|Year : 2022 | Volume
| Issue : 1 | Page : 40-43
Management of the anuric patient after Robotic-Assisted Laparoscopic Prostatectomy (RALP): A case report
Antonio Devanti Bardoli1, Amit Patel2, Sebastian Chang2, Christopher Lawrence3, Alex Hampson1, Gowrie Mohan Shan4, Nikhil Vasdev5
1 Department of Urology, Hertfordshire and Bedfordshire Urological Cancer Centre, Lister Hospital, Stevenage, UK
2 Department of Interventional Radiology, Lister Hospital, Stevenage, UK
3 Department of Nephrology, Lister Hospital, Stevenage, UK
4 Department of Anaesthesia, Lister Hospital, Stevenage, UK
5 Department of Urology, Hertfordshire and Bedfordshire Urological Cancer Centre, Lister Hospital, Stevenage; School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
|Date of Submission||28-Jan-2021|
|Date of Decision||25-Oct-2021|
|Date of Acceptance||18-Feb-2022|
|Date of Web Publication||03-May-2022|
Dr. Nikhil Vasdev
Department of Urology, Hertfordshire and Bedfordshire Urological Cancer Centre, Lister Hospital, Stevenage, Coreys Mill Ln, Stevenage SG1 4AB
Source of Support: None, Conflict of Interest: None
Robotic-assisted laparoscopic prostatectomy (RALP) has been linked to lower perioperative blood loss, lower transfusion rates, and shorter hospital stays. In addition, recent studies show that as compared to standard open prostatectomy surgery, there is less intraoperative blood loss. The authors report a unique case of anuric patients who have undergone RALP as well as the complications that arise when dealing with anuric patients after RALP.
Keywords: Anuria, robotic-assisted laparoscopic prostatectomy, management
|How to cite this article:|
Bardoli AD, Patel A, Chang S, Lawrence C, Hampson A, Shan GM, Vasdev N. Management of the anuric patient after Robotic-Assisted Laparoscopic Prostatectomy (RALP): A case report. J Precis Oncol 2022;2:40-3
|How to cite this URL:|
Bardoli AD, Patel A, Chang S, Lawrence C, Hampson A, Shan GM, Vasdev N. Management of the anuric patient after Robotic-Assisted Laparoscopic Prostatectomy (RALP): A case report. J Precis Oncol [serial online] 2022 [cited 2022 May 22];2:40-3. Available from: https://www.jprecisiononcology.com//text.asp?2022/2/1/40/344530
| Introduction|| |
Anuric patients post robotic-assisted laparoscopic prostatectomy (RALP) face inherent challenges. This case report discusses the challenges involved in managing an anuric patient postoperatively after RALP. Here, we describe a successful care regimen for this patient, who is now cancer-free, infection-free, and sexually active at the end of 8 months. Furthermore, we review the existing medical literature and propose a mechanism for postoperative anuria and show how it may be reduced.
| Case Report|| |
A 54-year-old Caucasian male with an incidental elevated prostate-specific antigen (PSA) of 3.36 ng/ml with no previous history of lower urinary tract symptoms or recurrent urinary tract infections was referred to the urology department through his general practitioner under the 2-week wait referral pathway. Assessment by the urologist included a concise clinical history and digital rectal examination which revealed a firm prostate. The patient was normotensive in the preoperative clinic with a blood pressure of 130/86 mmHg. The patients' father is on hemodialysis secondary to an unknown renal pathology. Prebiopsy imaging using T3 multiparametric magnetic resonance imaging scanning of the prostate revealed a moderate prostatic volume of 24cc with patchy low T2 signal enhancement in both peripheral zones without diffusion restriction or abnormal enhancement. There was no pelvic or abdominal lymphadenopathy and no focal bony pelvic lesions.
Prostate transrectal ultrasound biopsy concluded that there was a bilateral microacinar prostatic adenocarcinoma with two positive cores from 12 (Gleason score 3 + 3 = 6). Histopathology was suspicious for perineural invasion. The patient was counseled on all treatment options, including active surveillance, robotic prostatectomy, and radical radiotherapy. The patient chose surgery.
