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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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:
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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.
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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.
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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.
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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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