AUA Update SeriesLesson 2 Volume 29 2010

Complications of Contemporary Radical ProstatectomyLearning Objective: At the conclusion of this continuing medical education activity, theparticipant will be familiar with the most common complications associated with openand robot assisted radical prostatectomy; the incidence, etiology and diagnosis for eachof these complications; and their various preventive and treatment modalities.

G. Joel DeCastro, M.D., MPHDisclosures: Nothing to disclose

Uro-Oncology Fellow

Gagan Gautam, M.D.Disclosures: Nothing to disclose

Uro-Oncology Fellow

University of Chicago Medical CenterChicago, Illinois

and

Kevin C. Zorn, M.D., FRCSC, FACSDisclosures: Intuitive Surgical, American Medical Systems: Proctor/Consultant

Assistant ProfessorUniversity of Montreal

Montreal, Canada

This self-study continuing medical education activity is AUA Disclosure Policy: As a provider accredited by the Unlabled/Unapproved Uses: It is the policy of the AUAdesigned to provide urologists, Board candidates ACCME, the AUA must insure balance, independence, to require the disclosure of all references toand/or residents affordable and convenient access to objectivity and scientific rigor in all its activities. All unlabeled or unapproved uses of drugs or devicesthe most recent developments and techniques in faculty participating in an educational activity provided prior to the presentation of educational content.urology. The American Urological Association (AUA) is by the AUA are required to disclose to the provider Please consult the prescribing information for fullaccredited by the Accreditation Council for Continuing any relevant financial relationships with any disclosure of approved uses.Medical Education (ACCME) to provide continuing commercial interest. The AUA must determine if the Evidence-Based Content: As a provider of continuingmedical education for physicians. The AUA takes faculty’s relationships may influence the educational medical education accredited by the ACCME, it is theresponsibility for the content, quality and scientific content with regard to exposition or conclusion and policy of the AUA to review and certify that the contentintegrity of this CME activity. resolve any conflicts of interest prior to the contained in this CME activity is valid, fair, balanced,

commencement of the educational activity. The intent scientifically rigorous and free of commercial bias.Credit Designation Statement: The American Urologicalof this disclosure is not to prevent faculty withAssociation designates this educational activity for a Disclaimer: The opinions and recommendationsrelevant financial relationships from serving asmaximum of 1.0 AMA PRA Category 1 Credit™. Each expressed by faculty, authors and other expertsfaculty, but rather to provide members of thephysician should only claim credit commensurate with whose input is included in this program are their ownaudience with information on which they can makethe extent of their participation in the activity. and do not necessarily represent the viewpoint of thetheir own judgments. AUA.

Publication date: January 2010

Expiration date: January 2013

© 2010 American Urological Association, Education and Research Inc., Linthicum, MD

KEY WORDS: prostatic neoplasms, prostatectomy, complications

INTRODUCTION

Prostate cancer is one of the most common malignancies in Americanmen. In 2008 a total of 190,000 new cases were documented, with29,000 reported deaths.1 Since the advent of prostate specific antigenscreening there has been a concomitant increase in the detection andsurgical treatment of prostate cancer. Between 1986 and 1996 there wasa 2.2-fold increase in the number of radical prostatectomies performed,making it one of the most frequent surgeries in men.2-4

Open radical prostatectomy was once fraught with complications.Severe intraoperative hemorrhage was common, with nearly uniformerectile dysfunction and urinary incontinence postoperatively.5 Thepioneering work of Walsh and Donker in the early 1980s did much toelucidate the anatomical basis for these complications,6 leading to thedevelopment of the anatomical radical retropubic prostatectomy.7 Sincethen the number of intraoperative and postoperative complications hasdecreased dramatically.8-11

Optimizing anatomical knowledge, improving surgical techniques andincreasing surgical experience have been key in this trend. Just as theintroduction of the anatomical radical prostatectomy made the operationmore accessible to urologists, the wide acceptance of the robot assistedradical prostatectomy has made it the most commonly used techniquefor this surgery. While only 10% of RPs performed in 2005 were robotassisted, the proportion increased to more than 60% in 2008.12 It ispredicted that more than 85% of RPs performed this year will be robotassisted. Whether this new approach has actually led to further decreasesin complications is controversial.13, 14

This Update will focus on the most common complications of radicalprostatectomy, with comparisons made primarily between retropubicand robot assisted approaches. The perineal and pure laparoscopicapproaches, neither of which is widely used in the United States, willnot be reviewed in detail.

REPORTING BIASES

Outcomes comparisons between studies are difficult by the absenceof a standardized and well accepted classification system, resultingin wide variation in how complications are reported. The Clavienclassification system, which grades complications based on what addi-tional therapeutic measures are necessary, has been widely used in thegeneral surgery literature and, more recently, in urology.15, 16 Howeveruntil a standard classification system is widely adopted, accurate com-parisons between institutions will remain challenging.

Another obstacle to making accurate comparisons is the inherent biasin reporting complications as those centers with better outcomes aremore likely to publish than those with poorer outcomes.17 In addition,several studies have shown a relationship between increasing surgicalexperience and a lower rate of adverse operative outcomes, includingpositive surgical margins and biochemical recurrence.18, 19 Likewise,increasing surgical experience is associated with a decrease in perioper-ative complications.20 However, these studies originate from tertiarymedical care centers and represent only a small proportion of all RPsperformed annually.21 Data from large-scale population based data-bases, such as Medicare and Medicaid claims data, are largely free ofindividual surgeon biases.22, 23 While not as detailed as institutionaldatabases, they may provide more generalized statistics.

