Complications and Management of Robotic Lower Urinary Tract Procedures

Fig. 28.1

Fasciotomies of both calves to successfully manage compartment syndrome after RARP

The two common positions for the lower extremities during RARP include dorsal lithotomy position using stirrups and the split-leg position. The stirrups used in these patients should be multi-positional and adequately padded. While positioning the patients in these stirrups, the use of additional foam material is recommended to prevent any unexpected pressure on the nerves or joints. We recommend taking the additional minute or two to ensure all pressure points are adequately padded. The arms are usually tucked alongside the torso with the hand positioned in a closed fist action holding a roll of foam. This is the least traumatic positioning of the arms, considering that these cases can exceed 2–3 h of operative time. Periodic evaluation of the patient’s positioning to ensure lack of slippage and warmth of the extremities is highly encouraged. Positioning is done in conjunction with the anesthesia personnel so as to ensure adequate access to anesthesia-required parenteral lines and monitoring equipment.

In a cohort of 179 patients who underwent RARP or RARC in lithotomy position, 6 (1.68%) developed post-operative lower extremity neuropathy [6]. At 9 months of follow-up, only one of those six patients had neuropathic symptoms limiting daily activities. In comparison, in a retrospective study of 377 patients who underwent RARP in split-leg position, 5 (1.3%) developed lower extremity neuropathy [7]. Three of those patients had femoral mononeuropathy. Those authors noted that they often hyperextended the hips by 20°–25° to allow docking of the da Vinci^® S and Si Surgical Systems (Intuitive Surgical, Inc., Sunnyvale, CA). While age, height, weight, and body mass index were not significantly associated with lower extremity neuropathy, the authors noted that the five patients with lower extremity neuropathy had significantly higher mean operative time (496.2 min) compared to the entire cohort (377.9 min).

Extra caution must be exercised with morbidly obese patients. Increased pressure on the brachial plexus must be alleviated with additional padding, and one should not subject the arms to be tightly secured close to the abdomen. Doing so produces additional pressure on the brachial plexus because of subaxillary fat pad in these patients. These patients may not be able to grip objects with their hands for 24–72 h. Such obese patients have impaired arterial oxygenation and have higher risk for hypercapnia [8]. In rare instances, one may be faced with a diagnosis and management dilemma of rhabdomyolysis. In an epidemiologic study of major urologic procedures from the National Inpatient Sample from 2003 to 2011, 870 (0.1%) of 1,016,074 patients developed rhabdomyolysis [9]. Independent risk factors included younger age, male sex, diabetes, chronic kidney disease, obesity, and peri-operative bleeding (which were noted to serve as a surrogate for prolonged operating room time).

At our institution, we secure the patient on the operating room table, which is lined with egg-crate foam. The foam is taped to the table to prevent slippage of egg-crate foam. To minimize the risk of brachial plexus injury, we immobilize the patient’s upper extremities to his side with a draw sheet that is sandwiched in place between the egg-crate foam and the operating room table. Chest straps are not routinely used or recommended. The elbows and wrists are supported in neutral position to reduce the risk of ulnar and radial nerve injuries, respectively. With the da Vinci^® Si robot, the patient’s lower extremities are placed in low lithotomy position with Yellofin^® stirrups (Allen Medical, Acton, MA) to allow robot docking between the patient’s lower extremities. With the da Vinci^® Xi robot, we use the split-leg position in those cases without hyperextending the hips, as the robot docks to the patient from the side without the risk of collision between the split-leg positioners and the robot arms. These split-leg positioning attachments are standard with most operating room tables but must be special ordered. Details regarding appropriate positioning are described in the chapter on patient positioning in this book.

Non-musculoskeletal Adverse Events

Even though the majority of adverse events are related to the musculoskeletal system, one must be cognizant of other potential complications associated with positioning. In cases of prolonged Trendelenburg position, robotic pelvic surgery has also been associated with laryngeal edema, posterior ischemic optic neuropathy, and sanguinous otorrhea [10–12]. Cardiac-related complications have been a concern in these patients not only from the positioning but also age and pre-operative cardiac status concerns.

Patients who are morbidly obese or those with COPD may have pulmonary-related complications because of prolonged Trendelenburg position [13].

