the optimal time of catheter removal following radical prostatectomy ( rp ) is not defined . from a patient 's perspective ,
early removal of the urinary catheter is desirable due to catheter - related discomfort , penile pain , bladder irritation / spasm , pericatheter urine leaks , etc .
, however , the surgeon 's concerns with early catheter removal are the possibility of anastomotic site leak and acute urinary retention . with experience and improvement in techniques ,
the duration of catheterization has decreased from an average of 21 days in open rp era to 710 days in cases where robot - assisted rp ( rarp ) is performed .
in fact , there are numerous reports about the feasibility and safety of even earlier ( i.e. on the postoperative day 35 ) catheter removal after radical retropubic prostatectomy or rarp . with early catheter removal , some concerns have been raised about increased risk of acute urinary retention .
therefore , in practice , the majority of the institutions perform catheter removal after 7 days of surgery . however , there is a variation in the practice of performing cystograms before catheter removal which is done primarily to rule out anastomotic site leak . with the improvement in anastomotic technique , it is rare to find anastomotic site leak after rarp , and it may not always be necessary to obtain a routine check cystogram .
we , therefore , evaluated our 230 consecutive rarp patients and the outcomes of their cystogram findings to determine the indications for cystogram before catheter removal .
we reviewed our prospectively collected rarp database of 230 consecutive patients who underwent robot - assisted rp by 2 surgeons from april 2010 to january 2015 .
all the patients underwent rarp through transperitoneal approach using 4 arm da vinci surgical system .
clinical characteristics included patient 's age , biopsy gleason score , clinical stage , and history of transurethral resection of prostate ( turp ) or other urethral / bladder neck surgery .
intraoperative data recorded included : estimated blood loss , operative time , bladder neck reconstruction , visible leak upon bladder irrigation at completion of anastomosis , and placement of pelvic drains .
bladder neck sparing was done whenever possible . in patients with a wide bladder neck ,
bladder neck reconstruction was performed by placing sutures at the 3 and 9 oclock positions .
urethrovesical anastomosis was performed in 2 layers ( described earlier ) . at the end of anastomosis ,
a  bladder fill test  was performed ( using 120 ml of saline ) to assess intraoperative anastomotic leak .
patients were called for office cystography and catheter removal , usually a week after surgery .
cystography was performed at low pressure by gravity instillation of 150200 ml of diluted contrast through the catheter placed during rarp .
patients were observed under fluoroscopy in lateral oblique position for any contrast leak at the site of anastomosis . in the absence of extravasation ,
the catheter was left in place until a subsequent cystogram revealed resolution , typically 1 week later . in patients with retention of urine after catheter removal , placement of a 16fr foley catheter
all patients were followed for a minimum of 6 months , and the longest follow - up was 5 years .
postoperative data included pathologic gleason score and stage , hospitalization time , and catheterization time .
postoperative complications included urinary retention , urinary tract infection , bladder neck contracture , and urinary incontinence .
continence status was defined as the use of either  no pad  or just a security liner .
continence rate was assessed with the self - administered questionnaire during a visit in the outpatient department or by e - mail / postal mail at 6 week and at 3 , 6 , 9 , 12 , 18 , and 24 months and then once a year .
continuous parametric variables were reported as the mean  standard deviations or as the median values and interquartile range .
a total of 207 patients ( 90% patients ) underwent catheter removal on the 7 postoperative day while 10% ( 23 patients ) had catheter removal on the 10 day or later . a decision about delay in catheter removal
was usually made by the operating surgeon , based upon satisfaction with bladder neck reconstruction or observation of minimal leak on bladder fill test during surgery .
two of these patients had prior bladder neck reconstruction for the wide neck , and other two underwent standard anastomosis .
as a routine , patients with bladder neck reconstruction and/or intraoperative leak ( on bladder fill test ) had their catheter removed on the day 10
. only one patient out of four with an intraoperative leak on bladder fill test had leak on postoperative cystogram .
demographic details of patients total of nine patients ( 3.9% ) had extravasation on initial cystogram . among the patient with anastomotic site leak , two patients had a history of turp and seven other had wide bladder neck ( resulting from wide margin due to basal tumor ) .
out of the total nine patients with leak , 3 patients had a minimal amount of contrast leak ( which cleared on post void film ) ; therefore , catheter was still not replaced [ flow chart 1 ] . in rest of the 6 patient showing leak ,
continued catheter drainage was done for another week and repeat cystogram was done [ figure 1 ] .
four out of nine patient showing leak needed catheter for a total of 14 days while the two patients needed the catheter for a total of 21 days .
no significant difference in the intraoperative variables , blood loss , duration of drain , length of hospital stay , and continence outcomes was noted between the patients with anastomotic leak ( noted on cystogram ) when compared to rest of the patients .
flow chart of outcome of cystogram and their management ( a ) cystogram showing minimal anastomotic leak on the postoperative day 7 .
