Surgical Drain-Related Intestinal Obstruction After Robot-Assisted Laparoscopic Radical Prostatectomy in Two Cases

Abstract

Background: Drainage tubes are almost always routinely used after a laparoscopic or robot-assisted radical prostatectomy and pelvic lymphadenectomy to prevent urinoma formation and lymphoceles. They are seldom of any consequence. We present our unique experience of bowel obstruction resulting from the use of pelvic drains.

Case Presentation: We are reporting on two prostate cancer cases with rare postoperative complications. Each of them received robot-assisted laparoscopic radical prostatectomy and bilateral pelvic lymph node dissection and subsequently developed ileus and bowel obstruction. Series follow-up images suggested the bowel obstruction was related to their drainage tube. No evidence of urine leakage or intestine perforation was found based on drainage fluid analysis. We performed exploratory laparotomy in the first patient and found drainage tube kinking with the terminal ileum and adhesion band. The drainage tube was removed and patient recovery occurred over the following days. In the second case, the patient experienced bowel obstruction for 4 days after surgery. Based on our experience in the first case, and a drainage fluid survey showing no evidence of urine leakage, we removed the drainage tube on the morning of the 4th day, giving the patient a dramatic recovery with flatus and stool passage occurring in the afternoon. Both of the patients recovered well in hospital and during regular follow-up.

Conclusion: To best of our knowledge, despite there being certain case reports regarding drainage tube ileus in colorectal and bowel surgery, we have reported here on the first two cases of small bowel obstruction as a complication arising from the abdominal drainage tube used in robot-assisted urology surgery.

Introduction

Drainage tubes have been widely used that aimed at providing benefits including reducing postoperative infection, and fluid or air accumulation.¹ In laparoscopic and robot-assisted laparoscopic radical prostatectomy (RALRP), as well as bilateral pelvic lymph node dissection (BPLND), pelvic drainages are almost always, routinely used to prevent urinoma formation and lymphoceles with seldom of any consequence. In addition, pelvic drains may evacuate an unanticipated urine leak or lymphatic fluid collection.²

We are reporting on two patients who developed surgical drain-related bowel obstruction after RALRP, which is something that has never been reported on within the urology surgery and robot-assisted surgery medical communities. While reviewing previous articles that reported drainage tube ileus in colorectal and bowel surgery, we discovered similar presentation and treatment within those cases that may provide us with a solution when facing this rare complication.

Case 1

A 72-year-old gentleman had a history of hypertension and transforaminal lumbar interbody fusion for L4 to L5 spondylolisthesis. We performed a transrectal ultrasound (TRUS) prostate biopsy caused by mild elevated prostate specific antigen (PSA) levels (2.31 ng/mL), along with a digital rectal examination (DRE) finding bilateral prostate soft and elastic with palpable seminal vesicles, with the pathology report yielding prostate adenocarcinoma with a Gleason score rating of 4 + 4 = 8.

RALRP was performed under the diagnosis of prostate adenocarcinoma cT2cN0M0. During surgery, we performed a transperitoneal retropubic radical prostatectomy with BPLND. In detail, we mobilized the seminal vesicles through Denonvillier's fascia, dropped the bladder from the Retzius space, and carefully performed an anterior transaction of the bladder neck with bilateral neurovascular bundle preservation. This was followed by apical dissection of the prostate apex with maximal preservation of the urethra and urethrovesical anastomosis involving the Van Velthoven technique. The whole procedure required a total of 181 minutes without significant complications or blood transfusion.

After the surgery, we gradually began oral intake with water given first, followed by a liquid diet. On day 3 after surgery, abdominal fullness was complained about, with the patient experiencing abdominal diffused distention. Day 4 kidney, ureter, and bladder (KUB) radiograph revealed a small bowel obstruction (Fig. 1a). Therefore, we initially replaced the nasogastric tube and recorded the amount of drainage each day. However, the patient's bowel distention symptoms got worse. KUB radiograph on day 8 revealed that the bowel obstruction had progressed (Fig. 1b). The surgical wound was intact and no localized peritonitis.

FIG. 1.

