RUPTURE
OF VESICOURETHRAL ANASTOMOSIS FOLLOWING RADICAL RETROPUBIC PROSTATECTOMY
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MARCOS DALL’OGLIO, MIGUEL SROUGI, DANIEL PEREIRA, ADRIANO NESRALLAH, CÁSSIO ANDREONI, JOSÉ R. KAUFFMANN, LUCIANO NESRALLAH
Department of Urology, Federal University of São Paulo, UNIFESP, Paulista School of Medicine, São Paulo, SP, Brazil
ABSTRACT
Objective:
Rupture of vesicourethral anastomosis following radical retropubic prostatectomy
is a complication that requires immediate management. We evaluated the
morbidity of this rare complication.
Materials and Methods: We analyzed retrospectively
5 cases of disruption of vesicourethral anastomosis during post-operative
period in a consecutive series of 1,600 radical retropubic prostatectomies,
performed by a single surgeon.
Results: It occurred in a ratio of 1:320
prostatectomies (0,3%). Management was conservative in all the cases with
an average catheter permanence time of 28 days, being its removal preceded
by cystography. Two cases were secondary to bleeding, 1 followed the change
of vesical catheter and 2 by unknown causes after removing the Foley catheter.
Only one patient evolved with urethral stenosis, in the period ranging
from 6 to 120 months.
Conclusion: Rupture of vesicourethral anastomosis
is not related to the surgeon’s experience, and conservative treatment
has shown to be effective.
Key
words: prostatic neoplasms; retropubic prostatectomy; anastomosis,
surgical; rupture
Int Braz J Urol. 2003; 29: 221-7
INTRODUCTION
Prostate
adenocarcinoma is a worldly public health problem, and about 2 hundred
thousand men had a prostate cancer diagnosed in the USA in 2001 (1), with
a forecast of forty thousand deaths (2). Routine use of prostate-specific
antigen (PSA) has favored early diagnosis of prostate cancer (3,4) and,
thus, has improved the results of surgical treatment in controlling the
neoplasm (1,2,5). After significant advances in the surgical technique
established by Walsh et al. (6), including preservation of neurovascular
bundle and a better control of the penile dorsal vein complex, radical
prostatectomy has become safe and feasible for most urologists. Two decades
after the publishing of Walsh’s technique (6), several surgeons
have already achieved a large experience, obtaining expressive series
of treated patients (7-9), with major immediate and late complications
related to radical prostatectomy being well documented (5,10-13).
Disruption of vesicourethral anastomosis
following radical retropubic prostatectomy (RRP) is a rare complication
and, undoubtedly, a dramatic situation for the surgeon to decide between
surgical intervention and conservative management (7). Management is controversial,
since the superiority of a particular treatment method has not been established.
The objective of this study is to demonstrate
our experience when facing a rupture of vesicourethral anastomosis following
radical prostatectomy.
MATERIALS AND METHODS
One
thousand and six hundred consecutive patients submitted to RRP associated
to bilateral iliac lymphadenectomy due to prostate carcinoma, performed
by a single surgeon (MS) at our Institution, in the period from January
1988 to November 2002 were retrospectively assessed. Our study included
5 patients with ages ranging from 55 to 72 years (mean = 64.8 years) and
who presented disruption of vesicourethral anastomosis during RRP post-operative.
In 2 patients, the disruption occurred due to bleeding in surgical resection
bed, one due to inadvertent change of Foley catheter and 2 ruptures of
anastomosis occurred in the first and in the tenth day after Foley catheter
removal, 13 and 23 days post-operatively respectively.
Immediate management consisted in urethrocystoscopy
associated with introducing of a guide-wire and positioning of Foley catheter
by fluoroscopy in 4 cases. Only 1 patient was immediately catheterized.
Follow-up was performed through weekly cystographic examination, with
removal of Foley catheter after absence of extravasation of contrast media
confirmed in urethrocystography. Follow-up ranged from 6 to 120 months
(mean = 25.2 months). Patients were assessed through anamnesis, with emphasis
on voiding patterns and monthly urethrocystography during the first semester,
bi-annual PSA, abdomen tomography and bone scintigraphy yearly.
