Fig. 25.1
Flow chart of emergency conversion in case of bleeding
Bowel Injuries
These are less prone to acute complications, however, as they may occur out of camera view, they may to present in a delayed fashion. Bowel injuries may be divided into perforation and abrasion, with an incidence of 0.2–0.6%, respectively. Fifty percent were a result of electrocautery and 80% required laparotomy. Critically, 69% were not recognized intraoperatively [38]. The basis of prevention is a high level of alertness when the bedside surgeon enters laparoscopic or robotic instruments as to unusual resistance when outside the camera view. If in doubt, the console surgeon must inform the bedside surgeon if he needs visual help to place the instruments into view. To maximize the safe range of instrumentation, intraoperatively detected adhesions of small or large bowel should be freed sufficiently to drop cephalad, out of the range of both robotic and laparoscopic instruments . The additional time required for this is well invested for increased safety. If abdominal viscera are injured, repair can be done by primary robotic or laparoscopic repair. Alternatively, the closest trocar site to the injury can be opened, the bowel exteriorized for repair, repositioned intraabdominally, followed by trocar closure and continuation of the procedure. If only an abrasion of serosa is seen, a primary repair is done robotically. In doubt, the site of injury should be closed preliminarily, marked with a long thread, and the prostatectomy finalized. Intestinal injury from trocar insertion should be inspected on both sides, since the perforation can be through and through. In the extraperitoneal approach, transgression of the peritoneal reflection with a trocar can cause unrecognized bowel injury; hence, proper understanding of this potential danger is important. At the surgeon’s discretion, consultation with a general or colorectal surgeon may be advisable.
Signs and Management of Undetected Visceral Injuries
If unrecognized during surgery, patients with bowel injury will require laparotomy with or without fecal diversion. The patient generally is asymptomatic on the first postoperative day, as peritonitis will not yet have developed. If dissection was difficult or if significant adhesions were found and possible injury is suspected, the patient should remain hospitalized for further surveillance. Symptoms of unrecognized visceral injuries include focal trocar site pain, generalized abdominal pain, distension, fever, diarrhea, leukocytosis or leukopenia, peritoneal signs, wound succus, or elevated drain amylase levels. Diagnosis is made clinically and biochemically, but a low threshold for an abdominal CT-scan is advisable. Radiographic signs of intestinal injury include free intraperitoneal fluid, extravasation of enteric contrast, and ileus. Free intraperitoneal air is ambiguous, as even several days after a laparoscopic procedures, some free air may exist.
Pelvic Nerve Injury
The most common nerve injury involves the obturator nerve [39, 40]. An incidence of 0.7% has been reported in laparoscopic radical prostatectomy and 0.4% in RALP. Injuries are caused by stretching, but more commonly by direct thermal injury, or complete transection during lymph node dissection. As the obturator nerve is highly constant, the only way to prevent its injury is a high degree of alertness during lymph node dissection and proper visualization at all times. The nodal packet should be pulled medially and not anteriorly to visualize the nerve. Hem-o-lok clips must be placed in parallel, not perpendicular to the nerve, and only after completely visualization. Likewise, electrocautery must be used carefully, rather than blindly grabbing tissue where a bleeder is suspected. Control bleeding at this level is important because it has also been reported obturator neuropraxia secondary to an expanding hematoma compressing the nerve that required surgical drainage for clinical improvement [41].
Recovery of obturator function from neuropraxia occurs spontaneously within 6 weeks. After a full unrecognized transection , however, gait disturbance will persist, followed by atrophy of the adductor muscles. If recognized during the procedure, an attempt should be made to align the ends of the transected nerve and suture it [41, 42].
Rectal Injury
The incidence of rectal injury is similar with different approaches: open (0.5–1.5%) [43, 44], laparoscopically (0.7–2.4%) [44, 45] and robotic (0.2–0.8%) [44, 46, 47]. The most important point is to recognize the injury during surgery and to perform tension-free primary repair using sufficient vascularized tissue interposition [43, 45, 47, 48]. When the defect is too large or complex to be sutured tension-free, if fecal contamination is extensive or in a salvage-prostatectomy situation, a fecal diversion is indicated.
In the early postoperative phase, rectal injury may lead to major complications including septic peritonitis and death. Very small injuries may lead to rectourethral fistula development. In men with unrecognized rectal injury, rectourethral fistulae tend to persist and eventually require delayed surgical repair. The sequelae of rectal injuries are pelvic abscess (0.1%) and rectourinary fistula (0.03–1%) [43, 45, 47, 48].
