A Pelvic Drain Can Often Be Avoided After Radical Retropubic Prostatectomy An Update in 552 Cases

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1 european urology 50 (2006) available at journal homepage: Prostate Cancer A Pelvic Drain Can Often Be Avoided After Radical Retropubic Prostatectomy An Update in 552 Cases Motoo Araki, Murugesan Manoharan, Sachin Vyas, Alan M. Nieder, Mark S. Soloway * Department of Urology, Miller School of Medicine, University of Miami, Miami, Florida, USA Article info Article history: Accepted May 17, 2006 Published online ahead of print on June 8, 2006 Keywords: Prostate cancer Prostatic neoplasms Radical prostatectomy Drainage Surgery Abstract Objectives: The routine placement of a pelvic drain following radical retropubic prostatectomy (RRP) may not be required. We describe our experience in 552 consecutive RRPs to emphasise the safety of this approach and explain our rationale for avoiding a drain when possible. Methods: RRP was performed in 552 consecutive patients with clinically localised adenocarcinoma of the prostate between January 2002 and June Clinical and pathologic information was documented for each patient. After the prostate was removed and the anastomotic sutures tied, the bladder was gently filled with approximately 50 ml of saline through the urethral catheter. If there was no leak, a drain was not placed. Results: A drain was not placed in 419 (76%) of the 552 patients. We compared the postoperative complication rates in those with (D+) and without (D ) a drain. There were 27 (5%) immediate postoperative complications and no significant difference between the two groups (D+, 6%; D, 5%; p = 0.629): three (1%) patients who did not have a drain had a urinoma, one (1%) who had a drain had a lymphocele, and two (2%) who had a drain had a small pelvic haematoma. Conclusions: If the bladder neck is preserved or meticulously reconstructed, there may be little extravasation and, thus, routine drainage is unnecessary. Our 4-year experience indicates that morbidity is not increased by omitting a drain from the pelvic cavity after RRP in properly selected cases. # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Department of Urology, University of Miami School of Medicine, PO Box (M814), Miami, FL 33101, USA. Tel ; Fax: address: msoloway@med.miami.edu (M.S. Soloway). 1. Introduction Active treatment (surgery or radiation) is recommended for patients with localised prostate cancer, and a randomised controlled trial demonstrated a long life expectancy following radical prostatectomy [1]. Draining the pelvis following a radical retropubic prostatectomy (RRP) is routine. However, many /$ see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 1242 european urology 50 (2006) surgeons in different fields have questioned the necessity of routine drainage after surgery [2 7]. A drain can increase the risk of infection and cause pain [8]. We were the first to report the omission of a drain following RRP [9]. On the basis of this favourable experience, we have continued to place a drain for only specific indications. This study updates our results in 552 patients. 2. Methods RRP was performed between January 2002 and June 2005 in 552 consecutive patients with clinically localised adenocarcinoma of the prostate by a single surgeon (M.S.S.). Data on patient age, clinical stage, prostate-specific antigen (PSA) levels, biopsy Gleason score, performance of pelvic lymph node dissection or bladder neck preservation, estimated blood loss, and postoperative complications were recorded. Eighty-two percent (452) of patients underwent a bilateral pelvic node dissection involving the obturator triangle. Occasionally, patients with a PSA of <10 ng/ml or a Gleason score 6, and a small-volume cancer did not undergo a bilateral pelvic lymph node dissection. Sequential compression devices were used during and after the procedure as prophylaxis for thromboembolic events. RRP was performed with modifications of the Walsh technique [10]. The neurovascular bundles were identified and preserved or removed depending on several factors, including patient age, potency, Gleason score, and clinical stage, as well as ease of separation from the prostate [10]. Bladder neck preservation with careful dissection and preservation of the circular bladder neck fibers was performed when possible [11]. The anastomosis was performed with seven interrupted 2-0 chromic catgut or poliglecaprone 25 sutures. After the anastomosis was completed, approximately ml of sterile saline was instilled through the urethral catheter without pressure, and the anastomosis was assessed. A drain was placed in the pelvis if the anastomosis leaked or haemostasis was not adequate. A 20F urethral catheter was left in place postoperatively. When a drain was used, a 7-mm Jackson-Pratt closed suction drain was placed through a separate skin incision in the left lower quadrant. Almost all patients were discharged from the hospital on postoperative day 1 or 2. Drains were removed when drainage was <50 ml for the 8 hours prior to removal, which was almost always on day 1. All patients received 7 10 days of an oral quinolone. Catheters were removed on postoperative day 7 or 8. We do not perform cystography before catheter removal. We do not perform routine pelvic imaging studies such as ultrasound unless the patient develops symptoms. Any surgical or interventional radiologic procedures in the postoperative period were recorded. The primary end point of this study was the incidence of postoperative complications. The chi-square test with application of Yate s correction was used to compare postoperative