AUA Update Series

Lesson 2 Volume 29

2010

Complications of Contemporary Radical Prostatectomy

Learning Objective: At the conclusion of this continuing medical education activity, the participant will be familiar with the most common complications associated with open and robot assisted radical prostatectomy; the incidence, etiology and diagnosis for each of these complications; and their various preventive and treatment modalities.

G. Joel DeCastro, M.D., MPH

Disclosures: Nothing to disclose

Uro-Oncology Fellow

Gagan Gautam, M.D.

Disclosures: Nothing to disclose

Uro-Oncology Fellow University of Chicago Medical Center Chicago, Illinois

and Kevin C. Zorn, M.D., FRCSC, FACS

Disclosures: Intuitive Surgical, American Medical Systems: Proctor/Consultant

Assistant Professor al University of Montre al, Canada Montre

This self-study continuing medical education activity is designed to provide urologists, Board candidates and/or residents affordable and convenient access to the most recent developments and techniques in urology. The American Urological Association (AUA) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AUA takes responsibility for the content, quality and scientific integrity of this CME activity. Credit Designation Statement: The American Urological Association designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit. Each physician should only claim credit commensurate with the extent of their participation in the activity. AUA Disclosure Policy: As a provider accredited by the ACCME, the AUA must insure balance, independence, objectivity and scientific rigor in all its activities. All faculty participating in an educational activity provided by the AUA are required to disclose to the provider any relevant financial relationships with any commercial interest. The AUA must determine if the facultys relationships may influence the educational content with regard to exposition or conclusion and resolve any conflicts of interest prior to the commencement of the educational activity. The intent of this disclosure is not to prevent faculty with relevant financial relationships from serving as faculty, but rather to provide members of the audience with information on which they can make their own judgments. Unlabled/Unapproved Uses: It is the policy of the AUA to require the disclosure of all references to unlabeled or unapproved uses of drugs or devices prior to the presentation of educational content. Please consult the prescribing information for full disclosure of approved uses. Evidence-Based Content: As a provider of continuing medical education accredited by the ACCME, it is the policy of the AUA to review and certify that the content contained in this CME activity is valid, fair, balanced, scientifically rigorous and free of commercial bias. Disclaimer: The opinions and recommendations expressed by faculty, authors and other experts whose input is included in this program are their own and do not necessarily represent the viewpoint of the 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 American men. In 2008 a total of 190,000 new cases were documented, with 29,000 reported deaths.1 Since the advent of prostate specific antigen screening there has been a concomitant increase in the detection and surgical treatment of prostate cancer. Between 1986 and 1996 there was a 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 uniform erectile dysfunction and urinary incontinence postoperatively.5 The pioneering work of Walsh and Donker in the early 1980s did much to elucidate the anatomical basis for these complications,6 leading to the development of the anatomical radical retropubic prostatectomy.7 Since then the number of intraoperative and postoperative complications has decreased dramatically.8-11 Optimizing anatomical knowledge, improving surgical techniques and increasing surgical experience have been key in this trend. Just as the introduction of the anatomical radical prostatectomy made the operation more accessible to urologists, the wide acceptance of the robot assisted radical prostatectomy has made it the most commonly used technique for this surgery. While only 10% of RPs performed in 2005 were robot assisted, the proportion increased to more than 60% in 2008.12 It is predicted that more than 85% of RPs performed this year will be robot assisted. Whether this new approach has actually led to further decreases in complications is controversial.13, 14 This Update will focus on the most common complications of radical prostatectomy, with comparisons made primarily between retropubic and robot assisted approaches. The perineal and pure laparoscopic approaches, neither of which is widely used in the United States, will not be reviewed in detail. REPORTING BIASES Outcomes comparisons between studies are difficult by the absence of a standardized and well accepted classification system, resulting in wide variation in how complications are reported. The Clavien classification system, which grades complications based on what additional therapeutic measures are necessary, has been widely used in the general surgery literature and, more recently, in urology.15, 16 However until a standard classification system is widely adopted, accurate comparisons between institutions will remain challenging. Another obstacle to making accurate comparisons is the inherent bias in reporting complications as those centers with better outcomes are more likely to publish than those with poorer outcomes.17 In addition, several studies have shown a relationship between increasing surgical experience and a lower rate of adverse operative outcomes, including positive surgical margins and biochemical recurrence.18, 19 Likewise, increasing surgical experience is associated with a decrease in perioperative complications.20 However, these studies originate from tertiary medical care centers and represent only a small proportion of all RPs performed annually.21 Data from large-scale population based databases, such as Medicare and Medicaid claims data, are largely free of individual surgeon biases.22, 23 While not as detailed as institutional databases, they may provide more generalized statistics.

