Radical Prostatectomy

  • Alexander Haese
  • René Sotelo


Robotic-assisted laparoscopic radical prostatectomy (RALP) is the most common of all urologic surgeries. In fact, many urologists start their robotic experience with this procedure, which explains this chapter’s particular focus on robotic surgeons. The complications of this procedure may arise from the patient accommodation and access instruments until the time of surgery and even postsurgery in the operating room. Complications will never be completely eliminated from surgery and surgeons must learn from complications. In contrast to open surgery, routine recording of robotic surgery permits documentation and analysis of complications more thoroughly than previously possible. The purpose of this chapter is to follow the course of RALP, demonstrate risks, dangers, and pitfalls leading to immediate or delayed complications, and highlight strategies to prevent them.


Robotic surgery Prostate cancer Radical prostatectomy Complications 


  1. 1.
    Hohwu L, Borre M, Ehlers L, Venborg Pedersen K. A short-term cost-effectiveness study comparing robot-assisted laparoscopic and open retropubic radical prostatectomy. J Med Econ. 2011;14(4):403–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Hohwu L, Akre O, Pedersen KV, Jonsson M, Nielsen CV, Gustafsson O. Open retropubic prostatectomy versus robot-assisted laparoscopic prostatectomy: a comparison of length of sick leave. Scand J Urol Nephrol. 2009;43(4):259–64.CrossRefPubMedGoogle Scholar
  3. 3.
    Trinh QD, Sammon J, Sun M, Ravi P, Ghani KR, Bianchi M, et al. Perioperative outcomes of robot-assisted radical prostatectomy compared with open radical prostatectomy: results from the nationwide inpatient sample. Eur Urol. 2012;61(4):679–85.CrossRefPubMedGoogle Scholar
  4. 4.
    Chitlik A. Safe positioning for robotic-assisted laparoscopic prostatectomy. AORN J. 2011;94(1):37–45. quiz 46–8.CrossRefPubMedGoogle Scholar
  5. 5.
    Klauschie J, Wechter ME, Jacob K, Zanagnolo V, Montero R, Magrina J, et al. Use of anti-skid material and patient-positioning to prevent patient shifting during robotic-assisted gynecologic procedures. J Minim Invasive Gynecol. 2010;17(4):504–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Perreault L, Drolet P, Farny J. Ulnar nerve palsy at the elbow after general anaesthesia. Can J Anaesth (Journal canadien d’anesthesie). 1992;39(5 Pt 1):499–503.CrossRefGoogle Scholar
  7. 7.
    Sawyer RJ, Richmond MN, Hickey JD, Jarrratt JA. Peripheral nerve injuries associated with anaesthesia. Anaesthesia. 2000;55(10):980–91.CrossRefPubMedGoogle Scholar
  8. 8.
    Zhang J, Moore AE, Stringer MD. Iatrogenic upper limb nerve injuries: a systematic review. ANZ J Surg. 2011;81(4):227–36.CrossRefPubMedGoogle Scholar
  9. 9.
    American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. Practice advisory for the prevention of perioperative peripheral neuropathies: an updated report by the American Society of Anesthesiologists Task Force on prevention of perioperative peripheral neuropathies. Anesthesiology. 2011;114(4):741–54.CrossRefGoogle Scholar
  10. 10.
    Bruce RG, Kim FH, McRoberts W. Rhabdomyolysis and acute renal failure following radical perineal prostatectomy. Urology. 1996;47(3):427–30.CrossRefPubMedGoogle Scholar
  11. 11.
    Kikuno N, Urakami S, Shigeno K, Kishi H, Shiina H, Igawa M. Traumatic rhabdomyolysis resulting from continuous compression in the exaggerated lithotomy position for radical perineal prostatectomy. Int J Urol (official journal of the Japanese Urological Association). 2002;9(9):521–4.CrossRefGoogle Scholar
  12. 12.
    Romero FR, Pilati R, Kulysz D, Canali FA, Baggio PV, Brenny FT. Combined risk factors leading to well-leg compartment syndrome after laparoscopic radical prostatectomy. Actas Urol Esp. 2009;33(8):920–4.CrossRefPubMedGoogle Scholar
  13. 13.
