Novel Management of Anastomotic Disruption and Persistent Hematuria Following Robotic Prostatectomy: Case Report and Review of the Literature.

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.

Introduction

Radical Prostatectomy (RP) is the gold standard for surgical management of localized prostate cancer. Perioperative complication rates have been reported between 7.8% and 17.9%, which includes persistent vesicourethral anastomosis (VUA) leak in 3.5%–10% of cases. We present a case of disruption at the posterior 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 emergency 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 3 + 3 prostate cancer. The prostatectomy was performed via an anterior approach and the anastomosis was performed in a standard 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. Using fluoroscopy, 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.

Figure 1

Gravity cystogram on POD 17 showing clot retention in bladder (asterisk) and extravasation through the anastomosis (arrow).

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.

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 promote 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 cystogram 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 undetectable 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. The majority of disruptions resolve with conservative measures, with more aggressive intervention necessary in only 0.9%–2.3% of patients. Urine extravasation can lead to uroperitoneum, peritonitis, infected urinoma, or ileus. Hemorrhage 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.

Management of VUA disruption after RP typically begins conservatively, often by applying gentle traction to the indwelling catheter. Other 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.

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. Operative revision has been described through both the original open incision, as well as through a laparoscopic approach. Unfortunately, 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 represents a significant and challenging problem following radical prostatectomy. The first approach to such cases should be conservative 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 Fellowship in Minimally Invasive Urologic Surgery. It did not receive any other specific grant from funding agencies in the public, commercial, or not-for-profit sectors.