New standardization of checking the vesicourethral anastomosis for tightness following radical prostatectomy with dynamic transrectal ultrasound: can this new technique replace the traditional postoperative cystogram?

Abstract

Purpose: Urinary extravasation at the anastomosis is common after radical prostatectomies. Nevertheless, no data exist referring to the optimal date of catheter removal at the time of expected complete tightness of the leakage. Thus, we developed over the last 10 years a standardized concept to check the anastomosis, evaluating urinary extravasation using a dynamic transrectal ultrasound (dTRUS).

Methods: From 1999 to 2008, 1,479 radical prostatectomies have been performed. For complete tightness, 752 could be evaluated using the standardized concept of checking the anastomosis. The first 250 patients have been evaluated by cystogram and dTRUS and the following 502 patients only by dTRUS postoperatively. The date of checking the anastomosis was determined by the urine color.

Results: Urinary extravasation could be detected 4-8 days postoperatively in 41% (n = 308), 9-12 days in 16% (n = 120), 13-20 days in 8% (n = 60), and in no patient after 21 days. The coefficient of correlation comparing dTRUS versus cystogram was r = 0.99, P < 0.05. The measured volume of urinary extravasation after 4-8 days postoperatively was 15 ml (3-49 ml) using dTRUS and 16 ml (3-45 ml) using cystogram. After 9-20 days, the volume was determined as 9 ml (3-24 ml) by dTRUS and 9 ml (4-23 ml) by cystogram. The macroscopic evaluation of the urinary color was very well correlated with the likelihood of extravasation being still present. When the urine was cloudy or colored by old blood, extravasation was present in 96.9% of the patients. Microscopic evaluation like leukocyturia or hematuria of the urine on the same day shows specificity in only 34.3%.

Conclusions: Following radical prostatectomy, the urine color is essential to assess the chance of a persisting leakage at the anastomosis. The method of dTRUS can replace the cystogram in checking for complete healing of the anastomosis, thus decreasing the exposure to X-rays of the patient of about 60 cGy/cm(2).