ABBREVIATIONS: BNC (bladder neck contracture), CT (computerized tomography), DVC (dorsal vein complex), DVT (deep venousthrombosis), ED (erectile dysfunction), IVC (inferior vena cava), MI (myocardial infarction), ORP (open radical prostatectomy), PE(pulmonary embolism), PLND (pelvic lymphadenectomy), RARP (robot assisted radical prostatectomy), RP (radical prostatectomy)

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NON-SPECIFIC SURGICAL COMPLICATIONS

All major surgical procedures are associated with some risk of morbid-ity and mortality that should be discussed during informed consent.We will first discuss several general complications that, while notspecific to RP, may be exacerbated by the nature of the operation andthe underlying disease.

Myocardial infarction. The systemic cardiovascular stress of generalanesthesia (eg intubation, intravenous fluids), pneumoperitoneum dur-ing RARP and acute blood loss result in significant risk for myocardialinfarction. However, MI is a rare complication in the perioperativeperiod, with a reported incidence <0.5%. In a single surgeon seriesLepor et al reported only 1 case of MI after 1000 ORPs performedbetween 1994 and 2000.24 A similarly low incidence was reported byCatalona et al in 1999.25 In a Medicare claims based study of morethan 100,000 patients undergoing ORP between 1991 and 1994 Lu-Yao et al reported a low MI rate with a modestly increased risk afterORP vs perineal prostatectomy (0.39% vs 0.29%).26 A similarly lowincidence has been reported with RARP.27

The most important step in preventing MI is preoperative patientevaluation and selection. Patients with any significant risk factors forheart disease should be fully evaluated and, if necessary, referred to acardiologist for further assessment and optimization. Patients who aredeemed too ill to safely undergo RP should be referred for radiationtherapy or watchful waiting.

Thrombotic complications. Deep venous thrombosis and pulmonaryembolism are significant complications of urological cancer surgery,especially pelvic surgery. There are certain aspects of RP that heightenthe risk, including hypercoagulability associated with neoplastic diseaseand intraoperative handling of the iliac vessels during pelvic lymphade-nectomy. Although there has been a general decrease in the incidenceof thrombotic complications following RP, PE remains one of the mostcommon causes of non-surgical death.28

Contemporary series report a symptomatic DVT incidence of0.2% to 1% after ORP, with approximately 0.2% diagnosed witha PE with or without previously diagnosed DVT.11, 24 In addition,some studies have demonstrated a trend of increased DVT risk withPLND.11 These numbers represent a significant decrease compared tostudies from the 1980s and early 1990s.25, 29

The incidence of DVT and PE appears to be similarly low in RARPseries. In a multi-institutional study encompassing 13 institutions andalmost 6000 patients Secin et al reported an incidence of 0.5% forDVT and 0.2% for PE, with a median time to presentation of 10 dayspostoperatively.30 Similarly low figures have been reported by Hu(DVT 0.6% and no PEs)27 and Menon (DVT 0.1%)31 et al. However,it should be noted that most studies do not include routine postoperativevascular imaging to detect the ‘‘true’’ incidence of thrombotic events.

Routine use of pharmacological thromboprophylaxis remains contro-versial, as there is concern for increased intraoperative bleeding andpostoperative lymphocele. There is also contradicting evidence as towhether DVTs or PEs are prevented with prophyalxis.30, 32, 33 Ac-cording to the 2008 AUA best practice statement intermittent pneu-matic compression devices should be used during and after allrobotic assisted laparoscopic and open procedures. Pharmacologi-cal thromboprophylaxis should be added for patients in higherrisk groups, including those with prior venous thromboembolism,hypercoagulable state or age >60 years.34 In comparison, the Ameri-can College of Chest Physicians evidence-based clinical practice guide-lines suggest the addition of subcutaneous pharmacological thrombo-prophylaxis for all patients undergoing major general surgery.35

Upon discharge from the hospital all patients should be educatedon the signs and symptoms of DVT and PE, and advised to seekimmediate care if concerned. This is especially important since symp-tomatic DVTs tend to occur between 1 and 3 weeks postoperatively,which is well after most patients are discharged home.30, 36 Patientswith clinical findings suspicious for DVT should undergo Dopplerultrasound. If confirmed, therapy should be initiated in consultationwith a vascular surgeon.

DVT treatment focuses on preventing clot propagation and PE.37

Anticoagulation therapy with low molecular weight or unfractionatedheparin should be initiated immediately after diagnosis and continuedfor at least 5 days. At that time oral anticoagulation with coumadinmay be initiated but should overlap with heparin treatment for 4 to 5days. Anticoagulation should continue for at least 3 months at whichtime reevaluation may be performed. If anticoagulation is contraindi-cated (eg if there is active bleeding), insertion of an IVC filter maybe indicated. In certain patients with a proximal ileofemoral DVTwithout significant bleeding risk catheter directed thrombolysis maybe appropriate.37

Treatment for PE is similar to that for DVT. If high clinical suspicionexists, anticoagulation with heparin should be started immediately anda diagnostic CT angiogram or ventilation perfusion scan should bepromptly performed. If a PE is confirmed, clinical status will dictatewhether a thrombolytic agent should be administered. If the patient isstable, anticoagulation may be continued under close observation butif critical, fibrinolysis should be initiated while anticoagulation is with-held. If there is clinical improvement, anticoagulation should continuebut if not, surgical or catheter embolectomy should be considered. Inthe case of a PE in which anticoagulation is contraindicated an IVCfilter may be inserted.37

INTRAOPERATIVE COMPLICATIONS

Hemorrhage. Historically, one of the most morbid aspects of ORPwas the often unpredictable blood loss associated with the operation.Although anatomical radical retropubic prostatectomy results in re-duced intraoperative blood loss, significant hemorrhage remainscommon.6, 7 Most significant bleeding originates from the dorsalvenous complex, the arterial and venous pedicles, the neurovascularbundles or when a hypogastric vessel is unintentionally injured.The average blood loss during an ORP is 800 to 1500 ml.24, 25, 28, 32

