Introduction

Vesicourethral anastomotic leak (VUAL) is a known complication following radical prostatectomy. The incidence of VUAL is approximately 1% in the modern era of robotic-assisted radical prostatectomy (RARP).¹ The development of VUAL after RARP is multifactorial and risk factors likely include anastomotic technique, obesity, large prostate size or presence of a median lobe, and postoperative hematoma.^2-4 Clinically, patients present with pelvic pain, irritative voiding symptoms, or severe ileus before the VUAL diagnosis is made.²

Sequelae of a VUAL include infection, incontinence, and vesicourethral anastomotic stricture. The VUAL management approach and duration are variable and without expert consensus. Management has traditionally consisted of conservative measures such as prolonged catheterization and intra-abdominal drainage.⁵ If the VUAL is persistent, several techniques have been reported to aid in resolution. These include traction on the urethral catheter, a continuous needle vented suction system, ureteral catheter placement with externalization and suction system, as well as other modifications.^6-10 Surgical revision has long been regarded as a last resort intervention after conservative measures have failed.^2,8

To our knowledge, early robotic surgical revision has not been explored as an option for definitive management of VUAL in a contemporary RARP cohort. We present a novel Robotic Early Postprostatectomy Anastomotic Repair (REPAiR) technique for early (<6 weeks of index procedure) intervention of men who developed VUAL after RARP. Our intention is to evaluate this approach’s safety and short-term institutional results.

Materials and Methods

A retrospective review of a prospectively maintained database between July 2016 and October 2022 identified patients who underwent REPAiR. “Early” was defined as within 6 weeks of the index RARP. All index RARPs were completed in a multiport, transperitoneal fashion. No patients had a history of prior pelvic radiotherapy. Patients were diagnosed with VUAL on CT urogram or cystogram.

The primary outcome of interest was resolution of anastomotic leak, defined as no contrast extravasation on postoperative cystography. Secondary outcomes included postrepair catheter duration, 30-day readmission rates, and continence.

With respect to the surgical technique, the REPAiR technique is a transvesical approach and was implemented utilizing a multiport robotic platform for all cases under a single surgeon.

Cystoscopy and Robotic Port Placement

A cystoscopy is primarily performed to visualize the extent and location of the VUAL (Figure 1). We reuse the ports from the prostatectomy, but without the lateral 12-mm assist port.

Dissection and Access

After lysis of adhesions and drainage of any posteriorly located, loculated urinomas, a small cystotomy at the bladder dome is created. The bladder mucosa is then examined, taking note to locate the ureteral orifices as well as any other anatomical aberrations to take into consideration during the repair.

Anastomotic Repair

Noting the location of the defect(s), the bladder mucosa is advanced distally toward the membranous urethra with a 3-0 barbed absorbable suture in a running fashion effectively closing the defect (Figure 2). Necrotic or fibrinous tissue can be excised to ensure the reapproximation of viable tissue. It is critical to obtain a tension-free, watertight mucosa-to-mucosa anastomosis. Following completion of the anastomosis, an 18F urethral catheter is inserted into the bladder for a duration of 1 to 2 weeks, depending on the quality of the repair (Figure 3).

Results

Eleven patients were identified and underwent REPAiR. All 11 patients had a component of posterior anastomotic disruption, ranging from a small localized segment to complete 360° disruption. Mean time to intervention after RARP was 21.5 days (Table 1).

Table 1. Patient Demographics and Leak Characteristics

Eight of the 11 patients (72.7%) had no evidence of extravasation on post-repair cystogram, which was the primary outcome of interest. The range from intervention to first cystogram was 7 to 20 days. Median catheter duration for those with successful intervention was 10 days. Three of 11 patients (27.3%) did have a leak on the postoperative cystogram and median catheter duration for this subset was 20 days (Table 2).

Table 2. Results and Outcomes

Secondary outcomes were length of catheter time and 30-day readmission rates. Mean console time was 107 minutes. There were no intraoperative complications. The mean length of stay was 2.0 days, with a range of 0 to 5 days (Table 2).

At median follow-up time of 24.9 months, 8 patients reported using no pads/d and 3 patients reported 1 pad/d. There were no readmissions from any patients at the 30-day postoperative timepoint and no major Clavien-class complications.

Discussion and Conclusion

VUAL is a feared complication of prostatectomy. Management of VUAL has long relied on prolonged catheter drainage and is without expert consensus.² In the era of robotic reconstruction, it is important to reconsider prior dogmas that were established in the era of open surgery. The vast majority of VUAL occurs at the posterior anastomosis and is readily accessible via a small posterior cystotomy. Once transvesical, the repair should be straightforward and reproducible. Complete anastomotic disruptions can be more complex as one may need to suture in a very tight and limited anatomic space. Overall, our REPAiR technique was successful with 72% of patients having resolution of their VUAL and median catheter duration of 10 days after their negative cystogram. This series additionally reveals that the REPAiR technique for VUAL repair is safe. There were no intraoperative complications, 30-day readmissions, nor Clavien class > 3 complications during a 2-year follow-up.

With increasing emphasis on patient-reported outcomes, catheter duration and VUAL are likely associated with significant short-term quality of life impairment and patient regret, although not directly measured herein. Early surgical repair options have scarcely been employed nor presented in the literature. Although REPAiR technique doesn’t have a 100% success rate, it is a novel approach that is a departure from the traditional mantra of conservative management “till death do us part.” Preoperative counseling is paramount as patients need to understand that this is a new approach without extensive experience. The REPAiR technique gives the urologic surgeon an additional tool in aiding patient recovery and potentially improving patient satisfaction, without adding significant morbidity in appropriately selected patients.