Visceral and Gastrointestinal Complications in Robotic Urologic Surgery

Grade

Definition

Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, and radiological interventions

Allowed therapeutic regimens are drugs as antiemetics, antipyretics, analgesics, and diuretics, electrolytes, and physiotherapy. This grade also includes wound infections opened at the bedside

Requiring pharmacological treatment with drugs other than such allowed for grade I complications

Blood transfusions and total parenteral nutrition are also included

III Requiring surgical, endoscopic, or radiological intervention

III a Intervention not under general anesthesia

III b Intervention under general anesthesia

IV Life-threatening complication (including CNS complications)^a requiring IC/ICU^b management

IV a Single organ dysfunction (including dialysis)

IV b Multiorgan dysfunction

Death of a patient

suffix « d »

If the patient suffers from a complication at the time of discharge, the suffix “d” (for “disability”) is added to the respective grade of complication. This label indicates the need for a follow-up to fully evaluate the complication

From: Mitropoulos et al. [5] with permission from Elsevier

^aCNS = central nervous system complications: brain hemorrhage, ischemic stroke, subarachnoid bleeding, but excluding transient ischemic attacks

^b IC intermediate care; ICU intensive care unit

Given the lack of standards in reporting surgical complications, Martin et al. identified ten critical elements of accurate and comprehensive reports: data accrual, outpatient information, follow-up duration, mortality and morbidity rates, definition of complications, procedure-specific complications, severity grade, length of stay, and risk stratification analysis [8]. In 2007, Donat modified the criteria to include procedure-specific complications for urology, such as urine leak, lymphocele formation, ileus, or inadvertent visceral injury [9] (Table 13.2).

Table 13.2

The Martin–Donat complication reporting criteria

Reporting criteria	Definition of criteria
Method of accruing data defined	Prospective or retrospective accrual of data indicated
Duration of follow-up indicated	Report clarifies period of prospective accrual of complications such as 30 days or same hospitalization
Outpatient information included	Study indicates complications first identified after discharge are included in analysis
Definitions of complications provided	Report identifies at least one complication with specific inclusion criteria
Mortality rate and causes of death listed	A number of patients who died in postoperative period of study are recorded, together with the cause of death
Morbidity rate and total complications indicated	Number of patients with any complication and total number of complications are recorded
Procedure-specific complications included	Radical nephrectomy: bleeding/transfusion rate, vascular injury, inadvertent visceral injury (pleural, colon, pancreas, spleen), ileus Partial nephrectomy: same as for radical nephrectomy plus urine leak Radical cystectomy: bleeding/transfusion rate, ileus, urine/bowel leak, thromboembolic events, anastomotic stricture, fistula, rectal injury, vascular injury Radical prostatectomy: bleeding/transfusion rate, inadvertent visceral injury (nerve, rectal, ureteral), urine leak, lymphocele Retroperitoneal node dissection: bleeding/transfusion rate, vascular injury, lymphatic leak/ascites, pulmonary (atelectasis, ARDS^a, pneumonia), inadvertent visceral injury (pleural, colon, kidney, spleen, pancreas, ureteral), ileus
Severity grade used	Any grading system designed to clarify severity of complications, including “major versus minor,” is reported
Length of stay data	Median or mean length of stay indicated
Risk factors included in analysis	Evidence of risk stratification and method used indicated

From: Donat [9], with permission from Elsevier

^a ARDS acute respiratory distress syndrome

The use of both standardized classifications helps to objectively rate the cumulative data and to make well-established comparisons of the published literature. Agarwal et al. [4], for example, carried out an analysis of >3300 robot-assisted radical prostatectomy (RARP) cases by reporting the complications according to the Martin–Donat criteria and stratifying them using the Clavien–Dindo classification. The authors provided a safety profile for this procedure. Verification of these observations will require well-designed, collaborative, quality initiatives.

Rabbani et al. [10] retrospectively reviewed 4592 retropubic and laparoscopic (including robot-assisted) radical prostatectomy cases performed at a single institution. They captured and graded all medical and surgical complications according to the Clavien–Dindo classification and comprehensively reported the complications using the standards determined by the Martin classification. They found higher complication rates than those described in the literature, possibly because of more accurate reporting. In multivariate analysis, the laparoscopic approach was associated with higher incidence of complications except for the major surgical complications that were more frequent with the retropubic approach. The authors claimed that this finding could be related to the presence of more frequent and severe comorbidities in the laparoscopic group. Consequently, they concluded that accurate reports of complications based on standardized classification systems could result in higher complication rates but are crucial for identifying risk factors and making well-established comparisons with the literature.

The importance of correct classification lies in the ability to identify complications correctly and to determine their subsequent management.

First Trocar Placement

Laparoscopy and robot-assisted laparoscopy are minimally invasive techniques for access to the peritoneal cavity or to the retro- or extraperitoneal space. Insufflation of CO₂ is necessary for the correct creation of a working space in the abdomen.