The patient was consented for RALP with NeuroSAFE on the October 4, 2018. Total operative time was 180 min with 130 min of console time. There was a total of 50 ml intraoperative blood loss. During RALP, the patient was given gentamicin 120 mg and Augmentin 1.2 g perioperatively as per the protocol. The patient was placed in the steep Trendelenburg position at a 30°angle. A pneumoperitoneum of 12 mmHg was used with the patient in a steep Trendelenburg position. Under laparoscopic vision, the right interfascial and left intrafascial neurovascular bundles were excised, using robotic ports of 8-mm left (×2) and right (×1) and an AirSeal port of 12mm right. The neuroSAFE surgical margins were negative on the table. The vesicourethral anastomosis was performed with two continuous 3-0 V-Loc sutures. A new Foley catheter was inserted into the bladder after anastomosis. A leak test with 150 ml of normal saline confirmed watertight anastomosis. Hemostasis was checked and adequate. The patients' blood pressure had dropped to below 90 mmHg for 7 min intraoperatively at min 60 of the robotic prostatectomy.
Postoperatively while in recovery, the patient became oliguric with nil urine output after 5 h. An ultrasound scan at 2 and 12 h postsurgery showed no evidence of hydronephrosis or any intra/extraperitoneal or pelvic collections. The patient produced 10 ml/h of urine between 6 h and 10 h postoperatively. However, after 10 h, the urine output dropped, and the patient became anuric, associated with a 63% increase in serum creatinine from 88 umol/l to 143 umol/l. Serum creatinine further increased to 207 umol/l at 14 h postoperatively. An Arterial Blood Gas (ABG) showed the following: pH- 7.39, PaO2- 25.8 mmHg (on 50% O2), PCO2- 5.54 mmHg, HCO3- 25mEq/L, Base Excess -0.1 mmol/L, and lactate – 2.18.
The patient was managed with intravenous (IV) fluids and monitoring. Thirteen hours postoperatively, the patient complained of increasing loin pain. A noncontrast computed tomography of kidneys showed extensive perinephric, periureteric, and retroperitoneal inflammatory changes, and there was mild bilateral hydronephrosis and hydroureters [Figure 1]. In view of the above, the patient had emergency nephrostomies placed 20 h postoperatively by the on-call uroradiology interventional team.
A repeat nephrostogram on week 2 showed an abrupt cutoff at the level of the inferior sacroiliac joint on the right-hand side. This resolved after several minutes and was easily bypassed with a ureteric catheter and Terumo guidewire to the bladder. On performing a ureterogram, there was nil definitive drainage into the bladder with the distal ureter tapering smoothly to the right ureteric orifice.
On the left-hand side, the nephrostogram revealed a cutoff at the ureteric orifice with smooth tapering of the distal ureter. Both systems filled with neat contrast. On delayed screening, most of the contrast had cleared with some ill-defined opacification of the bladder, thereby indicating delayed drainage. The Bard catheter hub was cracked and therefore was exchanged for a new 8.5 F pigtail catheter.
The patient was then scheduled for cystogram and bilateral antegrade ureteric stenting. The cystogram with urografin 150 revealed a small right-sided leak arising from the anastomosis. Nephrostogram through the left nephrostomy catheter revealed prompt unobstructed downstream drainage.
The nephrostogram through the right nephrostomy catheter revealed smooth tapering of the distal ureter and a low insertion of the ureter at the level of the inferior pubic symphysis.
A ureterogram through BMC revealed retrograde filling of the urinary bladder. A wire was passed into the urethra; however, interventional radiology (IR) staff was unable to pass a guidewire into the bladder to stent due to the postoperative anatomical configuration. An 8.5 F nephrostomy catheter was resited without complication.
Three weeks later, repeat cystogram and nephrostogram were performed. The nephrostogram demonstrated prompt drainage downstream into the urinary bladder [Figure 2]. The nephrostomy catheter was capped and was removed 48 h later upon the patient being asymptomatic with nil loin pain/tenderness.
