Laparoscopic radical prostatectomy: omitting a pelvic drain

Abstract

Purpose: Our goal was to assess outcomes of a selective drain placement strategy during laparoscopic radical prostatectomy (LRP) with a running urethrovesical anastomosis (RUVA) using cystographic imaging in all patients. Materials and Methods: A retrospective chart review was performed for all patients undergoing LRP between January at the discretion of the senior surgeon when a urinary leak was demonstrated with bladder irrigation, clinical suspicion for a urinary leak was high, or a complex bladder neck reconstruction was performed. Routine postoperative cystograms were obtained. Results: 208 patients underwent LRP with a RUVA. Data including cystogram was available for 206 patients. The overall rate of cystographic urine leak was 5.8%. A drain was placed in 51 patients. Of these, 8 (15.6%) had a postoperative leak on cystogram. Of the 157 undrained patients, urine leak was radiographically visible in 4 (2.5%). The higher leak rate in node dissection (8 drained, 16 undrained). Three undrained patients developed lymphoceles, which presented clinically on average 3 weeks postoperatively. There were no urinomas or hematomas in either group. Conclusions: Routine placement of a pelvic drain after LRP with a RUVA is not necessary, unless the anastomotic integrity is suboptimal intraoperatively. Experienced clinical judgment is essential and accurate in identifying patients at risk for postoperative leakage. When suspicion is low, omitting a drain does not increase morbidity.

Prospective randomised non‐inferiority trial of pelvic drain placement vs no pelvic drain placement after robot‐assisted radical prostatectomy

“…First, the incidence of overall and major postoperative adverse events was similar in men who underwent RARP regardless of whether the pelvis was drained. Previous researchers have supported the safety of PD omission in open and minimally invasive RP series . However, the present study is the first in which patients who underwent RARP were randomised prospectively to PD omission and showed non‐inferiority.…”

“…Any adjustment to surgical technique that reduces patient discomfort, no matter how minor, deserves consideration. PDs have been associated with higher patient morbidity, infections, prolonged hospital stays, increased postoperative pain at the drain site, and an additional bedside procedure for removal with the potential for breakage and retention of drain material . As such, PD omission after RARP could reduce morbidity without increasing complications.…”

The final stage of the laparoscopic procedure: exploring final steps

“…Regarding other complications there was no increase of clinically detected urine leak, collection of urine, hematoma or lymphocele. Although routine pelvic drainage is usually part of the radical prostatectomy procedure, these findings support the possibility of drain omission when a urethrovesical anastomosis is watertight during the intraoperative test (58). This approach reduces hospital stay and costs, and has been demonstrated to be safe with no rise in the complication rates (59).…”

Impact of Routine Use of Surgical Drains on Incidence of Complications with Robot-Assisted Radical Prostatectomy

“…Only a few studies have examined the role of drains in preventing complications in open radical retropubic prostatectomy (RRP), 17 open RRP and RALP, 18 and laparoscopic prostatectomy. 19 The methods used in each of these studies are limited by a clear selection bias, in that, patients who received drains were thought to be at higher risk of developing complications and were compared with patients in whom a drain was omitted. In each of these reports, there were selection criteria for omitting the drain, including bladder neck preservation, hemostasis, and quality of the vesicourethral anastomosis.…”