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Post-resection: Hemostasis, Checking for Rectal Injury, and Anastomotic Leaks

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Robot-Assisted Radical Prostatectomy

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Abstract

Robotic prostatectomy is one of the more difficult procedures in urology today with multiple steps. The learning curve for this procedure can be long and requires attention to detail in order to achieve good outcomes. Perioperative morbidity, defined as those complications occurring within 90 days of surgery, is estimated to be 14 % (range, 7–33 %) (Novara et al., Eur Urol 2012;62(3):431–452). A discussion of hemostasis, rectal injury, and anastomotic leaks follows.

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References

  1. Novara G, et al. Systematic review and meta-analysis of perioperative outcomes and complications after robot-assisted radical prostatectomy. Eur Urol. 2012;62(3):431–52.

    Article  PubMed  Google Scholar 

  2. Nowfar S, et al. Initial experience with aspirin use during robotic radical prostatectomy. J Laparoendosc Adv Surg Tech A. 2012;22(3):225–9.

    Article  PubMed  Google Scholar 

  3. Guru KA, et al. Apical margins after robot-assisted radical prostatectomy: does technique matter? J Endourol. 2009;23(1):123–7.

    Article  PubMed  Google Scholar 

  4. Lei Y, et al. Athermal division and selective suture ligation of the dorsal vein complex during robot-assisted laparoscopic radical prostatectomy: description of technique and outcomes. Eur Urol. 2011;59(2):235–43.

    Article  PubMed  Google Scholar 

  5. Wu SD, et al. Suture versus staple ligation of the dorsal venous complex during robot-assisted laparoscopic radical prostatectomy. BJU Int. 2010;106(3):385–90.

    Article  PubMed  Google Scholar 

  6. Tufek I, et al. The use of a laparoscopic bulldog clamp to control the dorsal vein complex during robot-assisted radical prostatectomy: a novel technique. J Endourol. 2013;27(1):29–33.

    Article  PubMed  Google Scholar 

  7. Khan F, et al. Spread of thermal energy and heat sinks: implications for nerve-sparing robotic prostatectomy. J Endourol. 2007;21(10):1195–8.

    Article  PubMed  Google Scholar 

  8. Smith TL, Smith JM. Electrosurgery in otolaryngology-head and neck surgery: principles, advances, and complications. Laryngoscope. 2001;111(5):769–80.

    Article  CAS  PubMed  Google Scholar 

  9. Donzelli J, et al. Neuroprotection due to irrigation during bipolar cautery. Arch Otolaryngol Head Neck Surg. 2000;126(2):149–53.

    Article  CAS  PubMed  Google Scholar 

  10. Kumar N, et al. Functional anatomy of the deer spine: an appropriate biomechanical model for the human spine? Anat Rec. 2002;266(2):108–17.

    Article  PubMed  Google Scholar 

  11. Tugcu V, et al. Stone formation from intravesical Hem-o-lok clip migration after laparoscopic radical prostatectomy. J Endourol. 2009;23(7):1111–3.

    Article  PubMed  Google Scholar 

  12. Tunnard GJ, Biyani CS. An unusual complication of a Hem-o-Lok clip following laparoscopic radical prostatectomy. J Laparoendosc Adv Surg Tech A. 2009;19(5):649–51.

    Article  PubMed  Google Scholar 

  13. Blumenthal KB, et al. Bladder neck contractures related to the use of Hem-o-lok clips in robot-assisted laparoscopic radical prostatectomy. Urology. 2008;72(1):158–61.

    Article  PubMed  Google Scholar 

  14. Person B, et al. Comparison of four energy-based vascular sealing and cutting instruments: a porcine model. Surg Endosc. 2008;22(2):534–8.

    Article  PubMed  Google Scholar 

  15. Phillips JM, et al. Histological evaluation of cold versus hot cutting: clinical impact on margin status for laparoscopic partial nephrectomy. J Urol. 2008;180(6):2348–52.

    Article  PubMed  Google Scholar 

  16. Donzelli J, et al. Thermoprotective mechanisms of irrigation during bipolar cautery. Otolaryngol Head Neck Surg. 1998;119(3):153–8.

