Genitourinary Imaging Pictorial Essay

Transcription

1 Genitourinary Imaging Pictorial Essay Kawamoto et al. Robot-ssisted Radical Prostatectomy Genitourinary Imaging Pictorial Essay Satomi Kawamoto 1 Mohamad llaf 2 Frank M. orl 1 Tom Feng 2 Jithin Yohannan 2 Elliot K. Fishman 1 Kawamoto S, llaf M, orl FM, Feng T, Yohannan J, Fishman EK Keywords: anastomotic leak, T cystography, intraperitoneal leak, MDT, robot-assisted laparoscopic radical prostatectomy (RLRP) DOI: /JR Received January 31, 2012; accepted after revision March 16, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, JHO 3235, 601 N aroline St, altimore, MD ddress correspondence to S. Kawamoto (skawamo1@jhmi.edu). 2 The James uchanan rady Urological Institute, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, altimore, MD. WE This is a Web exclusive article. JR 2012; 199:W595 W X/12/1995 W595 merican Roentgen Ray Society nastomotic Leak fter Robot-ssisted Laparoscopic Radical Prostatectomy: Evaluation With MDT ystography With Multiplanar Reformatting and 3D Display OJETIVE. This article reviews the pattern of anastomotic leak after robot-assisted laparoscopic radical prostatectomy (RLRP) on MDT cystography with multiplanar reformatting and 3D display and discusses key surgical procedures to explain intraperitoneal leak and the incidence and clinical significance of anastomotic leak. ONLUSION. RLRP is a minimally invasive surgery for localized prostate cancer, and its use has increased recently. Intraperitoneal extension of vesicourethral anastomotic leak after RLRP can occur, which is not associated with radical retropubic prostatectomy. MDT cystography is a fast and accurate method for detection and evaluation of the extent of anastomotic leak after RLRP. R obot-assisted laparoscopic radical prostatectomy (RLRP) is a minimally invasive surgery for localized prostate cancer using robotic surgical technology. There has been an evolution of surgical treatment of prostate cancer from open prostatectomy to laparoscopic prostatectomy [1] to RLRP in recent years [2, 3]. Since it was first performed in 2000 [2, 3], RLRP has been gaining acceptance and popularity among urologists. RLRP provides several advantages over open and laparoscopic prostatectomy, such as precise dissection through improved instrument control with articulating tips, 3D vision and magnified views, intuitive eye-hand coordination, motion scaling, and filter of tremor [4]. fter RLRP, vesicourethral anastomotic urinary leak may occur, with reported incidence of % [5, 6], which is similar to the reported incidence of leak after open radical prostatectomy (3.9 23%) [7, 8]. However, intraperitoneal leak can be associated with RLRP. Intraperitoneal anastomotic leak is a unique complication of laparoscopic radical prostatectomy and is not associated with radical retropubic prostatectomy, which has been considered the standard surgical treatment of clinically localized prostate cancer. lthough intraperitoneal leak can be potentially associated with laparoscopic prostatectomy without robot assistance, this procedure has not been widely adopted [9]. With increasing use of robotic surgery for minimally invasive prostatectomy, intraperitoneal leak will likely become an increasingly important radiologic finding after RLRP. The purposes of this article are to illustrate the pattern of anastomotic leak after RLRP on T cystography and to review key surgical techniques of RLRP to explain the mechanism of the intraperitoneal leak. The incidence and clinical significance of anastomotic leak after RLRP are also reviewed. Key Surgical Techniques of RLRP and Mechanisms of Intraperitoneal Urine Leak The da Vinci Surgical System (Intuitive Surgical) is used for RLRP and has three components: a surgeon s console, a patientside robotic cart with four arms manipulated by the surgeon, and a high-definition 3D vision system that provides a true stereoscopic view of the operative field with 10- to 12-fold magnification transmitted to the surgeon s console. The system is controlled by a surgeon who is seated on the operative console a few feet away from the patient [4, 9]. The device senses the surgeon s hand movements and translates them electronically into scaleddown micromovements to manipulate the tiny proprietary instruments [4]. There are two approaches for RLRP: transperitoneal and extraperitoneal [9]. For the transperitoneal approach, pneumoperitoneum is initially achieved with carbon dioxide and a port and the laparoscope are introduced into JR:199, November 2012 W595

2 Kawamoto et al. the peritoneal space. Then the extraperitoneal space Retzius (retropubic) is entered through an inverted U-shaped incision to the parietal peritoneum superior to the bladder. efore further dissection of the prostate gland, some surgeons dissect the vas deferens and seminal vesicles retrovesically through an incision of the peritoneum overlying the vas deferens [3]. With this technique, two potential routes of interaperitoneal communication to the vesicourethral anastomosis (Fig. 1) are made: anterior to the bladder (Fig. 1) and posterior to the bladder (Fig. 1). lternatively, the seminal vesicles may be dissected after separation of the prostate from the posterior bladder neck [10]. fter removal of the prostate gland, the bladder and urethra are brought together and vesicourethral anastomosis is made (Fig. 1). For an extraperitoneal approach, working space is created in the space of Retzius using a trocar-mounted balloon dilator device. The use of a transperitoneal or extraperitoneal approach for RLRP is largely a matter of surgeon preference, and there is no consistently shown advantage for either approach [9]. However, the extraperitoneal approach helps to confine urine leak from the vesicourethral anastomosis within the extraperitoneal space [9]. T ystographic Findings of nastomotic Leak T ystography Technique T cystography was performed with 64- MDT scanners while the balloon-tipped Foley catheter was still in place. T was performed only when anastomotic leak was clinically suspected by clinical findings, such as abdominal pain, ileus, rising creatinine, high output from an abdominal drain, and low output from a Foley catheter. Unenhanced T of the pelvis was initially performed, then scanning was performed with the patient s bladder full, after ml of diluted sterile contrast material (30 ml of iohexol ([Omnipaque 350, GE Healthcare]) in a 500-mL bag of normal saline was dripped under gravity into the empty bladder. The volume of diluted contrast material is less than the standard volume used for T cystography for evaluation of traumatic bladder rupture [11, 12] due to concern for excessive hydrostatic pressure on the anastomosis shortly after the surgery. Tube parameters were 120 kvp and 250 effective ms. Detector collimation settings of mm were used. The data were reconstructed at 0.75-mm slice thickness at 0.5-mm intervals for multiplanar reformation and 3D imaging with a soft-tissue algorithm. For diagnostic reading, 3- or 5-mm slice thickness and 3- or 5-mm reconstruction intervals were used. Extraperitoneal nastomotic Leak On T cystography, when a leak is present, the site and extent of the leak is easily assessed. For an extraperitoneal leak, contrast material extending from the vesicourethral anastomosis confines to the extraperitoneal space (Figs. 2 and 3). When a pelvic fluid collection or hematoma is seen on T, T cystography can show the presence or absence of communication of the anastomotic leak to the pelvic fluid collection or hematoma (Figs. 3 and 4). Intraperitoneal nastomotic Leak Intraperitoneal anastomotic leak from vesicourethral anastomosis is an uncommon complication after RLRP. In patients with intraperitoneal leak, unenhanced T often shows ascites (Fig. 5). On T cystography, contrast material from the anastomotic leak extending into the peritoneal space is easily detected. nastomotic leak may extend into the peritoneal space anterior to the bladder (Figs. 5 and 6) or posterior to the bladder (Fig. 7). Typically, in our experience, patients with an intraperitoneal leak are found in early postoperative days, often within a few days after surgery, when T cystography was performed due to clinically suspected anastomotic leak. Most patients with an intraperitoneal leak were treated conservatively with a Foley catheter kept in place. Follow-up imaging often shows gradual resolution of the anastomotic leak without further intervention (Fig. 5). Incidence and linical Significance of nastomotic Leak The reported incidence of anastomotic leak after open radical prostatectomy is quite variable, ranging from 3.9% to 23% in the prior studies [7, 8]. For laparoscopic radical prostatectomy, anastomotic leak occurred in approximately 10 17% of patients [13, 14], grossly similar to RLRP. Patil et al. [5] reported that anastomotic leak was observed in 287 of 3327 patients (8.6%) on fluoroscopic cystography 7 days after RLRP. mong them, 24 patients (0.7% of 3327 patients) had intraperitoneal leak [5]. Williams et al. [6] reported that 67 of 442 patients (15.2%) who underwent fluoroscopic retrograde cystography after RL- RP on postoperative day 7 had urinary leak, and six patients (1.4% of 442 patients) had intraperitoneal leak. The vast majority of anastomotic leaks in this study were transient and required no follow-up intervention [6]. Two of six patients with intraperitoneal leak in this study required T-guided drainage for peritoneal urinoma. The incidence of large anastomotic leaks that required T-guided intervention was exceedingly low (< 0.5%) [6]. In our experience, intraperitoneal leak was seen in less than 1% of patients who underwent RLRP, and the majority of these patients were successfully treated conservatively. Lee et al. [15] reported that T cystography is more sensitive for anastomotic leak than conventional cystography after radical retropubic prostatectomy. In their study, 51 sets of T and fluoroscopic cystography studies in 46 patients after radical retropubic prostatectomy were compared. T cystography had a significantly better detection rate of leakage (80.4% vs 54.3%) and detected a significantly smaller volume of leakage (2.2 ± 2.1 ml vs 19.3 ± 14.1 ml) compared with fluoroscopic cystography [15]. Regarding intraperitoneal leak in patients after RLRP, diluted contrast material by urine ascites may be more conspicuous on T cystography than on fluoroscopic cystography. The disadvantages of T cystography are radiation exposure and cost, which are greater than for fluoroscopic cystography [16]. However, T cystography may be more economical if it reduces the number of necessary tests and reduces the rate of false-negative findings [15]. Summary nastomotic leak after RLRP is seen in approximately 10% of patients and is mostly limited to the extraperitoneal pelvic space, which is usually transient and requires no further intervention. Rarely, intraperitoneal leak may occur after RLRP. Most patients with intraperitoneal leak were treated conservatively. MDT cystography is a fast and accurate method for detection and evaluation of the extent of anastomotic leak after RLRP. References 1. Schuessler WW, Schulam PG, layman RV, Kavoussi LR. Laparoscopic radical prostatectomy: initial short-term experience. Urology 1997; 50: bbou, Hoznek, Salomon L, et al. Laparoscopic radical prostatectomy with a remote controlled robot. J Urol 2001; 165: Guillonneau, Vallancien G. Laparoscopic radical prostatectomy: the Montsouris technique. J Urol 2000; 163: El-Hakim, Tewari. Robotic prostatectomy: a review. MedGenMed 2004; 6:20 W596 JR:199, November 2012