complication rates for those with (D+) and those without (D ) adrain. Table 1 Patient characteristics 3. Results Drain (+) Drain ( ) Total No. of patients Mean age SD (yr) Mean PSA SD (ng/ml) Clinical stage (n [%]) T1 97 (73) 294 (71) 391 T2 33 (25) 113 (27) 146 T3 3 (2) 12 (3) 15 Mean biopsy Gleason score PSA: protein-specific antigen. This report details 552 consecutive patients operated on from January 2002 to June 2005 when the decision to omit a drain if specific criteria where met was initiated. The mean patient age was 60 7 years (median: 60, range: 35 77). Table 1 lists patient characteristics. Mean followup was months (range: ). Estimated blood loss was ml (median: 380, range: ). No patient received a homologous transfusion. Twenty-one percent (117 of 552 patients) received salvaged blood from the cell saver. The mean number of lymph nodes retrieved from the pelvic lymph node dissection was seven. We did not place a drain in 419 of the 552 patients (76%). Table 2 lists the indications for a pelvic drain. Bladder neck preservation was performed in 493 (89%) patients (Table 3). Of the 493 patients who underwent bladder neck preservation, 98 (20%) had a pelvic drain and 395 (80%) did not. Of the 59 patients without preservation of the bladder neck, 34 (57%) had a drain. If the bladder neck was not preserved, there was a significantly greater chance of a drain being placed ( p =0.002). Pelvic lymph node dissection was performed in 452 (82%) patients, of whom 105 (23%) had a drain and 347 (77%) did not. Twenty-eight of the 90 (31%) patients who did not have a lymph node dissection had a drain. Differences were not significant for patients who had pelvic lymph node dissection with or without drain insertion ( p = 0.16). Table 2 Indication for pelvic drainage Indication No. of patients Non water-tight anastomosis 129 Rectal injury 1 Inadequate haemostasis 3

3 european urology 50 (2006) Table 3 Operative procedures and drain status Drain (+) Drain ( ) Total No. of patients No. of bladder 98 (20%) 395 (80%) 493 (100%) neck preservations No. of pelvic lymph node dissections 105 (23%) 347 (77%) 452 (100%) There were 27 (5%) immediate postoperative complications. There was no significant difference at the complication rate between those who did or did not have a drain (8 [6%] and 19 [5%], respectively; p = 0.629)(Table 4). Nine patients developed urinary retention after catheter removal on day 7. They required uneventful catheter reinsertion and bladder drainage for an additional week. Four of these patients had a drain, and five did not. All nine patients voided well after this episode. There were five patients who required bladder irrigation after catheter removal; none had a drain, but there was no statistical difference between the two groups ( p = 0.187). An urinoma occurred in three patients. None of them had a drain at the time of surgery, but there was no statistical difference between the two groups ( p = 0.307). A drain was percutaneously inserted under computed tomography guidance and left to straight drainage for one of three patients. In this patient, hospital discharge was delayed by 2 days. The drain was removed on postoperative day 7, and the catheter was removed on day 10. For the other two patients, urine leaked from the incision after the catheter removal. The catheter was successfully reinserted in both, and percutaneous drainage was not required. One lymphocele was documented. This patient had a drain at the time of surgery. This patient complained of right abdominal pain and right thigh pain on postoperative day 26. An ultrasound demonstrated a lymphocele, and a percutaneous drain was placed. The drain was removed 17 days later. There was no recurrence. Urinary tract infection was observed in two patients without a drain. Both occurred 1.5 months following surgery in patients who had a drain. A symptomatic haematoma causing edema occurred in two patients who had a drain, but was treated conservatively without intervention. Five patients had haematuria on postoperative days 10, 11, 13, 29, and 31. All occurred after catheter removal. None of these patients had a drain following RRP. An anastomotic stricture was documented in five patients. Only one had a drain; all were successfully treated with an incision of the anastomosis, which did not recur. Table 4 Postoperative complications 4. Discussion Drain (+) (N = 133) (%) Drain ( ) (N = 417) (%) p value Urinary retention Haematuria requiring foley reinsertion Anastomotic stricture Urinoma Lymphocele Haematoma Urinary tract infection Total postoperative complications RRP is a common procedure for localised prostate cancer in patients with a reasonable life expectancy [10]. Placement of a pelvic drain has been a standard component of the procedure since the initial description of RRP in the early 1980s [12]. The management of localised prostate cancer has undergone important changes in the past two decades [13]. The incidence of prostate cancer has increased and a greater number of younger patients with pathologically organ-confined disease are diagnosed and treated [14,15]. The morbidity of RRP is low. The most common complications are erectile dysfunction, urinary incontinence, anastomotic leakage, prolonged lymph drainage, rectal injury, symptomatic lymphocele, pelvic abscess, or haematomas. These complications occur in <1 2% [16,17]. There was only one lymphocele and three urinomas, and no patients had a pelvic abscess or haematoma requiring drainage (two haematomas were managed without drainage) in the 10-year experience of a single surgeon (M.S.S.). We never performed routine postoperative ultrasound. Hence we do not know the incidence of asymptomatic lymphocele, which is clinically unimportant. The prophylactic value of drains in abdominal or pelvic surgery is decreasing. We previously reported the possibility of RRP without a pelvic drain [9]. Many prospective studies in fields other than urology (general surgery, gynecologic surgery, spine surgery, etc) have not shown a statistical difference in the rate of complications between patients with and without drainage [2,4,7,18 20]. For example, routine placement of intraperitoneal drains has been shown to be unnecessary after colon resection for cancer on a prepared bowel [4], perforated duodenum closure, open or laparoscopic cholecystectomy, elective liver resection [20], radical hysterectomy, pelvic [18,19]

