Abstract
Robotic-assisted laparoscopic radical prostatectomy (RALRP) has become a commonly employed method of surgical treatment for prostate cancer. The relative merits of the procedure, as compared to open radical prostatectomy (ORP), are highly controversial, but the RALRP, when performed by experienced surgeons, can be performed with low morbidity and functional outcomes equivalent to ORP. While the risk of morbidity is low, a number of complications can arise during the course of RALRP. Careful selection of candidates, based in part upon surgeon experience, greatly reduces the risk of complications. Early recognition and appropriate management can maintain an excellent outcome for patients, even in the face of complications.
Keywords
prostate cancer, prostatectomy, robotic prostatectomy, robotic assisted laparoscopic prostatectomy, lymphocele, urine leak, dorsal venous complex, neurovascular bundle, nerve-sparing
Key Points
- 1.
Candidates for robotic-assisted laparoscopic radical prostatectomy (RALRP) must have adequate ventilatory reserve and appropriate body habitus to allow maximal Trendelenburg position during the procedure.
- 2.
The risk of nerve and pressure injuries during RALRP can be reduced by avoidance of stirrups, adequate padding, and shoulder support.
- 3.
Unrecognized bowel injury most commonly occurs due to movement of instruments outside the visual field of the camera.
- 4.
Blind trocar insertion risks injury to the aorta, common iliac arteries, mesentery, bowel, and bladder.
- 5.
Bleeding resulting from incision of the dorsal venous complex can generally be managed by completing the transection, slightly increasing insufflation, and directly suturing the stump.
- 6.
Controlled urine leak from the vesicourethral anastomosis can generally be managed conservatively with catheter drainage, but persistent leak should draw concern for a ureteral injury.
- 7.
Ureteral injury can occur during node dissection, adjacent to the seminal vesical pedicle, but generally occurs during bladder neck transection.
- 8.
Rectal injury can be managed by robotic-assisted laparoscopic repair, except in cases of fecal soiling, large injuries, devitalized rectal wall, or previous radiation. In these cases, colostomy diversion should be considered.
The surgical management of prostate cancer has rapidly evolved over the past decade from a procedure most commonly performed open by a subset of urologists skilled in the approach, to a minimally invasive procedure more accessible to a wide range of well-trained urologists. The proportion of prostate cancer operations performed laparoscopically, with or without robotic-assistance, continues to grow globally. The choice of robotic-assistance is, in many cases, a function of accessibility within a given health-care system, but use of the robot often shortens the learning curve and facilitates a minimally invasive approach among surgeons not comfortable with the laparoscopic, nonassisted, approach. As a result, robotic-assisted laparoscopic radical prostatectomy (RALRP) became the surgical technique of choice in the treatment of localized prostate cancer with 60% of patients in the United States treated with this technique by 2009, and presumably far more by 2016.
Early evidence showed that RALRP was associated with reduced blood loss, decreased transfusion rates, and lower narcotic requirements postoperatively, but concerns remained regarding catastrophic complications in the hands of inexperienced surgeons, high cost, and a failure to demonstrate improvements in functional recovery following surgery. More recent data have also been promising regarding more durable – and arguably more clinically meaningful – outcomes, such as long-term cancer control, functional recovery, and health-related quality of life. Data suggest that these outcomes are at least equivalent to, and possibly superior to, outcomes after traditional open radical prostatectomy (ORP).
It is notable that in the hands of most surgeons experienced with the technique of RALRP, the procedure has become routine. A primary attraction of the procedure is that the approach allows adaptation, in most cases, irrespective of anatomic variation, gland size, or previous surgery. These factors add complexity to the operation, and thus surgeon experience remains a critical determinant of success or failure. While most surgeons carry a high level of comfort with the RALRP procedures, a risk of complications remains, and given the number of procedures performed in the United States, review of potential complications, their management, and strategies for prevention are critically important.