NON-SPECIFIC SURGICAL COMPLICATIONS All major surgical procedures are associated with some risk of morbidity and mortality that should be discussed during informed consent. We will first discuss several general complications that, while not specific to RP, may be exacerbated by the nature of the operation and the underlying disease. Myocardial infarction. The systemic cardiovascular stress of general anesthesia (eg intubation, intravenous fluids), pneumoperitoneum during RARP and acute blood loss result in significant risk for myocardial infarction. However, MI is a rare complication in the perioperative period, with a reported incidence <0.5%. In a single surgeon series Lepor et al reported only 1 case of MI after 1000 ORPs performed between 1994 and 2000.24 A similarly low incidence was reported by Catalona et al in 1999.25 In a Medicare claims based study of more than 100,000 patients undergoing ORP between 1991 and 1994 LuYao et al reported a low MI rate with a modestly increased risk after ORP vs perineal prostatectomy (0.39% vs 0.29%).26 A similarly low incidence has been reported with RARP.27 The most important step in preventing MI is preoperative patient evaluation and selection. Patients with any significant risk factors for heart disease should be fully evaluated and, if necessary, referred to a cardiologist for further assessment and optimization. Patients who are deemed too ill to safely undergo RP should be referred for radiation therapy or watchful waiting. Thrombotic complications. Deep venous thrombosis and pulmonary embolism are significant complications of urological cancer surgery, especially pelvic surgery. There are certain aspects of RP that heighten the risk, including hypercoagulability associated with neoplastic disease and intraoperative handling of the iliac vessels during pelvic lymphadenectomy. Although there has been a general decrease in the incidence of thrombotic complications following RP, PE remains one of the most common causes of non-surgical death.28 Contemporary series report a symptomatic DVT incidence of 0.2% to 1% after ORP, with approximately 0.2% diagnosed with a PE with or without previously diagnosed DVT.11, 24 In addition, some studies have demonstrated a trend of increased DVT risk with PLND.11 These numbers represent a significant decrease compared to studies from the 1980s and early 1990s.25, 29 The incidence of DVT and PE appears to be similarly low in RARP series. In a multi-institutional study encompassing 13 institutions and almost 6000 patients Secin et al reported an incidence of 0.5% for DVT and 0.2% for PE, with a median time to presentation of 10 days postoperatively.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 postoperative vascular imaging to detect the true incidence of thrombotic events. Routine use of pharmacological thromboprophylaxis remains controversial, as there is concern for increased intraoperative bleeding and postoperative lymphocele. There is also contradicting evidence as to whether DVTs or PEs are prevented with prophyalxis.30, 32, 33 According to the 2008 AUA best practice statement intermittent pneumatic compression devices should be used during and after all robotic assisted laparoscopic and open procedures. Pharmacological thromboprophylaxis should be added for patients in higher risk groups, including those with prior venous thromboembolism, hypercoagulable state or age >60 years.34 In comparison, the American College of Chest Physicians evidence-based clinical practice guidelines suggest the addition of subcutaneous pharmacological thromboprophylaxis for all patients undergoing major general surgery.35

ABBREVIATIONS: BNC (bladder neck contracture), CT (computerized tomography), DVC (dorsal vein complex), DVT (deep venous thrombosis), 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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Upon discharge from the hospital all patients should be educated on the signs and symptoms of DVT and PE, and advised to seek immediate care if concerned. This is especially important since symptomatic DVTs tend to occur between 1 and 3 weeks postoperatively, which is well after most patients are discharged home.30, 36 Patients with clinical findings suspicious for DVT should undergo Doppler ultrasound. If confirmed, therapy should be initiated in consultation with a vascular surgeon. DVT treatment focuses on preventing clot propagation and PE.37 Anticoagulation therapy with low molecular weight or unfractionated heparin should be initiated immediately after diagnosis and continued for at least 5 days. At that time oral anticoagulation with coumadin may be initiated but should overlap with heparin treatment for 4 to 5 days. Anticoagulation should continue for at least 3 months at which time reevaluation may be performed. If anticoagulation is contraindicated (eg if there is active bleeding), insertion of an IVC filter may be indicated. In certain patients with a proximal ileofemoral DVT without significant bleeding risk catheter directed thrombolysis may be appropriate.37 Treatment for PE is similar to that for DVT. If high clinical suspicion exists, anticoagulation with heparin should be started immediately and a diagnostic CT angiogram or ventilation perfusion scan should be promptly performed. If a PE is confirmed, clinical status will dictate whether a thrombolytic agent should be administered. If the patient is stable, anticoagulation may be continued under close observation but if critical, fibrinolysis should be initiated while anticoagulation is withheld. If there is clinical improvement, anticoagulation should continue but if not, surgical or catheter embolectomy should be considered. In the case of a PE in which anticoagulation is contraindicated an IVC filter may be inserted.37 INTRAOPERATIVE COMPLICATIONS Hemorrhage. Historically, one of the most morbid aspects of ORP was the often unpredictable blood loss associated with the operation. Although anatomical radical retropubic prostatectomy results in reduced intraoperative blood loss, significant hemorrhage remains common.6, 7 Most significant bleeding originates from the dorsal venous complex, the arterial and venous pedicles, the neurovascular bundles 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 reduced blood loss with average reports of 50 to 250 ml.27, 31, 38 The potential reasons for this difference include reduction of venous sinus bleeding by virtue of pneumoperitoneum (14 to 20 mm Hg), improved control during suturing and transection of the DVC, and enhanced visibility of periprostatic vessels during nerve sparing procedures. However, it is not clear whether the resultant need for blood transfusion is different between the 2 approaches.38-40 Management of hemorrhage depends on the source. In the case of ORP significant bleeding from the DVC should be addressed with figure-of-8 sutures, while minor oozing can be managed with a combination of cautery and pressure. In the case of RARP venous bleeding may be controlled with a temporary increase in pneumoperitoneum (typically to 20 mm Hg), and a combination of cautery, compression and suturing. With both surgical approaches small caliber arteries can be treated with meticulous cauterization or, if involving a larger vessel, suturing or clipping. Management of more significant bleeding, such as from perforation of an iliac vessel, depends on the size of the defect as well as on the experience of the surgeon. In the case of RARP repair with a non-absorbable suture may be possible but a low threshold for open conversion still exists. Obturator nerve injury. Damage to the obturator nerve, although uncommon, almost always occurs during PLND either as a crush,

