Postoperative Cystogram Can Be Safely Omitted After Bladder Cuff Excision in Patients Undergoing Nephroureterectomy
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SURGERY
Postoperative Cystogram Can Be Safely Omitted After Bladder Cuff Excision in Patients Undergoing Nephroureterectomy Nikita R. Bhatt 1
&
Tony Tien 1 & Niall F. Davis 2 & George Yardy 1 & Azad Hawizy 1 & Gautam Banerjee 1
Accepted: 4 November 2020 / Published online: 17 November 2020 # Springer Nature Switzerland AG 2020
Abstract In nephroureterectomy (NU), a crucial surgical step is excision of the bladder cuff. A urinary catheter is placed postoperatively and a cystogram prior to catheter removal is often performed to rule out a urine leak from the urinary bladder. We investigated the necessity of cystogram after bladder cuff excision prior to removal of the urinary catheter. A systematic review (SR) was also performed to investigate the incidence of urinary leak on cystography after NU bladder cuff excision. The primary outcomes were postoperative clinical complications including sepsis, fistula, voiding issues after catheter removal and/or any radiological abnormality indicating persistent leak from the bladder. A retrospective study was performed in a centre where cystograms are not routinely performed prior to catheter removal in NU patients. Patients were followed up clinically, radiologically and cystoscopically. A SR of 402 patients demonstrated that the incidence of urine leak from the bladder is 0.003% among patients after catheter removal after NU. In total, 67 patients were included and no clinical, radiological or cystographic evidence of a persistent urinary leak was noted at follow-up due to omission of cystogram. Based on this systematic review, it may be possible to safely omit routine cystography prior to removal of urinary catheter after bladder cuff excision in patients undergoing NU. Keywords Imaging . Choosing wisely . Urine leak . Laparoscopic . Healthcare cost
Introduction A crucial surgical step in nephroureterectomy (NU) is excision of the bladder cuff. There continues to be indecision around the management of the distal ureter during laparoscopic and robotic NU. Methods for excising the bladder cuff have evolved over time and different surgical techniques have their advantages and shortcomings. In terms of oncological advantages, there is significant controversy regarding the recurrence-free and cancer-specific survival with different methods of bladder cuff excision during laparoscopic and open
* Nikita R. Bhatt [email protected] 1
Department of Urology, Ipswich Hospital, Ipswich, UK
2
Department of Urology, Beaumont Hospital and Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
NU, with some studies suggesting that laparoscopic approach has poorer overall oncological outcome compared to open [1, 2] and others suggesting there is no difference [3, 4]. Laparoscopic stapling followed by transurethral incision of ureteral orifice and ureteral tunnel and placement of ureteral occlusion balloon was described initially [5]. Other techniques for excising the distal ureter and bladder cuff include transurethral Collings knife incision, transvesical laparoscopic deta
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