3 Robot-ssisted Radical Prostatectomy 5. Patil N, Krane L, Javed K, Williams T, handari and correlation between contrast extravasation and 12. Vaccaro JP, rody JM. T cystography in the M, Menon M. Evaluating and grading cystograph- anastomotic strictures. JR 1994; 162:87 91 evaluation of major bladder trauma. RadioGraph- ic leakage: correlation with clinical outcomes in 9. Su LM, Smith J. Laparoscopic and robotic- ics 2000; 20: patients undergoing robotic prostatectomy. JU assisted laparoscopic radical prostatectomy and 13. Guillonneau, Rozet F, athelineau X, et al. Int 2009; 103: pelvic lymphadenectomy. In: Wein J, Kavoussi Perioperative complications of laparoscopic radi- 6. Williams TR, Longoria OJ, sselmeier S, Menon LR, Novick, Partin W, Peters, eds. Wein: cal prostatectomy: the Montsouris 3-year experi- M. Incidence and imaging appearance of urethrovesical anastomotic urinary leaks following da Vinci robotic prostatectomy. bdom Imaging 2008; 33: Gnanapragasam VJ, aker P, Naisby GP, hadwick D. Identification and validation of risk factors for vesicourethral leaks following radical retropubic prostatectomy. Int J Urol 2005; 12: erlin JW, Ramchandani P, anner MP, Pollack HM, Nodine F, Wein J. Voiding cystourethrography after radical prostatectomy: normal findings ampbell-walsh urology. Philadelphia, P: Saunders Elsevier, 2007: Menon M, Tewari, Peabody JO, et al. Vattikuti Institute prostatectomy, a technique of robotic radical prostatectomy for management of localized carcinoma of the prostate: experience of over 1100 cases. Urol lin North m 2004; 31: han DP, bujudeh HH, ushing GL Jr, Novelline R. T cystography with multiplanar reformation for suspected bladder rupture: experience in 234 cases. JR 2006; 187: ence. J Urol 2002; 167: Rassweiler J, Seemann O, Schulze M, Teber D, Hatzinger M, Frede T. Laparoscopic versus open radical prostatectomy: a comparative study at a single institution. J Urol 2003; 169: Lee HJ, Shin I, Hwang SI, et al. MDT cystography for detection of vesicourethral leak after prostatectomy. JR 2008; 191: Deck J, Shaves S, Talner L, Porter JR. omputerized tomography cystography for the diagnosis of traumatic bladder rupture. J Urol 2000; 164:43 46 Fig. 1 Illustration of sagittal pelvis., Drawing of sagittal section of pelvis shows vesicourethral anastomosis after removal of prostate and retrovesical and retropubic space., Drawing of sagittal section shows intraperitoneal anastomotic leak anterior to bladder through retropubic space., Drawing of sagittal section shows intraperitoneal anastomotic leak posterior to bladder. JR:199, November 2012 W597