thermal or transecting injury. Its incidence is rare, with several large studies of open and robot assisted prostatectomy consistently reporting no nerve injuries.24, 27, 28, 41 For open and laparoscopic approaches, meticulous use of scissors, graspers and thermal energy around the nerve during PLND is critical. Postoperative sequelae include complaints of pain or numbness radiating over the ipsilateral inner thigh, weakness of thigh adduction and gait instability. Treatment depends on the type of injury. In the case of crush or thermal injuries prompt postoperative physiotherapy may be sufficient. If transection is recognized intraoperatively, primary suture repair should be performed using a fine non-absorbable suture (eg 6-zero nylon). Intraoperative neurosurgical consultation may be helpful. There have been some reports of repair being performed laparoscopically.42 Bowel injury. Injuries to the small or large bowel during open or robot assisted radical prostatectomy are rare. In their review of 322 patients treated with RARP Hu et al reported an incidence of 0.6%,27 with similar numbers from other groups.31 Nevertheless, urologists should be aware of the mechanisms of potential injury and principles of repair. Bowel adhesions to the anterior abdominal wall may lead to injury during initial Veress needle and trocar insertion. Scarred areas associated with previous surgeries, as well as areas containing mesh, should be avoided as sites of primary access. If initial attempt at insufflation using the Veress needle fails, the surgeon may use a Hasson incision. Blind introduction of a blunt trocar without establishment of a pneumoperitoneum should not be performed.43 The skin incision should be made long enough to accept the first trocar without requiring undue force. All subsequent trocars should be inserted under visual guidance. The space between the abdominal wall and abdominal contents should be maximized during trocar insertion, initial insufflation pressure should be 20 mm Hg, the stomach should be emptied with an orogastric tube and the patient should be placed in steep Trendelenburg position. Inadvertent bowel injury from either assistant or robotic instruments can be minimized by establishing a good pattern of communication between the bedside team and the console. It is essential that the assistant always asks for visual help if they cannot find their instrument on the screen and should never attempt to further push an instrument if meeting resistance. Likewise, the robotic instruments should always be kept within the visual field and, if they fall outside the field, the camera should be moved to find them before further movements are made. Intraoperative recognition of a bowel injury is essential. Before leaving the console the surgeon should carefully inspect the loops of bowel 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 the first clinical signs.44 If there is any degree of suspicion and the patient is stable, CT with oral Gastrografin may be diagnostic. However, if the clinical condition is poor, emergent exploratory laparoscopy or laparotomy should be performed. The mechanism, extent and location of the bowel injury will determine whether a primary repair versus a small bowel resection should be undertaken. If small and without evidence of surrounding ischemia, the defect may be repaired with a primary anastomosis. If a devascularization injury is suspected, management may be more complex and require the assistance of a general surgeon. Rectal injury. Rectal injury is a relatively rare but potentially devastating 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 patients at Veterans Administration medical centers reported that 1.8% of patients experienced a rectal injury requiring repair after ORP.4 In 2 RARP series no rectal injuries were recorded.27, 31
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Rectal injuries during RP tend to occur near the apex while developing the plane between the prostate and rectum (fig. 1). While Denonvilliers fascia can usually be used as a safe marker during dissection, previous prostate directed treatments including multiple biopsies, 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 of rectal injury.17, 45 In patients at higher risk for rectal injury (after pelvic radiation, previous transurethral resection or rectal surgery) a bowel preparation should be used. For RARP, initial posterior dissection of the seminal vesicles may facilitate bladder neck transection and allow earlier identification of the rectum. Intraoperative recognition is critical to minimize morbidity. Blumberg et al reported a multi-disciplinary treatment algorithm for rectal injury during RP (fig. 2).46 Rectal injuries can usually be treated with a primary 2-layer closure using an absorbable suture.17, 24 The repair may be tested by insufflating the rectum transanally with air and checking for a gas leak after filling the pelvis with fluid. If the defect is large with gross spillage or if the patient has been previously irradiated, diversion in consultation with a colorectal surgeon should be considered.28, 32, 47 Copious irrigation of the area is useful for preventing infection and abscess formation, and interposition of omentum or a perirectal fat flap over the defect may help prevent rectourethral fistulas.48 Such fistulas are usually associated with injuries not identified intraoperatively or with large rectal injuries that would have been best served with temporary diversion.27 Postoperatively, patients should remain on broad-spectrum antibiotics that cover colonic organisms, and advanced slowly to a low residue diet. Patients in whom intraoperative repair fails or who sustain an unrecognized injury can present with a pelvic abscess or a rectourethral fistula. Symptoms include fecaluria, pneumaturia, rectal bleeding, recurrent polymicrobial urinary tract infection, fever, pain and sepsis.46 Stable patients can be investigated with cystourethrography, cystoscopy, a Gastrografin enema, flexible sigmoidoscopy and pelvic CT. If a pelvic abscess is present, percutaneous drainage should be performed. Urethral catheterization should be performed in all patients. If a rectourethral fistula is present, it can be reassessed with cystourethrography 2 to 3 months postoperatively, and the Foley catheter removed once resolution of the fistula is documented. Patients who have undergone fecal diversion should undergo flexible sigmoidoscopy or Gastrografin enema before closure of the stoma. In patients with a persistent fistula definitive surgical treatment should not be considered for at least 3 months following injury to allow resolution of the inflammatory process. Repair performed sooner has a high failure rate.