One of the most commonly cited advantages of the RARP is the reducedblood loss with average reports of 50 to 250 ml.27, 31, 38 The potentialreasons for this difference include reduction of venous sinus bleedingby virtue of pneumoperitoneum (14 to 20 mm Hg), improved controlduring suturing and transection of the DVC, and enhanced visibilityof periprostatic vessels during nerve sparing procedures. However, itis not clear whether the resultant need for blood transfusion is differentbetween the 2 approaches.38-40

Management of hemorrhage depends on the source. In the case ofORP significant bleeding from the DVC should be addressed withfigure-of-8 sutures, while minor oozing can be managed with a combi-nation of cautery and pressure. In the case of RARP venous bleedingmay be controlled with a temporary increase in pneumoperitoneum(typically to 20 mm Hg), and a combination of cautery, compressionand suturing. With both surgical approaches small caliber arteries canbe treated with meticulous cauterization or, if involving a larger vessel,suturing or clipping. Management of more significant bleeding, suchas from perforation of an iliac vessel, depends on the size of the defectas well as on the experience of the surgeon. In the case of RARP repairwith a non-absorbable suture may be possible but a low threshold foropen conversion still exists.

Obturator nerve injury. Damage to the obturator nerve, althoughuncommon, almost always occurs during PLND either as a crush,

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thermal or transecting injury. Its incidence is rare, with several largestudies of open and robot assisted prostatectomy consistently reportingno nerve injuries.24, 27, 28, 41 For open and laparoscopic approaches,meticulous use of scissors, graspers and thermal energy around thenerve during PLND is critical.

Postoperative sequelae include complaints of pain or numbnessradiating over the ipsilateral inner thigh, weakness of thigh adduc-tion and gait instability. Treatment depends on the type of injury. Inthe case of crush or thermal injuries prompt postoperative physiotherapymay be sufficient. If transection is recognized intraoperatively, primarysuture repair should be performed using a fine non-absorbable suture(eg 6-zero nylon). Intraoperative neurosurgical consultation may behelpful. There have been some reports of repair being performed laparo-scopically.42

Bowel injury. Injuries to the small or large bowel during open orrobot assisted radical prostatectomy are rare. In their review of 322patients treated with RARP Hu et al reported an incidence of 0.6%,27

with similar numbers from other groups.31 Nevertheless, urologistsshould be aware of the mechanisms of potential injury and principlesof repair.

Bowel adhesions to the anterior abdominal wall may lead to injuryduring initial Veress needle and trocar insertion. Scarred areas associ-ated with previous surgeries, as well as areas containing mesh,should be avoided as sites of primary access. If initial attempt atinsufflation using the Veress needle fails, the surgeon may use a Hassonincision. Blind introduction of a blunt trocar without establishment ofa pneumoperitoneum should not be performed.43 The skin incisionshould be made long enough to accept the first trocar without requiringundue force. All subsequent trocars should be inserted under visualguidance. The space between the abdominal wall and abdominal con-tents should be maximized during trocar insertion, initial insufflationpressure should be 20 mm Hg, the stomach should be emptied with anorogastric tube and the patient should be placed in steep Trendelenburgposition.

Inadvertent bowel injury from either assistant or robotic instru-ments can be minimized by establishing a good pattern of communi-cation between the bedside team and the console. It is essential thatthe assistant always asks for visual help if they cannot ‘‘find’’ theirinstrument on the screen and should never attempt to further push aninstrument if meeting resistance. Likewise, the robotic instrumentsshould always be kept within the visual field and, if they fall outsidethe field, the camera should be moved to find them before furthermovements are made.

Intraoperative recognition of a bowel injury is essential. Beforeleaving the console the surgeon should carefully inspect the loops ofbowel that are in the trajectory of the assistant and robotic instruments.Bowel injury after RARP may present differently than after ORP,with single port site tenderness, diarrhea and leukopenia as thefirst clinical signs.44 If there is any degree of suspicion and the patientis stable, CT with oral Gastrografin may be diagnostic. However, ifthe clinical condition is poor, emergent exploratory laparoscopy orlaparotomy should be performed.

The mechanism, extent and location of the bowel injury will determinewhether a primary repair versus a small bowel resection should beundertaken. If small and without evidence of surrounding ischemia,the defect may be repaired with a primary anastomosis. If a devasculari-zation injury is suspected, management may be more complex andrequire the assistance of a general surgeon.

Rectal injury. Rectal injury is a relatively rare but potentially devasta-ting complication. ORP series cite an incidence of 0.1% to 0.5%.11, 24, 25

In comparison, a 1999 claims based study of more than 13,000 patientsat Veterans’ Administration medical centers reported that 1.8% ofpatients experienced a rectal injury requiring repair after ORP.4 In 2RARP series no rectal injuries were recorded.27, 31

Rectal injuries during RP tend to occur near the apex whiledeveloping the plane between the prostate and rectum (fig. 1).While Denonvilliers’ fascia can usually be used as a safe marker duringdissection, previous prostate directed treatments including multiplebiopsies, transurethral resections and radiation can obliterate this plane.In such cases sharp dissection along or even through Denonvilliers’fascia is recommended, as blunt dissection may increase the risk ofrectal injury.17, 45 In patients at higher risk for rectal injury (afterpelvic radiation, previous transurethral resection or rectal surgery)a bowel preparation should be used. For RARP, initial posteriordissection of the seminal vesicles may facilitate bladder neck transectionand allow earlier identification of the rectum.