Preoperative Considerations
As with any surgical procedure, determining surgical candidacy is an important element of the preoperative evaluation before considering RALRP. There are general contraindications to surgery that may relate to either general comorbidities precluding anesthesia, or cancer-related risk factors that predict a high likelihood of treatment failure. The oncologic indications for surgery are beyond the scope of this chapter, but given the wide variation in selection criteria, the ultimate decision to offer RALRP depends largely upon the treatment biases and strategy of the managing surgeon and institution. In general, candidates for a laparoscopic approach include patients at relatively low risk for adverse cardiopulmonary and anesthetic complications associated with the surgical procedure. In some circumstances, anesthetic considerations related to pulmonary disease and the ability or inability to compensate for the hemodynamic, cardiovascular, and metabolic changes associated with the various physiologic particularities that occur during laparoscopy might serve as relative contraindications. The steep Trendelenburg positioning undertaken during RALRP could further increase respiratory stress, and patients with underlying respiratory disease, morbid obesity, or anatomic abnormalities may not tolerate this surgical approach well.
A prior history of intraabdominal and pelvic surgical procedures, disease processes, or previous radiation therapy may also influence the appropriateness of a laparoscopic robotic-assisted approach. Although no clear guidelines are available, the presence of intraabdominal or pelvic adhesions may certainly make exposure and creation of a working space more difficult, and the decision to proceed laparoscopically is based upon surgeon experience and comfort level.
In general, we have not found previous intraabdominal surgery to be a contraindication to RALRP, but surgical time is clearly extended due to the need for laparoscopic lysis of adhesions to create working space. In these patients, options such as extraperitoneal approach RALRP could also be considered, but such an approach requires experience with the technique, and development of the extraperitoneal space may be limited by incisional adhesions as well. The need for conversion to an open surgical approach is a realistic possibility in these patients, and as such, preoperative arrangement for availability of a surgeon experienced with ORP is advisable. Likewise, in cases of complicated previous intraabdominal surgery or infection (i.e., perforated diverticulitis, trauma, abscess, etc.) one might consider advising ORP rather than attempting RALRP, depending upon the experience level of the surgeon.
Previous pelvic surgeries, including bladder surgery, simple prostatectomy, lower abdominal mesh placement, renal transplant, or vascular grafting, may create challenging extraperitoneal adhesions, limiting the approach to the prostate during RALRP. In our experience, mesh is the most commonly encountered obstacle, and a careful history with review of previous operative reports may aid in surgical planning. When mesh placement is limited to the deep inguinal ring or anterior abdominal wall, cautery along the mesh surface generally allows the bladder to drop easily away. Caution must be exerted not to stray laterally to the mesh, or through the mesh into the anterior abdominal wall, to avoid vascular injury. In this regard, dealing with mesh placed extraperitoneally over the inguinal ring is better dealt with by RALRP than ORP, as mesh is more likely to be encountered and traversed during the open or extraperitoneal approach while attempting to access the space of Retzius. Most troublesome is the scenario in which mesh extends over the iliac brim and vessels. In these cases, we generally do not attempt pelvic node dissection due to risk of vascular injury, and the bladder is released laterally only to the root of the superior pedicle. In general, mesh does not extend beyond the distal iliac vessels in these cases, and adequate bladder mobility can be achieved through simple release from the mesh.
In cases of previous bladder surgery, perivesical adhesions can be more substantial, and bladder injury often occurs during mobilization. Intravesical instillation of dilute methylene blue can allow recognition of small injuries that can easily be repaired. In patients with previous renal transplant or pelvic vascular graft, RALRP may be contraindicated, depending upon the experience level of the operating surgeon. Liberal use of cautery during bladder mobilization should be avoided if RALRP is undertaken, as inadvertent injury of blood vessels or transplant ureter can have dire consequences. We have previously performed RALRP in men with previous renal transplant, and preoperative assessment of anatomy is essential. In these patients, the allograft is generally seated well above the bladder, and the ureter enters the dome of the bladder. Avoidance of this region is feasible through cautious entry into the retropubic space along the anterior abdominal wall.
Salvage laparoscopic robotic-assisted prostatectomy following radiation therapy may be particularly challenging. In complex cases characterized by anticipated fibrosis, adhesions, and altered anatomic features, the decision to proceed with a laparoscopic approach should be based on risk assessment and the surgeon’s experience. In general, we have found salvage prostatectomy to be simpler through a robotic-assisted approach rather than open.