Numerous surgical approaches, including transabdominal, transsacral, trans-sphincteric, transanal, transperineal and transpubic, are available for repair of this complex fistula. Bladder injury. Although rare, injury to the bladder wall may occur during RP. If a PLND is performed before dissection of the Retzius space during RARP, lymph node removal medial to the medial umbilical ligament may inadvertently injure the bladder. Inadvertent cystotomy can also occur during bladder mobilization and posterior bladder neck transection. Repair of the bladder can usually be performed with absorbable figure-of-8 sutures. Ureteral injury. Ureteral injury during radical prostatectomy is uncommon, with past and more contemporary studies of ORP and RARP reporting similar incidences of 0% to 0.5%.9-11, 24, 25, 27 Injury may occur during pelvic lymph node dissection when the ureter lies in close proximity to the internal iliac artery, transection of the posterior bladder neck in the presence of a large intravesical prostatic lobe, ligation of the lateral vascular pedicles and posterior dissection of the seminal vesicles, or in cases of an ectopic ureter (fig. 3).32 To reduce the risk of injury during RARP, the ureter should be identified immediately upon entering the peritoneal space. In addition, immediately upon entering the bladder anteriorly the ureteral orifices should be identified and cannulated with a feeding tube if necessary. If this is difficult due to a large intravesical prostatic lobe or because of abnormal urothelium, intravenous injection of methylene blue or indigo carmine dye may be helpful. Treatment of a ureteral injury depends on the mechanism as well as location of the damage. Whether a thermal injury is significant and risks subsequent ischemic necrosis may be assessed visually. If deemed significant, resection of the affected segment and ureteral reimplantation may be performed. Transection injuries can usually be oversewn. Ureteral injury in close proximity to the trigone during seminal vesicle dissection will likely require reimplantation, as will laceration of an ectopic ureter.28 After any ureteral repair a stent should be kept in place for at least 2 to 6 weeks. In addition, since these patients are at risk for a ureteral stricture, imaging of the upper urinary tract (ultrasound or CT) or functional analysis (renal scan) may be performed 4 to 6 weeks after stent removal. POSTOPERATIVE COMPLICATIONS Immediate 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 after trocar removal. However, significant postoperative hemorrhage is rare. In a 1994 study of 1350 ORPs Hedican and Walsh reported an incidence

FIG. 1. A, intraoperative identification of rectal injury during wide resection RARP. Defect can be better identified by inserting gloved finger into rectum or by air insufflation along with fluid filling of pelvis in suspected cases. Once identified, operative field should be washed with copious saline. B, with margins being clearly defined, rectal closure can then performed in 2 layers with absorbable suture followed by vascularized interposition flap (omentum or perirectal fat).
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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 ORP and 0.4% to 0.6% for RARP.11, 24, 25, 27, 31 Preventing post-RARP hemorrhage involves identifying intraoperative sources of bleeding before removing the trocars, which can be done by reducing the pneumoperitoneum to 4 mm Hg, and closely observing the pelvis and lateral walls for any evidence of persistent bleeding. Removal of all trocars under vision will also facilitate immediate visualization of any abdominal wall bleeding previously compressed by a trocar. Using the Carter-Thomason device for fascial closure also ensures that any new bleeding, such as from the inferior epigastric vessels, is quickly identified. Postoperative hemorrhage is diagnosed based on physical examination findings (particularly urine output, blood pressure and heart rate) as well as drain outputs and serial hematocrits. Treatment depends largely on the severity of bleeding, with most cases managed with supportive care and blood transfusion as needed. If a patient is unstable or requires

FIG. 3. Potential sources of ureteral injury during RARP. A, during posterior bladder neck division in men with asymmetric prostatic lobes or median lobe that distorts trigonal anatomy. Arrow depicts left ureteral orifice which lies in close proximity to line of dissection. B, during right pelvic lymph node dissection ureter is partially incised with sharp scissors. Methylene blue can be seen extravasating from lumen and ureter was repaired with interrupted absorbable suture.
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more than 4 units, or if concern about persistent bleeding remains after transfusion, exploratory laparoscopy or laparotomy should be immediately performed.50 Anastomotic Leak: Because most anastomotic leaks are small and resolve spontaneously, the actual incidence of this complication is unknown (fig. 4). Anastomotic leaks occur in less than 3% of ORP cases8, 24 and in 1% to 8% of RARP cases.27, 51 The risk for anastomotic leakage is inversely proportional to the quality of the anastomosis. To achieve a good anastomosis, the caliber of the bladder neck should not be much larger than that of the urethra. If the bladder neck opening is large, it can be tapered appropriately with figure-of-8 sutures at the 3 and 9 oclock positions. For the open approach, 5 or 6 interrupted absorbable sutures are commonly used for the vesicourethral anastomosis. A running anastomosis is performed with RARP. Visualization of the anastomosis may be improved using a 30 downward angled lens. Lapra-Ty clips may facilitate construction of a watertight anastomosis by allowing the surgeon to adjust tension on the suture line.52 Before applying these clips, one must visually confirm that the anastomosis is tight, especially at the posterior edge. Regardless of approach, once the anastomosis is complete the bladder should be filled with water and observed for areas of leakage. Although improved visualization may facilitate the anastomosis during RARP, there are several unique technical challenges to using this approach. If the instruments do not reach the urethra, the arm and trocar should be carefully advanced further into the patient. The presence of a large overhanging pubic osteophyte may make it more difficult to access the urethra with the robotic instruments but this can usually be managed with inferolateral angulation of the arms. Leaving an intraperitoneal drain helps in the diagnosis and treatment of an anastomotic leak. Fluid analysis for creatinine from drain outputs can quickly differentiate between peritoneal fluid and urine. If consistent with urine, the drain should be left in place until the output decreases to minimal, at which time a repeat creatinine analysis of the fluid may be performed. Patients can be discharged home with the drain in place and instructions to carefully record outputs every 4 to 6 hours. If the output remains high, the drain should be placed off suction, as negative pressure may actually increase leakage from the

