Dr. Evans continued to discuss the issue of port placement and insufflation. The Hasson open technique may be preferable over the Veress needle in men with a history of prior abdominal surgery. Abnormal high intra-abdominal pressure indicates improper access. Surgeons should be aware of small penetrating injuries due to needle insertion. Injuries associated with trocars are more severe and usually require laparoscopic or open repair.
Subcutaneous and scrotal emphysema is not uncommon. It is related to the extent of CO2 leakage into the extraperitoneal space. Exacerbating factors include prolonged surgical time, use of high insufflation pressures, and insufflant leak around the fascial opening. When it is associated with high blood CO2 levels, delayed extubation may be required to allow the partial pressures of CO2 and of oxygen to normalize.
Gas embolism is less common when one uses CO2 compared with other gases. Classic signs include abrupt increase in end-tidal CO2 accompanied by a sudden decline in oxygen saturation and a subsequent decrease in end tidal CO2. Management includes immediate cessation of insufflation and repositioning of the patient in the left lateral decubitus position. In addition, the patient should be ventilated with 100% oxygen and in extreme circumstances, aspiration of the air embolism may be required.
Retroperitoneal vascular injuries are quite rare – 0.3% of laparoscopic cases. Most commonly injured vascular structures include the aorta and common iliac vessels, epigastric vessels, and mesenteric vessels. Injury is often immediately apparent: hypotension with compensatory tachycardia. If the trocar has not been withdrawn or manipulated, a blunt trocar should be replaced through the lumen. The trocar should be left in place while preparations are made for open laparotomy and vascular repair.
Bladder injury occurs in less than 2% of laparoscopic prostatectomy. Risk factors for this injury include pelvic surgery, hernia mash, or entry into the incorrect plane, too close to the detrusor muscle. The risk of injury to the bladder also exists during insufflation of the perivesical space for an extraperitoneal prostatectomy. Management includes two-layer closure and bladder decompression.
Bowel injury to the small bowel, colon or rectum can occur at various points during the surgery. In handling the bowel, blunt retraction, or during robotic/assistant movement outside the visual field. Cautery injury is common and more difficult to identify. Arc injuries occur when cautery is transmitted to adjacent structures from a monopolar instrument. Rectal injury occurs at an incidence of 0.2-1% during RALRP. It usually occurs during the dissection of the pre-rectal space or mobilization of the seminal vesicle. Risk factors include history of prior TURP, pelvic radiation, or with peri-prostatic inflammation. It is advisable to consider mechanical bowel preparation prior to surgery for high risk patients, as this can occur in these patients during an attempt for wider margins. Management includes direct two-layer repair by robotic approach for most small injuries of the rectum < 2 cm in size. It is important to test the air tight nature of the repair with instillation of air into the rectum with a piston syringe after filling the pelvis with water. Broad spectrum antibiotics are required, and following repair interposition of tissue between the repair and the vesicourethral anastomosis is desirable. In case of large or irregular rectal injuries, devitalized rectal wall, previous radiation, or excessive fecal soiling, it is recommended to consult with general surgery regarding proximal diversion by loop colostomy at the time of the repair.
Ureteral injuries are rare with an incidence between 0.046%-0.3%. Risk factors include history of a previous abdominal surgery, prostatitis, and pelvic radiation, or during an extensive lymph node dissection. Inadvertent thermal injury can also occur during seminal vesical dissection. The ureter courses lateral and deep to the tip of the seminal vesicle as it enters the trigone. Ureteral injury most commonly occurs however, at the level of the orifice during bladder neck division. Risk factors include large median lobe, infiltration of cancer at the bladder neck, requiring wide excision. Similarly, excessive traction following division can tear the posterior bladder neck, bringing the orifices very close to the cut edge. Extravesical ureteral injury is generally treated by reimplantation of the ureter to the bladder dome. In cases in which the ureteral orifice or distal intramural ureter is transected, or the cut edges of the bladder neck lies close to the orifice – a double J stent needs to be placed, followed by incision of the intramural ureter to mobilize the orifice cranially.
Several potential sources for bleeding exist, including the dorsal venous plexus, neurovascular bundles, epigastric vessels, and iliac vessels during PLND. The pneumatic pressure provided by insufflation reduces bleeding. A common cause of delayed bleeding is de-sufflation with ensuing bleeding from uncontrolled small vessels controlled by pneumatic pressure during the procedure. Inspection of the field under reduced insufflation pressure of 5-8 mm HG is advised after completion of the procedure. Early bleeding occurs immediately following surgery. Delayed bleeding occurs 3-4 days after surgery.
Anastomotic urine leak occurs usually after surgery, with risk decreasing substantially with time until about 3 weeks after surgery. Usually there is no need for continuing the indwelling catheter after 3 weeks. Controlled or contained leaks, regardless of the size will general close with a catheter.
Lymphocele occurs in >=10.3% of patients undergoing extended pelvic lymph node dissection (PLND). Minor subclinical lymphoceles are more common. For prevention, meticulous PLND coupled with the use of bipolar cautery with careful placement of hemostatic clips is sufficient. Percutaneous drain placement usually alleviates symptoms of pain, drain any infected fluid, and may decrease the incidence of late deep vein thrombosis. Drains with high output should remain in place until the output decreases.
Post site hernia has an incidence of 1%. Most surgeons advocate closure for port sites > 10 mm, located below the arcuate line.
In conclusion, surgeons who are at the beginning of their learning curve have longer operative times and higher complication rates. For surgeons experienced with open prostatectomy, the robotic learning curve requires approximately 250 cases. 
Presented by: C.P. Evans, Sacramento, CA, USA
Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre, twitter: @GoldbergHanan at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark
 Herrel SD et al. Urology 2005; 66 (5 suppl.): 105-107