    Article  CAS  PubMed  Google Scholar 

  17. Finley DS, et al. Hypothermic robotic radical prostatectomy: impact on continence. J Endourol. 2009;23(9):1443–50.

    Article  PubMed  Google Scholar 

  18. Zorn KC, et al. Application of ice cold irrigation during vascular pedicle control of robot-assisted radical prostatectomy: EnSeal instrument cooling to reduce collateral thermal tissue damage. J Endourol. 2010;24(12):1991–6.

    Article  PubMed  Google Scholar 

  19. Gill IS, et al. Improved hemostasis during laparoscopic partial nephrectomy using gelatin matrix thrombin sealant. Urology. 2005;65(3):463–6.

    Article  PubMed  Google Scholar 

  20. US Department of Health and Human Services. New fibrin sealant approved to help control bleeding in surgery. FDA Talk Paper T98-22 May 1988.

    Google Scholar 

  21. Evans LA, Morey AF. Current applications of fibrin sealant in urologic surgery. Int Braz J Urol. 2006;32(2):131–41.

    Article  PubMed  Google Scholar 

  22. Kumar U, Albala DM. Fibrin glue applications in urology. Curr Urol Rep. 2001;2(1):79–82.

    Article  CAS  PubMed  Google Scholar 

  23. Evans LA, et al. Fibrin sealant for the management of genitourinary injuries, fistulas and surgical complications. J Urol. 2003;169(4):1360–2.

    Article  CAS  PubMed  Google Scholar 

  24. MacDonald MF, Santucci RA. Adjunctive use of fibrin sealant in urethroplasty for early catheter removal. Issues Urol. 2006;36–40.

    Google Scholar 

  25. Hick EJ, Morey AF. Initial experience with fibrin sealant in pendulous urethral reconstruction. Is early catheter removal possible? J Urol. 2004;171(4):1547–9.

    Article  PubMed  Google Scholar 

  26. Diner EK, Patel SV, Kwart AM. Does fibrin sealant decrease immediate urinary leakage following radical retropubic prostatectomy? J Urol. 2005;173(4):1147–9.

    Article  CAS  PubMed  Google Scholar 

  27. Morey AF, et al. Drain-free simple retropubic prostatectomy with fibrin sealant. J Urol. 2002;168(2):627–9.

    Article  PubMed  Google Scholar 

  28. Flury SC, Starnes DN, Steers WD. Application of fibrin sealant at the urethrovesical anastomosis in robotic assisted radical prostatectomy: does it enable earlier Foley catheter and Jackson-Pratt drain removal? J Robot Surg. 2008;1(4):303–6.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Sabiston, DC. Jr. Antisepsis, technique, sutures and drains. In: Principles of Operative Surgery, 11th edition. W. B. Saunders Co., Philadelphia; 1977. p. 323–339.

    Google Scholar 

  30. Smith AM, Veenema RJ. Management of rectal injury and rectourethral fistulas following radical retropubic prostatectomy. J Urol. 1972;108(5):778–9.

    CAS  PubMed  Google Scholar 

  31. Borland RN, Walsh PC. The management of rectal injury during radical retropubic prostatectomy. J Urol. 1992;147(3 Pt 2):905–7.

    CAS  PubMed  Google Scholar 

  32. Lepor H, Nieder AM, Ferrandino MN. Intraoperative and postoperative complications of radical retropubic prostatectomy in a consecutive series of 1,000 cases. J Urol. 2001;166(5):1729–33.

    Article  CAS  PubMed  Google Scholar 

  33. Castillo OA, Bodden E, Vitagliano G. Management of rectal injury during laparoscopic radical prostatectomy. Int Braz J Urol. 2006;32(4):428–33.

    Article  PubMed  Google Scholar 

  34. Guillonneau B, et al. Laparoscopic [correction of laproscopic] management of rectal injury during laparoscopic [correction of laproscopic] radical prostatectomy. J Urol. 2003;169(5):1694–6.

    Article  CAS  PubMed  Google Scholar 

  35. Rassweiler J, et al. Laparoscopic versus open radical prostatectomy: a comparative study at a single institution. J Urol. 2003;169(5):1689–93.

    Article  PubMed  Google Scholar 

  36. Katz R, et al. Operative management of rectal injuries during laparoscopic radical prostatectomy. Urology. 2003;62(2):310–3.

    Article  PubMed  Google Scholar 

  37. McLaren RH, Barrett DM, Zincke H. Rectal injury occurring at radical retropubic prostatectomy for prostate cancer: etiology and treatment. Urology. 1993;42(4):401–5.