The patient's renal function normalized and remains under active follow-up with the urology team. At 6 weeks, the patient is continent, follow-up renal function test and ultrasound are both normal. His PSA is undetectable at 8 weeks. At the latest follow-up at 8 months, the patient is cancer-free, continent, and is sexually active without the need for a phosphodiesterase type 5 inhibitor.
| Discussion|| |
This case study addresses the difficulties in dealing with anuric patients after a RALP procedure. We have summarised the literature with various mechanisms attributing to this [Table 1]. RALP is associated with reduced perioperative blood loss, decreased transfusion rates, and shortened hospital stays. Furthermore, recent randomized controlled trials also highlight reduced intraoperative blood loss compared to traditional open prostatectomy surgery. Patients undergoing radical prostatectomy are at increased risk of acute kidney injury (AKI) due to intraoperative bleeding, obstructive uropathy, increasing age, and preexisting chronic kidney disease. However, RALP patients have additional risks to the traditional retropubic radical prostatectomy, with associated postoperative renal dysfunction secondary to pneumoperitoneum. This has been thought to impede cardiac output and subsequent renal perfusion pressures, leading to acute tubular necrosis and subsequent anuria.
|Table 1: Outlining mechanisms of acute kidney injury in the postoperative robotic-assisted laparoscopic prostatectomy patient|
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An increased pneumoperitoneum allows the surgeon to obtain adequate working space while identifying delicate and complex anatomical structures during the procedure. However, there is a trade-off, with the subsequent increased intra-abdominal pressures leading to direct renal parenchymal compression and reduced afferent arteriole blood supply. This concurrently stimulates the renin–angiotensin–aldosterone system, further enhancing renal vasoconstriction and decreasing renal perfusion. In our case report, a pneumoperitoneum of 20 mmHg was achieved, while the dorsal venous complex was identified, cut, and oversewn.
Furthermore, we discuss the mechanism of anuria secondary to anastomotic leaks.
Our case report outlines the mechanism of anuria which was a combination of both prerenal AKI secondary to intraoperative hypovolemia and also iatrogenic bilateral ureteric injury managed with bilateral nephrostomies with a small vesicoureteral anastomotic leak.
It has been reported that vesicourethral anastomotic urinary leakage occurs in roughly 8.6%–13.6% of the RALP patients, this is similar in incidence to laparoscopic radical prostatectomy (10%–17%). In addition, intraperitoneal leaks can also be associated with RALP, which is rarely associated with radical retropubic prostatectomy.
Patil et al. first documented in a study of 3327 patients that 8.6% (287 patients) of the RALP patients showed anastomotic leak 7 days postoperatively on fluoroscopic cystography. Of these, only 24 patients (0.7%) had an intraperitoneal leak. Williams et al. reported that 67 patients (15.2%) of 442 post-RALP patients had anastomotic leakage, with 1.4% showing intraperitoneal leakage.
Extraperitoneal anastomotic leak is defined as the direct extravasation of urine from the anastomosis and is confined to the extraperitoneal space. In contrast, intraperitoneal anastomotic leaks can occur anteriorly or posteriorly to the bladder, tracking into the peritoneal space through the retropubic or retrovesical space, respectively.
Tyritzis et al. concluded in a systematic review of 72 studies that obesity, increased prostatic volume, anastomotic technique, difficult anastomosis or anastomosis under tension, suture number/type, intraoperative blood loss, intraoperative flush test result, and postoperative urinary tract infection are all independent factors which also increase the likelihood of a vesicoureteral anastomotic leak.
| Conclusion|| |
Our treatment protocol for this patient involved IV fluid resuscitation, electrolyte correction, and nephrostomy insertions to relieve the bilateral hydroureteronephrosis resulting from the anastomotic leak. Our findings indicate that nephrostomy placement and adequate IV fluid resuscitation were effective in treating our patient postoperative anuria secondary to vesicoureteral anastomotic breakdown.
Statement of ethics
The following patient in this case report has given full written consent to publish this case. All information revealing the patient's identity has been avoided.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]