4 1244 european urology 50 (2006) and retroperitoneal lymphadenectomy [2], and lumbar spinal fusion surgery [7]. Conservative management of extraperitoneal bladder perforations with urethral catheter drainage is safe [21,22]. Routine drainage of the pelvic cavity is not required and is not associated with a higher incidence of complications. We performed a lymph node dissection in 83% of our patients. The incidence of lymphocele was low (one case in the D+ group). In our experience with 1000 consecutive RRPs, <1% has had lymph node metastasis. Because of such a low incidence of pelvic node metastases in patients with lowgrade tumours, low-serum PSA, and small tumour volume, pelvic lymph node dissection is often omitted in those with favourable tumour characteristics [23]. A modified (standard) lymph node dissection is not an indication for placement of a pelvic drain in our experience, although it may be required for extended lymph node dissection [24]. There are possible complications directly attributable to the Jackson-Pratt drain: bleeding and abdominal wall haematoma [2,18], infection, pain at the drain site [8], pseudoaneurysm of the inferior epigastric artery [25], and breaking of the drain [26] upon removal, requiring a return to the operating room. The inferior epigastric artery can be injured on drain placement, which can result in pseudoaneurysm formation, and may require intervention [25]. Our previous report did not show an increased incidence of wound infection at the drain site [2,18], although theoretically a drain may increase the incidence of infection since it is a foreign body. Breaking a drain during removal or retention of a piece of drain has been reported [26,27]. There were four cases in our series that required a return to the operating room to locate and cut sutures that entrapped the Jackson-Pratt drain. A drain may increase postoperative pain and may prolong postoperative recovery. Niesel et al. [8] investigated postoperative pain after RRP and found that pain was attributable to the drain site in 42 of 179 (24%) patients. We placed a pelvic drain for the following three reasons: (1) when there is leakage at the anastomotic site after irrigation, (2) when haemostasis is not excellent, and (3) when there is injury to adjacent organs. The most common indication is leakage at the anastomotic site (97%). A recent report indicates that a pelvic drain may not be necessary following a simple retropubic prostatectomy performed for benign prostatic hyperplasia [28]. They applied fibrin sealant over the closed prostatic capsule in five patients and did not place a pelvic drain. A three-way urethral catheter was used for continuous bladder irrigation. No complications were reported. Only three (3 of 419, 0.7%) of our patients had a complication related to the absence of a pelvic drain. These complications would likely have been avoided by routine drainage of the pelvic cavity. Despite these three cases, we believe that routine placement of a pelvic drain after uncomplicated RRP with a watertight anastomosis is not necessary. The benefit of not having a drain outweighs the slight risk of requiring later placement. The surgeon must carefully evaluate the anastomosis and weigh the benefits and potential risks of not leaving a drain. Twenty-one percent received salvaged blood collected by cell saver. In our series, not a single patient had a homologous transfusion or autologous transfusion (self-donated blood collected preoperatively). Our philosophy is to avoid any homologous transfusion, and thus we are reasonably liberal with cell saver, which is used only if the prostate is very large, or the patient is anemic or has some comorbidity such as coronary artery disease. We believe that the cell saver adds no additional morbidity, since it safely reinfuses blood collected from the patient during surgery. This approach facilitates rapid convalescence. We have previously demonstrated that intraoperative cell salvage during radical prostatectomy is not associated with a greater biochemical recurrence rate [29]. We updated our series of RRP without a pelvic drain with a much larger number of patients (552), more of whom had a lymph node dissection (82%), with longer followup (12 months). Our continued experience confirms our early observations. 5. Conclusion Our large series of RRPs demonstrates that, consistent with our previous report and those of recent studies in other surgical specialties, a drain may not be necessary in all cases. The routine use of a drain is unnecessary following RRP if the bladder neck is preserved or meticulously reconstructed and if there is little or no extravasation. In properly selected cases, morbidity is not increased by omitting a drain from the pelvic cavity after RRP. Acknowledgements We thank Adrienne Carmack, MD, for editing this paper and Victor A. Rodriguez for his generous financial support.

