Early removal of urethral catheter after endoscopic extraperitoneal radical prostatectomy

Background. Extraperitoneal radical prostatectomy (RP) in patients with prostate cancer is useful when there are no oncological indications to lymph node dissection (e.g. in low and intermediate-low risk of the disease), and allows to perform precise anastomosis and facilitates the early postoperative period. However, even minimally invasive approach does not avoid such factors as a urinary catheter that may disturb patients.

Objective. We assessed the possibility to remove the urinary catheter as early as possible.

Materials and methods. 28 patients with low (n = 22) and low-intermediate (n = 6) prostate cancer risk (according to NCCN (National Comprehensive Cancer Network) criteria) underwent an extraperitoneal laparoscopic RP from March 2017 to November 2018. All operations were performed by the same surgeon (A. Nosov). The inclusion criteria were the following: localized prostate cancer, prostate specific antigen (PSA) <10 ng/ml, ISUP group 1–2, life expectancy of more than 10 years and preoperative patient’s counseling (awareness about early catheter removal and discharge). All patients were continent before surgery. During surgery, the prostate and seminal vesicles were removed extraperitoneally without peritoneal cavity opening and conversion. Bladder neck sparing was performed in all cases but nerve-vascular bundles were spared according to indication (preoperative International Index of Erectile Function (IIEF), oncological reasons). Vesicourethral anastomosis was performed by two V-Loc circular sutures. No drainage tubes were inserted to control bleeding/urinary leakage. A urinary catheter Foley 20 Fr was inserted into the bladder after anastomosis completion. No other urinary drainage (suprapubic tubes, etc) was used. Anastomosis resistance and completeness were checked at the end of surgery by filling the bladder with 150 ml of saline through the catheter. Except for cases with macroscopic hematuria, urinary catheters were removed on the 1st postoperative day’s morning (<24 hours) with an active followup (daily voiding assessment, pelvic ultrasound and postvoided residual volume assessment) on Day 1. Immediately after the catheter removal, alpha-blockers (for urination alleviation) and PDE-5 inhibitors (in patients with neurovascular sparing) were prescribed. All patients were available for a 3-month follow-up. During the follow-up, a monthly combined assessment was performed, including IPSS, QoL, PSA analysis, pelvic ultrasound and urofloumetry.

Results. The average patient’s age was 63 years (52–71 years). The median preoperative PSA level was 7.6 ng/ml. The intraoperative technique was unremarkable with no blood transfusion or conversion. All early postoperative complications were classified as minor – grade I, II and IIIa in 2 (7.2 %), 5 (17.8 %) and 1 (3.6 %) patients, respectively. Related to the early catheter removal complications included 1 (3.6 %) patient with urinary leakage (resolved by repeated prolonged urinary catheter insertion) and 4 (14.3 %) with urinary obstruction – resolved by single catheterization (n = 2), percutaneous suprapubic cystostomy (n = 2). No major complications were noticed during the follow-up. Totally, 22 (78.6 %) patients were discharged on the next day after the catheter removal – on the 2nd postoperative day. All discharged patients did not need readmission during the follow-up. Remained 6 (21.4 %) patients stayed at the hospital for 5–18 days. The pathological investigation showed upgrading in 9 (32.1 %) patients with low risk and in 1 (3.6 %) patient with low-intermediate risk. Upstaging to locally advanced forms was noticed in 6 (21.4 %) patients. All patients had the PSA level of <0.2 ng/ml 30–90 days after surgery. Postoperative assessment showed improvement in urinary function and erectile function sparing in selected patients, with no compromising functional results due to the early catheter removal.

Conclusion. Despite the common widespread of minimally invasive RP, there is no consensus on the terms of a urinary catheter removal. According to our data, we suggested it might be of some benefit to remove a urinary catheter early in selected and well-informed patients. A thorough vesicourethral anastomosis pursuance, nerve-sparing, bladder neck sparing and Retzius sparing procedure, intraand postoperative assessment is necessary in all cases.

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