Intraoperative recognition is critical to minimize morbidity. Blumberget al reported a multi-disciplinary treatment algorithm for rectal injuryduring RP (fig. 2).46 Rectal injuries can usually be treated with aprimary 2-layer closure using an absorbable suture.17, 24 The repairmay be tested by insufflating the rectum transanally with air andchecking for a gas leak after filling the pelvis with fluid. If the defectis large with gross spillage or if the patient has been previouslyirradiated, diversion in consultation with a colorectal surgeonshould be considered.28, 32, 47 Copious irrigation of the area is usefulfor preventing infection and abscess formation, and interpositionof omentum or a perirectal fat flap over the defect may help preventrectourethral fistulas.48 Such fistulas are usually associated with in-juries not identified intraoperatively or with large rectal injuries thatwould have been best served with temporary diversion.27 Postopera-tively, patients should remain on broad-spectrum antibiotics that covercolonic organisms, and advanced slowly to a low residue diet.

Patients in whom intraoperative repair fails or who sustain an unrecog-nized injury can present with a pelvic abscess or a rectourethral fistula.Symptoms include fecaluria, pneumaturia, rectal bleeding, recur-rent polymicrobial urinary tract infection, fever, pain and sepsis.46

Stable patients can be investigated with cystourethrography, cystos-copy, a Gastrografin enema, flexible sigmoidoscopy and pelvic CT. Ifa pelvic abscess is present, percutaneous drainage should be performed.Urethral catheterization should be performed in all patients. If a recto-urethral fistula is present, it can be reassessed with cystourethrography2 to 3 months postoperatively, and the Foley catheter removed onceresolution of the fistula is documented. Patients who have undergonefecal diversion should undergo flexible sigmoidoscopy or Gastrografinenema before closure of the stoma. In patients with a persistentfistula definitive surgical treatment should not be considered forat least 3 months following injury to allow resolution of the inflam-matory process. Repair performed sooner has a high failure rate.

FIG. 1. A, intraoperative identification of rectal injury during wide resection RARP. Defect can be better identified by inserting gloved fin-ger into rectum or by air insufflation along with fluid filling of pelvis in suspected cases. Once identified, operative field should be washedwith copious saline. B, with margins being clearly defined, rectal closure can then performed in 2 layers with absorbable suture followed byvascularized interposition flap (omentum or perirectal fat).

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Numerous surgical approaches, including transabdominal, transsacral,trans-sphincteric, transanal, transperineal and transpubic, are availablefor repair of this complex fistula.

Bladder injury. Although rare, injury to the bladder wall may occurduring RP. If a PLND is performed before dissection of the Retziusspace during RARP, lymph node removal medial to the medial umbili-cal ligament may inadvertently injure the bladder. Inadvertent cysto-tomy can also occur during bladder mobilization and posterior bladderneck transection. Repair of the bladder can usually be performed withabsorbable figure-of-8 sutures.

Ureteral injury. Ureteral injury during radical prostatectomy isuncommon, with past and more contemporary studies of ORP andRARP reporting similar incidences of 0% to 0.5%.9-11, 24, 25, 27 Injurymay occur during pelvic lymph node dissection when the ureter liesin close proximity to the internal iliac artery, transection of the posteriorbladder neck in the presence of a large intravesical prostatic lobe,ligation of the lateral vascular pedicles and posterior dissection of theseminal vesicles, or in cases of an ectopic ureter (fig. 3).32 To reducethe risk of injury during RARP, the ureter should be identified immedi-ately upon entering the peritoneal space. In addition, immediately uponentering the bladder anteriorly the ureteral orifices should be identifiedand cannulated with a feeding tube if necessary. If this is difficult dueto a large intravesical prostatic lobe or because of abnormal urothelium,intravenous injection of methylene blue or indigo carmine dye may behelpful.

Treatment of a ureteral injury depends on the mechanism as well aslocation of the damage. Whether a thermal injury is significant andrisks subsequent ischemic necrosis may be assessed visually. If deemedsignificant, resection of the affected segment and ureteral reimplanta-tion may be performed. Transection injuries can usually be oversewn.Ureteral injury in close proximity to the trigone during seminal vesicledissection will likely require reimplantation, as will laceration of anectopic ureter.28 After any ureteral repair a stent should be kept inplace for at least 2 to 6 weeks. In addition, since these patients are at riskfor a ureteral stricture, imaging of the upper urinary tract (ultrasound orCT) or functional analysis (renal scan) may be performed 4 to 6 weeksafter stent removal.

POSTOPERATIVE COMPLICATIONSImmediate complications. Hemorrhage: The sources of postoperative

bleeding are most often the prostatic pedicles or dorsal venous complex.With RARP bleeding from the anterior abdominal wall may occur aftertrocar removal. However, significant postoperative hemorrhage is rare.In a 1994 study of 1350 ORPs Hedican and Walsh reported an incidence

FIG. 2. Treatment algorithm for rectal injury in laparoscopic radical prostatectomy. Reprinted with permission.46

of 0.5%,49 and more recent incidences range from 0% to 0.3% for ORPand 0.4% to 0.6% for RARP.11, 24, 25, 27, 31

Preventing post-RARP hemorrhage involves identifying intraop-erative sources of bleeding before removing the trocars, which canbe done by reducing the pneumoperitoneum to 4 mm Hg, andclosely observing the pelvis and lateral walls for any evidence ofpersistent bleeding. Removal of all trocars under vision will alsofacilitate immediate visualization of any abdominal wall bleeding

FIG. 3. Potential sources of ureteral injury during RARP. A, during posterior bladder neck division in men with asymmetric prostatic lobesor median lobe that distorts trigonal anatomy. Arrow depicts left ureteral orifice which lies in close proximity to line of dissection. B, duringright pelvic lymph node dissection ureter is partially incised with sharp scissors. Methylene blue can be seen extravasating from lumen andureter was repaired with interrupted absorbable suture.

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previously compressed by a trocar. Using the Carter-Thomason devicefor fascial closure also ensures that any new bleeding, such as fromthe inferior epigastric vessels, is quickly identified.