5 european urology 50 (2006) References [1] Aus G, Abbou CC, Bolla M, et al. EAU guidelines on prostate cancer. Eur Urol 2005;48: [2] Benedetti-Panici P, Maneschi F, Cutillo G, et al. A randomized study comparing retroperitoneal drainage with no drainage after lymphadenectomy in gynecologic malignancies. Gynecol Oncol 1997;65: [3] Conlon KC, Labow D, Leung D, et al. Prospective randomized clinical trial of the value of intraperitoneal drainage after pancreatic resection. Ann Surg 2001;234:487 93, discussion [4] Merad F, Yahchouchi E, Hay JM, et al. Prophylactic abdominal drainage after elective colonic resection and suprapromontory anastomosis: a multicenter study controlled by randomisation. French Associations for Surgical Research. Arch Surg 1998;133: [5] Merad F, Hay JM, Fingerhut A, et al. Is prophylactic pelvic drainage useful after elective rectal or anal anastomosis? A multicenter controlled randomized trial. French Association for Surgical Research. Surgery 1999;125: [6] Sagar PM, Couse N, Kerin M, May J, MacFie J. Randomized trial of drainage of colorectal anastomosis. Br J Surg 1993;80: [7] Scuderi GJ, Brusovanik GV, Fitzhenry LN, Vaccaro AR. Is wound drainage necessary after lumbar spinal fusion surgery? Med Sci Monit 2005;11:CR64 6. [8] Niesel T, Partin AW, Walsh PC. Anatomic approach for placement of surgical drains after radical retropubic prostatectomy: long-term effects on postoperative pain. Urology 1996;48:91 4. [9] Savoie M, Soloway MS, Kim SS, Manoharan M. A pelvic drain may be avoided after radical retropubic prostatectomy. J Urol 2003;170: [10] Walsh PC. Anatomic radical prostatectomy: evolution of the surgical technique. J Urol 1998;160: [11] Shelfo SW, Obek C, Soloway MS. Update on bladder neck preservation during radical retropubic prostatectomy: impact on pathologic outcome, anastomotic strictures, and continence. Urology 1998;51:73 8. [12] Walsh PC, Lepor H, Eggleston JC. Radical prostatectomy with preservation of sexual function: anatomical and pathological considerations. Prostate 1983;4: [13] Meraney AM, Haese A, Palisaar J, et al. Surgical management of prostate cancer: advances based on a rational approach to the data. Eur J Cancer 2005;41: [14] Ryan CJ, Small EJ. Advances in prostate cancer. Curr Opin Oncol 2004;16: [15] Hodge KK, McNeal JE, Terris MK, Stamey TA. Random systematic versus directed ultrasound guided transrectal core biopsies of the prostate. J Urol 1989;142:71 4, discussion 4 5. [16] Andriole GL, Smith DS, Rao G, Goodnough L, Catalona WJ. Early complications of contemporary anatomical radical retropubic prostatectomy. J Urol 1994;152: [17] Zincke H, Oesterling JE, Blute ML, et al. Long-term (15 years) results after radical prostatectomy for clinically localized (stage T2c or lower) prostate cancer. J Urol 1994;152: [18] Patsner B. Closed-suction drainage versus no drainage following radical abdominal hysterectomy with pelvic lymphadenectomy for stage IB cervical cancer. Gynecol Oncol 1995;57: [19] Patsner B. Routine retroperitoneal drainage is not required for uncomplicated pelvic lymphadenectomy for uterine cancer. Eur J Gynaecol Oncol 1999;20:87 9. [20] Fong Y, Brennan MF, Brown K, Heffernan N, Blumgart LH. Drainage is unnecessary after elective liver resection. Am J Surg 1996;171: [21] Kotkin L, Koch MO. Morbidity associated with nonoperative management of extraperitoneal bladder injuries. J Trauma 1995;38: [22] Corriere Jr JN, Sandler CM. Bladder rupture from external trauma: diagnosis and management. World J Urol 1999;17:84 9. [23] Fergany A, Kupelian PA, Levin HS, et al. No difference in biochemical failure rates with or without pelvic lymph node dissection during radical prostatectomy in low-risk patients. Urology 2000;56:92 5. [24] Heidenreich A, Ohlmann CH. The role of pelvic lymphadenectomy in the therapy of prostate and bladder cancer. Aktuelle Urol 2005;36: [25] Pinero A, Reus M, Agea B, et al. Case report: Conservative management of an arteriovenous fistula of the inferior epigastric artery. Br J Radiol 2003;76: [26] Leonovicz PF, Uehling DT. Removal of retained Penrose drain under fluoroscopic guidance. Urology 1999;53:1221. [27] Beshai AZ, Flashner SC, Walther PJ. Endoscopic release of retained Penrose drains: a simple solution for an old problem. J Urol 1992;147: [28] Morey AF, McDonough 3rd RC, Kizer WS, Foley JP. Drainfree simple retropubic prostatectomy with fibrin sealant. J Urol 2002;168: [29] Nieder AM, Carmack AJ, Sved PD, et al. Intraoperative cell salvage during radical prostatectomy is not associated with greater biochemical recurrence rate. Urology 2005; 65:730 4.