As in the open procedure, salvage RALP has an increased risk of rectal injury and should be avoided in the earlier learning phase. Likewise, a high degree of alertness, avoidance of both electrocautery and aggressive blunt dissection reduce the risk on rectal injury [49, 50]. Sharp dissection also can cause rectal lesions; however, these have typically smooth, well-vascularized edges that can be sewn safer than larger lacerations occurring with blunt dissection, or thermal necrosis that can be unrecognized. Diagnosis during surgery is done with the bubble test, which consists of passing a 22 Fr. catheter through the rectum and injecting 60 cc of air, while observing the pelvis filled with saline. If bubbling occurs, air is passing through the rectum to the pelvic cavity. The lesion should be closed in two-layers. In non-nerve-sparing surgery, the lateral tissue can be moved to the midline as an additional layer of safety. The rectal repair should be moved away from the anastomosis to reduce the risk of fistula formation.
After repairing the injury , repeat the bubble test. Generous irrigation of the operative field dilutes bacterial contamination. Even if normally no drain is placed after rectal injury, this should be done. Additional days of hospitalization, 3–7 days of antibiotic therapy with anaerobe coverage, and prolonged catheter placement is recommended. A cystourethrogram is mandatory prior to catheter removal.
Early symptoms of rectal injury are lower abdominal pain, fever, abnormal white blood count, and sepsis. If unrecognized, a larger rectal lesion may progress to septic peritonitis. Late presentation occurs as recurrent or persistent urinary tract infection, rectourethral fistula, pneumaturia, or urine loss per rectum . Such fistulae are diagnosed by retrograde urethrogram, urethrocystoscopy, colonoscopy, or CT-scan with rectal contrast.
Ureteric Injuries
The ureter may be injured in several typical locations:
Intertrigonal injuries: After the anterior bladder neck is separated, dissection continues downward, along the plane between prostate and bladder. If this plane is harder to identify, or in patients with median lobes, it is possible to “button-hole” the bladder neck. This typically happens in the trigonal area. In larger dorsal intertrigonal defects, the ureteral orifices can also be injured. To prevent this, it is recommended to repeatedly inspect the bladder via the orifice and delineate the full thickness of the detrusor with an inside and an outside view. If such defects occur, they must be closed; however, the ureteral orifices must be visualized for their location and urine efflux after each stitch with a Vicyl 4–0 suture. The catheter must not be removed without cystography. In predictably challenging cases (post-TURP, salvage) cystoscopy with ureteral catheter insertion at the beginning of the case may be prudent and should be considered in select cases.
The distal ureter is prone to injury when using the Montsouris approach [53, 54]. On too lateral a dissection, the ureter can be mistaken for the vas, thereby transected, thermally injured, or ligated. If a Montsouris approach is used, a tubular structure should never be divided without being completely sure it is the vas. Vas and ureters have different trajectories, where the vas converges in the midline from lateral to medial.
Medial ureteral injury occurs during extended lymph node in the vicinity of the iliac vessels. Again, visualization of the ureter at all times eliminates the risk of injury. The use of the third robotic arm to pull the ureter away from the lymph node template increases safety distance.
Special considerations after TUR-P: In patients with previous TURP, the ureteral orifices might be displaced from their typical location. Here, the anterior opening results in the bladder being wider open than usual. This permits visualization of the orifices. When the dorsal dissection is done, it is of utmost importance to continuously focus both orifices and check for urine efflux. Great care has to be taken to avoid cutting close to the ureteral orifice. In the early phase of the learning curve, post TURP patients should be avoided. Intravenous indigo carmine may be helpful in select cases.
Treatment of Intraoperatively Detected Ureteral Injuries
As a rule of thumb, all ureteral injuries can be corrected robotically. Cauterized, nontransecting ureteral injuries should be stented in a retrograde fashion. Partially or fully transected ureters can be repaired after stent placement with a 5–0 monocryl suture. Longitudinal defects should be closed transversally to prevent narrowing of the ureter. For trigonal lesions, the extent of the repair depends on the size of the injury. As mostly the distal end of the orifice is affected, the roof of the orifice can be incised after stent placement. If the ureter or orifice is widely injured, a ureteral reimplantation is recommended.
Technical Errors and Malfunction
Injuries Caused by Electrocautery or Thermal Energy
Electrical arcs can arise from monopolar instruments. Insulation failure is the typical cause for this type of injury [55]. Surgeons should avoid excessive instrument collision to maintain integrity of the insulation, and ensure insulation sleeves are placed properly and without defects. Electrosurgical arcs can cause immediate injuries to blood vessels. Thermal intestinal injury can lead to delayed necrosis and perforation several days after the procedure.