There are three options for initial port placement: (1) closed access with a Veress needle, (2) open Hasson technique, or (3) direct access with or without an optical port [11, 12].

Blind Veress Needle Access

Blind Veress needle access is the oldest and most common method of peritoneal insufflation [12]. The Veress needle design uses two cylinders: The inner one has a retractable blunt tip; the outer one, with a sharp edge, allows tactile feedback as it passes through the layers of the abdominal wall [13].

Once Veress needle is placed, before starting insufflation, several maneuvers can be used to confirm proper positioning (e.g., aspiration to exclude blood or bowel content, the “drop test,” the “advancement test”). The abdomen is then insufflated with CO₂. At that moment, the abdominal pressure should be <9 mm Hg. This low intra-abdominal pressure indicates the correct placement of the needle [13, 14].

To avoid failures such as placement into an adherence or the bowel, the Veress needle should be placed away from previous surgical scars [11, 13]. For Bianchi et al., the intestinal perforation rate with the blind access technique was 0.33% [12].

Open Hasson Access

The Hasson technique was developed in 1971 [15] as a safe way to enter into the peritoneal cavity. Since then, many laparoscopic and robotic urologists have used open Hasson access as a primary technique [16].

To begin, a 12- to 15-mm skin incision must be made and deepened to the fascia of the rectus. Next, the fascia is incised, and muscle layers are split. After that, the peritoneum is opened sharply. Using a finger, the surgeon checks the correct opening of the peritoneum and the absence of near adhesions. Finally, a blunt-tipped Hasson cannula is inserted directly into the peritoneum. Sutures are placed on both sides of the incised fascia to hold the trocar and to help with closure at the end of the surgery.

This technique is recommended when the patient has had previous abdominal operations, and the risk of abdominal adhesions is high. Retroperitoneal renal access also typically uses this technique [11]. The intestinal perforation rate with this technique has been described as 0.05% [12].

Direct Optical Access

Optical ports have a conical nonbladed trocar tip beside an inner sleeve-handle system for 10-mm lens insertion. This technique requires elevation of the anterior abdominal wall with hands or preplaced clamps. After skin incision, the bladeless optical trocar is placed at the entry site and allows visualization of the different tissue layers. With a twisting motion, the trocar advances in the desufflated abdomen until the peritoneal cavity is identified and entered. Despite visualization of tissue layers, these ports cannot prevent serious injuries because the lack of pneumoperitoneum can easily result in bowel or vascular injury [13]. Nevertheless, Bianchi et al. present this access technique to be one of the safest [12].

Intestinal Preparation

In 1977, Freiha applied the mechanical bowel preparation that was first developed for colorectal surgery to urologic surgery [17]. Preoperative bowel preparation attempts to reduce bacterial loading in the intestinal lumen to prevent complications after intestinal surgery and, historically, has been considered the standard of care for patients undergoing colorectal and urologic surgeries involving the bowel [18].

Surgeons performing bowel anastomosis strive to achieve quick recovery of bowel function, to reduce hospitalization days, and to avoid infectious complications, bowel leak, and anastomosis dehiscence.

In recent years, routine preoperative bowel preparation has been questioned. A number of nonrandomized and randomized clinical trials have shown that this kind of preparation may not be effective in reducing postoperative complications [19–21]. In fact, bowel preparation has some disadvantages such as potential nutritional imbalance, long hospitalization, patient exhaustion, and patient inconvenience [22, 23].

The literature suggests that mechanical bowel preparation can be safely omitted in robot-assisted laparoscopic prostatectomy [23], as well as in cystectomy with ileal urinary diversion, given the absence of demonstration that bowel preparation could prevent the development of postoperative complications [21–24].

The benefits of use of oral antibiotic bowel preparation in urologic surgeries have yet to be demonstrated but have been shown in colorectal literature to decrease infectious complications [23].

Preoperative Imaging to Prevent Injuries

Preoperative imaging based on computed tomography (CT) scan or magnetic resonance imaging (MRI) is mandatory for assessing the complexity of the cases and planning the appropriate operative intervention and approach. Consequently, the potential difficulties are predicted and anticipated, allowing better intra- and postoperative outcomes and low complication rates. These advantages create a safer surgical environment [25].

Initial trocar insertion, outside of the surgeon’s field of vision, could cause visceral damage (e.g., liver or spleen injuries). To avoid it, preoperative imaging studies based on CT scan are important to detect organomegaly; in such cases, the surgeon could perform lower abdominal or umbilical trocar placement [3].

In renal surgery, identifying the presence of intra-abdominal adhesions should change the surgical trocar access; therefore, initial retroperitoneal access should be considered in patients with multiple prior abdominal surgeries. It is important to note that both the retroperitoneal and transperitoneal approaches have equivalent overall complication rates [26]. Furthermore, in nephron-sparing surgery, it is important to correctly characterize renal masses to identify complexity groups and to estimate the potential perioperative complications. Several standardized anatomical classification-scoring systems have been described for this purpose [27, 28] and have proven to be important tools for preoperative planning and effectively correlating postoperative results and complication rates [29].