RESULTS
Table-1
presents the etiology of the rupture of anastomosis and early clinical
manifestations. Table-2 demonstrates the repercussions of long-term permanence
of the Foley catheter.
Of the 5 cases of rupture of vesicourethral
anastomosis following radical retropubic prostatectomy analyzed, 4 evolved
satisfactorily and 1 presented sclerosis of the anastomosis, requiring
the introduction of an urethral stent. Next, we present the report on
each case in details.
Case 1: RM, 64 years, stage pT2b, Gleason 2+3
On the third post-operative day (POD) the
Foley catheter was changed by nursing. Subsequently there was inversion
of urinary output, being larger through suprapubic Penrose drain and lower
through the Foley catheter. On 5th POD, the confirmation of disruption
of vesicourethral anastomosis was established during cystoscopy (Storz
flexible cystoscope). During this procedure, a vesical catheter was placed
with the aid of a guide-wire and cystographic control insufflating Foley’s
balloon with 60 mL of a solution containing iodated contrast media. Release
from hospital was granted on 8th POD and the patient remained with Foley
catheter for 31 days. Urinary continence was established in a definitive
way from the third month on, when hygienic diapers were dispensed, however
the patient evolved with erectile dysfunction.
Case
2: SM, 65 years, stage pT3a, Gleason 4+3
Following removal of Foley catheter on 13th
POD the patient evolved with acute urinary retention. An urethrocystoscopy
was performed, showing a disruption of anastomosis, which remained united
only by one point. Management was conducted on an outpatient basis, by
introducing a Foley catheter under fluoroscopy with the aid of a guide-wire
previously inserted in the bladder. On 35th POD, the vesical catheter
was removed after a normal urethrocystography. The patient evolved without
intercurrences remaining continent and with sexual potency preserved.
Case
3: FB, 55 years, stage pT3a, Gleason 3+2
On 4th POD, patient evolved with pallor,
tachycardia, sweating and interruption of urinary output through Foley
catheter associated to a drop in serum hemoglobin levels. Five units of
erythrocyte concentrate were transfused for correction of anemia. A fluoroscopy
was performed and a new vesical catheter was introduced with the aid of
a guide-wire through uretrocystoscopy, which evidenced the disruption
of vesicourethral anastomosis associated with the presence of hematoma
between the anastomosis margins, extending hospital permanence to 8 days
until clinical stability. The Foley catheter was removed on the 14th POD,
after a normal urethrocystography, and during follow-up, the patient did
not present any voiding difficulty remaining continent and with sexual
potency preserved.
Case
4: JCB, 68 years, stage pT2b, Gleason 3+3
On 23rd POD, 10 days after removal of Foley
catheter, the patient who was maintaining spontaneous diuresis entered
in acute urinary retention. Introduction of a vesical catheter was performed
without the need of aids from cystoscopy with drainage of 500 mL of clear
urine. Disruption of vesicourethral anastomosis was confirmed by cystography,
which demonstrated extravasation of contrast media. Removal of Foley catheter
took place on the 54th POD, after performing an urethrocystography, which
showed vesical filling and absence of extravasation of contrast media.
Patient evolved with sclerosis of the vesical
neck (vesico-urethral anastomosis site), which was corrected by urethral
stenting (UrolumeÒ). After the procedure, the patient manifested
urinary incontinence, which was subsequently resolved by placing an AMS
800 artificial sphincter. Sexual function is satisfactory with the aid
of intracavernous injections of prostaglandin.
