Postoperative Cystogram Research Articles

Imaging Findings Associated With Failure of Conservative Management After Blunt Extraperitoneal Bladder Injury

ObjectivesTo identify risk factors for failure of conservative management (CM) for uncomplicated extraperitoneal bladder injuries (EBI). MethodsThe trauma registry at a single Level 1 trauma center was queried for patients presenting with a blunt EBI between 2004 and 2022. Patients with CM and follow-up through at least one postoperative cystogram or catheter removal were included. A univariable analysis for associations with a composite outcome of either persistent leakage or delayed cystorrhaphy was completed. ResultsEighty-four patients with an EBI underwent CM. Seventy-eight (93%) patients had an associated pelvic fracture and 17 of 84 (20%) underwent embolization for pelvic hemorrhage. Thirty-four (41%) patients also had delayed phase imaging, 17 (20%) of whom had extravasation from their bladder on delays. Six (7%) patients failed initial CM. There was no association between the composite outcome and pelvic fracture (p=0.35) or embolization (p=0.41). American Association for the Surgery of Trauma (AAST) grade 5 injuries (p=0.01) and the presence of extravasation on delayed-phase Computed Tomography (p=0.03) were associated with the composite outcome. ConclusionsContrast extravasation on initial delayed-phase imaging despite urethral catheter drainage and AAST injury grade were associated with failed CM after EBI. This may reflect injuries that mechanistically yield incomplete antegrade drainage with CM.

Retrospective study on the feasibility and safety of laparoscopic surgery for complicated fistulizing diverticular disease in a high-volume colorectal center.

We assessed feasibility and safety of laparoscopic sigmoidectomy for complicated fistulizing diverticular disease in a tertiary care colorectal center. A single-center retrospective study of patients undergoing sigmoidectomy for fistulizing diverticular disease between 2011 and 2021 was realized. Primary outcomes were rates of conversion to open surgery and severe postoperative morbidity at 30 days. Secondary outcomes included rates of postoperative bladder leaks on cystogram. Among the 104 patients, 32.7% had previous laparotomy. Laparoscopy was the initial approach in 103 (99.0%), with 6 (5.8%) conversions to laparotomy. Clavien-Dindo grade ≥ III complication rate at 30 days was 10.6%, including two (1.9%) anastomotic leaks. The median postoperative length of stay was 4.0 days. Seven (6.7%) patients underwent reoperation, six (5.8%) were readmitted, and one (0.9%) died within 30 days. Twelve (11.5%) ileostomies were created initially, and two (1.9%) were created following anastomotic leaks. At last follow-up, 101 (97.1%) patients were stoma-free. Urgent surgeries had a higher rate of severe postoperative complications. Among colovesical fistula patients (n = 73), postoperative cystograms were performed in 56.2%, identifying two out of the three bladder leaks detected on closed suction drains. No differences in postoperative outcomes occurred between groups with and without postoperative cystograms, including Foley catheter removal within seven days (73.2% vs. 90.6%, p = 0.08). Laparoscopic surgery for complicated fistulizing diverticulitis showed low rates of severe complications, conversions to open surgery and permanent stomas in high-volume colorectal center.

(170) Missed Urinary Leak During an Inflatable Penile Prosthesis Insertion Presenting as a Post-Operative Hydrocoele