    Article  CAS  PubMed  Google Scholar 

  38. Yee DS, Ornstein DK. Repair of rectal injury during robotic-assisted laparoscopic prostatectomy. Urology. 2008;72(2):428–31.

    Article  PubMed  Google Scholar 

  39. Wedmid A, et al. Rectal injury during robot-assisted radical prostatectomy: incidence and management. J Urol. 2011;186(5):1928–33.

    Article  PubMed  Google Scholar 

  40. Thomas C, et al. Incidence, clinical symptoms and management of rectourethral fistulas after radical prostatectomy. J Urol. 2010;183(2):608–12.

    Article  PubMed  Google Scholar 

  41. Dal Moro F, et al. Successful repair of iatrogenic rectourinary fistulas using the posterior sagittal transrectal approach (York-Mason): 15-year experience. World J Surg. 2006;30(1):107–13.

    Article  PubMed  Google Scholar 

  42. Kheterpal E, et al. Management of rectal injury during robotic radical prostatectomy. Urology. 2011;77(4):976–9.

    Article  PubMed  Google Scholar 

  43. Hakimi AA, et al. Assessment of complication and functional outcome reporting in the minimally invasive prostatectomy literature from 2006 to the present. BJU Int. 2012;109(1):26–30. discussion 30.

    Article  PubMed  Google Scholar 

  44. Ramsden AR, Chodak GW. Can leakage at the vesico-urethral anastomosis be predicted after radical retropubic prostatectomy? BJU Int. 2004;93(4):503–6.

    Article  CAS  PubMed  Google Scholar 

  45. Gnanapragasam VJ, et al. Identification and validation of risk factors for vesicourethral leaks following radical retropubic prostatectomy. Int J Urol. 2005;12(11):948–52.

    Article  PubMed  Google Scholar 

  46. Eandi JA, et al. Robotic assisted laparoscopic salvage prostatectomy for radiation resistant prostate cancer. J Urol. 2010;183(1):133–7.

    Article  PubMed  Google Scholar 

  47. Tyritzis SI, Katafigiotis I, Constantinides CA. All you need to know about urethrovesical anastomotic urinary leakage following radical prostatectomy. J Urol. 2012;188(2):369–76.

    Article  PubMed  Google Scholar 

  48. Rebuck DA, et al. What is the long-term relevance of clinically detected postoperative anastomotic urine leakage after robotic-assisted laparoscopic prostatectomy? BJU Int. 2011;108(5):733–8.

    PubMed  Google Scholar 

  49. Fenig DM, Slova D, Lepor H. Postoperative blood loss predicts the development of urinary extravasation on cystogram following radical retropubic prostatectomy. J Urol. 2006;175(1):146–50. discussion 150.

    Article  PubMed  Google Scholar 

  50. Noguchi M, et al. Early catheter removal 3 days after radical retropubic prostatectomy. Int J Urol. 2004;11(11):983–8.

    Article  PubMed  Google Scholar 

  51. Guillonneau B, et al. Perioperative complications of laparoscopic radical prostatectomy: the Montsouris 3-year experience. J Urol. 2002;167(1):51–6.

    Article  PubMed  Google Scholar 

  52. Williams TR, et al. Incidence and imaging appearance of urethrovesical anastomotic urinary leaks following da Vinci robotic prostatectomy. Abdom Imaging. 2008;33(3):367–70.

    Article  PubMed  Google Scholar 

  53. Patil N, et al. Evaluating and grading cystographic leakage: correlation with clinical outcomes in patients undergoing robotic prostatectomy. BJU Int. 2009;103(8):1108–10.

    Article  PubMed  Google Scholar 

  54. Lee HJ, et al. MDCT cystography for detection of vesicourethral leak after prostatectomy. AJR Am J Roentgenol. 2008;191(6):1847–51.

    Article  PubMed  Google Scholar 

  55. Guru KA, et al. Is a cystogram necessary after robot-assisted radical prostatectomy? Urol Oncol. 2007;25(6):465–7.

    Article  PubMed  Google Scholar 

  56. Tan G, et al. Optimizing vesicourethral anastomosis healing after robot-assisted laparoscopic radical prostatectomy: lessons learned from three techniques in 1900 patients. J Endourol. 2010;24(12):1975–83.

