Research ArticleClinical Studies

Examination of Necessity for Pelvic Drain Placement After Robot-assisted Radical Prostatectomy

HIROAKI IWAMOTO, YOSHIFUMI KADONO, RYUNOSUKE NAKAGAWA, TOMOYUKI MAKINO, SUGURU KADOMOTO, HIROSHI YAEGASHI, MASASHI IIJIMA, SHOHEI KAWAGUCHI, TAKAHIRO NOHARA, KAZUYOSHI SHIGEHARA, KOUJI IZUMI and ATSUSHI MIZOKAMI
In Vivo September 2021, 35 (5) 2895-2899; DOI: https://doi.org/10.21873/invivo.12579

Abstract

Background/Aim: Pelvic drain (PD) placement is commonly performed after robot-assisted radical prostatectomy (RARP), but the need for PD placement is unclear. This study aimed to assess the need for PD placement after RARP. Patients and Methods: This retrospective study analysed the effect of PD placement on postoperative complications in patients who underwent RARP between 2009 and 2018. All patients prior to October 1, 2016 had a PD placed; those after did not. Results: Of the 308 study patients, 231 received a PD (PD group) and 77 did not (ND group). The incidence of ileus, urinary tract infection and anastomotic leak did not differ significantly between the groups; nor did the incidence of asymptomatic and symptomatic lymphocele at 2 weeks and 1 year after surgery. Multivariate analysis showed that lymph node dissection is a predictor of asymptomatic lymphocele development two weeks after surgery. Conclusion: PD placement is not necessary after RARP.

Prostate cancer is the most common cancer and second leading cause of cancer-related mortality in men (1). Most prostate cancers are diagnosed as localized prostate cancer (2, 3). Radical prostatectomy (RP) is the gold standard treatment for clinically localised prostate cancer (4). In addition to open radical prostatectomy (ORP) and laparoscopic radical prostatectomy, robot-assisted RP (RARP) has become widely used in recent years and is often the first choice of treatment (5, 6). Pelvic drain (PD) placement is commonly performed after RARP to prevent the formation of urinary cysts, pelvic hematomas and lymphoceles that would require further treatment. RARP has the same oncological outcome as ORP (7, 8) and is associated with shorter operation time and length of hospital stay, less bleeding and higher rate of erectile function improvement (8-10). This raises a question regarding the need for routine pelvic drainage after RARP. After experiencing two cases of ileus that may have been due to PD placement, we have not been placing PDs. Here, we present an uncontrolled before-after study that examined outcomes of PD placement, focusing on prevention of lymphoceles and other complications.

Patients and Methods

We retrospectively reviewed the charts of all patients who underwent transperitoneal RARP at Kanazawa University Hospital between May 2009 and April 2018 to record and analyse relevant data. PDs were routinely placed in all patients prior to October 1, 2016; they were not placed afterward. Preoperative evaluation included digital rectal examination, transrectal ultrasonography, measurement of serum prostate specific antigen (PSA) level and 10-12-core systematic prostate biopsies for cancer detection; cancer staging was conducted using computerised tomography (CT), magnetic resonance imaging (MRI) and bone scintigraphy. CT or MRI was performed approximately 2 weeks and 1 year after RARP to evaluate the presence of pelvic fluid retention. The need for and extent of lymph node dissection and use of nerve-sparing technique were at the discretion of the attending surgeon.

The collected medical data included age, body mass index (BMI), serum PSA level, prostate volume (PV), prostate biopsy pathology, clinical stage, imaging findings and surgical details. Pelvic fluid retention was determined using triaxial ellipsoid approximation. Complications were graded according to the extended Clavien–Dindo system: asymptomatic lymphocele was classified as grade 1 and symptomatic lymphocele was classified as grade ≥3 (11).

Statistical analyses were performed using SPSS software version 17.0 (IBM Corp., Armonk, NY, USA) and Prism software version 5 (GraphPad Software, San Diego, CA, USA). The chi-square and Mann–Whitney U-tests were used to compare data between groups. Binomial logistic regression was used for multivariate analyses. p<0.05 was considered significant. The present study was approved by the institutional review board of Kanazawa University Hospital (2016-328).

Results

RARP was performed in 308 patients during the study period. The PD group was comprised of 231 patients and the no PD (ND) group was comprised of 77. Table I shows the patient characteristics. The median age at the time of surgery was significantly lower in the PD group than in the ND group (66 years and 68 years, respectively; p=0.007). Furthermore, the median preoperative PSA level was significantly lower in the PD group than in the ND group (6.8 ng/ml and 5.8 ng/ml, respectively, p=0.03). There were no significant differences between the two groups in median BMI, biopsy Gleason score (GS), clinical stage, D’Amico risk classification, history of abdominal surgery, proportion of patients receiving neoadjuvant androgen deprivation therapy, or median estimated PV.