6 1246 european urology 50 (2006) Editorial Comment Markus Graefen In this paper Araki and co-workers investigated whether a pelvic drain following retropubic radical prostatectomy is necessary. In 476 out of 552 patients no drain was placed and the postoperative complication rate was compared to those patients with a drain. The decision whether or not to place a drain was based on an intraoperative cystogram with saline: if there was a leak a drain was placed, if no leak was apparent no drain was placed. The complication rate was low and not influenced by drain placement. I liked this paper as it questions a routine procedure which is obviously not necessary and probably mostly performed because we are used to it. Even though drain placement is not a critical point at radical prostatectomy, omitting it is another small step to a development we see over and over in the literature: radical prostatectomy is becoming less and less invasive. As drains can cause pain [1] I believe that we should really start to omit it. Indicating a drain can be based on the criteria Araki has mentioned like no leak at the intraoperative cystogram. Another interesting thing is that all patients were discharged on day 1 or 2 after the procedure. This demonstrates what has been shown before: open retropubic radical prostatectomy in experienced hands is a minimal invasive procedure and especially not more invasive than laparoscopic procedures [2,3]. References [1] Niesel T, Partin AW, Walsh PC. Anatomic approach for placement of surgical drains after radical retropubic prostatectomy: long-term effects on postoperative pain. Urology 1996;48:91 4. [2] Fornara P, Zacharias M. Minimal invasiveness of laparoscopic radical prostatectomy: reality or dream? Aktuelle Urol 2004;35: [3] Heinzer H, Heuer R, Nordenflycht VO, Eichelberg C, Friederich P, Goetz AE, et al. Fast-track surgery in radical retropubic prostatectomy. First experiences with a comprehensive program to enhance postoperative convalescence. Urologe A 2005;44: Editorial Comment Axel Heidenreich, Division of Oncological Urology, Department of Urology, University of Cologne, Germany axel.heidenreich@uk-koeln.de There has been a long discussion whether to drain or not to drain the pelvic cavity following radical cancer surgery of the small pelvis or the retroperitoneum. In many institutions, pelvic drainage has been used routinely to reduce potential complications such as lymphoceles, intrapelvic hematomas and infections due to urinary extravasations. However, only very few studies have assessed advantages and disadvantages of routine pelvic drainage. Following RPE it was shown that the volume of pelvic drainage did not predict the finding of urinary extravasation or the development of postoperative complications [1]. Furthermore, it has been demonstrated that early removal of a pelvic drain independent of volume of drainage did not increase postoperative morbidity, but decreased the length of hospital stay associated with a significant decrease in hospital-associated cost per case [2]. Following RPE and pelvic lymphadenectomy, a pelvic drain is inserted in most institutions to prevent lymphocele formation. The current paper demonstrates that the risk to develop symptomatic lymphoceles does not differ significantly between a group of patients with or without a pelvic drain. Formation of lymphoceles basically reflects the surgical technique of pelvic lymph node dissection. Although no studies are available with regard to pla and prostate cancer, several randomized trials have been performed in patients undergoing radical hysterectomy and pelvic lymphadenectomy which reflects the technique of extended pla in prostate cancer [3,4]. None of the trials demonstrated increased postoperative complications in the groups without drains, however, the rehospitalization rate due to febrile morbidity and pelvic cellulites was directly related to the presence of drains. Similar data have been published for combined retroperitoneal and pelvic lymphadenectomy in patients with gynaecological malignancies [5,6]. Prophylactic drainage confers no advantage over no drainage but seems to increase surgery-associated morbidity and hospital stay due to lymphocyst formation and symptomatic ascites. The current paper demonstrates that a pelvic drain can be omitted safely after RPE and pla without increasing postoperative complications.