Postoperative ileus after RALRP in case 1. (a) Day 4 KUB radiograph after surgery discovered small bowel obstruction. (b) KUB radiograph on day 8 discovered bowel obstruction had progressed. (c) Flatus passage and stool output were soon noted after exploratory laparotomy and drainage tube was removed. KUB radiograph 2 days later showed resolution of the bowel obstruction. KUB, kidney, ureter, and bladder; RALRP, robot-assisted laparoscopic radical prostatectomy.

Therefore, we subsequently performed an exploratory laparoscopy and found dilated bowels. However, because of poor vision and hardly recognized the transitional zone, we turned to exploratory laparotomy through the original wounds. There we discovered that the adhesion bands over the terminal ileum had twisted around the drainage tube, with proximal distention and a distal collapse in the small bowel having occurred (Fig. 2). No trocar site herniation was found. The drainage tube was removed and lysis of the adhesion band was performed. After surgery, flatus passage and stool output were soon noted. Two days later, KUB radiograph showed a partial resolving of the bowel obstruction (Fig. 1c), with significant improvement seen in the patient on the following day. He was then discharged after a 16-day hospital course without any further complications.

FIG. 2.

Exploratory laparotomy in case 1 that discovered adhesion bands over the terminal ileum that twisted around the drainage tube. We performed an exploratory laparotomy through the original wounds on day 8 and discovered adhesion bands over the terminal ileum that twisted around the drainage tube, with proximal distended and distal collapse in the small bowel.

Case 2

A 75-year-old gentleman had hypertension and hyperlipidemia, and had also received a left hernioplasty with mesh repair. A DRE of prostate revealed hard change at the apex, with a weight of ∼30 gm and moving freely. PSA and free PSA levels were 34.9 and 4.54 ng/mL, relatively. A preoperative MRI and TRUS biopsy demonstrated prostate cancer cT3bN1M0, with a Gleason score of 4 + 4 = 8.

RALRP with BPLND was performed involving the same maneuvers as outlined in case 1. The whole procedure required 212 minutes without significant complications or blood transfusion. The nasogastric tube was removed the following day with the patient beginning to drink water. On day 2 after surgery, the patient complained of diffused abdominal fullness and pain. A distended abdomen was subsequently found. KUB radiograph showed prominent bowel gas with bowel loop dilatation (Fig. 3a). KUB radiograph on day 3 showed prominent diffuse ileus with the bowel obstruction having progressed and the drainage tube moved upward (Fig. 3b).

FIG. 3.

Postoperative ileus after a RALRP in case 2. (a) KUB radiograph found prominent bowel gas with bowel loop dilatation on the 2nd day after surgery. (b) KUB radiograph on day 3 showed prominently diffused ileus with bowel obstruction progressed with the drainage tube moved upward. (c) The symptoms became worse with a severely distended abdomen in the afternoon of day 3, with KUB radiograph showing the surgical drain twisted with the small intestine. (d) Day 5 and KUB radiograph disclosed that bowel obstruction had improved after removal of the drainage tube.

On day 4, KUB radiograph showed the surgical drain twisted with the small intestine (Fig. 3c). A severely distended abdomen with a hypotonic bowel sound was also noted. The surgical wound was intact and there was no localized peritonitis related to trocar wound herniation. Based on the previous drainage discharge examination showing no evidence of urine leakage, we removed the pelvic drain under the suspicion of drainage tube-induced ileus. The patient showed dramatic improvement 4 hours later, and experienced flatus and stool passage in the afternoon. He began a soft diet on day 5 and KUB radiograph then disclosed that the bowel obstruction had improved (Fig. 3d). A cystourethrogram was subsequently performed that showed no evidence of urine leakage. The patient was discharged without any other significant complications after a 10-day hospital course.

Discussion

The placement of surgical drains has been widely debated because of several complications having been reported.¹ In 1973, Nehme first reported on a patient who developed small bowel obstruction after 1 week with ileal conduit urinary diversion. Copious diarrheic stools followed within a few hours of removal of the tubing.³ The bowel obstruction was credited with the compression of the loops of the intestine by a negative suction rubber drain.³ In 2007, Roger et al. reported on a 42-year old woman experiencing early postoperative small bowel obstruction (EPSBO) caused by a loop of bowel twisting around the abdominal drainage catheter.⁴ Her symptoms resolved immediately after the removal of the catheter.⁴ In 2009, Poon and Leong reported EPSBO on the 2nd day after a laparoscopic anterior resection in an 82-year-old man.⁵ An emergency laparoscopy was performed that uncovered a short segment of the small bowel behind the silicone drain, with the small bowel mesentery at the mesenteric border firmly herniated into the side holes of the drain, leading to a 90° acute turn of the small bowel in the z-axis, where small bowel obstruction had occurred. Bowel function recovered after 1 week of the second surgery.⁶