Postoperative hemorrhage is diagnosed based on physical examinationfindings (particularly urine output, blood pressure and heart rate) aswell as drain outputs and serial hematocrits. Treatment depends largelyon the severity of bleeding, with most cases managed with supportivecare and blood transfusion as needed. If a patient is unstable or requires

more than 4 units, or if concern about persistent bleeding remainsafter transfusion, exploratory laparoscopy or laparotomy should beimmediately performed.50

Anastomotic Leak: Because most anastomotic leaks are small andresolve spontaneously, the actual incidence of this complication isunknown (fig. 4). Anastomotic leaks occur in less than 3% of ORPcases8, 24 and in 1% to 8% of RARP cases.27, 51 The risk for anastomoticleakage is inversely proportional to the quality of the anastomosis. Toachieve a good anastomosis, the caliber of the bladder neck should notbe much larger than that of the urethra. If the bladder neck openingis large, it can be tapered appropriately with figure-of-8 sutures at the3 and 9 o’clock positions.

For the open approach, 5 or 6 interrupted absorbable sutures arecommonly used for the vesicourethral anastomosis. A running anasto-mosis is performed with RARP. Visualization of the anastomosis maybe improved using a 30° downward angled lens. Lapra-Ty clips mayfacilitate construction of a watertight anastomosis by allowing thesurgeon to adjust tension on the suture line.52 Before applying theseclips, one must visually confirm that the anastomosis is tight, especiallyat the posterior edge. Regardless of approach, once the anastomosisis complete the bladder should be filled with water and observedfor areas of leakage.

Although improved visualization may facilitate the anastomosis dur-ing RARP, there are several unique technical challenges to using thisapproach. If the instruments do not reach the urethra, the arm and trocarshould be carefully advanced further into the patient. The presence ofa large overhanging pubic osteophyte may make it more difficult toaccess the urethra with the robotic instruments but this can usually bemanaged with inferolateral angulation of the arms.

Leaving an intraperitoneal drain helps in the diagnosis and treat-ment of an anastomotic leak. Fluid analysis for creatinine from drainoutputs can quickly differentiate between peritoneal fluid and urine. Ifconsistent with urine, the drain should be left in place until the outputdecreases to minimal, at which time a repeat creatinine analysis of thefluid may be performed. Patients can be discharged home with thedrain in place and instructions to carefully record outputs every 4 to6 hours. If the output remains high, the drain should be placed offsuction, as negative pressure may actually increase leakage from the

FIG. 4. CT cystogram of anastomotic leakage. A, intraperitoneal extravasation of contrast medium. B, leakage from anterior and posteriorvesicourethral anastomoses. Treatment included prolonged Foley catheterization and pelvic drainage.

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anastomosis. The Foley catheter should not be removed until a cysto-gram confirms resolution of the leak.

Rhabdomyolysis: Rhabdomyolysis results from muscle necrosis andrelease of intracellular contents caused by prolonged compression ofmuscles during long surgical procedures, which may lead to renaltubular necrosis and renal failure. In urology rhabdomyolysis is mostcommonly associated with procedures requiring an exaggerated lithot-omy position (perineal prostatectomy) or flank position (laparoscopicnephrectomy).

Interestingly, a review of the literature reveals no reports of rhabdomy-olysis associated with ORP or RARP. However, urologists should befamiliar with this clinical entity and its management, particularly duringthe initial learning curve associated with RARP. During this periodrobotic time should be limited to a maximum of 6 hours and, ifnot completed by then, open conversion should be considered.

Prevention involves identifying and padding any muscles under com-pression. During RARP care should be taken to avoid contact betweenthe robotic arms and the patient. Postoperatively, patients with rhabdo-myolysis often have oliguria and brown urine due to the presence ofpigmented casts. Creatine kinase, an intracellular component in muscle,is invariably elevated, often exceeding 5000 units/dl.

Acute management involves hydration and alkalization to preventrenal failure. A nephrology consult should be obtained and renal func-tion monitored closely. After the acute period has resolved focus shouldbe placed on rehabilitating the affected muscles with physiotherapy.Unfortunately, some patients have permanent renal failure and/or physi-cal disability.

Nerve Palsy: Nerve palsy during RP occurs due to patient position-ing or nerve compression within the surgical field. From a largeRARP series Hu et al reported single postoperative cases of ulnar andmedian nerve as well as lumbosacral neuropraxias.27 In an ORP seriesAugustin et al reported on 6 patients (0.5%) complaining of sciaticaor lower back pain.11 Sciatic nerve injury is more likely to occur fromleg overextension, while femoral nerve palsy, although rare, may alsooccur due to compression from self-retaining retractors.24, 53

To avoid such injuries care must be taken to not overextend theextremities or the back. In addition, all possible pressure areas shouldbe appropriately padded. Similarly, care should be taken to avoid plac-

ing self-retaining retractors directly on nerve containing structures (thepsoas muscle) and to use padding between the retractor and tissues.Of equal importance is keeping the surgical time to less than 6 hours,especially if the surgery involves the patient being in a flexed position.Treatment of nerve palsy depends on the severity. Physiotherapy isindicated for mild cases, and a neurological consult should be obtainedfor severe cases to determine the extent of injury and the best manage-ment options.

Delayed complications. Lymphocele: Lymphocele forms when lym-phatic channels remain patent after surgery. The risk of lymphoceleincreases when a PLND is performed, especially if an extendedtemplate is used.54 Lymphoceles are relatively common complications,although the exact incidence is unknown since most will resolve withoutever being diagnosed. They are reported to occur in 0.1% to 2%of patients with no significant differences between surgicalapproaches.11, 24, 27, 55 Meticulous cautery or clipping of lymphaticchannels during open and laparoscopic prostatectomy may be importantin preventing lymphoceles.