anastomosis. The Foley catheter should not be removed until a cystogram confirms resolution of the leak. Rhabdomyolysis: Rhabdomyolysis results from muscle necrosis and release of intracellular contents caused by prolonged compression of muscles during long surgical procedures, which may lead to renal tubular necrosis and renal failure. In urology rhabdomyolysis is most commonly associated with procedures requiring an exaggerated lithotomy position (perineal prostatectomy) or flank position (laparoscopic nephrectomy). Interestingly, a review of the literature reveals no reports of rhabdomyolysis associated with ORP or RARP. However, urologists should be familiar with this clinical entity and its management, particularly during the initial learning curve associated with RARP. During this period robotic time should be limited to a maximum of 6 hours and, if not completed by then, open conversion should be considered. Prevention involves identifying and padding any muscles under compression. During RARP care should be taken to avoid contact between the robotic arms and the patient. Postoperatively, patients with rhabdomyolysis often have oliguria and brown urine due to the presence of pigmented casts. Creatine kinase, an intracellular component in muscle, is invariably elevated, often exceeding 5000 units/dl. Acute management involves hydration and alkalization to prevent renal failure. A nephrology consult should be obtained and renal function monitored closely. After the acute period has resolved focus should be placed on rehabilitating the affected muscles with physiotherapy. Unfortunately, some patients have permanent renal failure and/or physical disability. Nerve Palsy: Nerve palsy during RP occurs due to patient positioning or nerve compression within the surgical field. From a large RARP series Hu et al reported single postoperative cases of ulnar and median nerve as well as lumbosacral neuropraxias.27 In an ORP series Augustin et al reported on 6 patients (0.5%) complaining of sciatica or lower back pain.11 Sciatic nerve injury is more likely to occur from leg overextension, while femoral nerve palsy, although rare, may also occur due to compression from self-retaining retractors.24, 53 To avoid such injuries care must be taken to not overextend the extremities or the back. In addition, all possible pressure areas should be appropriately padded. Similarly, care should be taken to avoid plac-

FIG. 4. CT cystogram of anastomotic leakage. A, intraperitoneal extravasation of contrast medium. B, leakage from anterior and posterior vesicourethral anastomoses. Treatment included prolonged Foley catheterization and pelvic drainage.
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ing self-retaining retractors directly on nerve containing structures (the psoas 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 is indicated for mild cases, and a neurological consult should be obtained for severe cases to determine the extent of injury and the best management options. Delayed complications. Lymphocele: Lymphocele forms when lymphatic channels remain patent after surgery. The risk of lymphocele increases when a PLND is performed, especially if an extended template is used.54 Lymphoceles are relatively common complications, although the exact incidence is unknown since most will resolve without ever being diagnosed. They are reported to occur in 0.1% to 2% of patients with no significant differences between surgical approaches.11, 24, 27, 55 Meticulous cautery or clipping of lymphatic channels during open and laparoscopic prostatectomy may be important in preventing lymphoceles. When clinically significant, patients may present several weeks after RP complaining of unilateral leg swelling due to compression of pelvic venous return. Pelvic CT or ultrasonography may help to confirm the diagnosis (fig. 5). Treatment depends on the size of the lymphocele and the associated symptoms. Many large lymphoceles will resorb over time but if the patient has a fever, insertion of a percutaneous drain with or without sclerotherapy may be indicated.56 Marsupialization of the lymphocele via an open or laparoscopic approach may be performed if more conservative therapy is unsuccessful.57 Hernia: Incidentally detected inguinal hernias are common during radical prostatectomy. In a series by Lepor et al 12% of patients had a hernia, which was repaired intraoperatively.24 Similarly, Finley et al reported favorable outcomes with intraoperative inguinal hernia repairs using mesh during RARP.58 Inguinal hernias are also relatively common after RP with incidences as high as 17% after ORP and up to 14% after laparoscopic RP.59, 60 However, incisional hernias occur much less often (<1% in open and robotic series).24, 25, 31 While port site (spigelian) hernias are reported in the general surgery literature, few have been cited following RARP.61 Post-ORP inguinal hernias are likely to result from weakening of fascial planes as the rectus and transversalis fascias are incised.62 There is no simple way to prevent post-ORP inguinal hernias, as no clear association of modifiable factors has been established. Incisional hernias can be avoided by ensuring that the fascia underlying the suprapubic incision in cases of ORP and the specimen extraction site

in cases of RARP are completely closed. Although controversial, fascial closures should be performed in all ports 15 mm, while being careful not to incorporate bowel into the sutures. Bladder Neck Contracture: The etiology of bladder neck contractures is not definitively known but likely involves anastomotic urinary leakage 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% to 2% of robotic cases.24, 27, 28, 51, 63 In a large ORP series Erickson et al found that patients in whom BNCs developed had higher preoperative prostate specific antigen levels and were more likely to have undergone a non-nerve sparing RP.64 In addition, patients with contractures had lower postoperative potency and continence rates, and were more likely to have biochemical failure. Preventing bladder neck contracture involves the same techniques as preventing anastomotic leakage. Watertight anastomosis without tension and vascularized mucosa-to-mucosa apposition are essential. Some advocates of RARP have noted that bladder mobilization reduces tension at the vesico-urethral anastomosis and enhanced visualization allows for improved approximation of mucosal edges during the running anastomosis. Both of these advantages may help reduce the incidence of anastomotic leakage and BNC. Postoperatively, patients with bladder neck contracture usually present with weakened urinary stream and incomplete voiding due to overflow incontinence between 1 and 12 months after catheter removal.28, 51 The diagnosis can be confirmed cystoscopically, during which a strictured anastomosis, through which the cystoscope cannot pass, is visualized. Under vision, a wire should first be passed into the bladder and, after securing access, multiple incisions made at the bladder neck using a urethrotome. However incision may not be necessary, as simple dilation appears to be effective in many cases.65 Urinary Incontinence: Urinary incontinence is one of the most common long-term complications of RP. Because there is no set definition of urinary incontinence, it is important to understand how it is measured in any given study and how time elapsed since the operation can affect the data.28 Stress urinary incontinence is likely due to intrinsic sphincter deficiency resulting from trauma, although detrusor instability may also play a role.66 Injury to the rhabdosphincter may occur during apical dissection of the prostate, ligation of the DVC or insertion of the anastomotic sutures.28 In addition, large discrepancies in diameter between the bladder neck and urethra may increase the risk of incontinence. To reduce the likelihood that the proximal urethra remains open

