Laparoscopic Radical Prostatectomy : Omitting a Pelvic Drain

Purpose: Our goal was to assess outcomes of a selective drain placement strategy during laparoscopic radical prostatectomy (LRP) with a running urethrovesical anastomosis (RUVA) using cystographic imaging in all patients. Materials and Methods: A retrospective chart review was performed for all patients undergoing LRP between January at the discretion of the senior surgeon when a urinary leak was demonstrated with bladder irrigation, clinical suspicion for a urinary leak was high, or a complex bladder neck reconstruction was performed. Routine postoperative cystograms were obtained. Results: 208 patients underwent LRP with a RUVA. Data including cystogram was available for 206 patients. The overall rate of cystographic urine leak was 5.8%. A drain was placed in 51 patients. Of these, 8 (15.6%) had a postoperative leak on cystogram. Of the 157 undrained patients, urine leak was radiographically visible in 4 (2.5%). The higher leak rate in node dissection (8 drained, 16 undrained). Three undrained patients developed lymphoceles, which presented clinically on average 3 weeks postoperatively. There were no urinomas or hematomas in either group. Conclusions: Routine placement of a pelvic drain after LRP with a RUVA is not necessary, unless the anastomotic integrity is suboptimal intraoperatively. Experienced clinical judgment is essential and accurate in identifying patients at risk for postoperative leakage. When suspicion is low, omitting a drain does not increase morbidity.


INTRODUCTION
Acceptance of the laparoscopic radical prostatectomy (LRP) since its inception, and later its robotic counterpart, has been motivated by a drive to minimize perioperative morbidity.Room for improvement still exists, with the hope that minor technical adjustments will further decrease morbidity.The following editorial remark accompanies a 1996 article addressing the morbidity of drains following radical retropubic prostatectomy (RRP): "anything that reduces patient discomfort deserves consider ation" (1).might be omitted following an open RRP in an analy sis of 116 consecutive cases (2).These same authors updated this concept with 552 patients, arriving at the same conclusion (3).In a recent comprehensive review of published LRP literature, drain placement was not addressed (4), since published series seldom report this detail.In many centers, pelvic drainage remains a routine part of open and minimally invasive prostatectomy.We hypothesized that improved optical sis (RUVA) may obviate routine pelvic drainage.We assessed the relationship between pelvic drainage and postoperative complications in a consecutive series of 268 LRP in which routine postoperative cystography was performed in all patients, regardless of drain status.

MATERIALS AND METHODS
Laparoscopic radical retropubic prostatec tomy (LRP) was performed on 268 patients at the Lahey Clinic Medical Center between January 2003 and December 2004.Two hundred and eight patients patient information was obtained from a combina tion of a prospective database maintained by the Department of Urology Clinical Research Assistants score, clinical stage, estimated blood loss, blood transfusions, pelvic lymph node dissection (PLND), tate size, intravenous narcotic use, length of stay, and complications were recorded.The body mass index (BMI) was calculated from the preoperative height and weight documented in the anesthesia report.The operative time was calculated from incision start time to procedure end time as recorded in the opera tive nursing report.Narcotic use was calculated to be the sum of intravenous narcotics recorded by the nursing staff and administered via patient controlled analgesic or on an as needed basis.Different narcotics for comparison.
All patients underwent either a transperito neal or extraperitoneal LRP as described previously (5,6) by a single surgeon (IT).When nerve sparing was indicated and technically feasible, this was Surgery).Lymphadenectomy included the external iliac and obturator lymph nodes.The anastomosis Ty TM in the counterclockwise direction.The second suture stitches made in the clockwise direction.Therefore, prior to cinching the sutures, at least 4 to 6 running stitches were placed.Therefore, the initial tension is sutures were continued in a running manner in their appropriate direction until they meet at the anterior aspect of the anastomosis and tied together with an intracorporeal knot.
Anastomotic integrity was tested by distend ing the bladder with approximately 200 mL of saline, closed suction or Penrose drain was placed at the discretion of the senior surgeon (IT) when a leak was visualized at the anastomosis or a complex bladder neck reconstruction was performed.Indications for drain placement were obtained from the operative report.When omitted from the operative report, the placed in close proximity to the anastomosis.If drain removed.A routine cystogram was performed within remaining patients had a cystogram prior to postop Patients were seen postoperatively at 1 week, 5 weeks, 3 months, 6 months, 9 months, and 1 year in as any amount of contrast extravasation.Patients were examination was performed.Directed radiographic imaging was performed when warranted by clinical symptoms.The primary endpoint was the incidence of early postoperative complications: urine leak, uri noma, lymphocele, and hematoma.sociation between categorical data: (1) urine leak and drain placement, (1) urine leak and surgical approach, and (3) drain placement and performance of PLND.was used to compare mean values between the drained and undrained groups for the following parameters: prostate size, operative time, estimated blood loss, clinical and pathologic stage between both groups.