Morbid obesity itself does not pose a contraindication to RALRP, but particular preoperative considerations should be taken. Specifically, the surgeon should be aware that full Trendelenburg positioning might not be possible in these patients, due to difficulty with ventilation in the setting of abdominal insufflation. Further, port placement may need to be displaced somewhat inferiorly, often below the umbilicus, in order to allow for the robotic arms to gain access to the most caudad portions of the pelvis.
As in open radical prostatectomy, patients undergoing laparoscopic robotic-assisted prostatectomy should receive appropriate perioperative antibiotic and deep vein thrombosis prophylaxis. We have utilized both compression stockings and preoperative administration of prophylactic dose subcutaneous heparin as a routine in all men undergoing RALRP.
Complications of Positioning
Complications of positioning are discussed in detail in Chapters 9 and 31 . The da Vinci Si system (Intuitive Surgical, Sunnyvale, CA) has typically been employed with the patient in a modified low lithotomy position with steep Trendelenburg decline. The robot is generally positioned between the legs allowing the operating component of the robotic system to come into close proximity to the patient, with the operating arms and camera oriented toward pelvic targets, including the prostate, bladder, seminal vesicles, urethra, and genitourinary diaphragm. Alternatively, a side-docking approach, in which the robot is positioned at an angle lateral to the pelvis, allows adequate exposure and enables versatility of positioning the patient in a supine or lithotomy position. Since adaptation of the Xi system, we have routinely placed the patient supine in steep Trendelenburg position. Such an approach minimizes the risk of lower extremity compartment syndromes and perineal nerve injury related to the stirrups.
Close attention to positioning is important to prevent pressure or traction-associated nerve injuries. Accordingly, all pressure points should be padded adequately, and the surgical team, including the anesthesiologist and nursing staff, should ensure that areas of potential injury are addressed before sterile skin preparation and draping. In the SI positioning, the weight of the patient’s legs should be transmitted through the heel and foot, minimal pressure should be present on the lateral aspect of the calves and thighs, the extension of the hip and thigh should be anatomic to minimize the risk of femoral nerve injury, and the lower back should be contoured with lumbar support if necessary. If the arms are positioned by the patient’s side, the wrists and elbows should be well padded, and care should be taken to protect the patient’s hands and fingers from injury secondary to positioning of the table, robotic equipment, or the assisting surgical team. When the patient’s arms are not tucked, a natural anatomic position of the arm and shoulder should be achieved to prevent brachial plexus injury. Adequate shoulder support, without compression of the shoulders, is essential to avoid brachial plexus stretch injury.
Once the patient has been correctly positioned, he should be secured to the surgical table to prevent shifting during the surgical procedure. We generally observe the patient in Trendelenburg position prior to draping to ensure no slipping occurs. This goal can be achieved relatively easily by using padded straps across the patient’s chest. Additionally, the use of a high-density padding with a high coefficient of friction, such as the Pink Pad (Xodus Medical, Inc.), helps prevent patient slippage while in steep Trendelenburg and also protects against pressure ulcers and nerve injury. Prior to initiating the procedure, the patient’s airway pressure, facial swelling, and body habitus should be carefully observed. Inability to tolerate the position, prior to insufflation, may indicate limited ventilatory reserve, extreme truncal weight impinging upon the diaphragm, or poor venous return from the upper body. In these rare cases, the patient may be a poor candidate for robotic prostatectomy and one could consider aborting the procedure. Additional effects of Trendelenburg procedure can be reviewed in Chapters 9 and 31 .
In positioning the operating element of the robotic system, care must be taken to ensure that unintentional contact between the robot and the patient does not occur. The only contact between the robot and the patient occurs through the working ports, and at no time should any other moving or static element of the robot place pressure on the patient’s core or extremities. The most common area of potential contact is between the working elements (arms) and the patient’s thighs. This contact can be avoided by pivoting the arms of the robot up and away from the patient when the robotic arms are attached to the working ports. Of note, these complications may be less common with use of the da Vinci Xi system due to the fact that the patient is positioned in the supine rather than low lithotomy position, but in that case injury to the feet and lower extremities can occur as the robot is pulled in or out of the field.
One practical concern that may go unrecognized but is potentially serious is the placement of equipment (cables, light source, camera, suction tubing) in the vicinity of the patient’s face and the endotracheal tube. Care should be taken when considering placement of these laparoscopic accessories, and if at all avoidable, they should be routed away from the area of the patient’s head. In laparoscopic robotic-assisted prostatectomy, however, these accessories are often placed in that area out of necessity. In these cases, a protective foam barrier may be placed over the patient’s face after the endotracheal tube has been secured. This measure may prevent facial injuries such as corneal abrasion and may also reduce the risk of unintentional dislodgment of the endotracheal tube during the surgical procedure. Similarly, cords running along the floor should be neatly coiled and protected to avoid inadvertent pulling or disconnection from the robot or endoscopic tower. Such events during the course of surgery can result in loss of vision or failure of the robot.
Critical system failures, although uncommon, may occur, requiring abortion of the robotic-assisted approach and conversion to either a straight laparoscopic procedure or open prostatectomy. A recent survey of 176 urologists who perform RALRP reported that 57% of respondents had ever experienced “irrecoverable intraoperative malfunction” of the da Vinci robotic system either before or during a case. In some cases, system errors prevented initiation of the surgical procedure using a robotic approach (58% of these cases were rescheduled, 19% were performed open, and 15% were performed laparoscopically). Other times, these system errors occurred intraoperatively and required conversion to open or pure laparoscopy. Overall, fellowship trained urologists were statistically more likely to convert to a pure laparoscopic approach versus an open approach. Although information on estimates of system failure is limited, the impact of this system-specific complication on patient and cancer-related health outcomes has not been measured to date.
Complications of Access
Port Insertion/Insufflation
Complications of laparoscopic access are additionally reviewed in Chapters 30 and 31 . Laparoscopic robotic-assisted radical prostatectomy may be performed through either a transperitoneal or an extraperitoneal approach. Although the transperitoneal approach is more commonly used, some surgeons prefer the extraperitoneal approach because the peritoneal contents can be avoided. In this case, the working space is generally smaller, and cranial access to high lymph nodes may be limited. Both approaches have advantages and disadvantages and present different potential challenges in access. Regardless of which approach is used, initial access to the peritoneal or perivesical space is typically achieved through a small periumbilical or infraumbilical skin incision.
The transperitoneal approach uses intraperitoneal access with secondary entry to the retropubic, extravesical space through eventual incision of the parietal peritoneum. Access to the peritoneal cavity may be gained by abdominal insufflation through a Veress needle followed by blind insertion of the initial camera port or use of a Hasson technique for direct cut-down and visualization of the peritoneal incision. While we have generally preferred a Hasson technique of insertion in all cases, this technique is strongly indicated in cases of previous intraabdominal surgery from which bowel adhesions may be present, when direct visualization is preferable. Following standard laparoscopic principles, confirmation of an intraperitoneal position is necessary before insufflation. In obese patients, when using the Hasson technique, the trocar tip can easily be displaced to the preperitoneal space. Abnormally high initial intraabdominal pressures indicate probable malpositioning, and insufflation should not be initiated in this setting. Repositioning, removal, and replacement of the device are options to establish correct placement before insufflating the abdomen. Nonvisualized passage of the Veress needle and the initial trocar following insufflation is associated with potential injury to gastrointestinal and vascular structures. If an injury is suspected after placement of the Veress needle, insufflation should be delayed and the needle should be carefully removed in the trajectory of entry to avoid converting a penetrating injury to a potentially more severe laceration. In these cases, or in cases of previous midline incision, a Hasson technique for trocar insertion can be carried out laterally to visualize the midline adhesion and perform laparoscopic lysis of adhesion, or inspection of suspected injury, prior to placing midline trocars. Once safe access has been established in a different location, the area of initial entry and potential injury should be examined closely. In cases of small penetrating injuries due to needle insertion, usually no additional management is required for bowel or bladder entry. Injuries associated with trocars are generally more severe and often require laparoscopic or open repair. The surgeon must use his or her discretion regarding the need for repair or conversion to an open procedure.