Abstract Introduction This is a case of a revision of a three-piece penile prosthesis in a 53-year-old gentleman who had received an infrapubic implantable penile prosthesis (IPP) in Turkey over 12 months ago. He complained of an unsupported floppy shaft when the prosthesis was inflated, as well as a right hemi scrotal bulging which was exacerbated by activity but showed no signs of infection. A hydrocele had occurred 2 months following the IPP insertion and was confirmed on imaging. The MRI showed the pump within the hydrocele. He had previously had a laparoscopy gastric banding and a bilateral inguinal hernia repair with mesh. Objective Video to demonstrate the surgical case Methods This is a video demonstrating the steps of this operation. The procedure started with a transverse penoscrotal incision and dissection through the dartos muscle. The initial corporotomy allowed removal of the first cylinder of the prosthesis. Upon removing the right cylinder, the hydrocele was opened to reveal the presence of turbid fluid, 150ml of fluid was aspirated and sent for microbiology investigations. The next stage involved removal of the left cylinder and 7.5cm of rear-tip extenders (RTE) were subsequently removed intact, with further RTE from the right removed separately using a nasal speculum. Therefore, a 20cm IPP was removed with 7.5cm RTE on each side. An antibiotic salvage wash (Rifampicin/Gentamicin) was performed several times. At this point a 26cm + 1cm (13mm) malleable prosthesis was inserted as a spacer. The previous infrapubic wound was opened to remove the reservoir, 75ml of fluid was aspirated from around the reservoir prior to removal. Attempts are made to identify a possible fistula with flexible cystoscopy, but normal urethra, bladder neck and bladder are seen. Giving no evidence of any fistula into the abdominal cavity or urethral injury to explain fluid in the corporal cavities or around the components of the prosthesis. Methylene blue and distention were also used to attempt to identify a bladder leak, however this was also unremarkable. A suprapubic catheter was inserted to ensure the decompression of the urinary system to allow any small/undetected leaks to heal. This was done under direct vision using a cystoscope prior to being secured. Results The patient had a replacement of the inflatable penile prosthesis to a malleable prosthesis, a suprapubic catheter inserted and a drainage of his hydrocele. The patient recovered well from surgery and on examination the prosthesis tips were seated nicely in the glans. The fluid microbiology culture did not grow any organism. A subsequent cystogram showed no signs of any bladder leak. The patient was happy with the outcome and underwent a trial without catheter. He has a planned review and will be considered for an exchange to an inflatable device at this time. Conclusions This is an unusual presentation of a hydrocele, in the absence of any infective symptoms which is suggestive of a contained urine leak and even a missed bladder injury from the first prosthesis surgery. However, no fistula was found during the surgery or the post-operative cystogram. Disclosure No.

Description of a novel robotic early post-prostatectomy anastomotic repair technique and institutional outcomes

ObjectiveA vesicourethral anastomotic leak (VUAL) is a known complication following robotic-assisted radical prostatectomy. The natural history of a VUAL has been well described and is frequently managed with prolonged catheterization. With increasing emphasis on patient reported outcomes, catheter duration and VUAL are associated with significant short-term quality of life impairment. We aimed to present a case series of our robotic early post-prostatectomy anastomotic repair technique, defined as revision within 6 weeks from index surgery. MethodsA single institution prospective database identified eleven patients with a VUAL from July 2016 to October 2022 who underwent robotic early post-prostatectomy anastomotic repair by a single surgeon. Patients were diagnosed with a VUAL on pre-operative CT urogram or CT/fluoroscopic cystogram. The primary outcome was resolution of the anastomotic leak, defined as no contrast extravasation on post-operative cystography. Secondary outcomes included post-repair catheter duration and continence on the last follow-up defined as pad(s) per day. ResultsThe mean time to intervention after robotic-assisted radical prostatectomy was 21 days. Eight of the eleven (72.7%) patients had no evidence of extravasation on post-repair cystogram. The range from intervention to first cystogram was 7–20 days. The median catheter duration for those with successful intervention was 10 days. The median catheter duration for those with the leak on initial post-operative cystogram was 20 days. At a mean follow-up time of 25 months, eight (72.7%) patients reported using no pads per day, and three (27.3%) patients reported one pad per day. ConclusionManagement of a VUAL has traditionally relied on prolonged catheter drainage and the tincture of time. As the role of robotic reconstruction has been shown to be a viable modality for management of bladder neck contracture, it is important to reconsider prior dogmas of urologic care. Our case series suggests that an early repair is safe and has a high success rate. Early robotic intervention gives providers an additional tool in aiding patient recovery.