When clinically significant, patients may present several weeksafter RP complaining of unilateral leg swelling due to compressionof pelvic venous return. Pelvic CT or ultrasonography may help to con-firm the diagnosis (fig. 5). Treatment depends on the size of the lympho-cele and the associated symptoms. Many large lymphoceles will resorbover time but if the patient has a fever, insertion of a percutaneous drainwith or without sclerotherapy may be indicated.56 Marsupialization ofthe lymphocele via an open or laparoscopic approach may be performedif more conservative therapy is unsuccessful.57

Hernia: Incidentally detected inguinal hernias are common during radi-cal prostatectomy. In a series by Lepor et al 12% of patients had a hernia,which was repaired intraoperatively.24 Similarly, Finley et al reportedfavorable outcomes with intraoperative inguinal hernia repairs usingmesh during RARP.58 Inguinal hernias are also relatively common afterRP with incidences as high as 17% after ORP and up to 14% after laparo-scopic RP.59, 60 However, incisional hernias occur much less often (<1%in open and robotic series).24, 25, 31 While port site (spigelian) hernias arereported in the general surgery literature, few have been cited followingRARP.61

Post-ORP inguinal hernias are likely to result from weakeningof fascial planes as the rectus and transversalis fascias are incised.62

There is no simple way to prevent post-ORP inguinal hernias, as noclear association of modifiable factors has been established. Incisionalhernias can be avoided by ensuring that the fascia underlying thesuprapubic incision in cases of ORP and the specimen extraction site

FIG. 5. A, CT reveals bilateral symptomatic pelvic lymphocele 4 weeks after RARP. Patient presented with bilateral pedal edema, pelvic dis-comfort and low grade fever. B, treatment included percutaneous drainage of both lymphocele collections and antibiotics.

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in cases of RARP are completely closed. Although controversial, fascialclosures should be performed in all ports ≥15 mm, while being carefulnot to incorporate bowel into the sutures.

Bladder Neck Contracture: The etiology of bladder neck contracturesis not definitively known but likely involves anastomotic urinary leak-age or pelvic hematoma that causes chronic irritation and scarring.49

They are estimated to occur in 0.5% to 10% of ORP and 0.6% to2% of robotic cases.24, 27, 28, 51, 63 In a large ORP series Erickson etal found that patients in whom BNCs developed had higher preoperativeprostate specific antigen levels and were more likely to have undergonea non-nerve sparing RP.64 In addition, patients with contractures hadlower postoperative potency and continence rates, and were more likelyto have biochemical failure.

Preventing bladder neck contracture involves the same techniquesas preventing anastomotic leakage. Watertight anastomosis withouttension and vascularized mucosa-to-mucosa apposition are essential.Some advocates of RARP have noted that bladder mobilization reducestension at the vesico-urethral anastomosis and enhanced visualizationallows for improved approximation of mucosal edges during the runninganastomosis. Both of these advantages may help reduce the incidenceof anastomotic leakage and BNC.

Postoperatively, patients with bladder neck contracture usually pres-ent with weakened urinary stream and incomplete voiding due to over-flow incontinence between 1 and 12 months after catheter removal.28, 51

The diagnosis can be confirmed cystoscopically, during which a stric-tured anastomosis, through which the cystoscope cannot pass, is visual-ized. Under vision, a wire should first be passed into the bladder and,after securing access, multiple incisions made at the bladder neck usinga urethrotome. However incision may not be necessary, as simpledilation appears to be effective in many cases.65

Urinary Incontinence: Urinary incontinence is one of the most com-mon long-term complications of RP. Because there is no set definitionof urinary incontinence, it is important to understand how it is measuredin any given study and how time elapsed since the operation can affectthe data.28

Stress urinary incontinence is likely due to intrinsic sphincterdeficiency resulting from trauma, although detrusor instability mayalso play a role.66 Injury to the rhabdosphincter may occur duringapical dissection of the prostate, ligation of the DVC or insertion ofthe anastomotic sutures.28 In addition, large discrepancies in diameterbetween the bladder neck and urethra may increase the risk of inconti-nence. To reduce the likelihood that the proximal urethra remains open

and not coapted at rest, it may be important to reconstruct the bladderneck (when necessary) to an appropriate size before beginning theanastomosis.66

Overall, the incidence of post-RP urinary incontinence has decreasedduring the last 3 decades. Hautmann et al reported on 418 patientsbetween 1984 and 1993, of whom 55% reported complete continenceat 36 months after ORP.9 In contrast, in a more recent series Maffezziniet al reported an 89% continence rate after ORP.10 Catalona25 andWalsh67 et al reported continence, defined as requiring no pads, inmore than 90% of patients.

These contemporary results serve as a significant contrast to popula-tion based studies. Fowler et al reported that 40% of Medicare patientswho underwent ORP between 1988 and 1990 complained of somedegree of stress urinary incontinence postoperatively.68 Similarly, intheir questionnaire based study Kao et al found that 33% of patients whounderwent ORP after 1990 complained of some level of incontinence,defined by the need for any number of urinary pads.69 Similar data arereported from other population based studies.70

To improve the likelihood of postoperative continence, preoperativeKegel exercises and coordination of reflexive pelvic floor contractionsduring Valsalva maneuvers may be helpful. RARP may have certaintheoretical but unproven advantages in preserving urinary function.Improved visualization during dissection of the prostatic apex as wellas reduced bleeding may help limit injury to the rhabdosphincter.31

Ahlering et al reported that 76% of 60 patients required no pads 3months after RARP.71 Patel et al reported that at 12 months continencerates based on the same criteria were as high as 98%.72 Zorn et alreported subjective continence, defined as no pad use or occasionaluse of a protective pad, in 90% of 300 patients after RARP.73 Awatertight mucosal-to-mucosal anastomosis with minimal urinary ex-travasation, scarring and fibrosis may allow for restoration of physiolog-ical urethral coaptation at rest and during exercise, and is criticallyimportant for post-RP urinary continence.