Case
5: J G, 72 years, stage pT2c, Gleason 4+3
On 2nd POD patient presented an acute myocardial
infarction and was subjected to coronary angioplasty with placement of
a vascular stent associated to administration of anti-platelet aggregating
factor. He evolved with massive pelvic hemorrhage and hemodynamic instability,
requiring the transfusion of 6 units of erythrocyte concentrate to correct
anemia. Computerized tomography demonstrated disruption of the vesicourethral
anastomosis separated by a large hematoma that pushes the bladder cranially
(Figure-1). This hematoma was drained through puncture guided by computerized
tomography (Figure-2). After 3 weeks with Foley catheter, it was removed;
however, patient evolved with acute urinary retention. Foley catheter
was reinserted with the aid of urethrocystoscopy with introduction of
a guide-wire and positioning with fluoroscopic assistance. Control cystography
performed after 42 days, demonstrated persistence of extravasation of
contrast media, with the aggravation that Foley catheter was positioned
outside the bladder (Figure-3). Foley catheter was repositioned with the
aid of cystoscopy and dynamic cystography with insufflation of 80 mL of
contrast medium in the catheter balloon. During the passage of the cystoscope
there was drainage of hematic secretion around the device. Weekly urethrocystographies
were performed, until complete urethrovesical healing (Figure-4).Vesical
catheter was removed after 30 days (83rd POD), with patient obtaining
spontaneous diuresis. Currently, after a 6 months follow-up, the patient
is continent.
DISCUSSION
This
work demonstrated that conservative management for treating post-RRP rupture
of vesicourethral anastomosis through permanence of Foley catheter was
effective. The incidence of disruption of vesicourethral anastomosis is
0.2% to 0.5% (7-9) and the best management is still a subject for discussion.
The most common transoperative complication
of radical prostatectomy is bleeding (8), which decreases with surgeon’s
expertise (10), however, with a blood transfusion rate of 9% to 29% (5,8),
what can reflect in prognosis (11). Acute myocardial infarction is the
most common unrelated post-operative complication (10) oscillating between
0.1-0.5% (8,9,12), on the other hand, the need of using an anticoagulant
increases intraoperative bleeding and post-operative lymphatic drainage
(10). We had a patient who presented an acute myocardial infarction on
2nd POD in whom the use of anti-platelet aggregating factor had precipitated
the hemorrhage.
On the other hand, the incidence of significant
bleeding in the dissection bed during post-operative period ranges from
0.3% to 3.2% (7,9,12,14) and the need of blood transfusion is very rare
(10). Formation of small hematomas suggests an expectant management (10),
however bulky hematomas can compress and displace the bladder causing
disruption of vesicourethral anastomosis, if they are not drained (7).
In our series, 2 patients had bleeding with rupture of anastomosis whose
conservative treatment was effective. In one case there was the need of
draining the perivesical hematoma through punction guided by computerized
tomography in order to avoid infection and to control severe perineal
pain.
Hedican & Walsh (7) studied 7 patients
with rupture of vesicourethral anastomosis secondary to bleeding in surgical
bed, dividing the patients in 2 groups. In the first group, comprised
by 3 patients, a conservative treatment was instituted, with indwelling
vesical catheterization, whose outcome revealed sclerosis of vesical neck
in all 3 patients, with 2 of them evolving with prolonged urinary incontinence.
The second group, submitted to surgical exploration for hematoma drainage
with revision of anastomosis had a better outcome, presenting sclerosis
of vesical neck in 1 patient and prolonged urinary incontinence in another
one. When indicating a new surgery in cases of post-radical prostatectomy
pelvic hematomas, Lepor et al. (9), advised the repair of vesicourethral
anastomosis.
Conservative treatment can be associated
to sclerosis of vesical neck and also to prolonged urinary incontinence
(7,15), on the other hand, early intervention with suturing of urethral
margins increases the risk of complications such as urinary incontinence,
erectile dysfunction and bleeding (16). In our cases, out of 5 treated
patients, we had one case of sclerosis of vesical neck refractory to endoscopic
treatment, whose definitive treatment consisted in the placement of a
stent (Urolume), however the patient evolved with urinary incontinence
requiring the implantation of an artificial sphincter (AMS-800) in order
to solve definitely the problem.