FIG. 5. A, CT reveals bilateral symptomatic pelvic lymphocele 4 weeks after RARP. Patient presented with bilateral pedal edema, pelvic discomfort and low grade fever. B, treatment included percutaneous drainage of both lymphocele collections and antibiotics.
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and not coapted at rest, it may be important to reconstruct the bladder neck (when necessary) to an appropriate size before beginning the anastomosis.66 Overall, the incidence of post-RP urinary incontinence has decreased during the last 3 decades. Hautmann et al reported on 418 patients between 1984 and 1993, of whom 55% reported complete continence at 36 months after ORP.9 In contrast, in a more recent series Maffezzini et al reported an 89% continence rate after ORP.10 Catalona25 and Walsh67 et al reported continence, defined as requiring no pads, in more than 90% of patients. These contemporary results serve as a significant contrast to population based studies. Fowler et al reported that 40% of Medicare patients who underwent ORP between 1988 and 1990 complained of some degree of stress urinary incontinence postoperatively.68 Similarly, in their questionnaire based study Kao et al found that 33% of patients who underwent ORP after 1990 complained of some level of incontinence, defined by the need for any number of urinary pads.69 Similar data are reported from other population based studies.70 To improve the likelihood of postoperative continence, preoperative Kegel exercises and coordination of reflexive pelvic floor contractions during Valsalva maneuvers may be helpful. RARP may have certain theoretical but unproven advantages in preserving urinary function. Improved visualization during dissection of the prostatic apex as well as reduced bleeding may help limit injury to the rhabdosphincter.31 Ahlering et al reported that 76% of 60 patients required no pads 3 months after RARP.71 Patel et al reported that at 12 months continence rates based on the same criteria were as high as 98%.72 Zorn et al reported subjective continence, defined as no pad use or occasional use of a protective pad, in 90% of 300 patients after RARP.73 A watertight mucosal-to-mucosal anastomosis with minimal urinary extravasation, scarring and fibrosis may allow for restoration of physiological urethral coaptation at rest and during exercise, and is critically important for post-RP urinary continence. Whether reconstruction of the periprostatic tissues (the posterior musculofascial plate encompassing Denonvilliers fascia) improves urinary continence remains unclear.74-76 Rocco et al were one of the first to describe this technique for ORP, and they found that reconstructing the posterior fascial plane resulted in a markedly shorter time to continence compared to a historical cohort.76 Similar results have been reported by others.74 In contrast, in a randomized study of 116 patients undergoing RARP with or without reconstruction of the periprostatic tissues Menon et al found no difference in ultimate urinary continence.75 Treatment of incontinence should first focus on behavioral modifications, pelvic floor physiotherapy should continue postoperatively and consumption of diuretics like coffee or alcohol should be restricted. Initial therapy may include a trial of an anticholinergic to address the possibility of detrusor overactivity. If significant urinary incontinence persists for more than 1 year, surgical therapy such as an artificial urethral sphincter or urethral sling may be considered. Erectile Dysfunction: Erectile dysfunction is one of the most feared complications of radical prostatectomy for most men and their partners. Research in the early 1980s provided insight into the etiology of postprostatectomy erectile dysfunction, leading to the development of novel surgical techniques to prevent it.6, 77 The incidence of post-RP erectile dysfunction has since improved significantly.8, 78 However, reporting on postoperative ED is fraught with difficulties because of the various measurement methods used by different investigators and institutions. Only validated, standardized questionnaires, such as the International Index of Erectile Function, should be used to evaluate postoperative erectile function. Return of erectile function can take anywhere from 3 months to 3 years after surgery.79 At 3 months Walsh et al reported an erectile function rate of 38% after ORP, which increased to 86% by 18 months.67
16

Similar rates have been reported by others.80 However, some population based studies report lower statistics. Based on the Prostate Cancer Outcomes 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 postoperatively depend on several preoperative variables, including quality of preoperative erections, age, degree of comorbidity and cancer variables that determine whether the neurovascular bundles may be preserved.28, 67 Indeed, preoperative planning that takes all of these variables into account is important in deciding to what degree the neurovascular bundles can and may be preserved.81 Whether a nerve sparing approach is undertaken unilaterally or bilaterally may be important for recovery of erectile function.25 Furthermore, the degree of nerve sparing and subsequent erectile function also has been shown to be affected by whether an extra or interfascial nerve sparing technique is used.82 Preservation of the accessory pudendal artery and release of the levator fascia anteriorly (high anterior release) appear to improve erectile function after ORP and RARP.73, 83, 84 The robot assisted approach may have some theoretical advantages over the open approach. Developing the plane between the prostate and rectum facilitates identification (and preservation) of the medial border of the neurovascular bundle.28, 31 Dissection of the nerves in an antegrade manner may also facilitate avoidance of the neurovascular bundle. Conversely, there may be a tendency for increased use of cautery during neurovascular dissection during RARPs, whereas during ORP suturing and clips are more frequently used. In the experience of Khan et al avoidance of thermal injury produced a nearly 5fold improvement in early return of sexual function.85 Furthermore, thermal injury appears to induce a dense injury that may be largely reversible after 2 years. Treatment of post-RP erectile dysfunction may begin with oral phosphodiesterase inhibitors and, if unsuccessful, intracavernosal injections of prostaglandin E1. McCullough86 and Mulhall87 et al advocate early use of these agents as part of a penile rehabilitation regimen, which may serve to protect nerves and vascular endothelium. The goal of such therapy is to increase post-prostatectomy penile vascular flow, minimize corporal fibrosis and eventually improve erectile function. Rehabilitation may be important in the postoperative period when ischemic scarring has been demonstrated to occur within the cavernosa in experimental animal models. Within 2 months postoperatively decreases in cavernosal elastic and muscle fibers, and increases in collagenous content have been documented.88 Penile pump devices and intraurethral alprostadil may also be considered. If oral and intracavernosal therapies are unsuccessful, and reasonable 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 decreased dramatically during the last 2 decades. Comparisons among institutions and surgical techniques are limited by the absence of a standardized classification system. Therefore, we advocate the use of standardized, validated questionnaires for future studies. While surgical experience appears to play a role in the risk of complications, another important factor is careful patient selection. Familiarity with the associated complications and early recognition will result in efficient management with minimal long-term sequelae. More importantly, prevention of these complications is the ultimate goal. Nevertheless, all such potential complications should be fully discussed with patients during the process of informed consent. Acknowledgement: Drs. Gary D. Steinberg, Arieh L. Shalhav, Greg P. Zagaja and Scott E. Eggener critically reviewed and contributed to this Update.