Regarding prostate surgery, comprehensive preoperative planning, including MRI, is important to ensure safe and successful surgery, even among challenging operative cases [30]. MRI provides anatomical information about the prostate and pelvis cavity, and this prior knowledge allows the surgeon to perform precise prostate dissection, with preservation of neurovascular bundles if indicated, and to avoid complications like rectal perforation [31].

In robotic bladder surgery, specifically radical cystectomy, the complications include those relating to radical prostatectomy as well as those inherent to bowel-based urinary diversions. Imaging techniques used for assessment of local extension are CT and MRI, but both are able to distinguish only the macroscopic invasion of perivesical fat and adjacent organs, as well as upper urinary tract involvement, if present [24]. Consequently, prior knowledge of the extent of the disease is essential when planning surgery and preventing potential complications. In addition to gastrointestinal complications after robotic bladder surgery, such as rectal or bowel injury or anastomosis dehiscence, other potential visceral complications include ureteral injury. This may occur in patients in which ureteral identification is challenging, such as those with fibrosis, prior radiation, or chemotherapy. To avoid this problem, intraoperative retrograde instillation of indocyanine green (ICG) into the ureter could aid ureteral identification. ICG is instilled using a ureteral catheter and causes fluorescence, appearing bright green when viewed under infrared imaging using the Firefly system on the da Vinci robot system (Intuitive Surgical, Sunnyvale, CA) [1]. This tool might also be useful in renal and ureteral surgery.

In summary, preoperative imaging in robotic urology surgery may help decrease the likelihood of bowel or visceral injury and increase the chance of recognition when injury occurs.

Intra-Abdominal and Pelvic Visceral Lesions

Small Intestine

As in laparoscopic surgery, a bowel injury can occur anytime during robotic urologic surgery, from access to closure, and may be life-threatening if not recognized and repaired during the procedure. Van der Voort et al. showed that the incidence of gastrointestinal tract injury during laparoscopy was 0.13% [32]. Others described intestinal injury rates of 0.23% [12] and even 0.6% [2]. With an injury rate of 41.8%, the small intestine is the most commonly injured bowel portion. Access to the abdomen using a Veress needle or trocar is the main reason of this high rate. Most of the trocar-induced bowel injuries result from the first trocar placement, which is not positioned under direct vision [3].

Because of the high morbidity associated with duodenal leakage, injury of the duodenum is a very serious complication. These injuries could happen during right-side procedures, such as radical or partial nephrectomy and adrenalectomy.

Bowel injury that needs repair is rare in both laparoscopic and robotic surgery, occurring in 0.1% of cases [33]. Unfortunately, not all injuries are recognized. If a bowel injury is noticed during surgery, the required management depends on severity. Sometimes conservative treatment may be an option, but, alternatively, laparoscopic suturing techniques may be needed to repair the injury [3]. A recognized bowel injury that occurs during dissection is treated similarly to an injury that occurs during trocar placement [14].

Thermal damage from electrocautery is the second most common cause of intraoperative bowel injury, and most of these injuries are not recognized [32]. If an injury results from electrocautery, its degree must be evaluated. If electrocautery makes an enterotomy, all edges must be refreshed before the primary repair. If the area is blanched but there is no clear enterotomy or if there is only a superficial damage, the area must be excised until viable tissue is found, and only then is the suture done [14]. Some authors conclude that intraoperative repair of the damaged bowel is significantly safer and should be performed in every electrocautery bowel injury [34]. Thermal injury prevention is mandatory. The application of monopolar energy sources should be avoided, and the location of instruments that may injure the viscera must be actively observed.

Mechanical injuries , whether sharp or blunt, occur mostly outside the laparoscopic visual field in nontarget tissues and are caused by robotic arms and laparoscopic instruments with no tactile feedback. Consequently, all tissue handling and instrument insertion into the abdominal cavity should be performed under direct vision [35]. In robotic surgery, the fourth arm, when used, should be placed in a secure and visible location.

Colon

A colon injury that is discovered intraoperatively must be repaired immediately [3]. A skilled laparoscopic surgeon can perform a direct suture, avoiding colostomy, based on the extent of the injury. A general surgeon should be invited to the operating room for advice. The most commonly injured part of the colon is the rectum, as discussed in this section.

Liver and Spleen

Most splenic injuries (0.3%) occur in left upper urinary tract surgeries during spleen mobilization to expose the retroperitoneum [14]. There is an increased risk if adhesions are present [36]. Hepatic injury is not common, and management is usually similar to that of splenic injury. Because minor hepatic injuries are generally unreported, actual incidence is difficult to estimate. Compression alone can be enough to resolve minor injuries of the liver and spleen [3]. If bleeding is difficult to control, an argon beam coagulator could be helpful [14]. Splenectomy due to a major injury with massive bleeding is unusual but has been reported [37]. A preoperative CT scan can be useful to recognize organomegaly before starting surgery.

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