| RE:
LAPAROSCOPIC RADICAL PROSTATECTOMY: OMITTING A PELVIC DRAIN
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DAVID CANES, MICHAEL
S. COHEN, INGOLF A. TUERK
Lahey Clinic
Medical Center, Burlington, Massachusetts, USA
Int
Braz J Urol, 34: 151-158, 2008
To the Editor:
The
placement of a drain post prostatectomy is the subject of much discussion
these days. A lot has been made of surgeons moving to the non-drained
model of prostatectomy, the goal has been to become less invasive and
reduce patient morbidity. In open prostatectomy, the drain is placed via
a separate stab incision while in laparoscopic or robotic cases the drain
is brought out through a pre-existing port site. In both cases, the drain
is usually removed at day one in a simple manner without any additional
anesthesia. The purpose of a pelvic drain is to remove the abdominal fluid
contents resulting from the surgery. This can be blood, lymph or urine.
The point is what is the downside?
The drain provides an additional source
of diagnostic information during the postoperative period and can help
early diagnosis of postoperative problems. This is especially important
in modern day surgery with patients going home in under 24 hours. Identifying
potential bleeding or urinary extravagation can prevent readmissions and
potentially more catastrophic complications. While some are proud of not
having to use a drain post surgery, I am sure all would agree that they
have at times had to place one post surgery or have had postoperative
bleeding or urinomas that have remained undrained.
Though there are a few studies, which have
addressed the avoidance for, drain in open radical prostatectomy (1,2)
there is only one paper that addressed the avoidance of drain following
laparoscopic prostatectomy (3). This paper is a retrospective study concluding
that drains may be placed selectively following laparoscopic radical prostatectomy.
The authors subjectively omitted drain placement in 75% of 208 patients
undergoing this operation with no ill effects. The surgeon chose to place
drains based mainly on large bladder neck reconstructions or intraoperative
anastomotic leak on saline bladder lavage. A randomized prospectively
designed study with cystograms performed at a set time interval from surgery
would give better evidence for this ongoing debate. A crucial endpoint
for investigation would be the objective benefits of omitting drain placement
such as validated assessment of postoperative patient discomfort.
Advantages claimed for avoidance of the
drain have been decreased OR times, lack of pain at removal and shorter
hospital stay (4). Advantages of drain placement at laparoscopic prostatectomy
have been early recognition of inadequate hemostasis and urine leak while
allowing efflux of blood, urine and lymphatic fluid from the pelvis. Drain
placement may reduce hematoma formation, which has been shown to cause
bladder neck contractures and permanent incontinence in a significant
percentage of patients when they occur (5).
We believe that the simple drain is not
only acceptable but also essential to allow early diagnosis of postoperative
problems and to prevent more serious issues evolving. I would have to
see good evidence of the benefits in omitting drains to consider changing
this practice.
REFERENCES
1.
Araki M, Manoharan M, Vyas S, Nieder AM, Soloway MS: A pelvic drain can
often be avoided after radical retropubic prostatectomy--an update in
552 cases. Eur Urol. 2006; 50: 1241-7; discussion 1246-7.
2. Savoie M, Soloway MS, Kim SS, Manoharan M: A pelvic drain may be avoided
after radical retropubic prostatectomy. J Urol. 2003; 170: 112-4.
3. Sharma S, Kim HL, Mohler JL: Routine pelvic drainage not required after
open or robotic radical prostatectomy. Urology. 2007; 69: 330-3.
4. Licht MR, Klein EA: Early hospital discharge after radical retropubic
prostatectomy: impact on cost and complication rate. Urology. 1994; 44:
700-4.
5. Hedican SP, Walsh PC: Postoperative bleeding following radical retropubic
prostatectomy. J Urol. 1994; 152: 1181-3.
Dr. Vipul Patel
Associate Clinical Professor of Surgery
Associate Clinical Professor of Bioinformatics
Director of Robotic & Minimally Invasive Urologic Surgery
The Ohio State University
Columbus, Ohio, USA
E-mail: myurologist@aol.com
REPLY BY THE
AUTHORS
We
appreciate the thoughtful critique by Dr. Patel and are pleased that our
article has sparked continued debate on the subject of pelvic drain placement
following minimally invasive prostatectomy. He raises several points of
criticism to which we would like to respond.