APPENDIX: TREATMENT AND PREVENTION OF COMPLICATIONS OF RADICAL PROSTATECTOMY Specific surgical complications
Myocardial infarction T EKG T Serial troponin T Cardiology consult T Preoperative cardiac evaluation and screening (stress test, echocardiogram) T Identification of CAD risk factors (age >50, hypertension, hypercholesterolemia smoking, obesity, family history) T Intermittent compression devices placed before anesthesia induction T Pharmacological thromboprophylaxis (low molecular weight heparin, low dose unfractionated heparin) T Screening of high risk patients T Early ambulation T Patient education T Early diagnosis and treatment of suspected DVT T Preoperative evaluation of coagulation parameters in high risk patients T Discontinuation of antiplatelets/anticoagulants 7-10 days before surgery T Careful operative technique (knowledge of pelvic anatomy, adequate exposure of operative field, meticulous tissue dissection) T DVC suture/staple control T Meticulous technique and early identification during lymph node dissection T Avoid thermal energy close to the nerve T Preoperative bowel prep T Initial trocar entry through virgin area T Raise pressure to 20 mm Hg during initial trocar placement T Placement of all trocars under direct visualization T Decompress stomach with orogastric tube T Steep Trendelenberg position to displace bowel T Good communication between console and bedside surgeon T Careful inspection before closure T Full bowel prep in high risk patients T Sharp dissection through Denonvilliers fascia T In suspected cases digital inspection or rectal insufflation with air and assessing for gas leak in pelvis with fluid T Meticulous dissection of bladder neck T Avoid dissection medial to the medial umbilical ligament during lymphadenectomy T Early identification of ureter T Identification of ureteral orifices (previous transurethral resection, large median lobe) T Use of methylene blue/ureteral cannulation Postoperative complications Postoperative hemorrhage T T T T T T T T T Vitals monitoring Fluid replacement Blood transfusion Re-exploration Angiography and embolization Intraoperative bladder filling Drain fluid for creatinine Intraperitoneal drainage and indwelling Foley catheter Cystogram before catheter removal T Inspection of operative field under low pressure pneumoperitoneum before closure T Removal of all trocars under vision T Fascial closure with Carter-Thomason device T Avoid large discrepancy between size of urethra and bladder neck T Bladder neck reconstruction T Meticulous technique with watertight mucosa-tomucosa anastomosis T Inspection and repair of any leakage before case completion (continued)
17

Thromboembolic

Doppler ultrasound of lower extremities for DVT CT angiogram/VQ scan for PE Vascular consultation Anticoagulation IVC filter (especially in patients with contraindications for anticoagulation) T Fibrinolysis T Surgical or catheter embolectomy T T T T T Intraoperative complications Compression Increasing pneumoperitoneum Cautery Hemostatic sutures Fluid replacement Blood transfusion

Hemorrhage

T T T T T T

Obturator nerve injury

T Primary nerve repair of perineureum with nonabsorbable microsuture T Neurosurgical consultation T Early physiotherapy T T T T CT with oral Gastrografin General surgery consult Early recognition (primary repair) Delayed (primary repair, diversion, diagnostic laparoscopy/laparotomy, bowel resection)

Bowel injury

Rectal injury

T T T T T

Copious irrigation Primary 2-layer, interrupted absorbable suture closure Omental interposition Colorectal surgery consult Colostomy diversion

Bladder injury

T Primary repair with absorbable suture T Pelvic drain T T T T T Primary suture repair Ureteroureterostomy Ureteral reimplant Ureteral stent Pelvic drainage

Ureteral injury

Anastomotic leak

APPENDIX: TREATMENT AND PREVENTION OF COMPLICATIONS OF RADICAL PROSTATECTOMY (Cont.) Rhabdomyolysis T T T T T T T T T Myoglobinuria on urinalysis Serum creatine kinase measurement Nephrology consult IV hydration Urinary alkalization Renal function and output monitoring Physiotherapy and rehabilitation Physiotherapy and rehabilitation Neurology consult T Appropriate positioning and padding of pressure points T Avoidance of prolonged surgery and immobilization

Peripheral nerve injury

Lymphocele

Hernia Bladder neck contracture Urinary incontinence

T T T T T T T T T T

CT Conservative management Drainage with or without sclerotherapy Intraperitoneal marsupialization Surgical repair

T Appropriate positioning and padding of pressure points T Avoid overextension of extremities T Avoid excessive intraoperative stretch on nerves T Meticulous control of lymphatic channels during dissection

Erectile dysfunction

Bladder neck incision Behavioral therapy Kegel exercise Urodynamic evaluation Surgical management (male urethral sling, artificial urinary sphincter) T Early pharmacotherapy (phosphodiesterase inhibitors, intraurethral alprostadil suppository, intracavernosal injections, vacuum assisted devices) T Penile prosthesis

T Secure fascial closure of all incisions, extraction sites and ports 15 mm T As in anastomotic leak T Preoperative Kegel exercises T Meticulous apical dissection T Potential rhabdosphincter reconstruction

T T T T T

Nerve sparing dissection Avoidance of thermal and traction injury Preservation of accessory pudendal artery High anterior release of levator fascia Penile rehabilitation

