- To describe our technique of maintaining bladder drainage after robot-assisted radical prostatectomy (RARP) using a percutaneous suprapubic tube (PST) in place of a urethral catheter.
robot-assisted radical prostatectomy
percutaneous suprapubic tube
Postoperative urine drainage after vesico-urethral anastomosis during robot-assisted radical prostatectomy (RARP) remains an integral part of the operation and has traditionally been maintained using a urethral catheter (UC) . We have now replaced UC drainage after RARP with a percutaneous suprapubic tube (PST) [2, 3]. The advantage of this method is greater patient comfort with no increase in the urethral stricture rate . In this step-by-step guide with accompanying video, we outline the technical aspects required for its successful adoption.
A watertight anastomosis permits placement of the PST for bladder drainage. Relative contraindications include morbid obesity, concomitant inguinal hernia repair with mesh, anticoagulation therapy, patients with limited hand dexterity preventing adequate postoperative care of PST, bladder neck reconstruction and extensive adhesiolysis at RARP.
After completion of the anastomosis, the bladder is filled with 200 mL of normal saline via the UC to check for leaks. A non-absorbable suture (1/0 polypropylene-CT1 needle; Ethicon, Somerville, NJ, USA) is introduced into the pelvis through the 12-mm assistant port with the suture tail outside the port. The suture serves to anchor the bladder to the abdominal wall; the optimum point is in the midline, close to the dome. Using robotic needle drivers, a horizontal mattress suture is placed through the anterior bladder wall with a central space of 1–2 cm maintained for the PST. On completion, the needle is taken out of the port and cut. The two tails of the suture are aligned and delivered by the assistant to the robotic needle drivers.
A stab incision is made for the PST on the abdominal wall through the dermis in the midline, superior to the pubic symphysis and about one-third of the distance to the umbilicus. One cm lateral to this incision, a GORE® suture passer (WL Gore & Associates, Flagstaff, AZ, USA) is inserted by the bedside assistant until it is visualized above the bladder. The console surgeon then transfers the suture ends within the robotic needle drivers to the open claws of the suture passer. The suture passer is closed and withdrawn, bringing the suture to the outside, which is then secured with a haemostat to prevent it from re-entering the pelvis.
Under direct visualization, a 14-F Rutner PST (Cook Medical, Bloomington, IN, USA) is inserted through the abdominal incision. A careful two-handed insertion is important to overcome abdominal fascia in a controlled manner. Gentle upward traction on the anchoring sutures tents the bladder wall, and allows a secure entry between the two limbs of the sutures. It should enter the bladder perpendicularly to avoid traversing the detrusor muscle layers and is advanced a further 2 cm, after which the needle obturator is withdrawn whilst simultaneously advancing the catheter. Immediate drainage of fluid confirms proper placement. The 4 mL balloon is inflated after which the console surgeon releases the anchor sutures. The integrity of the balloon is confirmed as the assistant pulls on the tube to elevate the bladder.
The distal end of the PST is attached to a drainage bag via a connecting tube and three-way stop-cock. Once the bagged specimen is extracted, the pneumoperitoneum evacuated and the patient side-cart dedocked, the patient is taken out of the Trendelenberg position. The external sutures are pulled and tied onto the skin over a sterile plastic button, cinching the cystotomy to the anterior abdominal wall. The tails of the suture are wrapped around the tube after applying an adhesive (Mastisol®, Eloquest, Ferndale, MI, USA). The sutures are taped in place with Steri-Strip™ (3M, St Paul, MN, USA). The drainage bag tube is secured to the patient's thigh so that the connecting tube and PST are not under tension.
The PST is left to gravity drainage until postoperative day 5, after which the tube is clamped by the patient using the three-way stop-cock. Patients void per urethrum, and post-void residual urine volumes are recorded in a patient diary. After 48 h if the residual urine volume is <50 mL per void, the PST is removed on postoperative day 7. Cystograms are performed in patients with bladder pain, haematuria or when large residual volumes are recorded in the diary. If a leak is demonstrated, the PST is replaced with a UC for a further period of drainage.
Bleeding from the bladder wall may occur as a result of the puncture. If so, cautery can stop bleeding from superficial detrusor veins. Once the PST is sutured to the skin, the bladder should be irrigated via the UC to remove small clots and confirm passage of fluid from the bladder into the PST. Also, it is important not to tie the suture to the abdominal skin on the button too tightly, as this may be uncomfortable for the patient. Furthermore, if the fluid draining from the PST is heavily blood-stained, a 20-F UC may be placed along with the PST. The larger calibre UC is better suited to deal with any blood clots overnight and can be removed the following morning if bleeding has settled. In the event that the bladder has to be washed out via the PST, the three-way stop-cock allows irrigation via a Luer-lock syringe.
We have now performed PST drainage in >1500 patients. In an analysis of the first 339 patients undergoing this technique with over 2 years of follow-up, only one patient developed a bladder neck contracture requiring outpatient dilatation (rate 0.3%) . At 12 months, 86.4% had total urinary control and only 2.7% required >1 pad/day. Indeed, it has been hypothesized that a UC might actually contribute to bladder neck contracture as a result of a foreign body inflammatory response . Overall, we have noticed a marked reduction in pain from bladder spasms and an improvement in the quality of life in patients undergoing this technique , which has now become our standard of care.
Khurshid R. Ghani is supported by a Fellowship from The Urology Foundation, UK.