Robot-assisted ileocystoplasty for the treatment of adult neurogenic bladder: A video demonstration and outcomes

Abstract Ileocystoplasty is one of the treatment options in the armamentarium for the management of adults with neurogenic bladder dysfunction, after failure of less invasive treatment alternatives, such as intravesical onabotulinum toxin A injection therapy and sacral neuromodulation. It has traditionally been performed as open surgery and can be associated with significant morbidity, especially in the early postoperative period.[1] Complications associated with open ileocystoplasty include prolonged postoperative ileus, wound infections, and pain. Performing robot-assisted ileocystoplasty can reduce the morbidity associated with open surgery[2] and has been shown to be safe and feasible in experienced hands,[3] although it may be associated with increased operative duration because of its learning curve. Our technique of robot-assisted ileocystoplasty and early postoperative outcomes is demonstrated in this video (Supplemental Digital Content, http://links.lww.com/CURRUROL/A47). Robotic console time was 180 minutes, with minimal blood loss. Eight-hourly catheter aspiration and flushes were performed to manage the mucus in the urine. There were no metabolic acidosis or electrolyte derangements postoperatively. The patient was discharged on postoperative day 5. Postoperative cystogram at week 2 showed no leak and the patient is doing well at 1 year postoperatively. Robotic ileocystoplasty is safe and feasible and can reduce the morbidity associated with open surgery with good outcomes.

Early Urinary Catheter Removal After Colectomy for Colovesical Fistula is Not Associated With Increased Postoperative Complications.

Management of the bladder defect during colectomy for colovesical fistula (CVF) and recommendations for duration of urinary catheter drainage are inconsistent. This study aimed to determine if urinary catheter drainage duration was associated with postoperative complications. Retrospective single institution cohort study of patients undergoing resection for diverticular CVF from 2015 through 2021. Urinary catheter drainage was defined as Early (≤7days postoperative and then subdivided into 1-2days, 3-5days, 6-7days), and Late (>7days postoperative). Primary outcome was a composite measure of postoperative bladder leak, surgical site infection-III, sepsis, reoperation, and postoperative length-of-stay ≥7days. There were 73 patients-64 Early group and 9 Late group. Composite measure between groups (Early 25% vs Late 33.33%, P = .688) was not significantly different. The Late group had more patients with large bladder defects (33.3% vs 7.8%, P = .054), significantly more patients who underwent suture repair (55.6% vs 14.1%, P = .01), and significantly more patients that had an intraoperative pelvic drain (66.7% vs 15.6%, P = .003). After propensity score inverse weighting, the Late group had significantly more cystogram-detected postoperative bladder leaks (P = .002) and ileus (P = .042) than the Early group. There were no bladder leaks or ileus in those who had urinary catheter removal on postoperative days 1-2. Early urinary catheter removal was associated with no increase in bladder leaks and fewer postoperative complications after definitive management of CVF. Further investigation is required to determine if intraoperative bladder leak testing and postoperative cystograms are useful adjuncts in decision making.

113 Best practices for repair of iatrogenic bladder injury in gynecologic surgery

Bladder injury, particularly of a mechanical nature, is the most frequent major complication of gynecologic surgery, and can occur in other types of surgery or after trauma. Despite its frequency, there is limited research on best practices for bladder injury repair. This literature review aims to summarize types of iatrogenic bladder injuries, guidelines on bladder injury repair, expected follow-up care, and areas for further research. Literature review of societal guidelines, recent research, and expert opinions. This review is divided into 5 sections: types of bladder injury, pathophysiology of wound healing, repair techniques, indwelling catheter placement, post-operative care, and the special case of injury during sling placement. We discuss the classification of bladder injury. Iatrogenic bladder injuries are classified by the American Association of Surgery for Trauma Injury Severity Scale from grade 1-5 (Fig 1). Bladder injuries of grade 1 or 2 should be managed with prolonged drainage with indwelling urethral catheter for at least 7-14 days, although there is no consensus on duration. Injuries of grades 3 and higher require surgical management. Animal models for healing of the urothelium are reviewed. Surgical techniques for repair are summarized, followed by a review of current guidelines for post-operative care. American and European Associations of Urology guidelines recommend cystogram after conservatively treated bladder injuries and surgically repaired extraperitoneal injuries, but do not recommend it after surgical repair of simple intraperitoneal injuries. However, there is conflicting data on postoperative cystograms requiring further research. Lastly, special attention is granted to injury during bladder sling placement, a common gynecologic procedure. There is a consensus on types of bladder injury that need to be repaired surgically versus managed conservatively with an indwelling urinary catheter. There is also relative standardization in suture types used for surgical repair. Polyglactin 910 is the preferred suture to use for repair in one or two layers, depending on defect size. There are also standard guidelines for recognition and management of bladder injury during sling placement. However, more research is needed to determine duration of indwelling urinary catheter and the risk-benefit ratio of cystograms prior to catheter removal. Further studies should be designed with a larger sample size than what has been investigated in the available literature.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Clinical significance and risk factors of urethrovesical anastomotic urinary leakage following robot-assisted radical prostatectomy: a multi-institutional study