Intra-operative Complications

A variety of intra-operative complications can be encountered. This is not only during one’s robotic learning curve but also in the very experienced robotic surgeon as well [14]. This is thought to be because the experienced robotic surgeon is willing to tackle the more complex and complicated cases, and these patients are prone to their own share of complications. The intra-operative complications can be broadly categorized as follows:

1.

Vascular complications
2.

Non-vascular complications

Vascular Complications

Amongst the most acute of intra-operative complications are those associated with vascular injuries and subsequent hemorrhage. Injuries to the vasculature may present themselves during key components of robotic lower urinary tract surgery. Vascular injury can be initiated as early as initiating pneumoperitoneum because of the Veress needle and trocars, which can cause both vascular and non-vascular complications. We highly recommend following all recommended practice guidelines for creation of safe pneumoperitoneum. Safe use of Veress needle technique or the Hassan technique are recommended for initiating pneumoperitoneum. Following this, we recommend that the trocars be placed as much as possible under direct laparoscopic guidance.

The most common vascular injury associated with robotic pelvic surgery is laceration of the inferior epigastric vessels during trocar placement [15]. This type of injury is often recognized intra-operatively and is usually caused during insertion of the pararectus trocars [16]. If the bleeding is persistent despite judicious use of electrocautery and/or clipping, Stolzenburg et al. recommend placing a suture through the abdominal wall (with a straight needle or with the Carter-Thomason device) to encircle the bleeding vessel and tying down the suture extracorporeally for hemostasis [16]. The suture can then be removed from the skin on post-operative day 2 unless it is a self-absorbing suture. Even without bleeding during initial placement of the trocars, the authors have also advised laparoscopic inspection of all trocar sites for active bleeding after trocar removal, at the end of the procedure, and at lower pneumoperitoneum pressures, as unrecognized small bleeders can lead to large abdominal and/or secondary scrotal hematomas.

The incidence of major vascular injuries from Veress needle and initial trocar placement is approximately 0.1% [17]. The common iliac vessels and the aorta are the most common major vessels associated with Veress needle placement [18, 19]. To decrease the risk of overshooting the needle and puncturing those blood vessels, Sotelo et al. recommended advancing the Veress needle into the patient at a 45° angle to avoid advancing the needle too far into the abdomen [17]. For obese patients, they recommend using a 90° angle placement to traverse the more considerable skin to fascia distance.

Another source of vascular injury during robotic pelvic procedures is during standard and extended pelvic lymphadenectomy. This can be secondary to avulsion, laceration, or electrocautery injury. In rare cases, failure of laparoscopic insulation can lead to arcing of the electrocautery current directly into the vessel and lead to a thermal injury [20]. Venous injuries, such as laceration of the external iliac vein, can be controlled with the combination of temporary increase in pneumoperitoneum (to 20–25 mmHg), moderate compression of the vein, judicious compression and suctioning of the operative field by the bedside assistant, and precise suturing. A mini-laparotomy pad may be used to not only mop up excess blood in the operative field but also tamponade the operative site, while limiting the loss of pneumoperitoneum from the bedside assistant’s suction irrigator. Suturing can be accomplished with the use of a non-absorbable monofilament suture (e.g., 4-0 polypropylene) tagged with Lapra-Ty (Ethicon, Somerville, NJ) (a.k.a., “rescue stitch”) to minimize the need to physically tie down the suture. This maneuver saves precious time in the face of ongoing active bleeding. Other groups, such as Sotelo et al., advocated the use of a multifilament suture (e.g., 4-0 polyglactin on a RB-1 needle) with Hem-o-lok clip (Teleflex, Morrisville, NC) attached to the end, as such sutures have minimal memory and may be easier to throw in a continuous fashion [17]. Such simple technical modifications can save significant time in controlling bleeding. In the cases of bleeding that could not be controlled laparoscopically, the surgeon should be prepared to convert to an open procedure.