    Orihuela E, Nazemi T, Shu T. Acute renal failure due to rhabdomyolysis associated with radical perineal prostatectomy. Eur Urol. 2001;39(5):606–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Pridgeon S, Bishop CV, Adshead J. Lower limb compartment syndrome as a complication of robot-assisted radical prostatectomy: the UK experience. BJU Int. 2013;112(4):485–8.CrossRefPubMedGoogle Scholar
  15. 15.
    Larobina M, Nottle P. Complete evidence regarding major vascular injuries during laparoscopic access. Surg Laparosc Endosc Percutan Tech. 2005;15(3):119–23.CrossRefPubMedGoogle Scholar
  16. 16.
    Chandler JG, Corson SL, Way LW. Three spectra of laparoscopic entry access injuries. J Am Coll Surg. 2001;192(4):478–90. discussion 90–1.CrossRefPubMedGoogle Scholar
  17. 17.
    Hasson HM. Open laparoscopy: a report of 150 cases. J Reprod Med. 1974;12(6):234–8.PubMedGoogle Scholar
  18. 18.
    String A, Berber E, Foroutani A, Macho JR, Pearl JM, Siperstein AE. Use of the optical access trocar for safe and rapid entry in various laparoscopic procedures. Surg Endosc. 2001;15(6):570–3.CrossRefPubMedGoogle Scholar
  19. 19.
    Ahmad G, O’Flynn H, Duffy JM, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane Database Syst Rev. 2012;2:CD006583.Google Scholar
  20. 20.
    Agresta F, De Simone P, Ciardo LF, Bedin N. Direct trocar insertion vs Veress needle in nonobese patients undergoing laparoscopic procedures: a randomized prospective single-center study. Surg Endosc. 2004;18(12):1778–81.CrossRefPubMedGoogle Scholar
  21. 21.
    Catarci M, Carlini M, Gentileschi P, Santoro E. Major and minor injuries during the creation of pneumoperitoneum. A multicenter study on 12,919 cases. Surg Endosc. 2001;15(6):566–9.CrossRefPubMedGoogle Scholar
  22. 22.
    Guloglu R, Dilege S, Aksoy M, Alimoglu O, Yavuz N, Mihmanli M, et al. Major retroperitoneal vascular injuries during laparoscopic cholecystectomy and appendectomy. J Laparoendosc Adv Surg Tech A. 2004;14(2):73–6.CrossRefPubMedGoogle Scholar
  23. 23.
    Azevedo JL, Azevedo OC, Miyahira SA, Miguel GP, Becker OM Jr, Hypolito OH, et al. Injuries caused by Veress needle insertion for creation of pneumoperitoneum: a systematic literature review. Surg Endosc. 2009;23(7):1428–32.CrossRefPubMedGoogle Scholar
  24. 24.
    Vilos GA, Ternamian A, Dempster J, Laberge PY, The Society of O, Gynaecologists of C. Laparoscopic entry: a review of techniques, technologies, and complications. J Obstet Gynaecol Can JOGC (Journal d'obstetrique et gynecologie du Canada JOGC). 2007;29(5):433–65.Google Scholar
  25. 25.
    Vilos GA, Vilos AG, Abu-Rafea B, Hollett-Caines J, Nikkhah-Abyaneh Z, Edris F. Three simple steps during closed laparoscopic entry may minimize major injuries. Surg Endosc. 2009;23(4):758–64.CrossRefPubMedGoogle Scholar
  26. 26.
    Teoh B, Sen R, Abbott J. An evaluation of four tests used to ascertain Veres needle placement at closed laparoscopy. J Minim Invasive Gynecol. 2005;12(2):153–8.CrossRefPubMedGoogle Scholar
  27. 27.
    Bonjer HJ, Hazebroek EJ, Kazemier G, Giuffrida MC, Meijer WS, Lange JF. Open versus closed establishment of pneumoperitoneum in laparoscopic surgery. Br J Surg. 1997;84(5):599–602.CrossRefPubMedGoogle Scholar
  28. 28.
    Hashizume M, Sugimachi K. Needle and trocar injury during laparoscopic surgery in Japan. Surg Endosc. 1997;11(12):1198–201.CrossRefPubMedGoogle Scholar
  29. 29.