    Article  PubMed  Google Scholar 

  57. Shah G, Vogel F, Moinzadeh A. Nephroureteral stent on suction for urethrovesical anastomotic leak after robot-assisted laparoscopic radical prostatectomy. Urology. 2009;73(6):1375–6.

    Article  PubMed  Google Scholar 

  58. Mochtar CA, et al. Urinary leakage after laparoscopic radical prostatectomy: a systematic review. J Endourol. 2007;21(11):1371–9.

    Article  CAS  PubMed  Google Scholar 

  59. Moinzadeh A, et al. Continuous needle vented foley catheter suction for urinary leak after radical prostatectomy. J Urol. 2004;171(6 Pt 1):2366–7.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Associated Medical Professionals, Syracuse, NY, 13210, USA

    Dylan Stoy

  2. Clinica Urologica I, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca’ Granda, Università degli Studi di Milano, Via Commenda, 15, Milan, 20122, Italy

    Bernardo Rocco

  3. Department of Urology, University Vita-Salute, Milan, Italy

    Giancarlo Albo, Maria Chiara Clementi & Vladimir Mourviev

  4. Department of Urology, Fondazione IRCCS Ca, GrandaOspedale Maggiore Policlinico, University of Milan, Milan, Italy

    Francesco Alessandro Mistretta

  5. Department of Urology, Crouse Hospital, Syracuse, NY, USA

    David M. Albala M.D.

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  1. Dylan Stoy
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  2. Bernardo Rocco
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  3. Giancarlo Albo
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  4. Francesco Alessandro Mistretta
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  5. Maria Chiara Clementi
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  6. Vladimir Mourviev
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  7. David M. Albala M.D.
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Corresponding author

Correspondence to Dylan Stoy .

Editor information

Editors and Affiliations

  1. Department of Urology, Uro-surgical Prostate Cancer Program, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA

    John W. Davis

Editorial Comments—John W. Davis

Editorial Comments—John W. Davis

This is an important chapter, as many aspects of finishing up a resection go unreported compared to the traditional oncologic and functional outcomes. Team Albala has put together a very nice narrative with key citations to navigate this step of the operation. Every surgeon struggles with these steps of the operation and gains various preferences over time and as experience develops. Here are a few additional tips from my toolbox:

  • I have tried every hemostatic trick in this book and eventually have settled on the old fashion 4-0 Vicryl stitch. These cost under $2 USD each compared to hundreds spent on fibrin products. Occasionally I resort to Fibrular—a fluffier substance that Surgiceal—to pack small vein channels. However, I have often heard that these products can be acidic and possibly nerve damaging. So I do my best to just sew.

  • Check for hemostasis twice: first at the end of resection, and a final time after the anastomosis. If blood is welling from the nerve bundle and spilling downhill, it will likely continue postoperatively, and you may be left with an excellent estimated blood loss intraoperative but a discharge hemoglobin <10 or possibly need to transfuse or take-back.

  • The rate of rectal injury was definitely higher in the laparoscopic prostatectomy era. In part this was mechanical as with the fixed instruments it was harder to aim your tips up when going uphill to the apex. Articulation definitely helps. We used the air leak test routinely—fill the pelvis with water and then instill air in the rectum with a foley. If you see microbubbles then track those down and oversew. In the robotic era, I only do this for wide excision of nerve bundle cases where you are much closer to the rectum.

  • The tips and citations on anastomotic leaks are excellent. In addition, you can reference my previous group’s work on using a Lapra-Ty clip (Ball et al.). Prior to the Rocco stitch, this was our method of keeping tension on a running anastomosis to prevent leaks. When I see an occasional leak, there are two main possibilities—(1) gaps, and (2) inadequate tension. If there is a gap, then try and sneak another interrupted 3-0 Vicryl to close. If the running line is loose, then pull it tight, and slide a Lapra-Ty clip or two to hold the tension—much less traumatic than starting over. Of course, surgeons using barbed suture will have different circumstances to handle leaks.

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Stoy, D. et al. (2016). Post-resection: Hemostasis, Checking for Rectal Injury, and Anastomotic Leaks. In: Davis, J. (eds) Robot-Assisted Radical Prostatectomy. Springer, Cham. https://doi.org/10.1007/978-3-319-32641-2_11

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  • DOI: https://doi.org/10.1007/978-3-319-32641-2_11

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-32639-9

  • Online ISBN: 978-3-319-32641-2

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