RESULTS
A total of 208 patients underwent LRP with a RUVA between January 2003 and December 2004.
The drained and undrained groups did not differ with the drain and undrained groups in regards to operative ence in estimated blood loss between groups.When a drain was placed, operative time was longer by an  The incidence of urinary extravasation on Drains were placed in 51 patients (25%), and omitted in 157 (75%).Cystograms were available for 206 pa tients (99%).Mean duration of drainage was 48 hours.Overall, 12 patients had radiographic evidence of a urinary leak (5.8%).The patients with a drain had a statistically higher incidence of a urinary leak.Pres 7 postoperative days; the remainder were performed the following week.As expected, earlier cystograms demonstrate the majority of leaks, with 50% seen on ing after prolonged drainage.No patient developed a urinoma in this series.unilateral nerve sparing, and bilateral nerve spar ing procedures were performed in 21 (10.1%),55 (26.4%), and 126 (60.6%) patients.Nerve sparing data was missing in 6 (2.9%) patients.There were no postoperative bleeding complications, includ intraoperative or postoperative blood transfusion, secondary procedure for anastomotic urine leak.This patient had mild unilateral hydronephrosis and a clini the OR on POD 7 for ureteral stent and suprapubic catheter placement.Of note, had cystograms not been performed in any patient, this is the only patient whose leak was apparent from increased pelvic drain output.The remaining 11 patients with a radiographic leak had no increased drainage.
Three patients underwent laparoscopic lym phocele fenestration.Their lymphoceles (12.5% of patients undergoing PLND) presented on average 3 fever, urinary retention with bladder spasms, or lower extremity edema.Of the patients undergoing PLND in whom drains were omitted, the approach was ex traperitoneal in 14/16 (87.5%).Drain placement was

COMMENTS
The Miami group, who were the first to suggest that routine pelvic drainage after open RRP was unnecessary (2,3) placed drains with a similar selective strategy.Since their report, the Roswell Park group has also supported the safety of drain omission (7).These reports relied on global compari sons of complication rates, without imaging studies.which routine postoperative cystograms were used to assess the true radiographic leak rate underlying this clinically driven algorithm, adding to a growing body of literature to support selective drain omission.
Using this selective algorithm, drains were placed in as prior reports (2,7).The overall cystographic leak series is 5.8% and objective imaging was available for 99% of patients.Interestingly, only one of the ten patients with radiographic evidence of a leak had a clinical leak.
What is the correlation between clinical and radiographic impressions of water tightness?Ischia and Lidsay, in a study of 68 patients undergoing open prostatectomy, found a strong correlation between intraoperative assessment with saline instillation, 68 consecutive patients, 53 had no intraoperative leakage, and of these only two (3.7%) had leaks on day 7 cystograms (8).Our data are similar, in that unsuspected leaks in the undrained group occurred in only 4 patients (2.5%).
Our overall cystographic leak rate compares favorably with published series.Cystography data has generally been analyzed to assess the feasibility of early catheter removal, and to correlate leak rates with the occurrence of anastomotic strictures.Studies often  In another review of 619 open RRP with cystograms at day 10 a leak rate of 4.6% was reported (13), which Even when timing of cystography and anas Nadu et al. reported the only other series of LRP with a RUVA in which cystography was routinely performed (14).A cystographically apparent leak was present in 17/113 patients (15.1%), even though most parameters mirror our series.The RUVA was performed with a developed, and drain status was not reported.What accounts for the higher leak rate?Patients were asked to Valsalva during cystography, which may transmit greater pressures to the anastomosis, whereas patients are imaged while voiding without Valsalva at our institution.