4 Kawamoto et al. D Fig year-old man after robot-assisted laparoscopic prostatectomy for prostate cancer., Fluoroscopic cystogram obtained 13 days after surgery because of recurrent postoperative ileus shows moderate extraperitoneal leak within pelvis. No clear intraperitoneal leak is detected., xial T cystogram at superior aspect of bladder obtained 4 weeks after surgery shows moderate ascites within pelvis. and D, xial () and sagittal (D) multiplanar reformatted T cystograms obtained 4 weeks after surgery show persistent but decrease in size of extraperitoneal leak from anterior aspect of anastomosis (arrow). Patient was readmitted and treated conservatively. It was thought that intraperitoneal leak that was not detected on initial fluoroscopic cystogram may have led to peritonitis causing recurrent ileus. Fig year-old man after robot-assisted laparoscopic radical prostatectomy. Patient had abdominal pain after Foley catheter removal, and outside T showed pelvic fluid collections. T cystography was performed 20 days after surgery., Unenhanced axial T of pelvis shows fluid collections anterior and posterior to bladder., xial T cystogram at level of vesicourethral anastomosis shows leak from left posterior aspect of anastomosis (arrow). (Fig. 3 continues on next page) W598 JR:199, November 2012

5 Robot-ssisted Radical Prostatectomy Fig year-old man after robot-assisted laparoscopic radical prostatectomy. Urine leak was clinically suspected because of rising creatinine and increase in drain via Davol drain (ard Davol). T cystography was performed 2 days after surgery., xial unenhanced T image shows moderate ascites. Small amount of fluid and scattered air are seen within abdominal wall, indicating postsurgical changes. and, xial () and coronal () volume-rendered T cystograms show intraperitoneal leak. (Fig. 5 continues on next page) D Fig. 3 (continued) 59-year-old man after robotassisted laparoscopic radical prostatectomy. Patient had abdominal pain after Foley catheter removal, and outside T showed pelvic fluid collections. T cystography was performed 20 days after surgery., xial T cystogram above level of vesicourethral anastomosis shows contrast accumulation within pelvic fluid collections (asterisks) anterior and posterior to bladder. D, Sagittal volume-rendered T cystogram shows contrast leak from posterior aspect of anastomosis (arrow), accumulating in posterior pelvic collection. Fig year-old man after robot-assisted laparoscopic radical prostatectomy. Patient experienced episodes of leaking urine around Foley catheter with no drainage via Foley catheter. T cystography was performed 12 days after surgery., xial unenhanced T image shows moderatesized radiodense fluid collection posterior to bladder (asterisk), consistent with hematoma., Sagittal volume-rendered T cystogram shows thick-walled bladder and radiodense fluid collection posterior to the bladder (asterisk), but there is no evidence of anastomotic leak. JR:199, November 2012 W599

6 Kawamoto et al. D E Fig year-old man after robot-assisted laparoscopic radical prostatectomy. Urine leak was clinically suspected because of abdominal pain, rising creatinine, high output from drain, and low output from Foley catheter. T cystography was performed 3 days after surgery. and, Lateral volume-rendered () and axial () T cystograms show leak from anterior aspect of anastomosis (arrow) extending to peritoneal space., oronal volume rendered T cystogram shows contrast material within peritoneal space, indicating intraperitoneal leak. Patient s condition improved with conservative management, and patient was discharged. Fig. 5 (continued) 52-year-old man after robotassisted laparoscopic radical prostatectomy. Urine leak was clinically suspected because of rising creatinine and increase in drain via Davol drain (ard Davol). T cystography was performed 2 days after surgery. D, Sagittal volume-rendered T cystogram shows contrast leak from anterior aspect of anastomosis (arrow) extending into peritoneal space, indicating intraperitoneal leak. Patient s condition was improved with conservative management, and patient was discharged. E, Follow-up fluoroscopic cystogram obtained 18 days after surgery shows decrease in size of leak, confined to extraperitoneal pelvis. No intraperitoneal leak is detected. W600 JR:199, November 2012

7 Robot-ssisted Radical Prostatectomy Fig year-old man after robot-assisted laparoscopic radical prostatectomy. Urine leak was clinically suspected because of high output from drain and abdominal pain. T cystography was obtained 6 days after surgery., Unenhanced T image obtained at level of vesicourethral anastomosis shows small fluid collection (arrow) posterior to anastomosis., Sagittal multiplanar reformation T cystogram shows leak from posterior aspect of anastomosis (arrow), which accumulates in pelvic fluid collection and extends to peritoneal space., oronal volume-rendered T cystogram shows contrast material within peritoneal space, indicating intraperitoneal leak. Patient s condition improved with conservative management, and patient was discharged. Follow-up fluoroscopic cystography (not shown) showed gradual decrease in size of leak confined to extraperitoneal space. JR:199, November 2012 W601