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Surgical Techniques in Urology

ephroureteral Stent on Suction forrethrovesical Anastomotic Leak Afterobot-assisted Laparoscopic Radicalrostatectomy

aurang Shah, Frank Vogel, and Alireza Moinzadeh

BJECTIVES Delayed urinary anastomotic leak after transperitoneal robot-assisted radical prostatectomy(RALP) is an uncommon complication. After failure of conventional measures, we successfullymanaged this problem using a nephroureteral stent placed on intermittent suction.

ETHODS A 62-year-old man with clinical stage T1c prostate cancer (Gleason 3 � 3) developed apersistent urinary anastomotic leak after RALP. Conventional measures, including cathetertraction, passive drainage, and needle vented Foley catheter suction, failed. On postoperative day6 a unilateral nephroureteral stent was placed on intermittent suction.

ESULTS Placement of one nephroureteral stent on suction device immediately stopped the urinaryanastomotic leakage into the peritoneal cavity.

ONCLUSIONS In case of a persistent urinary leak after RALP that fails conservative management, a nephroureteralstent on suction may aid to stop the anastomotic leak. UROLOGY 73: 1375–1376, 2009. © 2009

Published by Elsevier Inc.

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ersistent urethrovesical anastomotic leakage is a rareoccurrence with an unclear incidence. Urinary leak-age beyond the immediate postoperative period is

sually self-limiting. On rare occasions urinary leakage mayontinue despite conservative measures. Various tech-iques, including gentle Foley catheter traction, placementf the retropubic drainage on passive suction, and continu-us needle vented Foley catheter suction, have been used inaparoscopic and open retropubic radical prostatectomy.eakage of undrained urine in the peritoneal cavity after theransperitoneal approach may lead to potential chemicaleritoneal irritation or possibly infection. We describe these of a nephroureteral stent placed on intermittent suctiono assist in management of a post–radical prostatectomynastomotic leak after failed conservative therapy.

ETHODS AND RESULT

62-year-old man with Gleason 3 � 3 � 6, clinical stage T1cdenocarcinoma of the prostate underwent a transperitonealobot-assisted radical prostatectomy (RALP) without complica-ion. Urethrovesical anastomosis was performed with 3-0

onocryl, as described by Van Velthoven et al.1 Bladder neckepair was not necessary. The patient’s initial Jackson Pratt (JP)

rom the Departments of Urology and Radiology, State University of New York,pstate Medical University, Syracuse, New YorkReprint requests: Alireza Moinzadeh, MD, Lahey Clinic, Institute of Urology,

irector of Robotic Surgery, 41 Mall Road, Burlington, MA 01890. E-mail:

mlireza.moinzadeh@lahey.org

Submitted: January 8, 2008, accepted (with revisions): March 24, 2008

2009 Published by Elsevier Inc.

rain output was 30 mL during the first 12 hours after surgery,nd as such the drain was removed on postoperative day 1. Onhe evening of postoperative day 1 the patient complained ofbdominal distention and pain. The JP site where the drain hadeen removed showed evidence of serosanguineous drainage. Byhe morning of postoperative day 2 his urine output diminished,he abdominal pain increased, and the JP site drainage in-reased. The patient’s abdominal examination was consistentith peritonitis. Computed tomographic (CT) scan of the ab-omen and pelvis showed a fluid collection within the pelvis, asell as air fluid levels in the bowel consistent with ileus. A CTrogram demonstrated the integrity of the ureters, the presencef a Foley catheter in the bladder, and leakage of contrast fromhe anastomosis (Fig. 1). Fluid creatinine collected from therior JP site was consistent with urine.A pelvic drain was placed by interventional radiology to

rain the pelvic collection. The patient’s abdominal pain sub-equently improved over the next 24 hours, and his ileus re-olved. However, nearly all of the urine drained through theelvic drain, with only trace amounts through the Foley cath-ter. Several techniques were used, including Foley catheterlacement on mild traction, decreasing fluid intake, pullingack of the drain, and continuous needle vented Foley catheteruction drainage, each without success.

On postoperative day 6 the patient had a 10-F rightephroureteral stent (Cook, Bloomington, IN) placed by interven-ional radiology (Fig. 2A). The stent was connected to a True-lose suction drainage system (Uresil, Skokie, IL). The bellows

uction device was kept on suction for the first 36 hours (Fig. 2B).he stent effectively diverted all urine output so that there was norine output from the Foley catheter or the pelvic drain. So as to

inimize the risk of continuous suction on the bladder and

0090-4295/09/$34.00 1375doi:10.1016/j.urology.2008.03.026

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enal pelvis mucosa, the bellows suction was then cycled off 6ours and on 6 hours for an additional 12 hours. Theephroureteral stent was capped after 48 hours. The pelvicrain was removed on postoperative day 14. On postoperativeay 26 the nephroureteral stent and Foley catheter were re-oved after nephrostogram and cystogram confirmed no uri-ary leakage. The patient has had no issues with bladder neckontractures or urinary incontinence.

OMMENTn our experience with more than 200 consecutive RALP,he case presented (number 53 in the series) was the firstccurrence of persistent urinary leakage from the ure-hrovesical anastomosis requiring intervention. Althoughe have experience with both techniques, the case pre-

ented was performed with a transperitoneal approach, perurgeon preference. The extraperitoneal approach duringonventional open radical prostatectomy or minimally in-asive prostatectomy minimizes the risk of urine leakage inhe peritoneal space. Urinary leakage is typically self-remit-ing; however, all urine output was through the percutane-usly placed drain nearly 1 week after the surgery. As such,decision was made to intervene in this case.The incidence of prolonged urethrovesical anastomotic

eakage after laparoscopic radical prostatectomy has beenstimated at 0.9%-2.5%.2 The senior author previously pre-ented a novel technique of continuous ventilated Foleyatheter suction to aid in such cases.3 However, all conser-ative techniques, including needle vented suction of theoley catheter, failed to resolve this intraperitoneal leak. Asuch, a previously undescribed percutaneous nephroureteralatheter suction technique was used with excellent results.

igure 1. Computed tomographic scan of the pelvis, show-ng urinary leak posterior to the bladder (black arrow) andoley catheter within the urinary bladder (white arrow). Theelvic drain seen was placed by interventional radiology.

he nephroureteral stent used in this case had multiple

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erforations throughout the length of the stent, which al-owed for suction of urine from within the bladder as well ashe ipsilateral renal pelvis. The suction nephroureteral stentllowed for immediate proximal diversion of the urine,iding anastomotic healing. This minimally invasive tech-ique prevented the need for bilateral nephrostomy tubelacement and/or major reconstructive procedure.

eferences. Van Velthoven RF, Ahlering TE, Peltier A, et al. Technique for

laparoscopic running urethrovesical anastomosis: the single knotmethod. Urology. 2003;61:699-702.

. Rassweiler J, Seemann O, Schulze M, et al. Laparoscopic versus openradical prostatectomy: a comparative study at a single institution.J Urol. 2003;169:1689-1693.

. Moinzadeh A, Abouassaly R, Gill IS, et al. Continuous needlevented Foley catheter suction for urinary leak after radical prosta-

igure 2. (A) Nephroureteral stent. Left-side insert illus-rates the numerous ureteral perforations, magnified (shortrrows). (B) Bellows device and collection bag. The bellowsevice generates negative pressure suction connected tohe nephroureteral stent.

tectomy. J Urol. 2004;171:2366-2367.

UROLOGY 73 (6), 2009