While significant bleeding from the dorsal venous complex (DVC) is less commonly encountered in RARP and RARC compared to open surgical techniques, the excess blood can stain the tissue planes as visualized with the robot and prolong the operative time by making other parts of the operation more visually difficult to complete, especially during the suturing of the vesico-urethral anastomosis or intracorporeal urinary diversion. As the bleeding is venous, it can be decreased and/or tamponaded with a temporary increase in pneumoperitoneal pressure. This is followed by oversewing the cut end of the DVC with a 2-0 polyglactin suture in a continuous running fashion. For persistent bleeding, an alternative is to apply pressure against the DVC such as with an inflated urethral catheter balloon (placed on stretch extracorporeally) for a few minutes to initiate hemostasis and to allow time for the appropriate sutures and hemostatic agents to be prepared, such as SURGICEL (Ethicon, Somerville, NJ) on the back table.

Of course, in patients where bleeding is anticipated, one need not to be reminded that adequate type and cross-matched blood products should be available, and appropriate informed consent should be obtained beforehand. Moreover, post-operative management will have to include close post-operative monitoring, including possible intensive unit care.

Non-vascular Complications

These complications can also start with the initiation of pneumoperitoneum and up until the end of the robotic surgical procedure. Once again, vigilance and early recognition are the keys to successful outcomes of unexpected complications.

Bowel Injury

Patients who have had prior abdominal surgery are at higher risk for intestinal adhesions and thereby should be managed accordingly. These patients need to be consented for the risk of enterotomies and the need for consultation with other surgical services as needed.

In patients who have had prior abdominal surgery, we recommend using an off-site trocar placement under direct laparoscopic visual guidance. Using the visual obturator is highly recommended. Once the peritoneum has been entered, then the abdomen is inspected for adhesions, and these are then released using instruments through the off-site trocar and additional trocars (which can be placed under direct visualization). If intestinal adhesions are excessive and overly time-consuming, the robotic surgeon may need to resort to other non-robotic techniques to complete the procedure. If lysis of intestinal adhesions is successfully completed, then the procedure is continued after appropriate placement of the robotic trocars and subsequent docking of the robot.

In order of gravity, the duodenum, colon, and the rest of the small bowel are to be respected for the most severe of complications, during trocar placement. Therefore, prompt diagnosis is crucial, and furthermore obtaining prompt general surgery consultation in managing these bowel injuries is highly recommended. More often than not, these bowel complications may present themselves post-operatively, and at this point general surgery consultation is considered mandatory.

As we focus on robotic pelvic surgery, the most common complications are injuries to the rectum. Patients who have undergone prior radiation treatment, obesity, and locally extensive cancers make rectal entry a risky possibility. During RARC, there is an additional risk of entry into the cecum and colon, especially during the extended pelvic lymph node dissection. Diagnosing rectal entry intra-operatively and making appropriate management decisions will decrease any post-operative complications such as vesico-rectal fistula, ensuing sepsis from fecal spillage, and so forth.

In a comprehensive review of records from six institutions (representing 6650 patients who underwent transperitoneal RARP), 11 patients sustained rectal injury (0.17%) [21]. Eight of those cases were recognized intra-operatively, with five being noted during dissection of the posterior prostate plane, one during seminal vesicle dissection, and two during apical dissection. In those recognized cases, they were full-thickness lacerations, with seven done with sharp scissors and one done by stapler inclusion. All eight underwent primary repair, with one patient additionally also received diverting colostomy per general surgery recommendations. The majority of the repairs were performed with at least a 2-layer closure with 3-0 polyglactin suture, thorough pelvic irrigation, and testing of the repair with air insufflation. Of the seven managed with primary repair alone intra-operatively, one did require a subsequent colostomy and suprapubic catheter to allow spontaneous closure of the recto-urethral fistula. None of the recognized cases developed pelvic abscess.

In contrast, the three patients whose rectal injuries were not recognized at the time of RARP all presented with signs and symptoms of recto-urethral fistula [21]. The fistulae were confirmed with Gastrografin enemas, were managed with diverting ileostomy or colostomy , and later repaired in delayed fashion with rectal advancement flap 16–24 weeks later. Interestingly, the authors report no long-term adverse effect on urinary and bowel function.

Of note, we use the rectal air insufflation technique to diagnose or rule out rectal injury intra-operatively. For this test, we recommend using a 20 French red rubber catheter into the rectum via the anus. The bedside assistant fills the pelvis with irrigation fluid. Air is then instilled through the red rubber tubing into the rectum. If air bubbles are seen in the irrigation fluid in the pelvis, then rectal injury is suspected, which is then located and treated with the suturing technique described above.