The extraperitoneal approach requires port placement slightly lower than in the transperitoneal approach but in the same configuration. Potential benefits of the approach include reduced anesthetic problems associated with increased intraperitoneal pressures, avoidance of the peritoneal contents and all associated intraoperative and postoperative consequences (ileus), and decreased need to retract the bowels during the surgical procedure. Additionally, the risk of trocar injury to the bowel is reduced, but bladder injury or vascular injury due to the reduced size of working space remains a potential problem. The working space is smaller, and care must be taken in developing the extraperitoneal space before port placement, particularly in the cranial and lateral areas where the robot working ports are placed. A balloon dilator is used to develop the prevesical space bluntly and may result in laceration or avulsion of small pelvic vessels. This is generally not problematic, except in the case of previous pelvic surgery or fibrosis secondary to previous pelvic infection. In these cases, fused tissue planes can result in adherence of the peritoneum to pelvic vessels, resulting in more significant vascular injury on insufflation. In cases of suboptimal development of the prevesical space, the working space can be limited, resulting in a relatively reduced ability to manipulate the working elements and translating to more difficult surgical dissection. Initial port placement to gain proper access to the space is essential because improper placement may result in occult or obvious intraperitoneal entry and bothersome intraperitoneal leak throughout the procedure. In cases of intraperitoneal insufflation, bulging of the peritoneum further restricts the working space. In the event of an intraperitoneal communication, a 5-mm port can be placed into the peritoneal space for decompression. Conversion to an intraperitoneal approach should be done if a large intraperitoneal CO 2 leak occurs.
Subcutaneous emphysema may develop during the course of the procedure, either due to trocar placement or migration to the preperitoneal space, a very prolonged procedure, or a CO 2 leak around the trocar site. Scrotal emphysema is common, and in prolonged cases, emphysema may migrate up the abdominal wall and involve the subcutaneous tissues of the neck and face. This problem is directly related to the extent of CO 2 leakage into the extraperitoneal space, which may be exacerbated by prolonged surgical time, use of high insufflation pressures, and insufflant leak around the fascial opening. Palpable crepitus is the principal clinical sign. When subcutaneous emphysema is associated with high CO 2 blood levels, delayed extubation may be required to allow the partial pressures of CO 2 and of oxygen to normalize. Maintaining intraperitoneal pressures of ≤15 mm Hg assists in minimizing this complication.
Many devices, including the Kii Balloon Blunt Tip System by Applied Medical, can reduce the chances of troublesome air leak around the trocar throughout the case, given the relatively large fascial opening required during the Hasson approach. This device works by trapping the fascial opening in an airtight manner between an external mobile gel cone and an internal balloon posterior to the peritoneal opening. Alternatively, a pre-placed “purse-string” fascial stitch can be used to tighten the point of fascial entry around the trocar, reducing the tendency of air leak. We have found the latter maneuver to work poorly and have routinely utilized the balloon port, both with the Si and Xi systems.
Although uncommon, the risks of gas embolism and resulting cardiopulmonary collapse are elevated during laparoscopy. Embolism is less common when one uses CO 2 compared with other insufflants, given the dissolvability of CO 2 in blood. In cases of unrecognized intravascular entry, injury, and insufflation, a CO 2 embolus may precipitate rapidly and may result in catastrophic consequences such as acute cardiovascular collapse. This is the most common cause of a gas embolism in the setting of CO 2 insufflant. Classic signs include an abrupt increase in end-tidal CO 2 accompanied by a sudden decline in oxygen saturation and a subsequent decrease in end-tidal CO 2 . Such cases should be managed on an emergency basis with immediate cessation of insufflation and repositioning of the patient in the left lateral decubitus position to minimize right ventricular outflow. The patient should then be ventilated with 100% oxygen, and in extreme circumstances, aspiration of the air embolism may be required.
Bowel Injury
Perforation of the small bowel or large intestine is the most common injury associated with initial blind trocar placement and usually relates to bowel adhesions or a downward angulation on trocar insertion. Prompt recognition of the injury is essential, and the decision regarding management is largely based upon surgeon experience and the severity of the injury. In cases of injury to bowel fixed by adhesion, release of the adhesion is essential to properly evaluate and, if needed, repair the injury. Additionally, tethering of the bowel can stretch and expand the diameter of the injury. Repair can be performed laparoscopically, with or without robotic assistance, or through an open converted approach, depending upon the comfort level of the surgeon. If converting to open, completion of the prostatectomy could be considered, with repair of the bowel via the specimen extraction site if intraoperative fecal spillage is not noted. In that case, isolation of the bowel with stay sutures until the time of repair is prudent. General principles of bowel repair are employed. Injury to intraperitoneal structures is less common with an extraperitoneal approach because the peritoneal contents are avoided. Nonetheless, small bowel and large intestine injuries are possible secondary to unintentional peritoneal entry during establishment of access, thermal injuries, or inadvertent traction to fixed bowel segments within the peritoneal cavity. Delayed recognition of a bowel injury can be catastrophic. Patients will often present with peritonitis, sepsis, and intraabdominal abscess within 2–7 days following surgery.
Bladder Injury
Significant bladder injuries may also occur during the establishment of access. Bladder injury by trocar is usually quite evident and is easily managed by direct repair. Suspected needle bladder injuries can be detected with intravesical instillation of dilute methylene blue. Small penetrating injuries associated with narrow-gauge needles can be managed conservatively. Urinary decompression with a Foley catheter reduces the risk of injury and should be routine practice before laparoscopic access is gained.
Retroperitoneal Vascular Injury
Major vascular injuries are rare and have been reported in recent meta-analyses to occur in 0.044% and 0.03% of laparoscopic cases using the Veress needle and Hasson approaches, respectively. The aorta and common iliac vessels are the most commonly injured vascular structures, as they lie directly beneath the periumbilical trocar insertion site. Injury to these major structures can result in catastrophic bleeding, but such injuries can usually be salvaged through prompt intervention. Mesenteric vessels may also be injured, resulting in mesenteric hematoma followed by possible vascular compromise and bowel ischemia. Clinical signs of significant bleeding are hypotension followed by compensatory tachycardia. After trocar entry into a major vessel, injury is often readily apparent on removal of the obturator or pull back of the trocar and insertion of the camera. If the trocar has not been withdrawn or manipulated, a blunt obturator should be replaced through the lumen and the trocar should be left in place while preparations are made for open conversion and repair. While usually evident, during some cases of tangential vascular injury, blood may dissect beneath the mesentery and bleeding may not be apparent, even on intraperitoneal inspection. An emergency laparotomy should proceed rapidly with vascular control and repair.
Epigastric/Abdominal Wall Vascular Injury
Trocar insertion commonly can also result in injury to the inferior epigastric artery and veins, or their tributaries. Injury is recognized either at the time of insertion, based upon visual inspection, or at the time of port removal. In general, the risk of injury can be minimized when the vessels are directly visualized and ports are placed >6 cm from the midline, and lateral ports are placed under direct vision. In thin patients, use of the laparoscope light to transilluminate the abdominal wall can aid in selecting an appropriate site for port insertion. Use of a spinal needle to map the trans-abdominal course of the trocar may also help prevent injury to the inferior epigastric vasculature.
Recognized inferior epigastric injuries should be managed promptly either laparoscopically or with a cut-down technique. When laparoscopic ligation or electrocautery is possible, additional skin incisions or port placements may be avoided. In some instances, the location of the injury may prevent adequate control without additional port placement. These cases may be managed effectively with additional port placement and subsequent internal ligation. When access to the site of bleeding is difficult, an externally placed (on the skin level) hemostatic occluding figure-of-eight stitch can be placed in the quadrant of identified bleeding to provide occlusion and control. Endoscopic suturing devices are very useful in this application because they allow full-thickness transabdominal suturing, and this has been our preferred management of abdominal wall bleeding when recognized intraoperatively. Unrecognized or inadequately managed hemorrhage from the inferior epigastric vessels may progress to a significant rectus sheath hematoma resulting in clinically significant pain, acute blood loss, anemia, and possible hemorrhagic shock.
