Urethral catheter entrapped in vesicourethral anastomotic sutures after laparoscopic radical prostatectomy successfully removed by transurethral approach
Abstract
Introduction
Urethral catheter entrapped in vesicourethral anastomotic sutures after radical prostatectomy is a relatively common complication. We herein present a novel and safe technique to remove urethral catheter.
Case presentation
A 64-year-old man was diagnosed with prostate cancer. Subsequently he underwent laparoscopic radical prostatectomy. On postoperative Day 7, the patient experienced difficulty in removing the catheter, and entanglement of the suture with the urinary catheter was suspected. After conservative follow-up, a rigid endoscope was inserted into the urethra beside urethral catheter, identifying suture entanglement with the catheter. Finally, the suture was cut with scissor forceps.
Conclusion
To the best of our knowledge, this is the first reported case in which scissor forceps were used to cut the entangled thread in such a complication. This case highlights a novel but simple method for difficult removal of an entrapped catheter.
Keynote message
For the patients who experienced an entrapment of urethral catheter within the anastomosis of the bladder and ureter, using scissor forceps under endoscope to cut the entangled thread is a simple and promising procedure.
Introduction
Radical prostatectomy is the standard treatment for localized prostate cancer as recommended in current guidelines.1 Urethral catheter entrapment in sutures at vesicourethral anastomosis is a relatively common complication of this procedure. Its management varies from conservative to aggressive procedures. In this report, we describe a novel and simple method of cutting sutures for the removal of an entrapped urethral catheter using scissor forceps.
Case presentation
A 64-year-old man was diagnosed with prostate cancer with a biopsy Gleason score of 4 + 5 in 4 of 14 cores. His initial prostate-specific antigen concentration was 12.2 ng/mL, and imaging studies showed no metastases (cT2aN0M0). Therefore, laparoscopic radical prostatectomy was performed. The vesicourethral anastomosis was sutured with eight stitches by interrupted suture using 3-0 Vicryl thread® (Ethicon, Bridgewater, NJ, USA). Then a 16Fr urinary foley catheter was placed, and a leak test was performed. Because urine leakage was observed at the 7-o'clock position of the anastomosis, additional sutures were placed. No further urine leakage was observed thereafter. The total operative time was 4 h 35 min, the insufflation time was 4 h 2 min, and the blood + urine loss was 520 mL. On postoperative Day 7, the patient experienced difficulty removing the catheter, and entanglement of the sutures with the urinary catheter was suspected. The patient was conservatively followed-up under the expectation of spontaneous removal of the catheter. However, it could not be removed even on postoperative Day 13. On postoperative Day 16, a 14-French rigid endoscope (Olympus Compact Cystoscopes®, Shinjuku, Tokyo, Japan) was inserted between the urethra and catheter to examine the vesicourethral anastomosis under general anesthesia. Suture entanglement with the catheter was identified at the 7-o'clock position, and the suture was cut with scissor forceps inserted through the device (Fig. 1). After cutting, the catheter was easily removed and examination of the anastomotic site revealed no bleeding (Fig. 2). The patient was discharged on postoperative Day 17. Postoperative pathologic examination revealed acinar adenocarcinoma (Gleason score 4 + 5/Grade Group 5, extraprostatic extension 1, resection margin 0, lymphovascular invasion 1, seminal vesicle invasion 1, and no lymph node involvement; thus, the pathological stage was pT3bN0M0).
The patient's prostate-specific antigen concentration had decreased to 0.03 ng/mL by 1 month postoperatively and remained stable without biochemical recurrence. The amount of urinary incontinence was initially high at six pads/day but had decreased to 0–1 pads/day by 6 months, and the patient had no complaints of difficulty urinating postoperatively.
Discussion
In this case report, we used scissor forceps to cut the suture entangled with the ureteral catheter. Such catheter-associated complications after radical prostatectomy are rare and usually result from inadequate cuff contraction or suture entanglement in the catheter during vesicourethral anastomosis. Cuff contraction problems may result from excessive negative pressure or misidentification of fluid and can be addressed by minimal saline infusion or disconnection of the inflation lumen.2 Reports on management of suture entanglement after prostatectomy are limited, and strategies range from conservatively waiting for natural absorption of sutures to aggressive interventions such as laser cutting.3 Cases of sutures becoming entangled in urethral catheters after prostatectomy, as in our patient, have occasionally been observed.4 Two approaches are available to manage such entanglement: a conservative approach that involves waiting for the suture to spontaneously absorb over 2–3 months, or an aggressive intervention that involves suture amputation. We used 3-0 Vicryl suture, which has an expected absorption period of 2–3 months and retention of approximately 25% tensile strength at 4 weeks (Table 1). Other widely used absorbable sutures, such as PDS® and Monocryl® (Ethicon) also take several months to absorb naturally (Table 1). When implementing conservative management, an attempt is made to remove the catheter in anticipation of suture relaxation. However, patients often face physical constraints, discomfort, and a risk of infection. Prolonged catheterization increases the risk of postoperative urethral stricture. By contrast, aggressive treatments such as laser-assisted suture cutting have been reported, in which sutures other than Gortex® (W.L. Gore & Associates, Newark, DE, USA) can be cut using a holmium:YAG laser.5 However, some facilities do not have laser equipment. In the present case, we used scissor forceps with a rigid endoscope to cut the sutures entangled with the vesicourethral anastomosis. This procedure allowed the suture to be visualized and cut, demonstrating that this is a convenient, safe, and clinically applicable technique. However, if continuous sutures are applied, suture removal may not be feasible. The suture retention may have weakened after a month, so it would be an appropriate time in a case with continuous suture. Finally, during the leak test at the end of the radical prostatectomy procedure in this case, a leak was observed at the 7-o'clock position; however, the catheter was not removed when placing the additional suture, which caused the entanglement. There is no justification for performing the procedure with the catheter in place. Therefore, to avoid entanglement, it is imperative that additional sutures be placed after the catheter is removed.
| Suture brand | Strength retention period | Absorption period |
|---|---|---|
| PDS® | 2 weeks 80% | 180 days |
| 4 weeks 70% | ||
| VICRYL® | 2 weeks 75% | 60 days |
| VICRYL PLUS® | 4 weeks 25% | |
| MONOCRYL® | 2 weeks 30% | 90 days |
| VICRYL RAPIDE® | 2 weeks 0% | 40 days |
| (Ethicon) | ||
In conclusion, we used a scissor forceps to cut the suture in this case, enabling successful removal of the urethral catheter. This effective technique can be easily and safely performed in such cases.
Author contributions
Kentaro Yoshihara: Writing – original draft. Kojiro Tashiro: Conceptualization; writing – review and editing. Shoji Kimura: Conceptualization. Keiji Yasue: Conceptualization. Fumihiko Urabe: Conceptualization. Hiroki Yamada: Supervision. Takahiro Kimura: Supervision; writing – review and editing.
Conflict of interest
The authors declare no conflict of interest.
Approval of the research protocol by an Institutional Reviewer Board
Not applicable.
Informed consent
Not applicable.
Registry and the Registration No. of the study/trial
Not applicable.
