Minimally invasive treatment of vesicourethral leak after laparoscopic radical prostatectomy

Objective: to describe our experience with a minimally invasive approach for persistent vesicourethral anastomotic leak (PVAL) after Laparoscopic Radical Prostatectomy (LRP). Methods: from 2004 to 2011, two surgeons performed LRP in 620 patients. Ten patients had PVAL, with initially indicated conservative treatment, to no avail. These patients underwent a minimally invasive operation, consisting of an endoscopically insertion of two ureteral catheters to direct urine flow, fixed to a new urethral catheter. We maintained the ureteral catheters for seven days on average to complete resolution of urine leakage. The urethral catheter was removed after three weeks of surgery. Results: the correction of urine leakage occurred within a range of one to three days, in all ten patients, without complications. There were no stenosis of the bladder neck and urinary incontinence on long-term follow-up. Conclusion: the study showed that PVAL after laparoscopic radical prostatectomy can be treated endoscopically with safety and excellent results.


INTRODUCTION
P rostate cancer is the most common malignancy in men.A large portion of the male population is subjected to screening tests, which makes early diagnosis increasingly frequent.Many of these patients are currently treated with laparoscopic radical prostatectomy (LRP) as a primary surgical approach aimed at cure 1,2 .
The vesicourethral anastomosis between the bladder neck and the membranous urethra for reconstruction of the lower urinary tract after removal of the prostate is a crucial point of LRP.Leakage of urine between the anastomosis stitches in the postoperative period is common, but is usually of low output and self-limited, during two or three days 3 .
Persistent vesicourethral anastomotic leaks (PVAL) can be defined as significant urinary losses through the drain after the third postoperative day, usually above 100 or 200 ml.It is a rare event, about which there is little published literature.However, its occurrence is of difficult control for the medical staff and patients, prolonging hospital stay, and bringing risks of potentially serious complications.
The objective of this study is to analyze the results of a endoscopic, minimally invasive approach to control PVAL when conservative treatment fails, thus avoiding more invasive surgical procedures, such as repair by conventional open surgery or nephrostomy, options traditionally used as the last resort in such cases.

METHODS
A total of 620 patients with adenocarcinoma of the prostate, clinical stage T1c, and a mean age of 61 years, underwent transperitoneal laparoscopic radical prostatectomy (LRP).The vesicourethral anastomosis was made with wire 3-0 Monocryl, as described by Van Velthoven et al., without bladder neck plasty prior to the anastomosis 3,4 .Ten patients had persistent vesicourethral anastomotic leaks (PVAL), with urine output by the perivesical drain of 100-400 ml in 24 hours, reaching 400-1100 ml on the second day after surgery.The fluids collected from the tubes were consistent with urine after laboratory results.
All patients underwent total abdomen computed tomography, which showed collection of fluid within the pelvis.
The ureters were preserved and the bladder Folley catheters were correctly positioned in the bladder.A retrograde cystogram was also carried out by urinary catheters in all ten patients, clearly showing contrast leak through the vesicourethral anastomosis (Figure 1).Initially, conservative techniques had been used, such as traction and attachment of the bladder catheter to the patient's thigh so that the catheter balloon occluded the urine leakage site, associated with a lower fluid intake.After the failure of these initial measures, these ten patients underwent endoscopic intervention for treatment of persistent urinary fistulas.The time interval between the LRP and the endoscopic reintervention ranged from three to nine days.
The procedure consisted of bilaterally placing ureteral catheters exteriorized alongside a new Folley catheter, to direct the urine out via the urethra and to reduce the leakage through the fistula, allowing its closure.
Initially, we carried out a urethrocystoscopy with a rigid, 19Fr cystoscope, under sedation and local anesthetic gel, allowing the exact identification of the fistula opening and its location relative to the ureteral ostia (Figure 2).Then 6Fr ureteral catheters were inserted bilaterally over a hydrophilic guidewire under radioscopic control and externalized through the urethra, along with a new, 18 Folley bladder catheter, also placed in the bladder with the aid of a guidewire.
All patients underwent a control retrograde cystogram to verify the complete resolution of the urine leakage before removal of the ureteral catheters, which took place after seven days.The bladder catheter was removed three weeks after prostatectomy.

RESULTS
The resolution of the persistent vesicourethral anastomosis leak (PVAL) occurred within a range of one to three days for all ten patients.There were no perioperative or immediate postoperative complications of the reintervention.The drains were removed after leakage become less than 50 ml per day (Table 1).There were no bladder neck stenosis or urinary incontinence after a mean follow up of 12 months (6-18 months).Our results were similar to the Yossepowitch group ones, with the same surgical technique.We believe, therefore, that the persistent vesicourethral anastomotic leaks (PVAL) can be treated by endoscopically draining the urinary system, with ease and security.The procedure is an alternative, less aggressive approach than any other surgical treatment, with excellent results.

188 Figure 1 .
Figure 1.Retrograde cystogram by the Folley catheter positioned in the bladder (A), where we can see the contrast leakage (B) from the posterior aspect of the anastomosis and the ureteral catheters (C) already positioned bilaterally
Figure 2. Urethrocystoscopy showing the fistulous orifice (arrow) in the anastomosis.R E S U M O