AUA 2018: Robotic Prostatectomy- Setbacks and Operative Solutions

San Francisco, CA ( The introduction of robotic assisted technology has had a tremendous impact in the care of patient with prostate cancer allowing surgeons to operate on the prostate with enhanced vision, control and precision. To date, robotic assisted laparoscopic radical prostatectomy (RALP) is the most common intervention for the care of patients with localized prostate cancer due to its minimal invasive approach and decreased complications compared to open radical prostatectomy. Although, robotic technology has improved the safety and reproducibility of the radical prostatectomy, complication due occur and early recognition and management of these complications is essential. Dr. Sotelo, from the University of Southern California, has assembled an all-star panel of robotic surgeons to discuss the common complication associated with robotic prostatectomy and their management. 

Dr. Sotelo starts the plenary discussing complications associated with patient positioning, which include brachial and ulnar neuropraxia, and lower extremity compartment syndrome. Positioning related complication constitute 12% of medical malpractice claims following RALP with brachial and ulnar injuries accounting for more than half (57%). Review of data from high volume centers has shown that operating time is closely related to positioning injuries with a 100-fold increase risk of a nerve injury occurring by for every hour spent in the lithotomy position. Patients at higher risk for injuries are those with elevated BMI, so the panel recommends against the use of shoulder pads and chest strap in these patients. Careful padding of the elbow is essential to avoid ulnar nerve injuries, and padding should be checked prior to draping in both the neutral and steep Trendelenburg position. For patients with muscular legs, and those with the peripheral vascular disease, who are subjected to long operative times, should be followed for development of compartment syndrome. Delayed diagnosis of compartment syndrome can have devastating consequences for the patients, such as kidney failure and permanent nerve and muscle damage. 

Vascular injuries during RALP are rare and occur often during the pelvic lymph node dissection (PLND). Devastating vascular injuries can occur during laparoscopic access, and these commonly involve injury of the epigastric vessels and right common iliac artery. During PLND vascular injuries occur due to limited exposure of the vessels, so the panel recommends a wife dissection of the external iliac vein to assure that no branches are missed. In the case a vascular injury is encountered, distal and proximal control is essential for arterial injuries, and this can be achieved with laparoscopic Klein Bulldogs. In the case of venous injuries, the pneumoperitoneum should be increased to 20 mmHg to prevent hemorrhage while the vein is closed.

Dr. Sotelo introduces the robotic hemorrhage tray (Figure 1), which includes all the necessary instruments that one would need to manage a vascular complication. Another structure that can be commonly injured during the PLND is the obturator never. Again like in vascular injuries this occurs due to limited exposure of the nerve during the dissection. It is also important to note that the obturator nerve is closely associated with an obturator vein and artery and the artery can be often confused with nerve leading to injury via clipping or transection. Injury of the obturator nerve is often associated with an obturator reflex and surgeons should watchful for this reflex is during the obturator node packet dissection. 

Urine leaks following RALP are often associated with anastomotic issues, but surgeons should always be a concern of a possible unrecognized ureteral injury. More than 70% of ureteral injuries are recognized in the post-operative period, and a delay in diagnosis is common. Risk factors associated with a ureteral injury are wide posterior dissection where the ureter is confused with the vas deferens, during extended pelvic dissections and in patients with large median lobes or prior TURPs. In the case of more proximal injuries, a ureteral re-implant should be performed if the injury is recognized. For patients in which the injury occurs at the level of the trigone, reconstruction of the trigone over double J stents usually results in proper outcomes. 

Lastly, the panel discusses rectal injuries. Rectal injuries tend to occur during the posterior apical dissection of the prostate where the recto-urethralis muscle tethers the rectum to the prostate. A combination of sharp and blunt dissection should be utilized to void a rectal injury. Early recognition of a rectal injury is essential since the consequences of a unrecognized rectal injury can be devastating (recto-urethral fistula, sepsis, and even death). In cases were the posterior dissection was challenging the panel recommends the use of the bubble test, which the pelvis is filled with water and air is pumped into the rectum to assess for an injury. In the case of injury the rectum should be closed in 2-layers, and a momentum or peritoneal flap should be considered for those with prior surgery or history of pelvic radiation. 

Rene Sotelo, MD, University of Southern California
Christopher Porter, MD FACS, Virginia Mason Medical Center
Thomas Ahlering, MD, University of California, Irvine
Rosalia Viterbo, MD FACS, Fox Chase Cancer Center

Written by: Andres F. Correa, Urologic Oncology Fellow, Fox Chase Cancer Center, Philadelphia, PA at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA