Traditionally, after an open radical prostatectomy, urinary catheters were left in place for two to three weeks[9]. However, with the introduction of RARP, surgical techniques have evolved, enabling earlier catheter removal due to improved precision in vesicourethral anastomosis. Research indicates that early removal of urinary catheters reduces discomfort and lowers the risk of catheter-related complications[10]. Our study investigated the feasibility and safety of early cystography and following catheter removal within POD3 after RARP, revealing potential benefits in reducing hospitalization and catheter indwelling days without increasing leakage risk. As demonstrated by previous research[8, 7], early removal of catheter (POD2-4) has been shown to significantly reduce both the catheter placement duration and hospitalization time. Our study further confirms these advantages through early cystography, with a reduction of approximately 3 days in both parameters. A recent meta-analysis published in BJU International in 2023 systematically compared the postoperative outcomes associated with varying times of catheter removal[11]. Notably, the results indicate that early catheter removal does not pose an increased risk of postoperative leakage, with respective incidence rates of 5.9% and 4.3%, aligning with our research findings.
Our results also highlight the importance of caution when considering early catheter removal. AUR rates for catheter removal before the third day following surgery vary from 1.5 to 11%, as most research have demonstrated[12, 8, 7, 13]. This meta-analysis also noted that the incidence rates of AUR were 7% and 0.8% in the respective groups, indicating a potential association between early urinary catheter removal and increased AUR risk. These findings are compatible with our study, which showed similar trends. However, the results of two randomized controlled trials (RCTs)[7, 14] did not demonstrate significant differences between the groups, possibly due to limited sample sizes or minimal disparities in catheter removal timing, resulting in underestimated outcomes. The etiology of AUR may involve various factors such as postoperative tissue edema, pain, hematoma compression, and elevated bladder neck smooth muscle tone[15]. Furthermore, other studies suggest that the sole relevant risk factor for AUR is the timing of Foley catheter removal: early removal correlates with an elevated AUR risk[12, 13]. Nadu et al.[16] reported that re-catheterization for AUR was required in 10% of cases. Our study also revealed a higher proportion of patients requiring re-insertion of Foley catheters due to AUR when early cystography was performed. While AUR can often be managed conservatively or with Foley re-insertion, clinicians should be vigilant in monitoring patients for this complication.
Addressing risk factors for urethrovesical anastomotic leakage, a comprehensive analysis from Tyritzis et al.'s publication[17] identified several contributing factors, including previous prostatic surgery and intraoperative blood loss, both aspects explored in our study. Even following BNR, patients with a history of prostate surgery have wider bladder neck opening, making precision suturing challenging[18]. Previous surgery-related scarring and fibrosis may contribute to suboptimal healing at the anastomotic site[19]. Moreover, increased intraoperative bleeding may result in ischemia and the surgical field less visible, which can make suturing difficult. Sutures that are necessary to keep hemostasis in place could worsen the ischemia[20]. Postoperative blood clot formation obstructing the catheter may impede drainage, adversely affecting the healing process. Other factors such as obesity, prostate size, type of anastomosis technique, suture number and type, eversion of the mucosa, difficult or under tension anastomosis, reconstruction of the musculofascial plate, intraoperative flush test result, and postoperative urinary tract infection were also mentioned in this study. Kakutani et al.'s study[20] also noted that the risk of leakage is only associated with BMI, console time, and prostate weight. However, these factors did not show significant differences in our study, and further research is warranted to explore this discrepancy.
The limitations of this study include its retrospective nature and single-center design, may result in limited generalizability. The difference of only one day in the postoperative cystography time between the two groups may underestimate the results. While previous studies have extensively evaluated functional outcomes, our study did not incorporate functional or urodynamic assessment indicators. There is also a significant difference in baseline console operation time between the two groups, which may be due to variations in surgical complexity or skill levels. This could affect the interpretation of the results, considering potential differences in surgical processes or techniques. Five separate skilled surgeons carried out the surgical procedures further suggests that the technique is easily repeatable and that the perioperative and postoperative outcomes in this instance are not dependent on the surgeon. However, Dal Moro et al. highlighted a significant correlation between leakage rate and the proficiency of robotic surgical skills[21], which might pose a potential limitation in our study. Despite these limitations, our study still provides valuable insights into the timing of postoperative cystography and its impact on patient outcomes.