First, Dr. Patel notes that surgeons are
moving to the “non-drained model”. We do not support such
a model, nor do we promote a sense of pride or cavalier behavior. Instead,
we are promoting a selective drainage strategy. Furthermore, we believe
that our selective drainage strategy as outlined in our article contains
much of the “good evidence” that Dr. Patel calls for to settle
this question, since no patient had a complication related to absence
of a drain, and cystograms were obtained in virtually all patients.
In the era of evidence-based medicine, the
question, “What is the downside?” is misdirected. Instead
of asking, “why not?” we should demand that there be a robust
reason for each of our maneuvers. Having initially presented this data
at regional and national meetings, we observed the tendency of surgeons
who, deeply accustomed to their routine, looked at the data and then tossed
it aside to rely on gut feelings. Instead, we need to look closely at
each potential complication for which at the outset we believe a drain
will raise a red flag.
Is a pelvic drain a reliable signal of serious
hemorrhage requiring reoperation in the immediate postoperative period?
Probably not. In our series, there were no cases of hemorrhage or hematoma.
We have all seen patients brought back to the operating room for severe
bleeding within the first 24 hours after prostatectomy in whom a clotted
Jackson-Pratt drain adjacent to a large hematoma had zero output. Of course,
if hemostasis is truly concerning and appropriate measures have been taken,
a drain should be placed, as was done for 2 patients in our series. However,
drain or no drain, patients with serious postoperative bleeding will display
clinical signs including decreasing hemoglobin, hemodynamic instability,
oliguria, or abdominal distension. In over 2,000 patients undergoing minimally
invasive prostatectomy in our experience, we have yet to see a patient
with bloody drain output as the sole indicator of evolving problems.
Does a pelvic drain signal impending lymphocele
formation? Absolutely not. As Dr. Patel points out, most patients are
discharged within 24 hours without drains. On average, lymphoceles present
2 - 4 weeks after surgery, long after the drain has been removed. Evacuation
of lymphatic fluid and/or diagnosing impending lymphoceles should not
generally be used as a justification for drain placement.
Potential urinary extravasation from the
anastomosis is the main justification for drain placement. We believe
that a selective strategy can correctly identify those patients at risk
for urine leak. In the remaining patients, the drain is simply unnecessary,
and a potential source of pain and anxiety for the patient. As regards
patient perception of the drain, we agree that the endpoints of validated
pain scores and directed questionnaires are lacking in our study.
Dr. Patel has correctly stated that a prospective
study is required, in which cystograms are performed at a set interval
from surgery. Our study, while retrospective, is the first in the literature
to contain cystograms in virtually all patients (206/208, or 99%), most
of which were done within the first week (90% of patients). However, we
respectfully disagree with Dr. Patel’s response in calling for randomization.
Herein lies the key point: we do not advocate omitting drains in all patients,
and randomizing patients to be drained or undrained would likely increase
the incidence of undiagnosed complications. In fact, we advocate selection
bias, in particular the bias of the senior surgeon. This is an active,
selective strategy whereby drains are placed at the surgeon’s discretion
when concerns exist regarding the bladder neck, the anastomosis, or overall
case complexity.
Our study adds to a growing body of literature
that selective drain placement is likely to be required in 25% of cases
(1-3). Can an experienced surgeon correctly identify the appropriate 1
out of 4 patients in whom drainage is required? Our data indicates the
answer is definitely yes. Table 4 in our manuscript displays the true
cystographic leak rate in the drained group is 15.6%, compared to 2.5%
in patients where a drain was deemed unnecessary (p = 0.002). In the latter
group, these were clinically insignificant extravasations, and no urinomas
developed. This is reassuring evidence in support of a selective strategy
for drain placement.
Having combined evidence from our own data
and the other referenced studies, we have changed our practice. In the
last 4 years, a selective drain placement strategy has not resulted in
any measurable increase in morbidity. Readers need to decide individually
how comfortable they are with this strategy and should not adopt this
approach during the learning curve.
Respectfully,
The
Authors
REFERENCES
Savoie M, Soloway MS, Kim SS, Manoharan M: A pelvic drain
may be avoided after radical retropubic prostatectomy. J Urol. 2003; 170:112-4
Araki M, Manoharan M, Vyas S, Nieder AM, Soloway MS: A pelvic drain can
often be avoided after radical Retropubic prostatectomy- an update in
552 cases. Eur urol. 2006; 50: 1241-7
Sharma S, Kim HL, Mohler JL: Routine pelvic drainage not required after
open or robotic radical prostatectomy. Urology 2007; 69: 330-3.
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