    Mac Cordick C, Lecuru F, Rizk E, Robin F, Boucaya V, Taurelle R. Morbidity in laparoscopic gynecological surgery: results of a prospective single-center study. Surg Endosc. 1999;13(1):57–61.CrossRefPubMedGoogle Scholar
  30. 30.
    Champault G, Cazacu F, Taffinder N. Serious trocar accidents in laparoscopic surgery: a French survey of 103,852 operations. Surg Laparosc Endosc. 1996;6(5):367–70.CrossRefPubMedGoogle Scholar
  31. 31.
    Schafer M, Lauper M, Krahenbuhl L. Trocar and Veress needle injuries during laparoscopy. Surg Endosc. 2001;15(3):275–80.CrossRefPubMedGoogle Scholar
  32. 32.
    Bhoyrul S, Vierra MA, Nezhat CR, Krummel TM, Way LW. Trocar injuries in laparoscopic surgery. J Am Coll Surg. 2001;192(6):677–83.CrossRefPubMedGoogle Scholar
  33. 33.
    Ahmad G, Duffy JM, Watson AJ. Laparoscopic entry techniques and complications. Int J Gynaecol Obstet (the Official Organ of the International Federation of Gynaecology and Obstetrics). 2007;99(1):52–5.CrossRefGoogle Scholar
  34. 34.
    van der Voort M, Heijnsdijk EA, Gouma DJ. Bowel injury as a complication of laparoscopy. Br J Surg. 2004;91(10):1253–8.CrossRefPubMedGoogle Scholar
  35. 35.
    Leibl BJ, Schmedt CG, Schwarz J, Kraft K, Bittner R. Laparoscopic surgery complications associated with trocar tip design: review of literature and own results. J Laparoendosc Adv Surg Tech A. 1999;9(2):135–40.CrossRefPubMedGoogle Scholar
  36. 36.
    Menon M, Tewari A, Peabody J, Team VIP. Vattikuti Institute prostatectomy: technique. J Urol. 2003;169(6):2289–92.CrossRefPubMedGoogle Scholar
  37. 37.
    Menon M, Tewari A, Peabody JO, Shrivastava A, Kaul S, Bhandari A, et al. Vattikuti institute prostatectomy, a technique of robotic radical prostatectomy for management of localized carcinoma of the prostate: experience of over 1100 cases. Urol Clin North Am. 2004;31(4):701–17.CrossRefPubMedGoogle Scholar
  38. 38.
    Bishoff JT, Allaf ME, Kirkels W, Moore RG, Kavoussi LR, Schroder F. Laparoscopic bowel injury: incidence and clinical presentation. J Urol. 1999;161(3):887–90.CrossRefPubMedGoogle Scholar
  39. 39.
    Nezhat FR, Chang-Jackson SC, Acholonu UC Jr, Vetere PF. Robotic-assisted laparoscopic transection and repair of an obturator nerve during pelvic lymphadenectomy for endometrial cancer. Obstet Gynecol. 2012;119(2 Pt 2):462–4.CrossRefPubMedGoogle Scholar
  40. 40.
    Rothmund R, Huebner M, Kraemer B, Liske B, Wallwiener D, Taran FA. Laparoscopic transection and immediate repair of obturator nerve during pelvic lymphadenectomy. J Minim Invasive Gynecol. 2011;18(6):807–8.CrossRefPubMedGoogle Scholar
  41. 41.
    Song MJ, Lee CW, Yoon JH, Hur SY. Transection of the obturator nerve by an electrosurgical instrument and its immediate repair during laparoscopic pelvic lymphadenectomy: a case report. Eur J Gynaecol Oncol. 2014;35(2):167–9.PubMedGoogle Scholar
  42. 42.
    Spaliviero M, Steinberg AP, Kaouk JH, Desai MM, Hammert WC, Gill IS. Laparoscopic injury and repair of obturator nerve during radical prostatectomy. Urology. 2004;64(5):1030.CrossRefPubMedGoogle Scholar
  43. 43.
    Borland RN, Walsh PC. The management of rectal injury during radical retropubic prostatectomy. J Urol. 1992;147(3 Pt 2):905–7.CrossRefPubMedGoogle Scholar
  44. 44.
