Fenestrated urethral catheter to aid anastomotic drainage after radical prostatectomy

doi:10.1016/j.urology.2004.08.029

Urology

Volume 65, Issue 1, January 2005, Pages 160-162

https://doi.org/10.1016/j.urology.2004.08.029 Get rights and content

Abstract

A simple technique using a fenestrated urethral catheter to assist in drainage of pericatheter urethral exudates from the anastomosis of the urethra to the bladder neck in radical prostatectomy is described. It is applicable to open and laparoscopic techniques of radical prostatectomy.

Section snippets

Surgical technique

A standard silicone urethral catheter has a fenestration cut into the side of the catheter with bone nibblers (Fig. 1) or by bending the catheter sharply and cutting the projecting kink angle of the flattened fold with scissors.⁵ The fenestration should be cut, below the balloon, at the approximate level of the anastomosis. The hole should be made on the opposite side to the balloon channel to avoid damaging the balloon mechanism (Fig. 1). No more than around one third of the width of the

Comment

This technique was inspired by Turner-Warwick,⁶ who in 1973, recognized the importance of exudates that extravasate from the suture line of the anastomosis in proximal urethral stricture repair and the detrimental effect they have on healing. Exudates are any material, such as fluid, cells, or cellular debris, that has escaped from blood vessels and have been deposited on tissues or tissue surfaces.⁷ In this instance, exudates are composed predominantly of blood and urine. If urethral exudates

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Cited by (5)

