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ERUS 2018: How to Manage Complications During Prostate Surgery

Marseille, France (UroToday.com) Dr. Sotelo gave the state of the art lecture in the ERUS 2018 meeting in Marseille. This talk focused on the major complication encountered in urologic robotic procedures and included some videos as well.

The number of robotic urological procedures performed worldwide is continuing to rise, with the most common procedure being robotic radical prostatectomy (RALP). This rise in robotic procedure prevalence is associated with the fact that more surgeons are in their learning curve, being more susceptible to make errors, which can result in major complications. Dr. Sotelo focused on three types of common urologic robotic complications:

  1. Vascular injuries
  2. Ureteral injuries
  3. Rectal injuries
Vascular injuries can occur at the beginning of the procedure, during the access to the abdominal cavity, and intraoperatively during dissection. Injury can occur to the great vessels during trocar insertion, and this can be a life-threatening event. A decision to repair the injury laparoscopically or convert to an open procedure should quickly be made. If repairing it laparoscopically, the pneumoperitoneum should be raised to 20-25 mm Hg. Additional trocars should be inserted as needed, and pressure should be applied with gauze or sponge. Later, the injured area should be exposed, and clamps should be used to clamp above or below the lesion before attempting to repair it.

Another common injury is to the inferior epigastric vessels, usually caused by insertion of the pararectal trocars. Coagulation and or clipping is quite effective in controlling this bleeding. Another possible injury is to the iliac vessels, during lymphadenectomy. The surgeon should first compress the area, increase the pneumoperitoneum to 20 mmHg, and the change to needle drivers. In cases of venous injury, the pressure will usually suffice to stop the bleeding. When the artery is injured, rolled gauze sponges should be used to stop the bleeding by tamponade effect. Afterward, the injured artery should be gasped and repaired with a rescue stitch (A multifilament suture with a CT-1 needle, 15 cm long, with a Hemlock clip tied to the end).

Next, Dr. Sotelo discussed ureteral injuries. Over 70% of these injuries are diagnosed intraoperatively. The incidence of these injuries are 0.8% during laparoscopy, and 0.3% during robotic prostatectomy1. The possible locations of these injuries include:

  1. Trigonal injury during posterior bladder neck dissection or anastomosis
  2. Distal ureter when doing a posterior approach in RALP
  3. Over iliac vessels (during pelvic lymphadenectomy)
When the ureteral orifices are seen close to the anastomosis, or in cases with a history of a previous TURP, bilateral double Js can be placed to prevent injury.  Another alternative to preventing possible injury is to perform a posterior tennis racquet repair, to distance the ureteral orifices from the anastomosis (Figure 1).

UroToday ERUS2018 Posterior tennis racquet repair to distance ureteral orifices from the anastomosis
Figure 1- Posterior tennis racquet repair to distance ureteral orifices from the anastomosis, to prevent ureteral injury:

When urine leak is evident postoperatively, Dr. Sotelo provided a clinical algorithm that surgeons managing this complication should follow (Figure 2). The fluid suspected of being urine should first be sent for a creatinine test. If positive, a CT cystography should be performed. When a leak is confirmed, it is important to note whether the patient is symptomatic or not. In a clinically non-symptomatic patient, expectant management is warranted. If the patient is symptomatic, complete urinary diversion should be attempted with nephrostomies and bilateral single J stents. If a urinoma develops, a drain should be placed to drain it.

UroToday ERUS2018 Clinical algorithm on how to manage a urinary leak
Figure 2- Clinical algorithm on how to manage a urinary leak:


The last topic discussed war injury to the rectum. When this occurs, the management should include these steps:

  1. Two layered suture repair
  2. If this is a non-nerve sparing procedure – The surgeon needs to imbricate this lateral tissue in the midline as an additional layer
  3. If there is a concern for proximity to the anastomosis and a possible fistula developing, it is important to tack the rectum to the levator muscle, pulling the rectal repair away from the anastomosis
  4. If possible, an omental pedicle should be brought down over the repair as another layer
  5. Administration of 7 days of broad-spectrum antibiotics
  6. The patient should be provided with stool softeners
  7. Before removal of the catheter, a cystourethrogram needs to be performed, to make sure no fistula has developed
This was a most interesting discussion, and Dr. Sotelo summarized it by reiterating that surgeons must proficiently know the anatomy before embarking to perform any procedure, whether robotic or not.


Presented by: R. Sotelo Noguera, Los Angeles, US 

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre, Twitter:@GoldbergHanan at the EAU Robotic Urology Section (ERUS) Meeting - September 5 - 7, 2018 - Marseille, France

References:
  1. Hu JC, Nelson RA, Wilson TG, et al. Perioperative complications of laparoscopic and robotic-assisted laparoscopic radical prostatectomy. The Journal of Urology 2006; 175(2): 541-6; discussion 6.