In the series from Henry Ford reported by Kheterpal et al., 10 of 4400 patients (0.2%) who underwent RARP sustained rectal injury [22]. All ten injuries were recognized intra-operatively and repaired primarily without tissue interposition. The one patient who subsequently developed recto-urethral fistula underwent a diverting colostomy, followed by delayed repair of the fistula. The same patient also had gross fecal spillage at the time of the rectal injury . Potential risk factors identified in these patients included six who underwent wide excision at the time of surgery because of concern for rectal wall involvement and one who previously had undergone saturation biopsies with 85 cores.

In the non-robotic literature, the incidence of rectal injury in open and laparoscopic radical prostatectomy is similarly low. In the series of 11,452 patients who underwent radical prostatectomy (10,183 radical retropubic, 1269 laparoscopic) at Johns Hopkins from 1997 to 2007, rectal injuries were present in 12 (0.12%) and 6 (0.47%) of the open and laparoscopic cases, respectively [23]. Sixteen of the injuries were identified intra-operatively and repaired primarily in multiple layers without fecal diversion. Omental interposition was used in four cases. Of the cases without omental interposition, two developed recto-urethral fistula and were either managed with prolonged urethral catheterization (9 weeks) or diverting colostomy with delayed fistula repair. For the two injuries not identified intra-operatively, they presented as recto-urethral fistula within 4 days in the post-operative period. Those cases were initially managed with prolonged urethral catheterization and fecal diversion with colostomy. Because of persistence of the fistula, both underwent rectal advancement flap to repair the fistula.

In a Japanese radical prostatectomy database of 35,099 patients who underwent either open or laparoscopic radical prostatectomy, 151 (0.43%) were identified with rectal injury [24]. The authors studied whether mechanical bowel preparation provided benefit in reducing perioperative morbidity associated with rectal injury . Based on multivariate analyses (on infectious complications, requirement of delayed colostomy formation, length of stay, and cost), they found no difference between groups of patients who used mechanical bowel preparation and those who did a non-mechanical bowel preparation.

Though we do not routinely recommend pre-operatively bowel preparation in our institution, we do recommend patients at risk for rectal injury to undergo bowel preparation.

Obturator Nerve Injury

The rate of obturator nerve injury cited in literature ranges from 0.2 to 5.7% [25]. Sequelae of the obturator nerve injury include adductor weakness, thigh paresthesia, leg pain, and abnormal leg movements and gait. In a retrospective case series of 3558 prostatectomies from a high-volume institution (of which 2531 and 1027 represent extraperitoneal laparoscopic radical prostatectomy and RARP, respectively), Gozen et al. identified five cases of obturator nerve injury [25]. In all cases, the injuries occurred during pelvic lymphadenectomy and were recognized intra-operatively. In three patients who underwent laparoscopic radical prostatectomy, surgical clips were inadvertently placed on the proximal aspect of the obturator nerve. Those clips were removed once the injury was recognized. (We recommend caution during removal of the clips, as exertion of too much force might lead to avulsion of the nerve.) In two patients who underwent RARP, the nerve was transected proximally. The nerve edges were re-approximated with 6-0 polypropylene monofilament suture in a tension-free manner. Additional treatments, if needed, included physiotherapy and neurotropic medication (in the form of Vitamin B6) in four and three of the patients, respectively. Per the authors, these patients did recover with no permanent defects in obturator nerve function, but they did not define the duration of their follow-up period.

Based on the literature review carried out by the same authors, they proposed a risk map for obturator injury during pelvic lymphadenectomy, with 7 and 2 cases from other groups representing injuries to the proximal and distal parts of the obturator nerve, respectively [25]. The proximal aspect of the obturator nerve was defined as the location where the nerve passes close to the external iliac vein and the internal iliac artery. Their recommendation was to retract the peritoneum more medially to increase visualization of this space. Sotelo et al. recommended medial retraction of the nodal packet and visualization of the nerve prior to placement of clips on the nodal packet [3]. The clips should be placed in parallel to the nerve to decrease the risk of clipping the nerve.

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