Imaging of complications after robotic-assisted laparoscopic radical prostatectomy: what every radiologist should know

Transcription

1 Imaging of complications after robotic-assisted laparoscopic radical prostatectomy: what every radiologist should know Poster No.: C-2256 Congress: ECR 2017 Type: Educational Exhibit Authors: I. Tavera Bahillo, G. González Zapico, A. I. Ezquerro Imaz, A. Urresola Olabarrieta, E. GOROSTIZA BERMEJO, J. Padilla Nieva, J. A. Zabala Egurrola, R. Llarena Ibarguren ; Barakaldo/ 2 ES, Bilbao/ES Keywords: Infection, Haemorrhage, Fistula, Surgery, Imaging sequences, Complications, Ultrasound, MR, CT, Urinary Tract / Bladder, Pelvis, Abdomen DOI: /ecr2017/C-2256 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 22

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3 Learning objectives Recently robot-assisted laparoscopic radical prostatectomy (RALRP) has become the predominant technique for localized prostate cáncer since its introduction in 2000 (1,2). Marked improvements in morbidity, oncologic and funcional results have been achieved. However there may be serious complications in around 4% of patients, and somtimes requires urgent diagnostic imaging. We propose the following objectives: 1.- Briefly discuss the key principles of surgical technique and the normal postoperative anatomy. 2.- Review the most frequent complications and establish best techniques that should be used to get the correct diagnosis. 3.- Show the ability of the imaging techniques such as computer tomography (CT), cystography and magnetic resonance imaging (MRI) to evaluate different surgical complications. Page 3 of 22

4 Background Surgical technique During the last years the treatment of prostate cancer has changed. RALRP has gained acceptance since its introduction because the advantages of minimally invasive approach but shortens learning curve. The davinci system (Intuitive Surgical) includes three components: a surgeon`s console, a patient-side robotic cart wtih four arms manipulated by the surgeon and a highdefinition-three-dimensional vision system that provides a stereoscopic view of the operative field with 10- to 12- fold magnification transmitted to the surgeon`s console. Radical prostatectomy can be perfomed using either a transperitoneal (TP) or extraperitoneal (EP) approach through the prevesical space of Retzius. There are no advantage for either approach and depens on the surgeon`s preferences. The extraperitoneal approach confine urine leak within the extraperitoneal space (3). In our institution surgeons prefer a tranperitoneal approach. After prostatectomy the urinary bladder base and levator muscle descend anterioly and caudally.we must keep in mind that we can find surgical clips and hemostasis material in the normal postoperative images. Page 4 of 22

5 Findings and procedure details The rate of complications varies according to diferent published series. Clavien et al(4) proposed a grading system for surgical complications modified in The complications rates for RALP serires included in some reviews was 9,8-10.5% (5, 6). Badani et al (7) evaluating 2766 consecutive RALPs showed an overall complications rate of 12,2%, (Clavien III 0,5%). Multidetector CT (MDCT) protocol should include a unenhanced pelvic acquiisition to detect blood and air collections. Abdominopelvic arterial, venous and an excretory phase after intravenous contrast medium (CM) at least 5-20 min after CM. CT cystography can be used when we suspect an urinary leak. We should make an unenhanced CT of the pelvis initially, then MDCT cystography is performed. We dilute 50 ml of sterile contrast material (Iomeron 350 ) in a 500-mL bag of normal saline and dripped under gravity into the bladder with an urinary Foley catheter. We usually use less volumen in postoperative patients than in other patients, as traumatic injuries, usually around 150 ml of the dilution. CT cystography had a better detection rate of leakage and detected smaller volumen of leakage tahn cystography. However conveltional cystography can also be used, especially in the follw-up of urinary leaks. Urinary leaks Anastomotic leak must be suspected when abdominal pain, ileus, abnormal renal función and high output from abdominal drain are present. After RALRP, vesicourethral anastomotic (VUA) urinary leak may occur in about % ( 8, 9). Limited extraperitoneal leak confined to the surgical bed is the most common finding. When a pelvic fluid collection is seen, a CT cystography should be done to show the presence of communication of the anastomotic leak to the collection or haematoma (Fig 1). The extraperitoneal leak is more frequent than intraperitoneal, whcih is an uncommon complication ( %). Typically intraperitoneal leaks appear in early postoperative Page 5 of 22