Great care must be taken when a monopolar instrument is in proximity of metallic tips of instruments of the bedside surgeon, such as a grasper or suction. Electronic arcs may jump over from the tip of the scissor to the nonisolated parts of the instrument, leading to bowel or visceral injury. As a safety measure, cautery should be minimized or avoided particularly on the rectal wall during posterior dissection.
Instrument Malfunction
The most common event of instrument malfunction is a break of the wires controlling the endowrist and instrument jaws. If this happens, the instrument can be removed easily. Events such as a break of an instrument tip or a disintegration of an instrument can be dangerous as the loose part might get lost intraabdominally [56, 57].
Needle Loss
A critical issue is needle loss during surgery [58, 59]. Preferably, only one needle at a time should be in situ, except when double-armed sutures are used. When needles are inserted or removed, a needle holder must be used (no grasper due to less grip), needles should be grasped directly but not on the thread and the bedside surgeon should verbally confirm successful needle retrieval each time.
In case of needle loss, it is extremely important not to move any robotic or laparoscopic instrument in a hurry [58]. Typically, the needle stays below to where it escaped, and careful, but easy search with the robotic camera will be successful. Too early movement with instruments will move intestines and potentially hide a needle. Magnetic search devices have been described [60]. In the process of searching, the lumen of the trocar should be inspected, and if in doubt, the trocar should be removed and X-rayed. Finally, the needle might be lost outside the abdominal cavity, between the surgical drapes.
End of Case Considerations
When finishing the case, the scrotum should be empty of gas, since this can distend it, causing skin lesions and breakdown. It is also crucial to assess for subcutaneous emphysema as this can easily be confused with other conditions such as generalized edema. Reduce insufflation pressure to 5 mm Hg to check for bleeders masked by higher pneumoperitoneal pressures.
Postoperative Complications
The incidence of postoperative complications is reported to be 1.9–9.0% [44, 61, 62]. The most common complications occur early after the procedure, thus it is crucial to evaluate the patient thoroughly in the first 2 or 3 h postoperatively. Assessment includes speed of regaining consciousness, vital signs, skin coloration, drainage type and volume, and abdominal tenderness.
Postoperative Hemorrhage, Blood Transfusion, and Reintervention
As in open surgery, this is the most relevant immediate to early complication. The incidence of blood transfusion is low (<1.5%) [44, 61, 62]. The transperitoneal approach allows larger blood loss before detection, as the space for the hematoma to spread is large and hematomas may not irritate intraabdominal structures, which is a unique difference to the open approach. The indication for transfusion and intervention is based on clinical findings [63, 64]. Particularly in rapidly worsening patients (tachycardia, hypotension, abdominal distension) immediate reintervention is preferable, as compared to waiting for a CT-scan, which may delay a necessary intervention. Drainage output is not a reliable sign of bleeding, as the blood clots in the drain, obscuring bleeding. More often than not, open exploration is advisable, as a larger hematoma, with its associated poor vision, slower chance of hematoma evacuation via suction, and vital instability, which worsens when the patients goes back to Trendelenburg position, requires a swifter, safer, and more predictable control.
In clinically stable patients, who experience postoperative bleeding, as determined by a drop in hemoglobin, a CT-scan with IV-contrast helps to assess the urgency to intervene: If an active bleeder is seen, reintervention is necessary. In the more common situation without active bleeding, the need to intervene is determined by size and position of the hematoma: smaller hematomas in the prostate fossa that do not expand will resolve over time. Hematomas affecting the anastomosis – evidenced by bloody catheter output – indicate anastomotic rupture, pelvic urinoma, ultimately longer catheterization time and increased risk of strictures. Here, a laparoscopic evacuation of the hematoma – albeit requiring reintervention – is more beneficial for the patient in the long-term perspective.
Urinary Anastomotic Leakage
The most common sign of massive urinary leakage is increased drain output, the type of fluid determined by drain fluid creatinine levels. The presence of urine is confirmed when drainage creatinine is higher than serum creatinine. To determine the origin of the leakage (anastomosis or ureteral injury), a cystography is the easiest form of assessment. A cystography shows either a partial or a total disruption of the anastomosis. To differentiate urine from a ureteric lesion from urine from an anastomotic insufficiency, the method of choice is a CT-scan with IV-contrast and urographic phase combined with 3D reconstruction: If ureter is partially or fully transected, an increased drain output with elevated creatinine can be expected. In particular after transperitoneal approach, abdominal pain and distension due to urine peritonitis is a common symptom.
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