When facing disruption of vesicourethral
anastomosis, in order to reposition Foley catheter, cystoscopy with introduction
of a guide-wire is fundamental (10,15), and while introducing the catheter,
its position must be confirmed by fluoroscopy with contrast injection.
Differently from Fisher & Koch (15), we did not fix the catheter on
the vesical dome; we simply used the artifice of insufflating the Foley
catheter’s balloon with a volume around 60 mL. Despite this precaution,
in one case occurred a displacement of the Foley catheter outwards the
bladder, due to complete dehiscence of vesical cervix with cranial displacement
of bladder. In radical retropubic prostatectomy, while confectioning the
new vesical neck, we usually use a 2-zero chromium catgut suture, making
separate stitches in total plane and vesicourethral anastomosis is done
with 8 separate stitches with poliglactin 3-zero incorporating the striated
sphincter together with the urethra. Normally, we remove the Foley catheter
on 13th POD, however there are series indicating the catheter’s
removal in an earlier period without impairment in healing (14). We had
2 cases of urinary retention following removal of the Foley catheter,
on the first and on the 10th days following catheter’s removal,
without evidencing the reason for such rupture. In only one case premature
change of catheter promoted the disruption of the anastomosis.
We believe that rupture of anastomosis is
not related to the surgeon’s experience, considering the occurrence
of such complication in teams with expressive casuistry (7-9), neither
is it changed by the number of stitches used for vesicourethral anastomosis
(5,8,9,13,15,17,18). Antibiotic therapy was used in all patients, and
no cases of sepsis were recorded. Upon confirmation of stability in the
clinical picture and adequate positioning of the Foley catheter, patient
is released from hospital with oral antibiotics and is re-evaluated every
week on an outpatient basis through cystography, thus avoiding an excessive
increase on treatment costs.
Analogously to trauma of posterior urethra,
where there is disruption of prostate-membranous urethra with cranial
displacement of the bladder, introducing of a Foley catheter through the
urethral route allows the alignment of margins with a lower incidence
of stenosis in the region, and subsequent descending of bladder to its
anatomical position (15), because of this, we do not advise performing
a cystostomy. Prolonged drainage constitutes an adequate management and
avoids potential failure in a new surgery.
REFERENCES
- Eton DT, Lepore SJ, Helgeson VS: Early quality of life in patients with localized prostate carcinoma. Cancer 2001; 92:1451-9.
- Berry MJ, Albertsen PC, Bagshaw MA, Blute ML, Cox R, Middleton RG et al.: Outcomes of men with clinically nonmetastatic prostate carcinoma managed with radical prostatectomy, external beam radiotherapy, or expectant management. Cancer 2001; 91:2302-14.
- Jacobsen SJ, Kausis SV, Bergstralh EJ, Oesterling JE, Orth, D, Klee GG et al.: Incidence of prostate cancer diagnosis in the eras before and after serum prostate-specific antigen testing. JAMA 1995; 274:1445-9.
- Epstein JI, Walsh PC, Carter HB: Dedifferentiation of prostate cancer grade with time in men followed expectantly for stage T1c disease. J Urol. 2001; 166:1688-91.
- Dillioglugil O, Leibman D, Leibman NS, Kattan MW, Rosas AL, Scardino PT: Risk factors for complication and morbidity after radical retropubic prostatectomy. J Urol. 1997; 157:1760-7.
- Walsh PC, Partin AW, Epstein JI: Cancer control and quality of life following anatomical radical retropubic prostatectomy. Results at 10 years. J Urol. 1984; 152:1831-6.
- Hedican SP, Walsh PC: Postoperative bleeding following radical retropubic prostatectomy. J Urol. 1994; 152:1181-3.
- Catalona WJ, Carvalhal GF, Mager DE, Smith DS: Potency, continence and complication rates in 1,870 consecutive radical retropubic prostatectomies. J Urol. 1999; 162:433-8.