7 european urology 50 (2006) According to the data presented and the current policy of our institution, placement of a drain might only be indicated in case of severe intraoperative bleeding, excessive urinary extravasation and severe intraoperative complications thereby reducing the need for a drain to less than 10% of the patients. References [1] Lepor H, Nieler AM, Fraiman MC. Early removal of urinary catheter after radical prostatectomy is both feasible and desirable. Urology 2001;58: [2] Licht MR, Klein EA. Early hospital discharge after redical retropubic prostatectomy: impact on cost and complication rate. Urology 1994;44: [3] Srisomboon J, Phongnarisorn C, Suprasert P, Cheewakriangkrai C, Siriarce S, Charoenkwan K. A prospective randomized study comparing retroperitoneal drainage with no drainage and no peritonization following radical hysterectomy and pelvic lymphadenectomy for invasive cervical cancer. J Obstet Gynaecol Res 2002;28: [4] Jensen JK, Lucci 3rd JA, DiSaia PJ, Manetta A, Berman ML. To drain or not to drain: a retrospective study of closetsuction drainage following radical hysterectomy with pelvic lymphadenectomy. Gynecol Oncol 1993;51:46 9. [5] Morice P, Lassan N, Pautier P, Haie-Meder C, Lhomme C, Castaigne C. Retroperitoneal drainage after complete para-aortic lymphadenectomy for gynaecological cancer: a randomized trial. Obstet Gynecol 2001;97: [6] Bafna UD, Umadevi K, Savitha M. Closed suction drainage versus no drainage following pelvic lymphadenectomy for gynecological malignancies. Int J Gynecol Cancer 2001;11: Editorial Comment Ziya Kirkali ziya.kirkali@deu.edu.tr We are living in a world of rapid changes. Many concepts in medicine are also changing so rapidly, and surgical principal dogmas are no exception to this. Many years ago, when I was training in urology, my mentors always taught me that, if the urinary tract is opened and if you are doing reconstructive surgery, it is always mandatory to place a surgical drain at the operation site as a safety precaution to prevent urinoma. For many years I obeyed this rule. On some occasions, I challenged this concept by performing drainless stone surgery in the past. In the vast majority of patients I managed to get away without any complications. Radical prostatectomy is a frequently performed operation for localized prostate cancer where a pelvic hematoma or urinoma may hamper the anastomosis and the outcome. A pelvic drain left at the operation site is a standard procedure for many urologists in order to drain any oozing from the pelvic veins as well as the urine leakage from the anastomosis. In the paper by Araki et al., Dr. Soloway and colleagues report that they omit the pelvic drain in 76% of the 552 consecutive radical prostatectomies performed in their institution. There is no statistical difference in the complication rates of those patients with and without a drain. I believe the key points in this paper are that they preserve the bladder neck and attain a water-tight anastomosis. As one becomes more confident in his surgical technique, there is no reason why one should not improve it further, and this is a perfect example. Despite being a retrospective series, this paper clearly tells us one thing: even open surgery can be minimally invasive. Together with a small incision, be it midline or Pfannenstiel, and a well-performed drainless radical prostatectomy and early catheter removal, this operation can be truly less invasive. There is an understandable big demand from the patients for less suffering after the operation, early return to home and quicker recovery. This is one of the reasons why laparoscopic and robotic radical prostatectomy are becoming more popular. A drain left after any surgical procedure is a major cause of post-operative pain. We all have noticed the relief on the patient s face when the drain is removed. If this pain can be avoided; why not try to avoid a drain?