Intraoperative Surgical Complications
Specific intraoperative complications arising during RALRP, unrelated to port insertion and insufflation, are similar to those occurring during ORP, but their cause and management may be distinct, owing to the surgical technique. Complications of ORP are reviewed in detail in Chapter 42 , and there may be great overlap with this chapter as they are by the same author. Complications of pelvic lymphadenectomy are detailed in Chapter 40 and will not be covered in this chapter.
Bleeding
A major attribute of RALRP as compared to ORP is the relatively small amount of bleeding encountered during the procedure. In general, while bleeding can occur at any point during the procedure, the severity of bleeding is relatively minimal as compared to with ORP, thus improving intraoperative vision, and improving the ability to control small bleeding sites through enhanced vision. The hemorrhagic advantage of RALRP over ORP is underscored by the differential blood loss between the two approaches: A recent prospective study of 2506 patients found an average blood loss of 185 mL versus 683 mL for RALRP and ORP, respectively. Another study which had similarly significant surgical blood loss differences (207 mL vs 852 mL) also showed that the RALRP group had a reduced incidence of peri-operative transfusion rates as compared to the ORP group (4.3% vs 30.3%) and that this likely contributed to a shorter hospital stay (1.8 d vs 2.9 d). It is important to remember that this is surgeon-dependent, and the high rate of transfusion reported in the latter study is extremely high for surgeons of experience performing ORP.
Sources of bleeding are the same as those described for the open procedure: the dorsal venous complex and Santorini’s complex overlying the anterior and lateral surfaces of the prostate and bladder, the inferior vesicle and proximal prostatic vascular pedicles, the neurovascular bundles coursing posterolateral to the prostate, the apical prostatic vessels, and the bladder neck. One reason for reduced bleeding during RALRP is the pneumatic pressure provided by insufflation of the working space. Under conventional insufflation pressures, small vessels surrounding the prostate, and in many cases even the dorsal venous complex, can be cut without major bleeding. This is an important recognition, as a common cause of delayed bleeding is de-sufflation with ensuing bleeding from uncontrolled small vessels controlled by pneumatic pressure during the procedure. As such, following completion of the procedure, inspection of the field under reduced insufflation pressure of 5–8 mm Hg can be a valuable tool in preventing delayed bleeding.
Division of the dorsal venous complex can be performed early in the procedure or late. If performed prior to bladder neck division and prostate mobilization, the dorsal vein should be controlled directly with a figure-of-eight suture of 2-0 Vicryl or, in some cases, an Endo GIA stapler. Adequate suture ligature of the dorsal vein requires sufficient division of the adjacent endopelvic fascia to allow central bunching of the complex within the suture. In cases of retraction of the dorsal vein following division, direct oversewing of the vein stump is generally feasible. We have generally divided the dorsal vein complex after division of the bladder neck and complete mobilization of the entire gland. In doing so, the complex can be sharply divided without prior suture ligature, allowing maximal anterior surgical margins while avoiding excessive dissection or suture placement in the periurethral space. During division of the uncontrolled dorsal vein, bleeding can be encountered, particularly when only partially transected. Bleeding can be minimized by avoiding stretch or traction on the vein, avoiding excessive suction or reduction of insufflation pressure, and, on occasion when needed, actually transiently increasing insufflation pressure to 20 mm Hg. The latter maneuver is generally safe, but one must be cautious if large open venous sinuses are visible, due to the rare occurrence of air embolus. Following division, we generally oversew the edge of the dorsal vein complex in a running fashion, incorporating only the edges of the vein complex to avoid deep suture placement. The complex is then suspended to the pubic symphysis by incorporating the posterior pubic periosteum into the running closure stitch. In general, dorsal vein complex bleeding should not be excessive in RALRP, regardless of the technique of division utilized.