Whether reconstruction of the periprostatic tissues (the posterior mus-culofascial plate encompassing Denonvilliers’ fascia) improves urinarycontinence remains unclear.74-76 Rocco et al were one of the first todescribe this technique for ORP, and they found that reconstructing theposterior fascial plane resulted in a markedly shorter time to continencecompared to a historical cohort.76 Similar results have been reported byothers.74 In contrast, in a randomized study of 116 patients undergoingRARP with or without reconstruction of the periprostatic tissues Menonet al found no difference in ultimate urinary continence.75

Treatment of incontinence should first focus on behavioral modifica-tions, pelvic floor physiotherapy should continue postoperatively andconsumption of diuretics like coffee or alcohol should be restricted.Initial therapy may include a trial of an anticholinergic to address thepossibility of detrusor overactivity. If significant urinary incontinencepersists for more than 1 year, surgical therapy such as an artificialurethral sphincter or urethral sling may be considered.

Erectile Dysfunction: Erectile dysfunction is one of the most fearedcomplications of radical prostatectomy for most men and their partners.Research in the early 1980s provided insight into the etiology of post-prostatectomy erectile dysfunction, leading to the development of novelsurgical techniques to prevent it.6, 77 The incidence of post-RP erectiledysfunction has since improved significantly.8, 78 However, reportingon postoperative ED is fraught with difficulties because of the variousmeasurement methods used by different investigators and institutions.Only validated, standardized questionnaires, such as the InternationalIndex of Erectile Function, should be used to evaluate postoperativeerectile function.

Return of erectile function can take anywhere from 3 months to 3years after surgery.79 At 3 months Walsh et al reported an erectilefunction rate of 38% after ORP, which increased to 86% by 18 months.67

16

Similar rates have been reported by others.80 However, some populationbased studies report lower statistics. Based on the Prostate CancerOutcomes Study, Stanford et al reported that at 24 months only 39%of patients had erections sufficient for intercourse.70

In general, the timing and degree of erectile function postopera-tively depend on several preoperative variables, including qualityof preoperative erections, age, degree of comorbidity and cancervariables that determine whether the neurovascular bundles maybe preserved.28, 67 Indeed, preoperative planning that takes all of thesevariables into account is important in deciding to what degree theneurovascular bundles can and may be preserved.81 Whether a nervesparing approach is undertaken unilaterally or bilaterally may be impor-tant for recovery of erectile function.25 Furthermore, the degree ofnerve sparing and subsequent erectile function also has been shown tobe affected by whether an extra or interfascial nerve sparing techniqueis used.82

Preservation of the accessory pudendal artery and release ofthe levator fascia anteriorly (‘‘high anterior release’’) appear toimprove erectile function after ORP and RARP.73, 83, 84 The robotassisted approach may have some theoretical advantages over theopen approach. Developing the plane between the prostate and rectumfacilitates identification (and preservation) of the medial border ofthe neurovascular bundle.28, 31 Dissection of the nerves in an antegrademanner may also facilitate avoidance of the neurovascular bundle.Conversely, there may be a tendency for increased use of cauteryduring neurovascular dissection during RARPs, whereas during ORPsuturing and clips are more frequently used. In the experience ofKhan et al avoidance of thermal injury produced a nearly 5-fold improvement in early return of sexual function.85 Furthermore,thermal injury appears to induce a dense injury that may be largelyreversible after 2 years.

Treatment of post-RP erectile dysfunction may begin with oralphosphodiesterase inhibitors and, if unsuccessful, intracavernosalinjections of prostaglandin E1. McCullough86 and Mulhall87 et aladvocate early use of these agents as part of a penile rehabilitationregimen, which may serve to protect nerves and vascular endothe-lium. The goal of such therapy is to increase post-prostatectomypenile vascular flow, minimize corporal fibrosis and eventuallyimprove erectile function. Rehabilitation may be important in thepostoperative period when ischemic scarring has been demonstratedto occur within the cavernosa in experimental animal models. Within2 months postoperatively decreases in cavernosal elastic and musclefibers, and increases in collagenous content have been documented.88

Penile pump devices and intraurethral alprostadil may also be consid-ered. If oral and intracavernosal therapies are unsuccessful, andreasonable time has passed since surgery (typically 1 to 2 years),a penile prosthesis may be considered.

CONCLUSIONS

The risks of significant complications associated with RP have de-creased dramatically during the last 2 decades. Comparisons amonginstitutions and surgical techniques are limited by the absence of astandardized classification system. Therefore, we advocate the use ofstandardized, validated questionnaires for future studies. While surgicalexperience appears to play a role in the risk of complications, anotherimportant factor is careful patient selection. Familiarity with the associ-ated complications and early recognition will result in efficient manage-ment with minimal long-term sequelae. More importantly, preventionof these complications is the ultimate goal. Nevertheless, all suchpotential complications should be fully discussed with patients duringthe process of informed consent.

Acknowledgement: Drs. Gary D. Steinberg, Arieh L. Shalhav, GregP. Zagaja and Scott E. Eggener critically reviewed and contributed tothis Update.

