Omitting postoperative cystography: urine color as a non-invasive predictor of anastomotic leakage after robot-assisted radical prostatectomy

Abstract Purpose Cystography is widely performed after robot-assisted radical prostatectomy (RARP) to exclude vesicourethral anastomosis (VUA) leakage. We evaluated whether urine color is a predictor for VUA leakage in cystography. Methods This retrospective study included patients treated with RARP for prostate cancer (PCa) between 01/2024 and 12/2024. The surgeons were stratified by experience level (< 100 vs. ≥100 prior RARPs). Cystography was performed postoperatively (5–7 days) to assess anastomotic integrity. Urine color was documented as clear or non-clear by reviewing medical records. Uni- and multi-variable logistic regression analyses were fitted to test for relation between leakage and urine color. Results A total of 498 RPs were performed, with 477 (95.6%) being robot-assisted. Most patients (92.5%) had intermediate- or high-risk PCa, and 360 (75.5%) procedures were performed by experienced surgeons. VUA leakage was detected in 32 patients (6.7%) during cystography. Non-clear urine was more frequently observed in patients with leakage (18.8%) compared to those without leakage (4.0%; p =0.003). Sensitivity analyses restricted to cystograms performed between days 5 and 7 ( n =424) yielded consistent results. In both uni- and multivariable logistic regression analyses, urine color was a predictor for absence of leakage in cystography. Conclusion The overall rate of VUA leakage was low and even lower when surgeries were performed by experienced surgeons. Non-clear urine was associated with a higher likelihood of leakage. Hence, cystography may be omitted in patients with clear urine following RARP performed by experienced surgeons. For less experienced surgeons, routine cystography should be performed regardless of urine color due to increased risk of leakage.