( b ) resolution of leak after 7 days of indwelling catheter ( day 14 ) acute urinary retention after catheter removal was noted in 3 patients .
only 1 out of 3 patients who had retention after catheter removal had bladder neck sparing surgery .
none of the patient experienced immediate retention of urine . out of those who developed retention ( 3 cases ) , one occurred after a week of catheter removal , and the other two developed after 48 h. the catheter was easily replaced in an emergency without any problem .
these patients were started on alpha - blocker and catheter removed after 3 days with successful voiding .
 no pad  status at 3 months , 6 months , and 1 year was 76% , 86% , and 94% , respectively .
all but one patient with urine leak was continent at 6 months ( one patient became continent by 9 months of follow - up ) .
no significant difference in the intraoperative variables , blood loss , and duration of drain , length of hospital stay , prostate volume , grade or stage of the tumor , and continence outcomes was noted between the patients with leak compared to rest of the patients .
cystogram at the time of catheter removal is an important tool that can help in documentation of healing at anastomotic site and identifying leak , if any . however , as noted in our study and also studied by other authors , the incidence of urine leak noted on cystogram done at day 7 is very low ( 25% ) .
therefore , instead of using cystogram in all the patients , selective use of cystogram can prove to be cost - effective . compared to studies published from developed countries , our patients had a higher clinical stage and more cases of post - turp status , thus requiring wide bladder neck dissection and subsequent reconstruction .
we found that there is specific utility of cystogram in the patients who have had a history of turp , wide bladder neck with intraoperative bladder neck reconstruction , or minimal leak noted on intraoperative bladder fill test .
although not supported by any evidence , it is our practice to delay catheter removal to postoperative day 10 ( instead of day 7 ) , in patients who undergo bladder neck reconstruction . the optimal time for catheter removal ( or indwelling catheter drainage ) is still a point of scrutiny
. understandably , catheter - related symptoms and discomfort are less with shorter duration of indwelling catheter . however , the risk of anastomotic leak , acute urinary retention , and the impact of urine leak on long - term continence and bladder neck contracture are some of the concerns with early catheter removal .
most of the authors consider catheter removal after 7 days minimizes the risk of anastomotic leak as well as the chance of acute retention .
interestingly , there are studies that have suggested even earlier catheter removal ( at 34 days ) without any significant increase in complication .
have reported 1% cystogram leak rate after catheter removal at 24 days , but with a higher rate of acute retention . it is considered that anastomotic site urine leak can potentially delay the time to continence , and adversely impact the overall continence rates .
several authors have studied the outcomes in their patients who had a varying degree of anastomotic site urine leak .
all the studies based on robotic prostatectomy have concluded that urinary extravasation had no adverse impact on the long - term continence status .
patil et al . reported that those patients who had a leak , 70% were dry at 3 months , compared to 90% in those with no leaks . at the 12-month follow - up ,
95.2% of the patients with no leak were dry , compared with 94% of those with a leak , thus concluding that at 12 months there was no difference . in our study , the number of patient with anastomotic site leak was too small to make a comparative statement about the impact on recovery pattern of continence .
however , all but one patient with urine leak had zero pad status at 6 months ( one patient became continent by 9 months ) . it is also postulated that urine leak ( especially prolonged duration ) will lead to a sustained inflammatory reaction , hampering wound healing , thus increasing the risk of delayed complication such as bladder neck contracture . in a large series reporting urine leak eight of 287 ( 2.8% ) patients
it was further clarified that bladder neck contracture developed in patients with higher grade leaks .
only three of our patient had retention of urine after few hour of catheter removal .
it is likely that the cause of acute retention is mucosal edema or hematoma or increase bladder neck smooth muscle tone .
the reported risk of acute retention is reportedly higher ( 6.721% ) with catheter removal at 4 days or less .
therefore , results may not be generalizable . however , at the same time , constancy of anastomotic technique , operating surgeons and the follow - up methodology is the strength of this study .
the results of our study suggest that in usual circumstances , urinary catheter can be safely removed on the 7 postoperative day after rarp without a routine cystography .
selective use of check cystogram can be done in cases where bladder neck reconstruction is performed or those who have a history of turp with wide bladder neck and when an intraoperative leak noted on the bladder fill test .
 introduction : with the improvement in anastomotic technique , it is rare to find anastomotic site leak after robot - assisted radical prostatectomy ( rarp ) 
 . it may not always be necessary to do regular check cystogram before catheter removal . 
 we evaluated our 230 consecutive rarp patients and their cystograms to determine the indications for selective use of cystogram before catheter removal.materials and methods : we reviewed our prospectively collected rarp database of 230 consecutive patients . 
 cystography was performed at low pressure by gravity instillation of diluted contrast through the catheter . 
 patients were observed under fluoroscopy in lateral oblique position for any contrast leak at the site of anastomosis . 
 all patients were followed for a minimum of 6 months , and the longest follow - up was 5 years.results:a total of 207 patients ( 90% ) underwent catheter removal on postoperative day 7 . 
 nine patients ( 3.9% ) had extravasation on initial cystogram . 
 two patients with leak had a history of transurethral resection of prostate ( turp ) and seven other had bladder neck reconstruction for wide bladder neck . 
 three patients with minimal leak did not require catheter replacement . 
 in rest of the 6 patient with leak , continued catheter drainage was done . 
 no significant difference in the intraoperative variables , blood loss , duration of drain , length of hospital stay , and continence outcomes was noted between the patients with leak compared to rest of the patients . 
 none of the patient needed any procedure / intervention related to the surgery and none developed bladder neck stenosis.conclusion:in usual circumstances , catheter removal can be done safely on a postoperative day 7 without routine cystography . 
 selective use of check cystogram can be done in the case where bladder neck reconstruction is performed or those had a prior turp and a wide bladder neck . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSION
None
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