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32. Keech D, Andriole D and Catalona WJ: Complications of radical retropubic prostatectomy. AUA Update Series 1994; XIII: lesson 6. 33. Koya M, Manoharan M, Kim S et al: Venous thromboembolism in radical prostatectomy: is heparinoid prophylaxis warranted? BJU Int 2005; 96: 1019. 34. Forrest J, Clemens J, Finamore P et al: Best practice statement for the prevention of deep vein thrombosis in patients undergoing urologic surgery. J Urol 2009; 181: 1170. 35. Geerts W, Bergqvist D, Pineo G et al: Prevention of venous thromboembolism. Chest 2008; 133: 381S. 36. Beyer J, Wessela S, Hakenberg O et al: Incidence, risk profile and morphological pattern of venous thromboembolism after prostate cancer surgery. J Thromb Haemost 2009; 7: 597. 37. Kearon C, Kahn S, Agnelli G et al: Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians EvidenceBased Clinical Practice Guidelines. Chest 2008; 133: 454S. 38. 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Orvieto M, Breyer B, Sokoloff M et al: Aortic injury during initial blunt trocar laparoscopic access for renal surgery. J Urol 2004; 171: 349. 44. Bishoff J, Allaf M, Kirkels W et al: Laparoscopic bowel injury: incidence and clinical presentation. J Urol 1999; 161: 887. 45. Shekarriz B, Upadhyay J and Pontes JE: Salvage radical prostatectomy. Urol Clin North Am 2001; 28: 545. 46. Blumberg J, Lesser T, Tran V et al: Management of rectal injuries sustained during laparoscopic radical prostatectomy. Urology 2009; 73: 163. 47. Yee D and Ornstein D: Repair of rectal injury during robotic-assisted laparoscopic prostatectomy. Urology 2008; 72: 428. 48. Borland R and Walsh P: The management of rectal injury during radical retropubic prostatectomy. J Urol 1992; 147: 905. 49. Hedican S and Walsh P: Postoperative bleeding following radical retropubic prostatectomy. J Urol 1994; 152: 1181. 50. Gong E, Zorn K, Gofrit O et al: Early laparoscopic management of acute postoperative hemorrhage after initial laparoscopic surgery. J Endourol 2007; 21: 872. 51. Msezane L, Reynolds W, Gofrit O et al: Bladder neck contracture after robot-assisted laparoscopic radical prostatectomy: evaluation of incidence and risk factors and impact on urinary function. J Endourol 2008; 22: 97. 52. Zorn K: Robotic radical prostatectomy: assurance of water-tight vesicourethral anastomotic closure with the Lapra-Ty clip. J Endourol 2008; 22: 863. 53. Bumett A and Brendler C: Femoral neuropathy following major pelvic surgery: etiology and prevention. J Urol 1994; 151: 163. 54. Naselli A, Andreatta R, Introini C et al: Predictors of symptomatic lymphocele after lymph node excision and radical prostatectomy. Urology 2009; Epub ahead of print. 55. Zorn K, Katz MH, Shikanov SA et al: Pelvic lymphadenectomy during robot-assisted radical prostatectomy: assessing nodal yield, perioperative outcomes, and complications. Urology 2009; 74: 296. 56. Treiyer A, Haben B, Stark E et al: Uni- vs. multiloculated pelvic lymphoceles: differences in the treatment of symptomatic pelvic lymphoceles after open radical retropubic prostatectomy. Int Braz J Urol 2009; 35: 164. 57. Waples M, Wegenke J and Vega R: Laparoscopic management of lymphocele after pelvic lymphadenectomy and radical retropubic prostatectomy. Urology 1992; 39: 82. 58. Finley D, Rodriguez EJ and Ahlering T: Combined inguinal hernia repair with prosthetic mesh during transperitoneal robot assisted laparoscopic radical prostatectomy: a 4-year experience. J Urol 2007; 178: 1296. 59. Abe T, Shinohara N, Harabayashi T et al: Postoperative inguinal hernia after radical prostatectomy for prostate cancer. Urology 2007; 69: 236. 60. Lodding P, Bergdahl C, Nyberg M et al: Inguinal hernia after radical retropubic prostatectomy for prostate cancer: a study of incidence and risk factors in comparison to no operation and lymphadenectomy. J Urol 2001; 166: 964. 61. Spaliviero M, Samara EN, Oguejiofor IK et al: Trocar site spigelian-type hernia after robot-assisted laparoscopic prostatectomy. Urology 2009; 73: 1423.e4. 62. Sekita N, Suzuki H, Kamijima S et al: Incidence of inguinal hernia after prostate surgery: open radical retropubic prostatectomy versus open simple

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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 a thromboembolic event? a. Age >60 years b. Malignancy c. Pelvic surgery d. Previous venous thromboembolism e. All of the above 2. What is the estimated percent of symptomatic DVT for ORP? a. 2-4 b. 5-7 c. 0.2-1 d. 8-10 e. 11-13 3. Postoperative findings most likely to be associated with an obturator nerve injury include a. Inability to flex the ipsilateral big toe b. Inability to abduct the ipsilateral leg c. Decreased ipsilateral patellar reflex d. Inability to adduct the ipsilateral leg e. Increased pain sensation over the contralateral thigh 4. Where is the most common site of rectal injury during radical prostatectomy? a. Near the seminal vesicles b. Near the prostatic apex c. During vesicourethral anastomosis d. During pelvic lymphadenectomy e. Laterally during dissection of the neurovascular bundle 5. What is a way to prevent postoperative hemorrhage after RARP? a. Reducing the pneumoperitoneum to 4 mm Hg before camera and trocar removal b. Removing trocars after the camera is removed c. Increasing pneumoperitoneum during trocar removal d. Avoiding pelvic lymphadenectomy e. Placing the Foley catheter on traction postoperatively

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