Utility of a Pigtail Cope Loop Catheter for Bladder Drainage in Treating a Large/Persistent Urethrovesical Anastomotic Leak Following Radical Prostatectomy

Abstract

Background: A large or persistent urethrovesical anastomotic leakage after a laparoscopic or robot-assisted laparoscopic radical prostatectomy (RALRP) although infrequent can be a difficult complication to treat. We describe a simple technique to facilitate resolution of a urethrovesical anastomotic leak by exchanging the in-place bladder Foley catheter for a pigtail drainage catheter.

Case Presentation: Between 2014 and 2019, we had three patients who had a large/persistent urine leak after a radical prostatectomy (one laparoscopic and two robot assisted). All three patients had a wide bladder neck requiring bladder neck reconstruction with ureteral orifices close to the anastomosis. The bladder Foley catheter was exchanged to a pigtail Cope loop catheter™ (14F) or an Origin™ self-retaining drainage catheter (16F) under flexible cystoscopic guidance over a guidewire. Placement of a Cope loop bladder catheter stopped anastomotic leakage expeditiously with no need for further intervention. At minimum 3 months follow-up none had bladder neck stricture with 0-1 pad urinary incontinence.

Conclusion: Drainage of the bladder through the use of a loop pigtail nephrostomy catheter can be useful in rapidly resolving a large persistent urethrovesical anastomotic leak.

Introduction and Background

Radical prostatectomy is the gold standard surgical intervention of localized prostate cancer. In 1.4% of robot-assisted laparoscopic radical prostatectomy (RALRP) cases persistent urethrovesical anastomotic leakage beyond the expected postoperative period may cause significant morbidity.¹ After laparoscopic/robotic/open retropubic radical prostatectomy, several techniques have been utilized for urinary leak management, including retropubic drainage with passive suction, Foley catheter traction, and continuous needle vented Foley catheter suction.² Uroperitoneum caused by ineffective leak therapy may lead to ileus formation, possible infection or sepsis, or peritonitis. We describe hereunder a simple technique using a Cope loop™ nephrostomy tube (Cook^® Medical, Bloomington, IN) or Origin™ self-retaining drainage catheter (Uresil^® Skokie, IL) in exchange for a Foley catheter to expedite the resolution of postradical prostatectomy anastomotic leak.

Cases

Patient 1: A 51-year-old man with a body mass index (BMI) of 37 underwent an extraperitoneal laparoscopic radical prostatectomy for Gleason 3 + 3 disease (pT2cN0). He had a large prostate of 82 g and required a bladder neck reconstruction using the tennis racquet handle method. Intraoperatively, urethrovesical anastomosis (UVA) was water tight and he was discharged on postoperative day (POD) 1 with a Foley catheter after Jackson–Pratt (JP) drain removal. Cystogram after POD 9 and 26 showed a large posterior extraperitoneal anastomotic leak (Fig. 1A). On POD 26, the Foley catheter was then replaced with a 14F Cope loop under cystoscopic guidance with local anesthesia. A cystogram 9 days later showed no leak (Fig. 1B, C) and the catheter was removed. Three months later, patient had no urinary symptoms with no urinary incontinence.

FIG. 1.

(A) Bladder with a Foley catheter in-place displaying a large urethrovesical anastomotic leak. (B) After exchanging Foley catheter for a Cope loop catheter, contrast dye was injected into the bladder. (C) Postvoid cystogram exhibits orientation of the pigtail component of the Cope loop catheter proximal to the bladder neck and absence of dye extravasation outside of the bladder.

Patient 2: A 65-year-old man with a BMI of 30, 40 g prostate, and Gleason 4 + 3 = 7 adenocarcinoma (pT2c, N0) underwent a RALRP and bilateral pelvic lymph node dissection. A posterior tennis racquet handle bladder neck reconstruction was performed for a wide bladder neck. It was noted that his ureteral orifices were close to the bladder neck margin. UVA was performed with a double arm 3-0 V-loc suture on a Rb-1 needle in method described by Van Velthoven.³ A 16F Foley catheter was placed in the bladder and bladder filling with saline revealed a small leak from the posterior anastomotic site, leading to the placement of a JP pelvic drain. On POD 1, the urine output from the Foley catheter was minimal (<100 mL in 12 hours) with a large output from his JP drain. Bladder catheter position was confirmed by irrigation and aspiration of saline from the bladder. On POD 2, the JP output was still high with JP fluid creatinine consistent with urine. His Foley catheter was exchanged to a 16F Origin drainage catheter (Uresil) over a Benson guidewire at the bedside under flexible cystoscopic guidance. During cystoscopy, a posterior anastomotic defect ∼1–2 cm wide was noted. Within 24 hours of Origin catheter placement, the JP output reduced to 70 mL/24 hours and good output from his bladder catheter drain was demonstrated. JP fluid creatinine level was 0.81 mg/dL on the day of discharge (POD 3). Follow-up cystogram on POD 16 showed no anastomotic leak. As this was a transperitoneal approach, the bladder catheter was left in situ for another week to facilitate anastomotic healing and was removed on POD 20. At 3 months follow-up, patient experienced no bothersome symptoms and was wearing 1 pad per day for urinary incontinence.