6 days. The presence of ascites should raise a suspicion of intraperitoneal extravasation and a MDCT urography should be performed (Fig 2). Bleeding complications Bleeding complications are one of the most common postoperative complications. Increasing abdominal swelling, hypogastric pain and hematocrit fall are usually the most frequent manifestations. Postoperative haematomas may involve the prostatic bed and pouch of Douglas. We also can see hyperattenuating effusion in the peritoneal cavity consist with haemoperitoneum (45-75 HU attenuation), fluid-fluid levels often present. Focal contrast extravasation indicating active bleeding is sometimes observed in arterial or venous phase (Fig 3 y 4). Massive haemorrhage may require urgent treatment. Postoperative collections When we find postoperative pelvic collections we must make the differential diagnosis between the following options: urinoma, lymphocele, abscess and haematoma. Lymphoceles are thin-walled homogeneous collections. Large lymphoceles may require percutaneous drainage if symptomatic (Fig 5). The drain can be removed if the imaging study show resolution of the fluid collection. A thickened wall collection in a patient with fever, pain and acute phase reactants is consistent with local infection. The most common site of infections is in the surgical bed, but we can find then in other places (Fig 6). In rare cases septic arthritis of the pubis may be seen in patients with leakage and pelvic collections ( Fig 7). Rectal injury The incidence of rectal injury ranges from 0 to 2.5% in the literature in RALP (10). Intraoperative identification with meticulous closure is critical to avoid additional morbidity. Unrecognised recto-urethral fistulas may manifest with fever, peritonitis, Page 6 of 22

7 fecaluria and sepsis. At MCTC it manifest as an abnormal communication between bladder and rectum (Fig 8). It represents an indication for surgical repair and occasionally may require colostomy. Other complications Prolonged ileus after minimally-invasive prostatectomy can have multiple etiologies. When is suspected we can find generalized and uniform distension of the large and small bowel. (Fig 9). If it`s not resolve in several days we should consider additional imaging to evaluate other etiologies. Trocar hernia causing small bowel obstruction should be considered (Fig 10). Venous thromboembolism events include deep vein thrombosis (DVT) and pulmonary embolism (PE). During hospitalitation, patients should be monitored for signs and symptoms of VTE, including leg swelling or pain, tachycardia, and oxygen desaturation. These findings should be evaluated with the use of Doppler ultrasound or computed tomography imaging of the chest. Another unfrequent complication we have collected in our series is urethral stenosis several months after RALRP. This patient required cystocath and reintervention (Fig 11). In one case a gastric perforation was diagnosticated in the near postoperative of RALRP. Reintervention was required with total recovery (Fig 12). Page 7 of 22

8 Images for this section: Fig. 1 Page 8 of 22

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20 Conclusion RALRP has become a well-accepted treatment modality for localized prostate cancer. General radiologist should be familiar with more important and frequent postoperative complications because urgent diagnostic imaging is ingresing. Such familiarity allows accurate diagnosis and prompt appropriate management of any complications. The surgical details, main postoperative complications and appropiate MDCT acquisition techniques should be known. Special care is needed to identify those complications that require reintervention or specific treatment. Page 20 of 22

21 References 1.- Abbou CC, Hoznek A, Salomon nl, et al. Laparoscopic radical prostatectomy with a remote controlled robot. J Urol 2001; 165: Kawamoto S, Allaf M, Corl F M, et al. Anastomotic Leak After RobotAssisted Laparoscopic Radical Prostatectomy: Evaluation with MDCT Cystography with Multiplanar Reformatting and 3D Display. AJR 2012, 199: W595-W Tonolini M, Vila F, Bianco R et al. Multidetector CT imaging of post-robot-assisted laparoscopic radical prostatectomy complications. Insights Imaging (2013) 4 : Dindo D, Demartines N, Clavien PA et al. Classification of surgical complications. A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240: Coelho R, Chauhan S, Palmer K et al. Robotic-assisted radical prostatectomy: a review of current outcomes. BJUI 104, Agarwal PK, Sammon J, Bhandari et al. Safety profile of robot-assisted radical prostatectomy: a standardized report of complications in 3317 patients. Eur Urol 2011 May; 59 (5): Badani KK, Kaul S, Menon M et al. Evolution of robotic radical prostatectomy: ssessment after 2766 procedures. Cancer 2007; 110: Patil N, Krane L, Javed K, et al. Evaluating and grading cystographic leakage: correlation with clinical outcomes in patients undergoing robotic prostatectomy. BJU Int 2009; 103: Williams TR, Longoria OJ, Asselmeier S, et al. Incidence and imaging appearance of urethrovesical anastomotic urinary leaks following da Vinci robotic prostatectomy. Abdom Imaging 2008; 33: Novara G, Ficarra V, D'Elia C, et al. Prospective evaluation with standardized criteria for postoperative complications after robotic-assisted laparoscopic radical prostatectomy. Eur Urol Page 21 of 22

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