In general, use of sharp dissection and nonthermal mobilization of the periprostatic layers, desirable for minimizing trauma to the adjacent neural structures, increases the risk of bleeding both in the field and postoperatively. High anterior release of the lateral prostatic fascia requires mobilization of the fascia from the lateral surface of the prostate. As the fascia is often intimately adherent to the periprostatic venous complex, small venotomies are frequently encountered. We have generally utilized an approach of retrograde neurovascular bundle mobilization, adapted from our open technique ( Fig. 42.3 ), by releasing the lateral fascia of the prostate and mobilizing it sharply and bluntly from the posterolateral prostate, to the level of Denonvillier’s fascia, thus laterally displacing the nerve bundle ( Fig. 32.1 ). Denonvillier’s fascia is then incised, entering the perirectal space ( Fig. 32.2 ), and a cottonoid sponge is packed into the defect to tamponade venous oozing from the mobilized nerve bundle and lateral fascia ( Fig. 32.3 ). After excision of the prostate, bleeding encountered along the neurovascular bundles or lateral prostatic fascia can generally be controlled by reapproximating the overlying fascial layers in a running or interrupted layer of 3-0 Vicryl suture, or by cautious point coagulation with bipolar cautery, as needed.
Division of the bladder neck, particularly the lateral attachments of the bladder to the prostate, when establishing the posterior plane behind the bladder neck can result in significant bleeding from the perivesical extension of Santorini’s plexus and the arterial branches extending to the bladder neck. Generous use of bipolar cautery or preemptive clip placement can avoid oozing from this location, which may impair vision greatly. Once bleeding from a transected vessel occurs, it often retracts within the partially divided bladder neck. Efforts to control small bleeding points are often fruitless and may be best employed following complete division of the bladder neck and prostate pedicle. Prostatic pedicle bleeding is not unusual, but is generally minimizing by liberal use of clips during the division to avoid excessive cautery. Upon division of the pedicle, small venous bleeding often stops as traction on the cut vessel is released. Direct suture ligature of the divided pedicle is preferable to attempts at clipping or cauterizing retracted vessels.
A final point of potential bleeding is the seminal vesical pedicle. Arterial supply of the seminal vesical branches arises from the inferior vesical circulation of the hypogastric artery. As such, retracted vessels can be the cause of intraoperative or delayed postoperative bleeding. Direct control of the pedicle with clips is desirable to avoid transmission of cautery to the neurovascular bundle, but if avulsed and retracted, exposure followed by point coagulation with bipolar cautery can be utilized.
Visceral Injury: Bladder, Bowel, and Rectum
Visceral injuries during RALRP can include injuries to bowel, bladder, and rectum by a number of variable mechanisms. Early recognition and repair is a critical tenet of management, regardless of the site of injury. Direct injury during dissection or mobilization is often recognized while injuries due to instrumentation out of the visual field, thermal injuries, or traction injuries may go unnoticed and present later at the time of visceral leak or infection.
Bladder injuries commonly arise during mobilization of the bladder. In the transperitoneal approach, division of the urachus and entry into the retropubic space can result in an inadvertent cystotomy. Such injuries are most often encountered in cases of previous pelvic surgery, hernia mesh, or by entry into the incorrect plane, too close to the detrusor muscle. Similar risks of injury to the bladder exist during insufflation of the perivesical space for an extraperitoneal approach prostatectomy. The incidence is <2% during laparoscopic prostatectomy, and this complication can be effectively managed with two-layer closure and bladder decompression. In cases of multiple cystotomies or when the integrity of the anterior bladder has been compromised secondary to misguided surgical dissection, additional repair may be necessary.
Mobilization of the bladder should be carried out in a largely avascular plane, identified upon complete division of the urachus ( Fig. 32.4 ). When traversing this plane to the level of the endopelvic fascia, excessive bleeding may indicate entry into the perivesical space or the posterior rectus fat, adjacent to the epigastric vessels. Early lateral mobilization of the bladder during the pelvic node dissection often defines the appropriate plane, thereby facilitating release of the urachus. In cases of sliding hernia, the bladder wall may extend into the hernia defect. Early recognition of the hernia, followed by reduction of the contents prior to further bladder mobilization, will avoid inadvertent cystotomy.
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