Laparoscopy and Robotics Persistent Vesicourethral Anastomotic Leak After Laparoscopic Radical Prostatectomy: Laparoscopic Solution Octavio A. Castillo, Celeste Alston, and Rafael Sanchez-Salas OBJECTIVES To describe our experience with laparoscopic reintervention for persistent vesicourethral anas- tomotic leak (PVAL) after laparoscopic radical prostatectomy (LRP). PVAL after LRP is an unusual complication. Surgical repair is uncommon but can be done safely through the laparo- scopic approach. METHODS From 2000 to 2006, 391 patients were treated with LRP performed by a single surgeon. Four patients presented with PVAL and conservative treatment was initially indicated. Owing to failure of the initial management, 4 patients underwent reoperation using a laparoscopic approach for PVAL at 5-12 days. RESULTS The vesicourethral anastomosis was endoscopically repaired using intracorporeal sutures. Four procedures were performed, 2 extraperitoneal and 2 transperitoneal, without any complications. The patients were discharged 4-6 days after reintervention. Follow-up has shown adequate results in these 4 patients. CONCLUSIONS The results of our study have shown that when conservative management fails in cases of PVAL after LRP, a laparoscopic repair of the urethrovesical anastomosis can be safely performed. However, the long-term functional results must be addressed. UROLOGY 73: 124 –126, 2009. © 2009 Published by Elsevier Inc. R eporting complications from urologic laparoscopy is important. 1,2 Laparoscopic radical prostatec- tomy (LRP) was developed to parallel the success achieved with the open approach, while offering the advantages of minimally invasive surgery. 3 A decade after the initial description by Guillonneau et al., 4 open rad- ical prostatectomy remains the standard of care for the surgical treatment of prostate carcinoma. 5 Considering the interest in LRP, and the actual need for supporting evidence, it is necessary to describe the difficulties and complications with this procedure to improve the treat- ment of prostate carcinoma. 6 Previous series have described the perioperative com- plications 7,8 and the incidence of persistent anastomotic leakages and disrupted vesicourethral anastomosis seen with LRP. 9-12 A persistent vesicourethral anastomotic leak (PVAL) after LRP is an uncommon complication. Several conservative treatment methods are available, including prolonged retropubic and bladder drainage, passive rather than active drainage, adjustment of the drain position, bladder catheter traction, and/or reduced fluid intake or delayed bladder catheter removal. When the conservative approach fails, we believe a laparoscopic approach to PVAL is feasible, safe, and effective. In this report, we describe our technique and experience with laparoscopic repair of PVAL. MATERIAL AND METHODS From 2000 to 2006, 391 patients with clinically localized pros- tate cancer who were candidates for radical prostatectomy un- derwent LRP at our institution. All procedures were performed by a single surgeon (O.C.). Depending on each patient’s pa- rameters, either a transperitoneal or an extraperitoneal ap- proach was used for LRP. Five ports were used for all cases. The creation of the pneu- moperitoneum varied depending on the approach (extraperito- neal or transperitoneal). After reaching the space of Retzius, we incised the endopelvic fascia bilaterally. The dorsal venous complex was controlled laparoscopically, using a figure-of-eight 3-0 polyglycolic acid multifilament stitch. Next, both of the vas deferens and the seminal vesicles were dissected at the vesi- coprostatic junction. Vascular control of the prostatic pedicles was performed with neurovascular preservation, when indi- cated. The prostatic apex was then circumferentially dissected and the urethra incised. The specimen was then removed by way of the umbilical incision using an Endocatch retrieval device. A watertight urethrovesical anastomosis was created with 6-8 interrupted or continuous 2-0 polyglycolic absorbable sutures tied laparoscopically over a 20F Foley catheter. When From the Section of Endourology and Laparoscopic Urology, Clínica Santa María; and Department of Urology, Universidad de Chile Faculty of Medicine, Santiago, Chile Reprint requests: Octavio Castillo, M.D., Section of Endourology and Laparoscopic Urology, Department of Urology, Clínica Santa María, Avenida Santa María 0500, 7530234 Providencia, Santiago de Chile, Chile. E-mail: octaviocastillo@vtr.net Submitted: November 27, 2006, accepted (with revisions): August 21, 2008 124 © 2009 Published by Elsevier Inc. 0090-4295/09/$34.00 doi:10.1016/j.urology.2008.08.469