Patient 3: A 65-year-old man with a BMI of 36, chronic kidney disease, and serum creatinine of 1.8 mg/dL underwent a transperitoneal RALRP for Gleason 3 + 4 disease (pT3b). He had a 48 g prostate with a median lobe and required a bladder neck reconstruction in a posterior tennis racquet handle method. The ureteral orifices were close to the bladder neck resection margin. Postoperatively, he developed abdominal pain and distention. Patient's renal function progressively worsened with a serum creatinine of 2.3 mg/dL. Ultrasonography showed mild right hydronephrosis with his JP drain and bladder catheter in place. His cystogram showed a large intraperitoneal anastomotic leak. On POD 5, he was taken to the operating room and a posterior anastomotic defect was seen on rigid cystoscopy with the ureteral orifices close to the bladder neck margin. Bilateral retrograde urography was normal. A 14F Cope loop was placed over a guidewire and its position was confirmed under fluoroscopy. After 3 days, his JP drain creatinine decreased to 1.7 mg/dL (same as his baseline serum creatinine). He was discharged on POD 10. Cystogram on POD 19 showed no leak and the catheter was removed. At 3 months follow-up, patient experienced urinary incontinence requiring 1 pad per day with good stream.

Discussion

Urethrovesical anastomotic leakage postoperatively after trans- or extraperitoneal radical prostatectomy is infrequent and often self-limiting. However, occasionally there can be a large leak from the anastomosis with a high JP fluid output and minimal drainage from the Foley catheter. Outside of traditional leak therapy, persistent leaks can be managed through various interventions depending on amount of extravasation. Elmor et al. describes utilizing a minimally invasive procedure to endoscopically insert two ureteral catheters attached to a third catheter, redirecting urine flow away from the healing anastomotic line.⁴ Diamand et al. reports the resolution of a urethrovesical leak through the exchange of a Foley catheter for a fenestrated one, reversing the fluid output seen in the Foley catheter and drain.⁵

With catheter tip orientation dictated by the Foley balloon and away from the ureteral orifices and anastomotic line, urine finds its way easily through the defective anastomotic line. We believe placement of the Cope loop/Origin or Nephro-Cath Uresil™ catheter resolves this issue through an intrinsic suction effect provided by its multiple side holes upon the trigonal and ureteral orifice regions of the bladder. We can see the pigtail part of the catheter close to the bladder neck as confirmed on cystogram (Fig. 1B, C). The Nephro-Cath/Origin drainage catheter (Fig. 2) is available in 8F–16F and in lengths 18–21 cm, whereas the Cope loop nephrostomy catheter is available from 10F to 14F in 19.5 cm length. Depending on the degree of hematuria and penile urethra length, an appropriate diameter and length of catheter can be used. The Cope loop catheters are shorter than Foley catheters and may not be a good option if a patient has a long penile urethra. If the patient had a council tip Foley catheter placed at the time of radical prostatectomy across the anastomosis, the Cope loop catheter can be exchanged at bedside over a guidewire placed through the council tip catheter (with a hole at the tip of the catheter) without cystoscopic guidance. The catheter position can be confirmed by bladder irrigation of saline or a cystogram. If not, the use of flexible cystoscopic guidance is necessary to exchange the Foley catheter to a Cope loop catheter. It should be noted that patients with Cope loop catheters may experience leakage around the catheter from the urinary meatus; however, this was minimal and not bothersome in our patients. An anticholinergic tablet may be helpful to prevent bladder spasm and pericatheter leakage. It is important to rule out ureteral injury with retrograde ureterogram if the cystogram shows no anastomotic leak and the patient has a high JP output consistent with urine on fluid creatinine.

FIG. 2.

On the left is the Origin drainage catheter (Uresil^®, Skokie, IL). Enhancement on right demonstrates the Cope loop catheter's multiple perforations at the pig tail end.

Conclusion

Upon identification of a large or persistent leak, the earlier approach utilizing a Cope loop nephrostomy tube/Origin Uresil pig tail catheter was helpful in our experience in providing an accelerated resolution of the anastomotic leak. Alongside alleviating morbidities associated with prolonged leakage, this technique is a simple and cost-effective solution compared with the other invasive and noninvasive methods described.

Abbreviations Used

BMI

body mass index

JP

Jackson–Pratt

POD

postoperative day

RALRP

robot-assisted laparoscopic radical prostatectomy

UVA

urethrovesical anastomosis

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Cite this article as: Bhatt R, Paradis A, Venkatesh R (2020) Utility of a pigtail Cope loop catheter for bladder drainage in treating a large/persistent urethrovesical anastomotic leak following radical prostatectomy, Journal of Endourology Case Reports 6:2, 64–66, DOI: 10.1089/cren.2019.0096.