NARUS 2018: Complications, Intraoperative, Decision Making, and Troubleshooting
The first case was 2.5-hour robotic partial nephrectomy performed in a young healthy, muscular male with a weight of 105 kg and BMI of 33. Postoperatively he had pain and tightness in his right buttocks, with associated paresthesia over the right buttock and lateral thigh. He was able to freely move his hip and had excellent strength. However, his creatinine kinase elevated to 10,752 on post-operative day #2 with increasing pain and paresthesia, at which point it was recognized that he was suffering from rhabdomyolysis. Orthopedic surgery was consulted and this gentleman ultimately needed a buttock fasciotomy. Dr. Sundaram then highlighted several points regarding rhabdomyolysis, noting that this is diagnosed when CK levels are > 4-5 x normal, +/- symptoms of muscle pain, weakness, skin changes and darkened urine. Thankfully the incidence after urologic surgery is only 0.1%. Risk factors include male gender, comorbidities such as diabetes, obesity or pre-existing kidney disease, and prolonged surgery (>5 hours). Sequelae of rhabdomyolysis include acute kidney injury, longer hospital stay, and higher hospital costs.
A second case highlighted a complication that is common to all pelvic and oncologic procedures, which was a patient presenting with leg swelling and resulting diagnosis of a deep vein thrombosis (DVT) following a robotic partial nephrectomy. Certainly, we have to be vigilant regarding the use of chemoprophylaxis for these patients and have a high-index of suspicion when these patients develop signs and symptoms of DVT.
A final case was a complex left partial nephrectomy in which the operating surgeon took a direct hilar approach. After identifying the aorta, the surgeon identified an arterial structure coming off of the aorta in a horizontal fashion, anterior to the main renal vein. This artery was then clipped and divided, as well as subsequent division of the renal vein. The operating surgeon then discovered the main renal artery behind the renal vein and divided this as well, completely freeing the kidney. At this point it was noticed that the affected vessel was in fact the superior mesenteric artery that was inadvertently divided. According to the panel, the catastrophic mistake the operating surgeons made was that when they immediately examined the bowel intraoperatively it still appeared pink and viable, however within 24 hours this bowel will be necrotic and the patient is at essentially 100% risk of mortality. Uniformly, the panel notes that the correct management is to notice the error, call a vascular surgeon, and re-anastamose the SMA severed ends. Furthermore, this highlights the importance of knowing the anatomy around the hilum, notably: (i) the renal vein is anterior to the renal artery and thus any artery anterior to the renal vein is not the renal artery, and (ii) having the kidney “on stretch” when taking the hilum will further delineate the appropriate renal hilar structures.
Presented By: Mihir M. Desai, University of Southern California, Los Angeles, CA; James Porter, Swedish Medical Center, Seattle, WA; Chandru Sundaram, Indiana University School of Medicine, Indianapolis, IN
Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, @zklaassen_md ,at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV