Fig. 24.1
(a) Incision of the prostatic capsule is “vesicotranscapsular ” vertical [1], horizontal in the vesicoprostatic junction [2], or horizontally as in the Milan approach or prostatic capsule [3]. (b–d) Intrafascial single robotic prostatectomy (IF-RSP). (b) Front view. (c) Upper view. Traction of the prostate with maneuver of the “fisherman.” (d) Upper view. Seminal vesicles-sparing
Intrafascial radical prostatectomy , initially described as a surgical technique for the treatment of low-risk prostate cancer (PC) , optimizes the preservation of the neurovascular bundle and the endopelvic fascia to improve the results of postoperative continence and sexual function by being performed in the level between the prostatic capsule and the prostatic fascia [5]. Subsequently, using this concept with modifications, including the preservation of the seminal vesicles, the Denonvillier fascia, and urethra to the veru montanum, the Robot-Assisted Intrafascial Simple Prostatectomy (IF-RSP ) is introduced for the management of obstructive lower urinary tract disease by BPH with adequate results [6]. Being a controversial subject, for applying concepts of radical surgery to benign surgery, robotic technique improved the knowledge of anatomy and, together with the surgical precision that this platform offers and an adequate learning curve, it was possible to demonstrate in a study from Martin et al. [7], a better extraction percentage of adenoma, improvement in the maximum flow (Qmax), reduction of the International Prostate Symptom Score (I-PSS) , and elimination of the need for bladder irrigation, with similar bleeding and transfusion rates compared to laparoscopic simple prostatectomy (LSP) and the robotic-assisted laparoscopic simple prostatectomy (RLSP), with results of continence and sexual function at 12 months, being thus equal to other laparoscopic and robotic techniques, with a greater additional advantage of increased detection of PC and high-grade intraepithelial neoplasia (HG-PIN) up to 26% and 12%, respectively, vs. 5.06–6.09% PC and 0% HG-PIN [7].
Complications
The number of robotic procedures has increased in the last 4 years in the United States and Europe. Procedures performed worldwide have nearly tripled from 80,000 to 205,000 since 2007. Between 2007 and 2009, the number of da Vinci systems, the leading robotic technology, installed in US hospitals grew by approximately 75%, from almost 800 to around 1400, and the number installed in other countries doubled, from 200 to nearly 400, according to Intuitive Surgical, da Vinci’s manufacturer [8]. This increased use of the robotics platform has also been seen in benign prostatic disease. This requires that urologists better understand the prevention, diagnosis, and management of complications.
Overall complications during the simple prostatectomy are around 10.6–33% [9–12]. Complications are characterized by the time at which they occur in relation to the surgery and may be categorized as intraoperative, early postoperative, or late postoperative (see Table 24.1).
Table 24.1
Review of the literature of the robotic-assisted simple Prostatectomy (RSP) and simple intrafascial prostatectomy series results (IF-RSP)
Author/year | N | Ultrasound prostate volume (Average ml) | Pathology weight (Average gr) | Blood loss (Average mL) | Hospital stay (Average days) | Intraoperative complication (%) | Postoperative complication (Clavien) |
|---|---|---|---|---|---|---|---|
Sotelo 2008 [13] | 7 | 77.66 | 50.48 | 298 | 1.4 | 0% | Grade 2: 14% |
Yuh 2008 [12] | 3 | 323 | 301 | 558 | 1.3 | 0% | Grade 3: 33.3% |
John 2009 [14] | 13 | 100 | 82 | 500 | 6 | 0% | Grade 3: 7.7% |
Uffort 2010 [15] | 15 | 70.85 | 46.4 | 139 | 2.5 | 0% | 6.7% |
Coelho 2011 [3] | 6 | 157 | 145 | 208 | 1 | 0% | 0% |
Sutherland 2011 [11] | 9 | 137 | 112 | 206 | 1.3 | 0% | 0% |
Matei 2012 [16] | 35 | 107 | 87 | 121 | 3.2 | NR | NR |
Vora 2012 [17] | 13 | 163 | 127 | 219 | 2.7 | 0% | Grade 2: 7.7% |
Clavijo 2013 [6] | 10 | 81 | 81 | 375 | 1 | 0% | Grade 2: 20% |
Nething 2014 [18] | 5 | 132.89 | 89.8 | 440 | 1.8 | 0% | 0% |
Banapour 2014 [19] | 16 | 94.2 | 93 | 197 | 1 | 0% | 12.5% |
Leslie 2014 [20] | 25 | 150 | 88 | 143 | 4 | 0% | Grade 2: 8% Grade 3: 8% Grade 3b: 4% |
Elsamra 2014 [21] | 15 | 157 | 110 | 290 | 2.4 | 6.6% | Grade 1: 6.6% Grade 2: 6.6% |
Hoy 2015 [22] | 4 | 239 | 123.6 | 218 | 2.25 | 0% | 0% |
Autorino 2015 [9] | 487 | 75 | 110 | 200 | 2 | 3.2% | Grade 1: 6.5% Grade 2: 8% Grade 3a: 2% Grade 4: 0.2% Grade 5: 0.2% |
Pokorny 2015 [23] | 67 | 129 | 84 | 200 | 4 | 0% | Grade 1: 15% Grade 2: 6% Grade 3a: 4.5% Grade 3b: 4.5% |
Martin 2016 [7] | 79 / 75 | 80.3/70.5 | 68.5/74.5 | 390/535 | NR | 4.9 / 3.8 | Grade 2: 10.6%/6.3% Grade 3a: 2.6% Grade 3b: 1.3% |
Intraoperative and Early Postoperative Complications
Intraoperative and early postoperative complications are the most common and are those that occur within the first month after the surgery. They include vascular complications, infections, urinary or intestinal injury, and cardiovascular or thromboembolic events (see Table 24.1).
