Continence. The office charts of all patients were reviewed to determine their continence status with a minimum 8-month followup. Of the patients 46 (84 per cent) have excellent control. Mild stress incontinence not requiring pads is present in 8 patients (15 per cent). One patient requires 1 to 2 pads per day for moderate stress incontinence 8 months postoperatively. DISCUSSION
It is evident that gravity cystography can safely direct early decatheterization in the majority of patients following nervesparing radical retropubic prostatectomy. In our series of 55 patients 22 per cent were rendered free of a catheter by postoperative day 8, 62 per cent by postoperative day 11 and 80 per cent by postoperative day 14. A review of the literature on radical retropubic prostatectomy has revealed no detailed description on postoperative catheter management. The common practice appears to be to discharge the patient from the hospital with an indwelling Foley catheter and to have him return to the office for removal of the catheter 3 weeks postoperatively. Our data indicate that anastomotic integrity is intact in 92 per cent of the patients at 3 weeks, suggesting that this practice is, indeed, safe. However, our impression is that patients would prefer to be discharged from the hospital free of a catheter and our data indicate that they can be with safety. Furthermore, the method described allows one to replace personal prejudice with objective evidence in the decision-making process for decatheterization following radical prostatectomy. We observed that the amount of extravasation present on the oblique view of the initial cystogram predicted the duration of extravasation and, therefore, the duration of catheterization required. Therefore, we recommend the following decatheterization protocol ( fig. 2). The initial cystogram should be performed about 1 week postoperatively except in the presence of persistent drainage or compromised postoperative status. All patients should have urine cultures 24 hours before perform-
Fm. 1. A, typical group 2 patient with 2.6 crn. extravasation on initial crystograrn requiring 48 hours for resolution. Bilateral vesicoureteral reflux is noted. B, group 2 patient with slightly more severe extravasation (4.2 crn.) requiring 4 days to resolve. C, group 3 patient with severe extravasation (6 crn.) requiring 11 days for radiographic resolution.
RADIOGRAPHIC ASSESSMENT FOR DECATHETERIZATWN FOLLOWING PROSTATECTOMY GRAVITY CYSTUGRA>i ON PO!.l7 (OR WHEN D \lNAGE ~TOPS)
NO OK MINIMAL EXTRAVASATION
S::J"S'?AT_IO_N__ e,:::::::::t::O' WITH
cAI'"'
REPEAT YSTOGRAM AT 3 WEEKS
=ummo,
'"
C"'
REMOVE CATHETER
REMOVE CATHETER
FIG. 2. Proposed scheme for catheter management following radical prostatectomy. POD7, postoperative day 7.
ance of the cystogram and they should receive prophylactic antibiotics at the examination. At our institution the cost of performing a cystogram (in the office) preceded by a urine culture and prophylactic antibiotics is $117. If the cystogram reveals minimal or no extravasation the catheter may be removed safely. If a small amount of extravasation is evident defined as 4.2 cm. or less as measured on the oblique view of the initial cystogram, the catheter should be left in place and the cystogram should be repeated in 72 hours. In our study all such patients were free of a catheter by postoperative day 15. Patients otherwise able to be discharged from the hospital may undergo repeat cystography in the office as an outpatient. Those with a large amount of extravasation on the initial cystogram, defined as more than 5 cm. on the oblique view, should be discharged from the hospital with an indwelling Foley catheter if other factors permit, and they should return to the office for repeat cystography and probable catheter removal 3 weeks postoperatively. The reported incidence of anastomotic stricture ranges from 2.6 to 12 per cent. 6 The relatively high incidence of anastomotic stricture in our series, 18 per cent, may be due to several factors. We made no attempt to evert the bladder mucosa before constructing the vesicourethral anastomosis as suggested by Walsh. 