© Springer International Publishing AG 2018
René Sotelo, Juan Arriaga and Monish Aron (eds.)Complications in Robotic Urologic Surgery https://doi.org/10.1007/978-3-319-62277-4_2929. Incontinence and Pelvic Organ Prolapse Surgery
Óscar Sánchez-Resendis1 , José María Mojarra-Estrada2 , Juan Arriaga3 , Eduardo Rivas-Larrauri4 and Lionel Leroy-López5
(1)
Department of Gynecology Endoscopy, UNIDIM, S.A. de C.V., la Paz 104, Colonia Alameda, 38050 Celaya, Guanajuato, Mexico
(2)
Hospital CIMA Hermosillo, Infertility Unit, 83282 Hermosillo, Sonora, Mexico
(3)
Hospital CIMA Hermosillo, UMANO Department of Urology, 83270 Hermosillo, Sonora, Mexico
(4)
Department of Gynecology and Obstetrics, Institute for Social Security and Services for State Employees (ISSSTE), 38050, Celaya, Guanajuato, Mexico
(5)
“Hospital 20 de Noviembre ISSSTE”, Department of Gynecology and Obstetrics, Mexico City, Mexico, 03229
Keywords
RoboticsBurch procedureSacrocolpopexyCistouretropexyUrogynecologicStress urinary incontinencePelvic organ prolapseMesh erosionIntroduction
Since 2005, the Food and Drug Administration (FDA) granted its approval to use the da Vinci Robotic Surgical System for gynecological practice. The da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, CA, USA) was developed to overcome the tough learning curve of laparoscopic surgery in different reconstructive surgical procedures. The robotic instrument’s three-dimensional vision, stereotaxy and more precise and controlled movements allow surgeons to perform minimally invasive complex procedures in a safe and comfortable environment. Currently, robotic procedures are being used to treat urinary incontinence and to treat pelvic organ prolapse with good results around the world [1]. Ulubay (2015) reported similar results in a 6-month follow-up when curing urinary incontinence with both conventional Burch and robotic laparoscopy [2]. Constant progress in robot surgery has also warned of possible complications. Wechter et al., report that intraoperative complications occur between 1.6% and 3.5% of all gynecologic surgeries: damage to the intestine, 0.7–2.8%; damage to the urinary tract from 1.2% to 3.5% and conversion to laparotomy from 0% to 26.3% [3]. Other reported complications include de novo detrusor instability, acute urinary retention, failure in the procedure requiring another operation and a possible increase in posterior compartment prolapse.
In spite of the ever more generalized use of the robot, there is still limited experience in the prevention of complications. Since a detailed review of the different techniques goes beyond the objectives of this chapter, we will focus on analyzing the major complications reported in robotic surgery for stress urinary incontinence and pelvic organ prolapse.
General Complications
Measures to prevent complications start with the selection of the patient. The surgeon should be aware of the fact that a variety of factors, such as advanced age, hormonal status, obesity, and associated illnesses will greatly influence whether a patient is eligible for urogynecologic robotic surgery, in order to counterbalance the risk of complications [1].
As concerning the positioning of the patient, the Trendelenburg extreme position has been reported as not necessary in benign gynecological disorders. Thus, increased morbidity in ventilatory and anesthetic mechanics is greatly lessened [4]. Prolonged time in surgery [5], in addition to significantly raising costs, may favor nerve damage by prolonged lithotomy position. The most commonly affected nerve bundles are the posterior tibial in the lower extremities and the brachial plexus in the upper limbs [1]. Once surgeons gain experience and dominate surgical anatomy, such surgical times and the appearance of complications are significantly reduced [6].
Robot laparoscopy has some risk factors inherent to it, such as loss of tactile sensitivity, the surgeon’s position being far from the surgical field; use of the robot’s fixed rigid arms, and potential electrothermal damage because often the arm carrying the electric instrument escapes from the visual field of the surgeon [3].
Chen (2015) reports 5% robotic surgery complications in urogynecology benign pathologies and 8.6% in oncological gynecological surgery. The resulting complications were intestine and ureter lacerations and bladder injury [7], although we must consider that oncology gynecologic surgery per se bears more risk of complications than those in benign procedures such as Burch and Sacrocolpopexy [8].
Surgery for Urinary Incontinence
Burch Procedure
Retropubic cystourethropexy or Burch colposuspension is considered the golden standard for the management of stress urinary incontinence. It currently shares this place with the use of tights and straps [9]. The advantage of using the robot in this procedure has been demonstrated since the articulated movements make dissection and suture easier [10]. The most commonly reported complication is damage to urinary organs, up to 4%. This is similar to the open procedure technique, which can have greater incidence when there are concomitant procedures such as hysterectomy or oophorectomy [11].
Damage to Urinary Organs
Bladder Injury
Bladder injuries can occur in the bladder dome during initial dissection, or in the neck of the bladder during suturing, and they can be repaired intraoperatively if noticed in the moment. Inadvertent bladder lesions can cause urinary leakage and chemical peritonitis if they communicate with the abdominal cavity, or urinomas and abscesses of the pelvic cavity if located in the Retzius space, which will trigger systemic inflammatory response and sepsis, the reasons of suspicion.
How Can It Be Prevented?
The empty bladder is less susceptible to intraoperative injury because it takes up less space in the surgical field and thus contact is avoided. To accomplish this, the proper functioning of the urinary catheter has to be verified, as well as making sure that the device is not pinched and there is no kink in its path. Bladder neck injury can be prevented by separating the side walls of the vagina from the bladder neck and the urethra, aided by the thimble of an assistant, who can also countertract the urinary catheter for better differentiation of tissues.
Diagnosis
Bladder injury can cause macroscopic hematuria, evident in the urine collection bag, so its presence must rule out urinary injury. Intraoperative cystoscopy is mandatory in all major urogynecological procedures, its use can confirm suspected or unseen bladder injuries. It may also show bladder suture entrapment or displacement of the trine to one side and bleeding through the ureteral meatus, which gives way to suspicion of ipsilateral ureteral injury. The instillation of dyes such as methylene blue through the urinary catheter can help identify bladder lesions in the operative field. Those injuries that are not initially suspicious require a cystogram and pelvic tomography for later diagnosis.
Treatment
A singular, short, and linear bladder injury can be repaired intraoperatively ideally with two suture planes, ensuring the proper functioning of the urinary catheter that will remain for 7–10 days. Extensive, multiple, or complex stroke injuries, aside from the closing, may require cystostomy tube to reduce intraluminal pressure, and placing a drain outside to avoid collection and evaluate their output. Intestinal or vascular injuries require the inclusion of other specialists and the possibility of conversion to the open technique.
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