In 2014, Dr. Darshak Shah documented the case of a 78-year-old male patient who underwent a low anterior resection with a loop ileostomy and Jackson-Pratt drain placement for rectal cancer, which was complicated by small bowel obstruction and necrosis. The Jackson-Pratt drain acted as a “maypole” around which the small bowel was twisted, causing obstruction and necrosis. An exploratory laparotomy with small bowel resection and primary anastomosis was subsequently performed.⁷ In 2015, Salati and Lone⁶ reported that a silicone suction drain mechanically obstructed the small gut of a 62-year-old gentleman. They performed a relaparotomy achieving effective management.⁶

Al Khaldi et al.⁷ in 2019 concluded four previous cases and reported on a 30-year-old male who had developed biliary peritonitis on postoperative day 4 after having underwent bile duct resection with a hepaticojejunostomy for cholangiocarcinoma. An exploratory laparotomy found that the proximal jejunum was looped around one of the JP drains close to the hepaticojejunostomy. Removal of the drain resolved the obstruction and led to significant improvement in the patient.⁷ Among these cases, except for the first and second, the patients had all received an exploratory laparotomy that revealed intestine obstruction caused by a surgical drain, with all of them recovering gradually after removal of the drain.

These cases point out that even though surgical drain-associated bowel obstruction rarely occurs, we still cannot ignore it, as the complications surrounding it may be life threatening. In addition, the use of KUB radiograph or CT scans can each play a significant role in the diagnosis surrounding such a condition.

Of our cases, we had performed an exploratory laparoscopy initially and turned to exploratory laparotomy in the first case and found intestine obstruction related to drainage tube, and based on that experience, we removed the drainage tube immediately in the second case. We ruled out trocar site herniation based on clinical presentation and surgical findings, including no localized pain or peritonitis, the surgical wound was intact and no herniation was found during the reoperation. Both of those patient's symptoms were resolved after we removed the drains and each recovered well. Reviewing all the previously reported cases, all of them involved colorectal or intestinal surgery.

In our cases requiring surgery in the genitourinary tract, there was no bowel damage nor bowel anastomosis during surgery, and postoperative ileus was not common, although this may occur in the rare situation. The need for an exploratory laparotomy depends on the severity of the bowel obstruction and the patient's clinical condition or a diagnosis of peritonitis. Drainage tube removal can be the initial treatment based on there being no evidence of bowel or urine leakage, although any further surgical indication should be based on each independent situation.

Since drainage tube-related bowel obstruction is rare and only a few cases have been reported, we have offered a feasible solution after reviewing previous articles. To the best of our knowledge, we have reported on the first two cases of small bowel obstruction as a complication arising from the abdominal drain of RALRP.

Conclusions

Surgical drains are routinely used in most abdominal surgeries with obvious benefits and the rare relative complication. However, we should always consider the potential occurrence of drain-associated ileus in postoperative patients. In our cases, as well as previous reports, the removal of surgical drains can be seen as the initial treatment regarding this complication, and an exploratory laparotomy should also be considered based on clinical course and a diagnosis of peritonitis.

Abbreviations Used

BPLND

bilateral pelvic lymph node dissection

CT

computed tomography

DRE

digital rectal examination

EPSBO

early postoperative small bowel obstruction

KUB

kidney, ureter, and bladder

MRI

magnetic resonance imaging

PSA

prostate specific antigen

RALRP

robot-assisted laparoscopic radical prostatectomy

TRUS

transrectal ultrasound

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding information was received for this article.

Cite this article as: Su YW, Chang LW, Li JR, Chiu KY, Hung SC (2020) Surgical drain-related intestinal obstruction after robot-assisted laparoscopic radical prostatectomy in two cases, Journal of Endourology Case Reports 6:4, 343–347, DOI: 10.1089/cren.2020.0121.