View this table:
Table I.

Patient characteristics.

Table II shows the perioperative and pathological outcomes of the two groups. The PD group had a significantly higher proportion of patients who underwent pelvic lymph node dissection (PLND) (48.1% vs. 24.7%, p<0.001) and higher median estimated blood loss (100 ml vs. 80 ml, p=0.03). The median length of hospital stay was significantly longer in the PD group (6.8 days vs. 5.8 days, p<0.001). There were no significant differences between the two groups in median operation time, pathological GS, pathological stage, median volume of resected prostate, median length of urinary catheter placement period, or proportion of patients who underwent nerve-sparing surgery, received a complete resection, or had extraprostatic extension. The incidence of complications, including ileus, urinary tract infection (UTI) with fever and anastomotic leak, did not significantly differ between the two groups; nor did the incidence of asymptomatic and symptomatic lymphocele at 2 weeks and 1 year after surgery.

View this table:
Table II.

Perioperative and pathological outcomes.

Table III shows the results of the univariate and multivariate analyses for predictors of asymptomatic lymphocele 2 weeks after surgery. Significant univariate predictors included BMI <25 kg/m2 (p=0.04), biopsy GS ≥8 (p=0.03), pelvic lymph node dissection (p<0.001) and pathological GS ≥8 (p=0.03). In the multivariate analyses, the only significant independent predictor was pelvic lymph node dissection (p<0.001).

View this table:
Table III.

Analyses for prediction of asymptomatic lymphocele 2 weeks after surgery.

Discussion

PD placement after RP has previously been considered necessary (12). However, RP has changed significantly in recent years with the introduction of robot-assisted surgery. The reported incidence of post-RARP anastomotic leakage ranges between 0.1% and 6.7% (13-15) and the incidence of symptomatic lymphocele in patients undergoing RARP with extended pelvic lymph node dissection ranges between 1.2% and 5% (16-19). This study found similar anastomotic leak and symptomatic lymphocele rates (4.5% and 0.3%, respectively). In addition, the incidence of complications, such as ileus, UTI, anastomotic leakage and asymptomatic and symptomatic lymphocele did not differ according to PD placement, suggesting that routine PD placement is not necessary during RARP. Furthermore, the length of hospital stay was significantly shorter in the ND group.

We also found that lymph node dissection was the only significant independent predictor of postoperative asymptomatic lymphocele development. Previous reports have shown that lymphocele incidence increases after extended pelvic lymph node dissection and with the number of lymph nodes removed (20-23). Although PDs are placed to prevent lymphoceles, their absence did not predict asymptomatic lymphocele development two weeks after surgery in this study. A previous systematic review and meta-analysis reported that PD placement after RARP with extended pelvic lymph node dissection does not prevent symptomatic lymphocele or postoperative complications (24), which also suggests that PD placement after RARP is not required. However, PD placement cannot be deemed unnecessary in all cases. PD placement may still be beneficial in patients undergoing extended pelvic lymph node dissection and those who are administered perioperative prophylactic low-molecular-weight heparin.

This study has several limitations. The sample size may have been too small to determine significant differences between groups. In addition, the proportion of patients who underwent lymph node dissection and median intraoperative blood loss significantly differed between the two study groups. Larger prospective studies and data from patients of other ethnic backgrounds are needed to confirm our findings. Future studies may indicate more clearly those patients who would benefit from PD placement.

PD placement after RARP did not affect the incidence of postoperative lymphocele development. Lack of a PD did not predict development of asymptomatic lymphocele two weeks after surgery. Future large-scale studies are required to identify patients that would benefit from PD placement.

Footnotes

  • Authors’ Contributions

    H.I. and Y.K. designed the experiments. H.I., R.N., T.M., Y.K., H.Y., M.I., S.K. and T.K. collected clinical data. H.I., Y.K., T.K., K.S., K.I. and A.M. analyzed the data. H.I., Y.K. and A.M. drafted and revised the manuscript. All Authors read and approved the final version of the manuscript

  • This article is freely accessible online.

  • Conflicts of Interest

    All Authors declare that there are no potential conflicts of interest relevant to this article.

  • Received June 3, 2021.
  • Revision received June 16, 2021.
  • Accepted June 17, 2021.

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Examination of Necessity for Pelvic Drain Placement After Robot-assisted Radical Prostatectomy
HIROAKI IWAMOTO, YOSHIFUMI KADONO, RYUNOSUKE NAKAGAWA, TOMOYUKI MAKINO, SUGURU KADOMOTO, HIROSHI YAEGASHI, MASASHI IIJIMA, SHOHEI KAWAGUCHI, TAKAHIRO NOHARA, KAZUYOSHI SHIGEHARA, KOUJI IZUMI, ATSUSHI MIZOKAMI
In Vivo Sep 2021, 35 (5) 2895-2899; DOI: 10.21873/invivo.12579
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