dure (15). The difference in early integrity between
Theoretically, suture tension may be distributed more evenly over the circumference of the anastomosis.
Authors have assumed, based on lack of symptomatic urine leak, that the anastomosis is watertight (16).Our cohort includes the learning curve for the RUVA, as well as objective imaging.Therefore, a low leak rate of 5.8% lends further evidence to this clinical obser vation.Although a selective drain placement strategy may be appropriate when a laparoscopic interrupted We also noted that although the senior surgeon had performed several hundred LRP prior to this time period, this cohort contains his learning curve for the RUVA.We have previously reported that a low leak rate may be a good surrogate endpoint for advanced anastomotic integrity should be accurate, and objec tive imaging substantiates this impression.When higher.When the anastomosis was watertight intraop eratively and a drain omitted, the leak rate was indeed undrained group did have leaks, none of which devel oped into urinomas.The longer operative time in the we did not conclude that placing a drain led to a statistically longer operative time.In the majority of A narrow pelvis or otherwise small working space, prostatitis may all contribute a sense of complexity to and translate into prolonged operative time.Since indications for placement were neither prospective nor randomized, selection bias of the senior surgeon is inherent in this study.That this bias has statistically Traditionally, drains are placed to allow the increasing the chance of urinoma.Symptomatic lymphoceles were also acceptably uncommon ( for adjuvant radiation had lymphoceles (18).The approach, whether transperitoneal or extraperitoneal, absorbed, compared to an extraperitoneal approach where the retropubic space is an enclosed area where any lymphatic drainage can readily form a lympho mandatory even after PLND and an extraperitoneal approach.Of the 16 patients undergoing PLND with out postoperative drainage, 87.5% were approached extraperitoneally and only 3 developed symptomatic lymphocele.A larger study with power to address this can be made.The morbidity of the drain itself is not a primary endpoint of this study.The drained group utilized more narcotic medication than the undrained group.We cannot conclude that the increased pain was naires and pain score assessment, the contribution of drains to increased narcotic use is speculative.Evi dence for drain related pain was reported by Niesel et al., who found that roughly one out of every four patients experience pain after RRP attributable only to the drain site and not the incision (1).The longer length of stay in the drained group is also likely mul tifactorial.The single patient with a clinical urine leak had an 11 day hospital stay, which may have contributed to the increased mean length of stay in the drained group.
In addition to the retrospective, nonrandom ized nature of this study, a potential criticism is the radiographically, and prolonged catheterization and repeat imaging were performed.Can the cystogram itself be omitted?At the present time, after the results of the present study and with increased experience, we have ceased performing routine cystography.Us ing this selective drain algorithm we have found no increased incidence of complications.

CONCLUSIONS
Routine pelvic drainage has traditionally ac companied radical prostatectomy.Our results suggest a pelvic drain can be omitted in patients undergoing an LRP with a RUVA if the anastomosis is watertight intraoperatively.Incidence of clinically detected urine leak, urinoma, hematoma, and lymphocele is not increased with this selective strategy.

Figure 1 -
Figure 1 -Distribution of cystogram based on postoperative day performed.Leaks are indicated as numbers above bar graphs.
BMI = body mass index; SD = standard deviation.

Table 2 -
Operative and postoperative data.

Table 3 -
Indications for drain placement.