BackgroundThere has been a limited number of reports on the significance and risk factors of urethrovesical anastomotic urinary leakage (AUL) following robot-assisted radical prostatectomy (RARP). We aimed to analyze the clinical significance of AUL and evaluated its risk factors.MethodsWe conducted a multi-institutional study to review patients with prostate cancer undergoing RARP in three centers (The University of Tokyo Hospital, Mitsui Memorial Hospital, and Chiba Tokushukai Hospital). “Positive AUL” was defined as urinary extravasation at the anastomosis detected by post-operative cystogram and was further categorized into minor or major AUL. Univariate and multivariate analyses were performed to identify predictors of AUL. Postoperative continence rates and time to achieve continence were also analyzed.ResultsA total of 942 patients underwent RARP for prostate cancer in 3 centers. Of these patients, a cystogram after the RARP procedure was not performed in 26 patients leaving 916 patients for the final analysis. AUL was observed in 56 patients (6.1%); 34 patients (3.7%) with minor AUL and 22 patients (2.4%) with major AUL. Patients with major AUL exhibited a significantly longer time to achieve continence than those without major AUL. Multivariate analysis demonstrated that longer console time (≥ 184 min) was significantly associated with overall AUL, and higher body mass index (≥ 25 g/kg2) was a significant predictor of both major and overall AUL.ConclusionsThe presence of major AUL was associated with the achievement of urinary continence, suggesting clinical relevance of its diagnosis by postoperative cystogram. A selective cystogram has been proposed for high-risk cases. Furthermore, identification of the risk factors of AUL will lead to optimal application.

Postoperative Cystogram Can Be Safely Omitted After Bladder Cuff Excision in Patients Undergoing Nephroureterectomy

In nephroureterectomy (NU), a crucial surgical step is excision of the bladder cuff. A urinary catheter is placed postoperatively and a cystogram prior to catheter removal is often performed to rule out a urine leak from the urinary bladder. We investigated the necessity of cystogram after bladder cuff excision prior to removal of the urinary catheter. A systematic review (SR) was also performed to investigate the incidence of urinary leak on cystography after NU bladder cuff excision. The primary outcomes were postoperative clinical complications including sepsis, fistula, voiding issues after catheter removal and/or any radiological abnormality indicating persistent leak from the bladder. A retrospective study was performed in a centre where cystograms are not routinely performed prior to catheter removal in NU patients. Patients were followed up clinically, radiologically and cystoscopically. A SR of 402 patients demonstrated that the incidence of urine leak from the bladder is 0.003% among patients after catheter removal after NU. In total, 67 patients were included and no clinical, radiological or cystographic evidence of a persistent urinary leak was noted at follow-up due to omission of cystogram. Based on this systematic review, it may be possible to safely omit routine cystography prior to removal of urinary catheter after bladder cuff excision in patients undergoing NU.

Robotic conservative treatment for prostatourethrorectal fistula: original technique step by step

ABSTRACTPurpose:Prostatourethrorectal fistula (PURF) is an uncommon complication resulting from surgery, radiation or trauma (1). The most common therapeutic management is transperineal surgery (1). Transabdominal approach is less used and limited to large fistulae needing cystectomy and rectal resection (1). The aim of this study was to show an original robotic technique of conservative treatment for PURF.Materials and Methods:A 75 years old man referred recurrent UTI, pneumaturia and urinary loss from rectum due to PURF arising after TURP performed after transvesical prostate adenomectomy. Cystogram, cystoscopy and MRI confirmed PURF. We used a robotic approach performing isolation, resection and suture of the fistulous tract on rectal and urethral side. Leak test was negative. We carried out an omental flap, positioned between rectum and prostatic urethra, and a temporary ileostomy without any bowel resection or urinary diversion.Results:Operative time was 210 minutes, estimated blood loss 50ml. Oral feeding was restored at 48 hours. Bladder catheter was removed on the 15th post-operative day. Post-operative cystogram was negative. Post-operative complications were ileus and urinary tract infection. Hospital stay was 10 days. At 6 months follow-up, before temporary ileostomy closure, cystoscopy showed a totally re-epithelised fovea, and cystogram and CT enterography were negative.Conclusions:Robotic conservative treatment of PURF seems to be safe and feasible (2, 3). Robotic approach allows accurate surgical dissection, through easier access to the rectal-prostatic plane, reducing the need for resection. To our knowledge, this is the first robotic conservative treatment for PURF reproducing the same steps of laparotomic approach with the advantages of minimally invasive technique (4).