7 In addition, we may have been overzealous in our attempt to construct a tight bladder neck to assure postoperative continence. While duration of catheterization was not correlated with stricture development, it is possible that extravasation occurring after decatheterization initiated a local tissue reaction resulting in stricture development. Indeed, early decatheterization itself may allow normal postoperative tissue reaction to proceed to stricture formation in the absence of the stenting function of the catheter, The local tissue effects of contrast material is another potential factor. It is evident that immediate post-decatheterization urinary retention portends development of anastomotic stricture. Whether retention results from stricture formation, or stricture results from the catheterization required to treat retention is a matter of conjecture, although each undoubtedly has a role in individual patients. Regardless, patients suffering post-decatheterization urinary retention should be followed closely for the development of anastomotic stricture. All strictures in our series became evident in the early postoperative period (mean 3.80 ± 2.08 months, range 1.5 to 8 months). Their presence usually was heralded by the development of obstructive voiding symp-
81
toms. Of 10 patients with anastomotic stricture 6 were managed easily in the office with a single dilation using either Van Buren sounds or filiforms and followers. A useful adjunct was endoscopic visualization of the anastomosis with an initial dilation performed with the cystoscope when possible. Exact visual placement of the filiform catheter via the cystoscope also was helpful. Four patients (7 per cent) have been more difficult to manage and have required intermittent dilation every 3 months (1), endoscopic incision (1) and endoscopic incision with continued 3-month dilations (2). More meticulous placement of the Penrose drains to avoid redundancy and/or contact with the anastomosis may reduce extravasation and perianastomotic tissue reaction. Total urinary incontinence appears to be a rare complication of radical retropubic prostatectomy. In the immediate post?ecath_eterization period mild to moderate stress and urgency mcontmence may be expected but in our experience almost all patients have discarded protective padding by 3 months postoperatively. Infrequent minimal stress urinary incontinence may persist in a minority of patients. The 4-suture anastomosis used in this series has several benefits. It is relatively easy to perform and the surgeon does not have multiple strands of suture to deal with in a space that is at times difficult to reach and see. Continence rates and anastomotic integrity have been excellent. In summary, gravity cystography safely directs early decatheterization in the majority of patients following radical retropubic prostatectomy. Findings on the initial cystogram predict which patients will require prolonged catheterization allowing their early discharge from the hospital with an indwelling catheter. The relatively high incidence of anastomotic stricture experienced in this series may be due to the perianastomotic reaction associated with early catheter removal, reaction to contrast material and/or excessive tightening of the bladder neck in an attempt to assure postoperative continence. The majority of patients in whom stricture developed were treated easily in the office with a single dilation. Postoperative urinary continence has been excellent. REFERENCES
1. Elder, J. S., Jewett, H. J. and Walsh, P. C.: Radical perinea! prostatectomy for clinical stage B2 carcinoma of the prostate. J. Urol., 127: 704, 1982. 2. Elder, J. S., Gibbons, R. P., Correa, R. J., Jr. and Brannen, G. E.: Efficacy of radical prostatectomy for stage A2 carcinoma of the prostate. Cancer, 56: 2151, 1985. 3. Reiner, VV. G. and Walsh, P. C.: An anatomical approach to the surgical management of the dorsal vein and Santorini's plexus during radical retropubic surgery. J. Urol., 121: 198, 1979. 4. Walsh, P. C., Lepor, H. and Eggleston, J.C.: Radical prostatectomy with preservation of sexual function: anatomical and pathological considerations. Prostate, 4: 4 73, 1983. 5. Kozlowski, J. M. and Grayhack, J. T.: Carcinoma of the prostate. In: Adult and Pediatric Urology. Edited by J. Y. Gillenwater, J. T. Grayhack, S. S. Howards and J. W. Duckett. Chicago: Year Book Medical Publishers, vol. 2, chapt. 34, pp. 1126-1219, 1987. 6. Walsh, P. C.: Radical retropubic prostatectomy. In: Campbell's Urology, 5th ed. Edited by P. C. Walsh, R. F. Gittes, A. D. Perlmutter and T. A. Stamey. Philadelphia: W. B. Saunders Co., vol. 3, sect. XV, chapt. 76, pp. 2754-2775, 1986. 7. Walsh, P. C.: Radical retropubic prostatectomy-an anatomic approach with preservation of sexual function. A pictorial review of urologic procedures. New York: Bristol Laboratories, 1986.