novel management of anastomotic disruption and persistent hematuria following robotic prostatectomy case report and review of the literature

Novel Management of Anastomotic Disruption and Persistent Hematuria Following Robotic Prostatectomy: Case Report and Review of the Literature Charles J.. We present a case of a 59-year-o

Novel Management of Anastomotic Disruption and Persistent

Hematuria Following Robotic Prostatectomy: Case Report and

Review of the Literature

Charles J Paul, Conrad M Tobert, Chad R Tracy*

University of Iowa, Department of Urology, 200 Hawkins Drive, Iowa City, IA 52242, USA

a r t i c l e i n f o

Article history:

Received 27 July 2016

Accepted 11 August 2016

Keywords:

Prostate

Prostate cancer

Instrumentation

Robotics

a b s t r a c t

Vesicourethral anastomosis leaks are not uncommon following radical prostatectomy We present a case of

a 59-year-old male who presented to our ED with hematuria, abdominal pain, and clot retention 17 days after a robotic-assisted laparoscopic prostatectomy A 50% vesicourethral disruption was ultimately managed endoscopically and with hemostatic agents At 9-month follow-up he is fully continent with normal erectile function Vesicourethral leaks can typically be managed conservatively with gentle traction and prolonged catheterization Persistent hematuria can complicate management, and hemostatic agents may allow for completely endoscopic management with minimal morbidity as seen in this case

Ó 2016 The Authors Published by Elsevier Inc This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Introduction

Radical Prostatectomy (RP) is the gold standard for surgical

management of localized prostate cancer Perioperative

compli-cation rates have been reported between 7.8% and 17.9%, which

includes persistent vesicourethral anastomosis (VUA) leak in

3.5%e10% of cases.1We present a case of disruption at the

pos-terior aspect of the VUA, complicated by persistent hematuria

and clot retention, managed with a completely endoscopic

approach

Case presentation

An otherwise healthy 59-year-old male presented to our

emer-gency department (ED) with hematuria, severe abdominal pain,

and clot retention 17 days after undergoing an uncomplicated

robotically assisted RP at an outside hospital for pT2cN0MX Gleason

3þ 3 prostate cancer The prostatectomy was performed via an

anterior approach and the anastomosis was performed in a

stan-dard vanVelthoven fashion using a barbed Quill suture (Surgical

Specialties Corp, Wyomissing, PA) Postoperatively, he had a 20Fr

Foley catheter placed and his urine remained bloody, but he was

discharged without event on postoperative day (POD) 2 He was

seen again on POD8 with persistent hematuria, and cystogram showed a small amount of extravasation at the VUA The catheter was left in place with planned follow-up in 10 days

Upon presentation to our ED on POD17, he was tachycardic, complaining of severe suprapubic pain, and hemoglobin was 10.9 g/

dL Attempts were made to hand irrigate the clot through the existing catheter without success Usingfluoroscopy, a guide wire was passed through the catheter and it was exchanged for a 22Fr Emmett hematuria catheter (Bard Medical, Covington, GA) Gravity cystogram at that time showed a large clot in the bladder with extravasation at the bladder neck (Fig 1) Further irrigation failed and the decision was made to go to the operating room for a formal clot evacuation

Following initiation of general anesthesia, a wire was again passed through the catheter under fluoroscopy and a rigid 17Fr cystoscope was visually advanced over the wire into the bladder The anastomotic suture was visible with disruption along the posterior rim, approximately 50% of the anastomosis A highly organized blood clot was noted and the use of an Ellik evacuator was unsuccessful To prevent further anastomotic disruption, an open cystotomy was performed with evacuation of 300 cc of clot from the bladder An 18Fr self-retaining suprapubic tube and 22Fr 3-way urethral catheter were placed, his urethral catheter was placed on traction for 4 h, and his urine cleared He was discharged

on POD2 with light hematuria and returned 8 days later for a repeat cystogram, now 27 days following his initial surgery, which showed persistent extravasation

* Corresponding author Fax: þ1 319 356 3900.

E-mail address: chad-tracy@uiowa.edu (C.R Tracy).