- Lepor H, Nieder AM, Ferrandino MN: Intraoperative and postoperative complications of radical retropubic prostatectomy in a consecutive series of 1000 cases. J Urol. 2001; 166:1729-33.
- Shekarriz B, Upadhyay J, Wood DP: Intraoperative, perioperative, and long-term complications of radical prostatectomy. Urol Clin North Am. 2001; 28:639-53.
- Oefelein MG, Conlangelo LA, Rademaker AW, McVary KT: Intraoperative blood loss and prognosis in prostate cancer patients undergoing radical retropubic prostatectomy. J Urol. 1995; 154:442-7.
- Lu-Yao GL, Albertsen P, Warren J, Yao SL: Effect of age and surgical approach on complications and short-term mortality after radical prostatectomy. A population-based study. Urology 1999; 54:301-7.
- Heinzer H, Graefen M, Noldus J, Hammerer P, Huland H: Early complication of anatomical radical prostatectomy: Lessons from a single-center experience. Urol Int. 1997; 59:30-3.
- Guillonneau B, Rozet F, Cathelineau X, Lay F, Barret E, Doublet JD et al.: Perioperative complications of laparoscopic radical prostatectomy: The Montsouris 3-years experience. J Urol. 2002; 167:51-6.
- Fisher RE, Koch MO: Recognition and management of delayed disruption vesicourethral anastomosis in radical prostatectomy. J Urol. 1992; 147:1579-81.
- Kotkin L, Koch MO: Impotence and incontinence after immediate realignment of posterior urethral trauma: result of injury or management? J Urol. 1996; 155:1600-3.
- Igel TC, Barrett DM, Rife CC: Comparison of techniques for vesicourethral anastomosis: simple direct modified Vest traction sutures. Urology 1988; 31:474-7.
- Petroski RA, Thrasher JB, Hansberry KL: New use of Foley catheter for precise vesicourethral anastomosis during radical retropubic prostatectomy. J Urol. 1996; 155:1376-7.
________________________
Received: February 21, 2003
Accepted: April 4, 2003
_______________________
Correspondence address:
Dr. Marcos Dall’Oglio
Rua Manoel da Nóbrega, 853 casa 22
São Paulo, SP, 04001-084, Brazil
Fax: + 55 11 3885-0658
E-mail: marcosdalloglio@uol.com.br
EDITORIAL COMMENT
Fortunately
it is an uncommon situation, but a rather concerning one. The authors
were very fortunate when choosing conservative management, with excellent
results in the 5 cases presented. We entirely agree that this complication
is not related to the learning curve.
However, being controversial, immediate
surgical approach must be restricted to surgeons with a larger casuistry,
thus avoiding major complications, such as sphincter compromise, leading
to urinary incontinence, as well as lesions of neurovascular bundle.
In our casuistry, using continuous suture
in 471 cases of radical retropubic prostatectomy, there were no cases
of rupture of vesicourethral anastomosis. It is interesting to emphasize
that in 6 patients with short urethras that were too much embedded into
the urogenital diaphragm, in addition to such adverse pelvic anatomy,
it was impossible to perform the vesicourethral continuous suture (1.2%;
6 in 477 consecutive RRP). Of these patients, 2 presented rupture of anastomosis
during immediate post-operative, as a consequence of replacement of Foley
catheter by nursing. These 2 patients were immediately reoperated, and
it was verified that the Foley catheters balloons had been insufflated
in the anastomosis area, tearing it completely. We performed a new vesicourethral
anastomosis with 6 separate stitches. The Foley catheter was maintained
for 4 weeks and the patients were continent after 6 months.
We believe that continuous suture of vesicourethral
anastomosis enables the safe removal of the Foley catheter on 3rd or 4th
post-operative day, and additionally can prevent the rupture of vesicourethral
anastomosis.
Dr.
Aloysio Floriano de Toledo
Section of Urology, General Hospital
Catholic University of Rio Grande do Sul
Porto Alegre, Rio Grande do Sul, Brazil