APPENDIX: TREATMENT AND PREVENTION OF COMPLICATIONS OF RADICAL PROSTATECTOMY

Specific surgical complications

Myocardial infarction T EKG T Preoperative cardiac evaluation and screening (stressT Serial troponin test, echocardiogram)T Cardiology consult T Identification of CAD risk factors (age

>50, hypertension, hypercholesterolemia smoking,obesity, family history)

Thromboembolic T Doppler ultrasound of lower extremities for DVT T Intermittent compression devices placed beforeT CT angiogram/VQ scan for PE anesthesia inductionT Vascular consultation T Pharmacological thromboprophylaxis (low molecularT Anticoagulation weight heparin, low dose unfractionated heparin)T IVC filter (especially in patients with T Screening of high risk patients

contraindications for anticoagulation) T Early ambulationT Fibrinolysis T Patient educationT Surgical or catheter embolectomy T Early diagnosis and treatment of suspected DVT

Intraoperative complications

Hemorrhage T Compression T Preoperative evaluation of coagulation parameters inT Increasing pneumoperitoneum high risk patientsT Cautery T Discontinuation of antiplatelets/anticoagulants 7-10T Hemostatic sutures days before surgeryT Fluid replacement T Careful operative technique (knowledge of pelvicT Blood transfusion anatomy, adequate exposure of operative field,

meticulous tissue dissection)T DVC suture/staple control

Obturator nerve injury T Primary nerve repair of perineureum with non- T Meticulous technique and early identification duringabsorbable microsuture lymph node dissection

T Neurosurgical consultation T Avoid thermal energy close to the nerveT Early physiotherapy

Bowel injury T CT with oral Gastrografin T Preoperative bowel prepT General surgery consult T Initial trocar entry through ‘‘virgin’’ areaT Early recognition (primary repair) T Raise pressure to 20 mm Hg during initial trocarT Delayed (primary repair, diversion, diagnostic placement

laparoscopy/laparotomy, bowel resection) T Placement of all trocars under direct visualizationT Decompress stomach with orogastric tubeT Steep Trendelenberg position to displace bowelT Good communication between console and bedside

surgeonT Careful inspection before closure

Rectal injury T Copious irrigation T Full bowel prep in high risk patientsT Primary 2-layer, interrupted absorbable suture closure T Sharp dissection through Denonvilliers’ fasciaT Omental interposition T In suspected cases digital inspection or rectalT Colorectal surgery consult insufflation with air and assessing for gas leak inT Colostomy diversion pelvis with fluid

Bladder injury T Primary repair with absorbable suture T Meticulous dissection of bladder neckT Pelvic drain T Avoid dissection medial to the medial umbilical

ligament during lymphadenectomy

Ureteral injury T Primary suture repair T Early identification of ureterT Ureteroureterostomy T Identification of ureteral orifices (previousT Ureteral reimplant transurethral resection, large median lobe)T Ureteral stent T Use of methylene blue/ureteral cannulationT Pelvic drainage

Postoperative complications

Postoperative hemorrhage T Vitals monitoring T Inspection of operative field under low pressureT Fluid replacement pneumoperitoneum before closureT Blood transfusion T Removal of all trocars under visionT Re-exploration T Fascial closure with Carter-Thomason deviceT Angiography and embolization

Anastomotic leak T Intraoperative bladder filling T Avoid large discrepancy between size of urethra andT Drain fluid for creatinine bladder neckT Intraperitoneal drainage and indwelling Foley catheter T Bladder neck reconstructionT Cystogram before catheter removal T Meticulous technique with watertight mucosa-to-

mucosa anastomosisT Inspection and repair of any leakage before case

completion

(continued)

17

APPENDIX: TREATMENT AND PREVENTION OF COMPLICATIONS OF RADICAL PROSTATECTOMY (Cont.)

Rhabdomyolysis T Myoglobinuria on urinalysis T Appropriate positioning and padding of pressureT Serum creatine kinase measurement pointsT Nephrology consult T Avoidance of prolonged surgery and immobilizationT IV hydrationT Urinary alkalizationT Renal function and output monitoringT Physiotherapy and rehabilitation

Peripheral nerve injury T Physiotherapy and rehabilitation T Appropriate positioning and padding of pressureT Neurology consult points

T Avoid overextension of extremitiesT Avoid excessive intraoperative stretch on nerves

Lymphocele T CT T Meticulous control of lymphatic channels duringT Conservative management dissectionT Drainage with or without sclerotherapyT Intraperitoneal marsupialization

Hernia T Surgical repair T Secure fascial closure of all incisions, extraction sitesand ports ≥15 mm

Bladder neck contracture T Bladder neck incision T As in ‘‘anastomotic leak’’

Urinary incontinence T Behavioral therapy T Preoperative Kegel exercisesT Kegel exercise T Meticulous apical dissectionT Urodynamic evaluation T Potential rhabdosphincter reconstructionT Surgical management (male urethral sling, artificial

urinary sphincter)

Erectile dysfunction T Early pharmacotherapy (phosphodiesterase inhibitors, T Nerve sparing dissectionintraurethral alprostadil suppository, intracavernosal T Avoidance of thermal and traction injuryinjections, vacuum assisted devices) T Preservation of accessory pudendal artery

T Penile prosthesis T High anterior release of levator fasciaT Penile rehabilitation

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Study Questions Volume 29 Lesson 2

1. According to the AUA guidelines on DVT prophylaxis,which of the factors place the patient at increased risk for athromboembolic event?

a. Age >60 yearsb. Malignancyc. Pelvic surgeryd. Previous venous thromboembolisme. All of the above

2. What is the estimated percent of symptomatic DVT for ORP?a. 2-4b. 5-7c. 0.2-1d. 8-10e. 11-13

3. Postoperative findings most likely to be associated with anobturator nerve injury include

a. Inability to flex the ipsilateral big toeb. Inability to abduct the ipsilateral legc. Decreased ipsilateral patellar reflexd. Inability to adduct the ipsilateral lege. Increased pain sensation over the contralateral thigh

Take this test online at http://www.auanet.org/eforms/cme/

4. Where is the most common site of rectal injury during radicalprostatectomy?

a. Near the seminal vesiclesb. Near the prostatic apexc. During vesicourethral anastomosisd. During pelvic lymphadenectomye. Laterally during dissection of the neurovascular bundle

5. What is a way to prevent postoperative hemorrhage afterRARP?

a. Reducing the pneumoperitoneum to 4 mm Hg beforecamera and trocar removal

b. Removing trocars after the camera is removedc. Increasing pneumoperitoneum during trocar removald. Avoiding pelvic lymphadenectomye. Placing the Foley catheter on traction postoperatively