Pediatric bladder augmentation - Panacea or Pandora's box?

Bladder augmentation is a surgery that can increase bladder capacity and compliance. The objective of this study was to provide a longitudinal review of pediatric bladder augmentation at a tertiary Canadian center. A retrospective review was performed on patients who underwent bladder augmentation at a tertiary pediatric hospital between 1986 and 2014. The primary objective was short- and long-term complications of augmentation. Secondary objectives were to review number of augmentation procedures performed over time and the utility of routine postoperative cystograms. A total of 56 procedures were performed on 54 patients (28 males, 26 females) of mean age 10 years (standard deviation [SD] 5) and mean followup eight years (SD 5). The most common bowel segment used was ileum (87.5%). Twenty-eight patients (50%) received catheterizable channels. Overall complication rate was 15% and the most common complications were urinary tract infections (68.5%), worsening hydronephrosis (14.8%), bladder stone formation (14%), and hematuria (13%). In total, 19 of 54 (35.2%) patients returned to the operating room. The incidence of bladder perforation was 3.6%. Complications with the catheterizable channel occurred in 13 of 28 (46.4%), of which 10 were related to stomal stenosis. Forty patients had postoperative cystograms and extravasation was seen in three (7.5%). There was no malignancy during the followup. Only four augmentations were performed from 2008-2014. Bladder augmentation likely represents a safe surgical treatment option. Extravasation on postoperative cystogram was uncommon and, thus, it may not be indicated routinely. The number of augmentation procedures performed has declined in recent years.

Preoperative MRI Parameters Predict Urinary Continence after Robot-Assisted Laparoscopic Prostatectomy in Prostatic Cancer Patients

We aimed to investigate whether preoperative MRI findings could predict the bladder neck location on postoperative cystography and recovery of urinary incontinence after robot-assisted laparoscopic radical prostatectomy (RALP). We retrospectively reviewed 270 consecutive patients who had complete preoperative data, including MRI, and underwent postoperative observation for more than three months. Preoperative MRI parameters consisted of the membranous urethral length (MUL) and pubic symphysis-prostate apex length (PAL) on sagittal images. The bladder neck location on a postoperative cystography was defined as the lowest extension of the tapering contrast medium in the bladder, and its relation to the pubic symphysis (above (higher group) and below (lower group) the middle of the pubic symphysis height) was evaluated. Those who required no pad or a safety pad were defined as being continent. PAL was significantly shorter in the higher group than that in the lower group (25.5 vs. 29.1 mm; p < 0.0001). The continent group at three months had a significantly longer MUL and shorter PAL than those in the incontinent group (8.1 vs. 6.7 mm; p < 0.05, and 26.0 vs. 28.1 mm; p < 0.05, respectively). Preoperative MRI parameters could predict the bladder neck location on postoperative cystograms and the recovery of urinary incontinence after RALP.

Selective use of cystogram following segmental bowel resection in patients with enterovesical fistula.

Patients undergoing resectional surgery for enterovesical fistulas generally have an indwelling urinary catheter postoperatively to prevent a recurrent fistula. The aim of this study was to assess the role of a cystogram as part of the postoperative follow-up of such surgery, when it should be performed and for how long the bladder should be drained after surgery. A retrospective single-centre study of all patients undergoing ileocaecal or sigmoid resection for surgery for enterovesical fistula with the primary end-point of recurrent urinary fistula. Between 1994 and 2015, 46 patients (23 male; mean age 55.4±18.3years) underwent surgery [23 (50%) for diverticular disease, 16 (34.8%) for Crohn's disease, five (10.9%) for malignancy and two (4.3%) for previous radiotherapy]. Closure of the bladder fistula was by simple suture in 21 (46%) patients and with an omental pedicle in 16 (36%). Overall median duration of urinary drainage was 10.5 [interquartile range (IQR): 7.3-14.0] days. A postoperative cystogram was performed in 26 (57%) patients after a median of 10.0 (IQR: 8.0-13.0) days. This demonstrated persistent leakage in three patients, of whom two had undergone surgical closure of the bladder. This group required prolonged drainage (7, 19 and 40days). One patient who had undergone surgery following radiotherapy for urothelial cancer developed a recurrent malignant fistula at 9months, even though the postoperative cystogram had been negative. This study suggests that a routine postoperative cystogram after surgery for enterovesical fistula may not be necessary for all patients if the bladder is drained for 1-2weeks after bowel resection.

Postoperative cystogram findings predict recovery of urinary continence after robot-assisted laparoscopic radical prostatectomy.

To assess the association between postoperative cystogram findings and subsequent outcomes on urinary continence after robot-assisted laparoscopic radical prostatectomy (RALP). A retrospective review of 250 consecutive patients who were observed for at least 12 months after RALP. The postoperative cystogram findings examined were: the location of the bladder neck, degree of bladder abnormalities, and presence of outflow of contrast medium into the urethra during the filling phase of cystography. The continence status based on pad usage was recorded. Those who required no pad or only a safety pad were defined as continent. Patients with a bladder neck location above the middle of the pubic symphysis height exhibited significantly higher continence levels than those with a lower bladder neck location at both postoperative 3 and 12 months (P < 0.0001 and P = 0.0002, respectively). The higher a bladder neck was located, the earlier the urinary continence was achieved after RALP (P < 0.0001). Patients without contrast outflow into the urethra during cystogram demonstrated a significantly more favorable continence status at the 3-month follow-up (P = 0.004). Patients without bladder abnormalities on postoperative cystogram demonstrated a significantly more favorable continence status at the 12-month follow-up than those with bladder abnormalities (P = 0.01). Postoperative cystogram findings may predict recovery of urinary continence after RALP.

Perioperative Management of Patients with Colovesical Fistula

BackgroundColovesical fistula (CVF) is an uncommon complication of diverticulitis. Substantial heterogeneity exists in the perioperative management of this condition. We seek to evaluate the role of bladder leak testing, closed suction drainage, prolonged bladder catheter usage, and routine postoperative cystogram in the management of CVF. Study DesignThis is a retrospective study from a single academic health center investigation patients undergoing operation for diverticular CVF from 2005 to 2015 (n = 89). ResultsPatients undergoing operative repair for diverticular CVF resection had a mortality of 4% and overall morbidity of 46%. Intraoperative bladder leak test was performed in 36 patients (40%) and demonstrated a leak in 4 patients (11%). No patients with a negative intraoperative bladder leak test developed a urinary leak. Overall, five (6%) patients developed postoperative bladder leak. Three were identified by elevated drain creatinine and two by cystogram. The diagnostic yield of routine cystogram was 3%. All bladder leaks were diagnosed between postoperative day 3 and 7. Of patients with a postoperative bladder leak, none required reoperation and all resolved within 2 months. ConclusionsThere is significant variability in the management of patients undergoing operation for CVF. Routine intraoperative bladder leak test should be performed. Cystogram may add cost and is low yield for routine evaluation for bladder leak after operation for CVF. Urinary catheter removal before postoperative day 7 should be considered.

VESICOVAGINAL FISTULA CAUSED BY CYSTOCELE: A CASE REPORT

Typical etiologies of vesicovaginal fistula (VVF) include obstructed labor, iatrogenic surgical injury, pelvic irradiation and cancer invasion. VVF caused by cystocele are very rare. To date, there are no documented cases in Japanese literature.A 74-year-old woman presented with near total incontinence. On physical examination, she was found to have severe cystocele and pressure necrosis of anterior vaginal wall, which caused partial breakdown of vaginal mucosa and VVF. She underwent vesicovaginal fistula repair using transvaginal and transabdominal approaches. Catheter drainage was performed for 10 days and postoperative cystogram showed no sign of leakage. She is currently symptom-free at 55 months.

V09-09 ROBOT-ASSISTED LAPAROSCOPIC PYELOTOMY & ILEAL URETER SUBSTITUTION: VIDEO DEMONSTRATION

You have accessJournal of UrologyPediatric Urology1 Apr 2018V09-09 ROBOT-ASSISTED LAPAROSCOPIC PYELOTOMY & ILEAL URETER SUBSTITUTION: VIDEO DEMONSTRATION Rachel Shannon, BS, Deborah L. Jacobson, MD, Edward M. Gong, MD, and Bruce W. Lindgren, MD Rachel Shannon, BSRachel Shannon, BS More articles by this author , Deborah L. Jacobson, MDDeborah L. Jacobson, MD More articles by this author , Edward M. Gong, MDEdward M. Gong, MD More articles by this author , and Bruce W. Lindgren, MDBruce W. Lindgren, MD More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2181AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES While robot-assisted laparoscopic (RAL) ileal ureter substitution is a known treatment option for managing recurrent ureteral stricture, video documentation of this procedure is lacking. We aim to visually demonstrate the surgical technique used in an RAL pyelotomy & ileal ureter substitution. METHODS We present an 18 year old female with a history of cystinuria, recurrent urolithiasis, chronic kidney disease (stage 3), solitary functioning kidney, recurrent ureteropelvic junction (UPJ) obstruction, and worsening renal function. She had previously undergone multiple procedures for urolithiasis management, a failed laser endopyelotomy, and a failed RAL pyeloplasty. It was elected to perform RAL pyelotomy with removal of renal calculi and ileal ureter substitution to address stenosis at the UPJ and ureter caliber. RESULTS The patient was placed in a modified supine position and the da Vinci XI robotic surgical system was docked. Ports were placed in the umbilicus, right lower quadrant, epigastric area, and inferior to the umbilical port, left of the midline. The ureter was dissected out and spatulated laterally through the strictured UPJ. A flexible cystoscope was inserted through a robotic port and multiple renal stones were retrieved. A 26cm segment of ileum was harvested, passed through a window in the colonic mesentery, and anastomosed to the renal pelvis. The native ureter was transected and tied off. A stent was placed antegrade and the distal end of the ileal limb was anastomosed to the bladder wall. Total operative time was nearly 12 hours and estimated blood loss was 100mL. The patient was discharged home in stable condition on post-operative day 7. The ureteral stent was removed at 4 weeks. Post-operative cystogram was without evidence of extravasation. Renal ultrasound obtained 10 months post-operatively demonstrated near-complete resolution of the hydronephrosis with renal parenchymal preservation. The patient demonstrated stable renal function 20 months post-operatively. CONCLUSIONS This video demonstrates the surgical technique used in an RAL pyelotomy and ileal ureter substitution in the setting of recurrent UPJ obstruction and chronic nephrolithiasis. The patient continues to report excellent results 20 months post-operatively. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e905 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Rachel Shannon, BS More articles by this author Deborah L. Jacobson, MD More articles by this author Edward M. Gong, MD More articles by this author Bruce W. Lindgren, MD More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Is a cystogram necessary after bladder cuff excision?

ObjectiveNephroureterectomy with bladder cuff excision is the current gold standard for the treatment of upper-tract urothelial carcinoma (UTUC). Currently, routine follow-up cystogram is performed prior to Foley catheter removal to evaluate the bladder cuff excision wound. The aim of this study was to investigate the role of the postoperative cystogram in the bladder cuff excision procedure. Materials and methodsThis was a retrospective study of 193 patients diagnosed with UTUC post nephroureterectomy and bladder cuff excision between January, 2010, and January, 2016. Patient demographics, performance of cystogram, types of bladder cuff excision, and postoperative outcomes were recorded. Patients were classified into two groups depending on whether or not routine postoperative cystogram was performed. ResultsA total of 125 patients were included in this study and, of these, 102 patients underwent routine cystogram on Postoperative Day 7 (Group 1), while 23 patients underwent Foley catheter removal on Postoperative Day 7 without any imaging studies (Group 2). Univariate analysis showed no differences in age, sex, comorbidities, surgical approach, or stage of the primary tumor. No patient from either group had urinoma, pelvic abscesses, and tumor growth from bladder cuff wound was not observed in any patient within the 1-year postoperative follow-up period. Both groups of patients had a similar rate of postoperative urinary tract infections with sepsis (p = 0.639), time to Foley catheter removal (p = 0.630), time to drainage tube removal (p = 0.264), and length of hospitalization (p = 0.373). ConclusionFoley catheter removal on Postoperative Day 7 after nephroureterectomy with bladder cuff excision without routine cystogram appears to be safe in the majority of the UTUC patients. A large, multi-institutional study is required before this method can be recommended for widespread clinical practice.