Contents lists available atScienceDirect Urology Case Reports

j o u r n a l h o m e p a g e : w w w e l s e v ie r c o m / l o c a t e / e u c r

2214-4420/Ó 2016 The Authors Published by Elsevier Inc This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ).

http://dx.doi.org/10.1016/j.eucr.2016.08.002

Urology Case Reports 11 (2017) 28e29

That evening he re-presented to our ED in urinary retention His

hemoglobin had declined to 9.1 g/dL His bladder was evacuated via

the urethral and suprapubic catheters and the urethral catheter was

placed on traction His urine cleared initially, but he then began

bleeding further and we were unable to irrigate Following

informed consent, he was taken back to the operating room for

definitive management of bleeding and repair of the disruption

Cystoscopy showed significant bleeding from the area of the

anastomotic disruption without a clear vascular source A wire was

passed into the bladder under direct visualization and a second

wire was passed into the large defect A catheter was passed over

the wire into the defect, after which 10 mL of Floseal (Baxter

Healthcare, Deerfield IL) was injected into the defect A 22Fr

catheter was passed over the bladder wire, balloon inflated with

30 cc of sterile water, and traction held for 10 min The cystoscope

was reintroduced, no bleeding was seen from the fossa, and clot

evacuation was performed through the rigid cystoscope To

pro-mote adhesion and hemostasis, 4 mL of Tisseel (Baxter Healthcare)

was injected into the defect through the scope and a 22Fr catheter

with 30 cc balloon was replaced into the bladder over a wire

Postoperatively, urine remained clear and he was discharged on

POD3

Following discharge, he did well without hematuria and

cysto-gram on POD14 showed remarkable improvement in the VUA

extravasation The urethral catheter was removed 1 week later and

the suprapubic catheter was removed after an additional week of

being capped At 9-month follow-up, his PSA remained

undetect-able and he was not having urinary incontinence or symptoms of

bladder neck contracture

Discussion

VUA disruption is a common complication following RP, and

persistent leakage is seen in up to 10% of cases.1The majority of

disruptions resolve with conservative measures, with more

aggressive intervention necessary in only 0.9%e2.3% of patients.1

Urine extravasation can lead to uroperitoneum, peritonitis,

infec-ted urinoma, or ileus.2Hemorrhage can exacerbate the disruption

via hematoma formation and lead to hemodynamic instability, and

some believe these patients are at risk for long-term urinary

continence and development of bladder neck contracture.2

Management of VUA disruption after RP typically begins

conservatively, often by applying gentle traction to the indwelling

catheter.2Other non-operative techniques include active suctioning

of the pre-vesicular space, passive drainage, manipulation of the drain location, needle-vented suctioning, or nephroureteral stent suction.3

Persistent bleeding may require more aggressive management Transarterial embolization has been used successfully, although this technique does not address the anastomotic disruption or clot within the bladder.4Operative revision has been described through both the original open incision,2as well as through a laparoscopic approach.5Unfortunately, time to complete urinary continence is often delayed Our endoscopic approach allowed for less-invasive assessment and management of the persistent hemorrhage and VUA disruption

Floseal and Tisseel have been used for a number of applications, but the combination of these agents in the setting of VUA disruption and hemorrhage is undocumented The gelatinous consistencies allow adaptation to irregular surfaces and make them well-suited for endoscopic applications Using these agents, in combination with mechanical pressure and clot evacuation, was successful in managing this patient’s VUA hemorrhage, preventing additional morbidity from a reoperative anastomotic repair

Conclusion Anastomotic disruption with continued pelvic bleeding repre-sents a significant and challenging problem following radical prostatectomy Thefirst approach to such cases should be conser-vative with progressively more intervention as required The use of tissue sealants and hemostatic agents may allow for endoscopic management and should be considered prior to operative revision

of the anastomosis

Consent N/A

Conflict of interest This research received support from the Watts Family Fellow-ship in Minimally Invasive Urologic Surgery It did not receive any other specific grant from funding agencies in the public, commer-cial, or not-for-profit sectors

Acknowledgment

We thank the Watts Family Fellowship in Minimally Invasive Urologic Surgery for its support of this project

References

1 Tewari A, Sooriakumaran P, Bloch DA, et al Positive surgical margin and perioperative complication rates of primary surgical treatments for prostate cancer: A systematic review and meta-analysis comparing retropubic, laparoscopic, and robotic prostatectomy Eur Urol 2012;62:1e15

2 Tyritzis SI, Katafigiotis I, Constantinides CA All you need to know about urethrovesical anastomotic urinary leakage following radical prostatectomy.

J Urol 2012;188:369e376

3 Hora M, Stransky P, Klecka J, et al Managing urine leakage following laparoscopic radical prostatectomy with active suction of the prevesical space Wideochir Inne Tech Maloinwazyjne 2013;8:49e54

4 Jeong CW, Park HY, Ku JH, et al Minimally invasive management of postoperative bleeding after radical prostatectomy: Transarterial embolization J Endourol 2010;24:1529e1533

5 Castillo OA, Alston C, Sanchez-Salas R Persistent vesicourethral anastomotic leak after laparoscopic radical prostatectomy: Laparoscopic solution Urology 2009;73:124e126

Figure 1 Gravity cystogram on POD 17 showing clot retention in bladder (asterisk) and

extravasation through the anastomosis (arrow).

C.J Paul et al / Urology Case Reports 11 (2017) 28e29 29