Secondary partial rupture of the vesicourethral anastomosis following robot-assisted laparoscopic radical prostatectomy. Diagnosis, therapy and functional oucomes

Vahudin Zugor, Apostolos P. Labanaris, Jorn H. Witt

Department of Urology and Pediatric Urology – Prostate Center Northwest, St. Antonius Medical Center, Gronau, Germany

Introduction & objectives:
To demonstrate our experience with secondary partial rupture of the vesicourethral anastomosis (SPROVA) following robot-assisted laparoscopic radical prostatectomy (RALP) focusing on its diagnosis, therapy as well as functional outcomes in such patients.

Material & Methods:
The records of N=3000 men who underwent RALP from February 2006 to August 2011 were retrospectively reviewed. A total of N=16 patients (0.53%) were identified as having SPROVA after RALP. Prior to primary catheter removal all patients had undergone a cystogram which was none pathologic in all cases. The parameters analyzed included: symptoms, laboratory findings, radiological examinations, age, body-mass index (BMI), prostate weight, PSA values, bilateral neurovascular bundle (NVB) preservation, intraoperative complications, bladder neck reconstruction, length of catheterisation, continence (defined as no pad use), potency (defined as erections sufficient for penetration with or without phosphodiesterase inhibitors).

All symptoms of the patients involved in this series were noted the first day after catheter removal. N=4 patients (25%) exhibited peritonitis-like symptoms, with an increase of creatinine levels (median 2.15 mg/dl), CRP levels (median 198.7 mg/l) and leukocytosis (median 14.2 Th/cu). N=7 patients (43.7%) exhibited lower abdomen discomfort with an increase only of CRP levels (median 216.4 mg/l) and N=5 patients (31.2%) exhibited urinary retention without any pathological laboratory findings. A new catheter was inserted in the bladder of all patients and a new cystogram was performed exhibiting the presence of a SPROVA. After a median of 2.4 days all patients were asymptomatic and after a median of 9.6 days all laboratory findings were non pathologic. The median patient age was 65.1 years (51-74), median BMI 26.1 kg/m2 (21-28 kg/m2) and median prostate weight 94 gr. (35-204 gr.). The median PSA value was 12.7 ng/ml (1.5-48 ng/ml) and bilateral NVB preservation was performed in N=8 patients (50%). No intraoperative complications were evident. A bladder neck reconstruction was performed in N=6 patients (37.5%), the median length of catheterization prior to the SPROVA was 5 days and after its diagnosis was 9.9 days (7-31). After a median follow up of 21.6 months (36-10), N=14 patients (87.5%) were continent (0 Pads/d) and N=2 (12.5%) had mild incontinence (1-2 Pads/d). N=5 patients (62.5%) who underwent bilateral NVB preservation were potent.

Peritonitis-like symptoms, lower abdomen discomfort, urinary retention and pathological laboratory findings, especially increased CRP levels, following catheter removal are strong indications for the presence of SPROVA in patients following RALP. A conservative approach seems to solve this life threatening condition without compromising the long term functional results in these patients.