Postoperative cystographic findings as an independent predictor of urinary incontinence three months after radical prostatectomy.

Postoperative cystogram has been used to identify clinically significant leaks before catheter removal after radical prostatectomy (RP). The aim of the present study was to investigate the relationship between cystogram findings after RP and early urinary incontinence. From January 2011 to February 2015, 417 patients who had undergone a cystography after RP at our hospital were retrospectively analyzed. The ratio dividing the length from the upper part of the pubic symphysis to the neck of the bladder with the length of the total pubic symphysis height (bladder neck pubic symphysis ratio [BNPSR]) was measured and urinary incontinence was assessed by the subjects' use of a pad. In the total patient sample, urinary incontinence 3 months after RP was 28.5%. The mean BNPSR for the group with urinary incontinence and the group without was 0.49±0.26 and 0.38±0.17, respectively (P<0.001). Additionally, the rate of urine leakage in the group with urinary incontinence and the group without was observed to be 14.3% and 6.4% on cystogram, respectively (P=0.012). Open vs. robotic surgeries resulted in urinary incontinence frequencies of 41.0% vs. 22.3% (P<0.001). In a multivariate logistic regression analysis, both a high BNPS ratio (Odds ratio [OR], 23.14; P<0.001) and surgical technique (OR=2.29; P<0.001) were shown to be independent predictive factors for urinary incontinence 3 months after surgery. BNPSR measured by cystogram after RP can be useful for predicting the occurrence of urinary incontinence and managing a patient's progress after RP.

Prognostic Factors for Anastomotic Urinary Leakage Following Retropubic Radical Prostatectomy and Correlation With Voiding Outcomes.

This study aimed to determine the occurrence and grade of cystographically detected urinary leakage (UL) in a contemporary series of open retropubic radical prostatectomy (RP), whether patients’ clinical variables predict occurrence of UL, and whether occurrence of UL correlates with patients’ voiding outcomes in terms of urinary continence and anastomotic stricture (AS).Enrolled patients underwent cystography 7 days after retropubic RP; in case of UL, the catheter was left in situ and cystography repeated at 7 days intervals until demonstrating absence of UL. Leakage was classified as grade I = extraperitoneal leak <6 cm, grade II = extraperitoneal leak >6 cm, grade III = leak freely extending in the small pelvis. Voiding was evaluated at 3, 6, and 12 months after RP using the 24-hour pad test and uroflowmetry; in cases of maximum flow rate <10 mL/s, urethrocystoscopy was carried out to determine presence and location of an AS.The first postoperative cystogram showed UL in 52.6% of patients (grade I in 48.1%, grade II in 21.5%, and grade III in 30.4% of the cases). Multivariate analysis demonstrated that patients with UL had significantly greater prostate volume (64.5 vs 34.8 cc, P < 0.001), loss of serum hemoglobin (4.77 vs 4.19 g/dL, P < 0.001), lower postoperative serum total proteins (4.85 vs 5.4 g/dL, P < 0.001), and higher rate of AS (20.6% vs. 2.8%, p < 0.001) than those without UL. Continence rate at 3, 6, and 12 months postoperatively was 34.2%, 76%, and 90%, respectively, in patients with UL compared with 77.5%, 80.3%, and 93% in patients without UL; such difference was statistically significant (P < 0.001) only at 3 months follow-up. ROC curve analysis showed that prostate volume and postoperative serum total proteins had the best AUC (0.821 and 0.822, respectively) and when combined, their positive and negative predictive values for UL were 90% and 93%, respectively.In conclusion, half of the patients undergoing open retropubic RP may present, 7 days postoperatively, some degree of cystographically detected UL; prostate volume, loss of serum hemoglobin, and postoperative serum total proteins could be used to predict it. UL delayed return to urinary continence without affecting long-term results, but led to a significantly higher rate of AS.