Vascular Injury
Vascular injury is the most frequently occurring intraoperative complication. Both large and small vessels may be affected, resulting in blood loss during and after surgery and the need for transfusion or additional surgical intervention. Reports indicate that transfusion is required for 0–33% of cases [12, 19] while the need for immediate reoperation for bleeding complications is rare, ranging from 1% to 3.7% of cases [24].
Prevention
The points of greatest risk of bleeding are the dorsal vein plexus of the prostatic segment at the time of capsulotomy and the prostatic lateral pedicles and micro-vasculature between adenoma and the prostate capsule at the moment of adenoma enucleation. The best way to avoid bleeding throughout the surgical procedure, especially at these three points, is to perform a thorough dissection with constant sealed or vessel closure (Fig. 24.2).
Fig. 24.2
(a) Vesicoprostatic junction lateral incision lateral (capsulotomy), (b) prostatic lateral plexus dissection and ligation. (c) Adenoma dissection
The best way to avoid vascular lesions of large or medium vessels is to have an adequate knowledge of anatomy, perform careful dissection of the structures near the vessels by delicate movements, and always under direct vision.
At the end of the enucleation, it is essential to review the surgical area with low-pressure pneumoperitoneum (<5 mmHg), to ensure there is no bleeding and to remove any clots in the area of the lateral pedicles (4–5 o’clock and 7–8 o’clock points).
Although vascular injury in robotic simple prostatectomy has not been reported, it is important to have knowledge about it because it could occur at any time. Vascular injury in minimally invasive surgery has been reported to occur in 0.03–2.7% of cases [25]. It mainly occurs when the peritoneal cavity is entered [26, 27] or during the times a trocar or Veress needle or any of the robot arms is introduced [28, 29].
Risk Factors
For the vascular lesions of large, medium, or small vessels, no clear risk factors have been described. Risk factors for intra- and postsurgical bleeding include obesity, previous transrectal biopsy, and previous endoscopic prostate surgery. These conditions promote an increase of the vascular network, adherence of periprostatic tissues and fibrosis, and thus bleeding and possible transfusion.
Diagnosis and Identification
The majority of vascular injury lesions are diagnosed immediately after they occur; however, venous bleeding or that from very small caliber arteries is sometimes not detected because of the pneumoperitoneal pressure. Diagnosis is generally made within the first 48 h after surgery by indirect signs such as a decline in the hemoglobin and the hematocrit or blood in the abdominal drainage or urine. In some cases, CT scan with or without contrast is used to evaluate the location and amount of the bleeding.
Persistent hematuria beyond 1 week generally requires cystoscopic examination. The procedure is diagnostic and it can help in determining the need for other procedures. It also presents an opportunity for initial removal of intravesical clots.
Treatment and Control
The procedures that may be used for vascular control of the prostatic capsule bleeding are:
Endoscopic. It is the first approach that you can try to control bleeding. Direct cauterization on areas of bleeding in the prostate capsule may provide effective control.
Control of the lateral plexuses. The prostatic lateral venous plexuses are generally found at the sides in positions 4–5 and 7–8 o’clock. Bleeding can be externally controlled with a lateral stitch to the prostate prior to the dissection of the adenoma. Within the prostatic capsule, bleeding may be controlled by applying mono- or bipolar energy directly over the plexus during dissection of the adenoma or by passing stitches over the plexus within the capsule, once the adenoma has been enucleated (see Figs. 24.2b and 24.3).
Fig. 24.3
Control of bleeding (a), external stitches, lateral to the prostatic capsule and the dorsal venous plexus (b) placement of stitches within the capsule
Ligate the dorsal venous complex. Another important vascular segment of the prostate is the dorsal venous plexus, which can be ligated distally to the prostate or proximally in a more selective way in the blood vessels with active bleeding (Fig. 24.3a).
Ligation/clamping of the hypogastric arteries. In case of persistent bleeding, one option is to ligate the hypogastric vessels. This extreme measure has a greater chance of controlling the bleeding; however, it poses the risk of tissue hypoxia and secondary lesion from necrosis. Sergi and colleagues [30] proposed occlusion of the hypogastric arteries bilaterally for 12 min during enucleation of the adenoma. The transient occlusion of the internal iliac arteries is a proven maneuver to reduce bleeding during pelvic surgery. Another alternative to control bleeding is hypogastric artery embolization by interventional radiology.
When a large vessel injury occurs, direct compression has to be done to immediately control the bleeding. Additionally, the pneumoperitoneum should immediately be raised to 20 mmHg, and it must be determined if the injury should be repaired through robot-assisted, laparoscopic, or open surgery.
If it is decided to continue with minimally invasive surgery after the immediate bleeding is controlled with direct compression, then further dissection must be made distal and proximal to the vessel injury in order to finally proceed with the injury site closure with vascular prolene in a continuous running fashion (rescue suture, Fig. 24.4). Always bear in mind when performing the closure of the vessel that the use of suction on the injury area must be avoided since it can absorb the pneumoperitoneum and encourage bleeding. Perform continuous irrigation over the lesion to allow better visualization as well as suction within the hematic content (blood pool) so as to not absorb the pneumoperitoneum .