A Clinician's Guide to Avoiding and Managing Common Complications During and After Robot-assisted Laparoscopic Radical Prostatectomy
2016, European Urology Focus
Citation Excerpt :
If these measures fail, nephrostomy placement or reoperation should be considered to repair the UVA [116]. Prevention relies on proper training and execution of anastomotic principles; however, utilization of a fenestrated catheter, fibrin sealants, and oxidized cellulose sponges facilitate a watertight UVA [126–128]. Fortunately, although UVAL can be troublesome to manage, two retrospective analyses found no long-term impact on erectile function, bladder neck contracture (BNC), or continence [129,130].
Robot-assisted radical prostatectomy (RARP) is on the advance globally, and it is essential for surgeons and patients to know the rates of perioperative complications.
To provide evidence-based clinical guidance on avoiding and managing common complications during and after RARP in the context of a comprehensive literature review.
In concordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis 2015 statement guidelines, a literature search of the PubMed database from August 1, 2011, to August 31, 2015, using the predefined search terms robot* AND radical prostatectomy, was conducted. The search resulted in 653 unique results that were subsequently uploaded to DistillerSR (Evidence Partners, Ottawa, Canada) for team-based screening and processing of references.
Overall, 37 studies met the inclusion criteria and were included. Median rate of overall complication was 12.6% (range: 3.1–42%). Most of the complications were minor (Clavien-Dindo grades 1 and 2). Grade 3 complications comprised the bulk of the major complications with a median rate of 2.7%; grade IV and V complications were exceedingly rare in all reports.
Despite continued adoption of the RARP technique globally, rates of overall complication remain low. Many of the complications experienced during and after RARP can be mitigated and prevented by experience and the implementation of safe techniques.
Despite continued adoption of the robot-assisted radical prostatectomy (RARP) technique globally, rates of overall and major complications remain low at 12.6% and 2.7%, respectively. Complications can be minimized and successfully managed using established techniques. RARP is a safe and reproducible technique.
All you need to know about urethrovesical anastomotic urinary leakage following radical prostatectomy
2012, Journal of Urology
Citation Excerpt :
The only additional measures that can be regarded as preventative with the exception of applying the basic surgical principles of anastomosis are the use of a fenestrated catheter, the application of fibrin sealant in the anastomosis and the placement of oxidized cellulose sponges around the anastomosis. A fenestrated catheter is used to prevent exudate composed of blood and urine from accumulating in the urethral space, thereby preventing UVAL.21,47,48 The fenestration is placed below the balloon, helping the free drainage of the exudate from the important site of UVAL that is healing.
Radical prostatectomy is a challenging operation demanding a high level of surgical expertise and experience. Urinary leakage at the urethrovesical anastomosis is one of the most common short-term complications of radical prostatectomy, reaching an incidence of 0.3% to 15.4%. In this review we investigate and discuss all matters directly related to urethrovesical anastomotic leak, specifically how to diagnose it properly, how to determine when it is clinically significant and when intervention is required, how to prevent or predict it and, finally, the possible long-term sequelae.
We conducted a systematic analysis of the literature searching for English and nonEnglish language publications from a preidentified time frame (1985 to 2011) using primary search databases (PubMed®, Web of Science®). Manual selection was performed by 2 authors and the third reviewed the final common selection. We also created an algorithm for the diagnosis and management of urethrovesical anastomotic leak.
A total of 72 studies were finally selected, including 48 (67%) observational case series, 16 (22.2%) prospective trials, 1 letter to the editor, 1 review and 1 systematic review which was focused only on laparoscopic radical prostatectomy. We also found 2 experimental studies performed in animal models and 3 case reports. Of these studies 7 reported results from fewer than 20 patients. No consensus was recorded on a strict definition of urethrovesical anastomotic leak. The factors determining possible definitions included postoperative day of urethrovesical anastomotic leak, amount of extravasation on cystography and the need for intervention. Urethrovesical anastomotic leak should be classified according to the Clavien classification system, depending on severity and the need for intervention. To our knowledge the role of the open, laparoscopic or robotic approach in the incidence of urethrovesical anastomotic leak has not been systematically investigated. Risk factors for urethrovesical anastomotic leak include obesity, prostate size, previous prostatic surgery, type of anastomosis technique, suture number and type, eversion of the mucosa, a difficult anastomosis or an anastomosis under tension, reconstruction of the musculofascial plate, blood loss, intraoperative flush test result and postoperative urinary tract infection. Diagnosis can be determined primarily by establishing the nature of the drain output. Retrograde cystography, computerized tomography cystography, transrectal ultrasound, contrast enhanced ultrasound and excretory urography are the indicated imaging modalities, and are not always necessary. Finally, the development of anastomotic stricture and incontinence due to urethrovesical anastomotic leak are additional complications.
We gathered all relevant critical information concerning urethrovesical anastomotic leak to encourage standardization in the diagnosis and management of this common complication. Systematic meta-analysis of each debatable issue is required to provide definite answers.
Vesicourethral Anastomosis During Radical Retropubic Prostatectomy: Does the Number of Sutures Matter?
2007, Urology
Citation Excerpt :
In addition, we applied oxidized cellulose sponges around the anastomotic site in the pelvic fossa to block exudates or any material, such as fluid, cells, or cellular debris, that had escaped from the blood vessels. If urethral exudates accumulate in the urethral space, the urethra may become inflamed and even infected, compromising healing.21 As shown by Diner et al.,9 fibrin sealants are very effective in promoting tissue healing; however, because of their high cost, we limited their use only to cases of intraoperative leakage at the anastomotic site.
To prospectively evaluate the outcome of radical retropubic prostatectomy using three different techniques of vesicourethral anastomosis (VUA), with a different number of sutures used during this surgical step.
Three groups of patients who had undergone nerve-sparing radical retropubic prostatectomy were compared. Overall, 90 patients with localized prostate cancer were recruited. The patients were randomly assigned to undergo one of three different VUA techniques. The anastomotic sutures consisted of four or six monocryl 2-0 stitches. The “two-suture” anastomosis in group 1 was performed by passing two U-shaped horizontal stitches at the 6-o’clock and 12-o’clock positions. The following intraoperative and perioperative parameters were considered for the comparative analysis: time to perform VUA, blood loss, hospitalization, and time to drain removal.
A statistically significant difference was found in terms of the mean time to anastomosis between groups 1 and 2 (3.61 ± 1.14 versus 16.6 ± 4.04, P <0.0001) and between groups 1 and 3 (3.61 ± 1.14 versus 23.45 ± 5.4, P <0.0001). No significant differences could be detected for blood loss, time to drain removal, or hospitalization. No significant difference was detected in terms of functional outcome (stricture rate, erectile function, and continence).
The number of stitches used for VUA during radical retropubic prostatectomy did not influence the perioperative and postoperative parameters. The time to VUA was considerably lower using our “two-suture” technique.
Effect of vesicourethral anastomosis technique on functional results in retropubic radical prostatectomy
2021, International Journal of Clinical Practice
Side-fenestrated catheter decreases leakage at the urethrovesical anastomosis after robot-assisted laparoscopic radical prostatectomy
2014, Scandinavian Journal of Urology

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Surgeon’s workshopFenestrated urethral catheter to aid anastomotic drainage after radical prostatectomy

Abstract

Section snippets

Surgical technique

Comment

J Urol

J Urol

J Urol

Bladder neck strictures after radical retropubic prostatectomystill an unsolved problem

Br J Urol

Surgeon’s workshop
Fenestrated urethral catheter to aid anastomotic drainage after radical prostatectomy