    Tewari A, Sooriakumaran P, Bloch DA, Seshadri-Kreaden U, Hebert AE, Wiklund P. Positive surgical margin and perioperative complication rates of primary surgical treatments for prostate cancer: a systematic review and meta-analysis comparing retropubic, laparoscopic, and robotic prostatectomy. Eur Urol. 2012;62(1):1–15.CrossRefPubMedGoogle Scholar
  45. 45.
    Masuda T, Kinoshita H, Nishida S, Kawa G, Kawakita M, Matsuda T. Rectal injury during laparoscopic radical prostatectomy: detection and management. Int J Urol (official journal of the Japanese Urological Association). 2010;17(5):492–5.CrossRefGoogle Scholar
  46. 46.
    Kheterpal E, Bhandari A, Siddiqui S, Pokala N, Peabody J, Menon M. Management of rectal injury during robotic radical prostatectomy. Urology. 2011;77(4):976–9.CrossRefPubMedGoogle Scholar
  47. 47.
    Wedmid A, Mendoza P, Sharma S, Hastings RL, Monahan KP, Walicki M, et al. Rectal injury during robot-assisted radical prostatectomy: incidence and management. J Urol. 2011;186(5):1928–33.CrossRefPubMedGoogle Scholar
  48. 48.
    Roberts WB, Tseng K, Walsh PC, Han M. Critical appraisal of management of rectal injury during radical prostatectomy. Urology. 2010;76(5):1088–91.CrossRefPubMedGoogle Scholar
  49. 49.
    Yuh B, Ruel N, Muldrew S, Mejia R, Novara G, Kawachi M, et al. Complications and outcomes of salvage robot-assisted radical prostatectomy: a single-institution experience. BJU Int. 2014;113(5):769–76.CrossRefPubMedGoogle Scholar
  50. 50.
    Chauhan S, Patel MB, Coelho R, Liss M, Rocco B, Sivaraman AK, et al. Preliminary analysis of the feasibility and safety of salvage robot-assisted radical prostatectomy after radiation failure: multi-institutional perioperative and short-term functional outcomes. J Endourol (Endourological Society). 2011;25(6):1013–9.CrossRefGoogle Scholar
  51. 51.
    Jhaveri JK, Penna FJ, Diaz-Insua M, Jeong W, Menon M, Peabody JO. Ureteral injuries sustained during robot-assisted radical prostatectomy. J Endourol (Endourological Society). 2014;28(3):318–24.CrossRefGoogle Scholar
  52. 52.
    Teber D, Gozen AS, Cresswell J, Canda AE, Yencilek F, Rassweiler J. Prevention and management of ureteral injuries occurring during laparoscopic radical prostatectomy: the Heilbronn experience and a review of the literature. World J Urol. 2009;27(5):613–8.CrossRefPubMedGoogle Scholar
  53. 53.
    Guillonneau B, Rozet F, Cathelineau X, Lay F, Barret E, Doublet JD, et al. Perioperative complications of laparoscopic radical prostatectomy: the Montsouris 3-year experience. J Urol. 2002;167(1):51–6.CrossRefPubMedGoogle Scholar
  54. 54.
    Vallancien G, Cathelineau X, Baumert H, Doublet JD, Guillonneau B. Complications of transperitoneal laparoscopic surgery in urology: review of 1,311 procedures at a single center. J Urol. 2002;168(1):23–6.CrossRefPubMedGoogle Scholar
  55. 55.
    Lorenzo EI, Jeong W, Park S, Kim WT, Hong SJ, Rha KH. Iliac vein injury due to a damaged Hot Shears tip cover during robot assisted radical prostatectomy. Yonsei Med J. 2011;52(2):365–8.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Park SY, Ahn JJ, Jeong W, Ham WS, Rha KH. A unique instrumental malfunction during robotic prostatectomy. Yonsei Med J. 2010;51(1):148–50.CrossRefPubMedGoogle Scholar
  57. 57.
    Park SY, Cho KS, Lee SW, Soh BH, Rha KH. Intraoperative breakage of needle driver jaw during robotic-assisted laparoscopic radical prostatectomy. Urology. 2008;71(1):168 e5–6.CrossRefGoogle Scholar
  58. 58.
    Barto W, Yazbek C, Bell S. Finding a lost needle in laparoscopic surgery. Surg Laparosc Endosc Percutan Tech. 2011;21(4):e163–5.CrossRefPubMedGoogle Scholar
  59. 59.
    Smith BM, Brown RA, Lobe TE. The lost needle: a laparoscopic dilemma. J Laparoendosc Surg. 1993;3(4):425–6.CrossRefPubMedGoogle Scholar
  60. 60.
    Small AC, Gainsburg DM, Mercado MA, Link RE, Hedican SP, Palese MA. Laparoscopic needle-retrieval device for improving quality of care in minimally invasive surgery. J Am Coll Surg. 2013;217(3):400–5.CrossRefPubMedGoogle Scholar
  61. 61.
    Hu JC, Nelson RA, Wilson TG, Kawachi MH, Ramin SA, Lau C, et al. Perioperative complications of laparoscopic and robotic assisted laparoscopic radical prostatectomy. J Urol. 2006;175(2):541–6. discussion 6.CrossRefPubMedGoogle Scholar
  62. 62.
    Novara G, Ficarra V, Rosen RC, Artibani W, Costello A, Eastham JA, et al. Systematic review and meta-analysis of perioperative outcomes and complications after robot-assisted radical prostatectomy. Eur Urol. 2012;62(3):431–52.CrossRefPubMedGoogle Scholar
  63. 63.
    Ahmed F, Rhee J, Sutherland D, Benjamin C, Engel J, Frazier H 2nd. Surgical complications after robot-assisted laparoscopic radical prostatectomy: the initial 1000 cases stratified by the clavien classification system. J Endourol (Endourological Society). 2012;26(2):135–9.CrossRefGoogle Scholar
  64. 64.
    Coelho RF, Palmer KJ, Rocco B, Moniz RR, Chauhan S, Orvieto MA, et al. Early complication rates in a single-surgeon series of 2500 robotic-assisted radical prostatectomies: report applying a standardized grading system. Eur Urol. 2010;57(6):945–52.CrossRefPubMedGoogle Scholar
  65. 65.
    Filip V, Plesa C, Tarcoveanu E, Bradea C, Moldovanu R. Incisional hernias after operative laparoscopy. Rev Med Chir Soc Med Nat Iasi. 2000;104(4):83–6.PubMedGoogle Scholar
  66. 66.
    Liu CD, McFadden DW. Laparoscopic port sites do not require fascial closure when nonbladed trocars are used. Am Surg. 2000;66(9):853–4.PubMedGoogle Scholar
  67. 67.
    Parihar JS, Ha YS, Kim IY. Bladder neck contracture-incidence and management following contemporary robot assisted radical prostatectomy technique. Prostate Int. 2014;2(1):12–8.CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Breyer BN, Davis CB, Cowan JE, Kane CJ, Carroll PR. Incidence of bladder neck contracture after robot-assisted laparoscopic and open radical prostatectomy. BJU Int. 2010;106(11):1734–8.CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Msezane LP, Reynolds WS, Gofrit ON, Shalhav AL, Zagaja GP, Zorn KC. Bladder neck contracture after robot-assisted laparoscopic radical prostatectomy: evaluation of incidence and risk factors and impact on urinary function. J Endourol (Endourological Society). 2008;22(1):97–104.Google Scholar
  70. 70.
    Orvieto MA, Coelho RF, Chauhan S, Palmer KJ, Rocco B, Patel VR. Incidence of lymphoceles after robot-assisted pelvic lymph node dissection. BJU Int. 2011;108(7):1185–90.CrossRefPubMedGoogle Scholar
  71. 71.
    Raheem OA, Bazzi WM, Parsons JK, Kane CJ. Management of pelvic lymphoceles following robot-assisted laparoscopic radical prostatectomy. Urol Ann. 2012;4(2):111–4.CrossRefPubMedPubMedCentralGoogle Scholar
  72. 72.
    Khoder WY, Trottmann M, Buchner A, Stuber A, Hoffmann S, Stief CG, et al. Risk factors for pelvic lymphoceles post-radical prostatectomy. Int J Urol (official journal of the Japanese Urological Association). 2011;18(9):638–43.Google Scholar
  73. 73.
    Keegan KA, Cookson MS. Complications of pelvic lymph node dissection for prostate cancer. Curr Urol Rep. 2011;12(3):203–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Martini Klinik Prostate Cancer Center, University Clinic EppendorfHamburgGermany
  2. 2.USC Institute of Urology, University of Southern CaliforniaLos AngelesUSA

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