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Table of Contents
Year : 2022  |  Volume : 33  |  Issue : 4  |  Page : 192-198

Complications of robotic-assisted laparoscopic radical prostatectomy: Experience Sharing from 2000 cases involving a single surgeon

1 Department of Surgery, Divisions of Urology, Tungs' Taichung Metroharbor Hospital, Taichung, Taiwan
2 Department of Surgery, Divisions of Urology, Tungs' Taichung Metroharbor Hospital, Taichung; Jenteh Junior College of Medicine, Nursing and Management, Taiwan

Date of Submission21-Dec-2020
Date of Decision23-Feb-2022
Date of Acceptance07-Mar-2022
Date of Web Publication25-Oct-2022

Correspondence Address:
Yen-Chuan Ou
1650 Taiwan Boulevard Sect. 4, Taichung Veterans General Hospital, Taichung, Taiwan 40705
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/UROS.UROS_173_20

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Purpose: Sharing experiences of complications with robotic-assisted laparoscopic radical prostatectomy (RALP) in 2000 patients treated by a single surgeon. Materials and Methods: We retrospectively reviewed 2,000 prostate cancer patients who underwent RALP (Group I, cases 1–1,000; Group II, cases 1001–2000) from December 2005 to September 2020 to compare the complications of the first 1000 patients with those of the latter 1000. All procedures were performed by the same experienced surgeon. Perioperative surgical complications were classified using the Clavien–Dindo classification. Complications were classified as minor (Clavien–Dindo Grades I–II) and major (Clavien–Dindo Grades III–IV), respectively. There was no Grade V complication. Results: Seventy-two cases developed complications in Group I: 26 with Clavien–Dindo Grade I, 29 with Grade II, 12 with Grade III, and 4 with Grade IV. The cases that developed complications in Group II, however, were lower at 48 cases: 15 with Clavien–Dindo Grade I, 17 with Grade II, 15 with Grade III, and 1 with Grade IV. Cases with minor Clavien–Dindo Grade (I–II) complications decreased significantly from Group I to Group II, at 55–32 patients (P = 0.0416). The transfusion rate was 1.1% in Group I, which was significantly higher than that in Group II at 0.1% (P = 0.0151). Conclusion: The assessment of the two groups indicated that the surgeon's learning curve for RALP improved with significantly fewer minor Clavien–Dindo Grade (I–II) group complications after 1000 surgeries.

Keywords: Prostate cancer, robotic-assisted laparoscopic radical prostatectomy, surgical complications

How to cite this article:
Lu CH, Ou YC, Lin YS, Huang LH, Weng WC, Hsu CY, Tung MC. Complications of robotic-assisted laparoscopic radical prostatectomy: Experience Sharing from 2000 cases involving a single surgeon. Urol Sci 2022;33:192-8

How to cite this URL:
Lu CH, Ou YC, Lin YS, Huang LH, Weng WC, Hsu CY, Tung MC. Complications of robotic-assisted laparoscopic radical prostatectomy: Experience Sharing from 2000 cases involving a single surgeon. Urol Sci [serial online] 2022 [cited 2023 Feb 6];33:192-8. Available from: https://www.e-urol-sci.com/text.asp?2022/33/4/192/359676

  Introduction Top

One of the perioperative variables included in the pentafecta outcomes used to evaluate the quality of robotic-assisted laparoscopic radical prostatectomy (RALP) is the absence of postoperative complications. Apart from the lack of complications, the pentafecta outcomes include potency, negative surgical margins, and no biochemical recurrence.[1],[2] Patel et al.[3] classified complications in RALP using the Clavien–Dindo grading system. According to his research, RALP complications ranged from 6.1% to 26%. With experience, surgeons may be able to reduce complication rates.

Ou et al.[4] evaluated the outcomes of 200 RALP cases in 2010. After 150 RALP procedures performed by a single surgeon, there was a significant reduction in complications. Significantly lower blood loss and blood transfusion rate were noted after 50 cases. After 150 cases, there was a significant decrease in complications. In 2014, Ou et al.[5] reported a significant decrease in the positive surgical margin rate in pT3a patients after 250 cases. The complication rate fell from 9.6% to 5.6%, but this was not statistically significant (P = 0.129), and the number of cases with Clavien–Dindo Grades I/II/III/IV fell from 5/11/6/2 to 5/5/1/3 cases. In a series of 1,000 consecutive RALP cases, Ou et al.[6] reported significantly fewer blood transfusions and lower complication rates in 2016. Coelho et al.[7] reported a 9.3% complication rate in the first 300 cases in a study of 2500 single-surgeon RALP case series in 2010, which decreased to 3.3% in cases 2101–2400.

According to the above-mentioned studies, complication rates decreased with experience. In practice, only a few surgeons have had extensive experience with RALP. The goal of this study was to describe a single surgeon's learning curve in terms of the number and type of complications encountered in 2000 RALPs performed.

  Materials and Methods Top


We looked back on 2000 patients with prostate cancer who had undergone RALP between December 2005 and September 2020. All procedures were carried out by the same skilled surgeon (Y. C. Ou). The Clavien–Dindo grading system was used to record and classify perioperative surgical complications.[8] As described previously by Patel et al.,[3] complications are classified as minor (Clavien–Dindo Grades I–II) and major (Clavien–Dindo Grades III–IV).[3],[9] Patients were divided into two groups: Group I, cases 1–1000 (from December 2005 to June 2015), and Group II, cases 1001–2000 (from July 2015 to September 2020).

Preoperative assessments

Preoperative evaluation included a thorough review of the patient's medical history, including the identification of comorbidities, abdominal surgical history, and medication history, particularly anticoagulation drugs, antiplatelet drugs, supplemental drugs, and herbs. Under continuous medication, the underlying diseases recorded included hypertension, diabetes, renal insufficiency, and gouty arthritis. The cardiovascular and pulmonary systems were examined. All patients had preoperative anesthetic consultations with anesthesiologists. All patients had preoperative multiparametric magnetic resonance imaging (MRI). The tumor status (including location, staging, extracapsular extension, bladder neck, Denonvillier fascia or seminal vesicle invasion, lymph node, pelvic wall or bone metastasis, and pelvic cavity) and prostate anatomical information (including narrow pelvic cavity, deep prostate, large prostate size, intravesical prostate protrusion, and apical configuration), as well as other abnormalities, were determined using MRI (including prostate abscess and calcification, large seminal vesicle cyst, vesicle stone, and bladder tumor). Based on this information, a surgical plan, including neurovascular bundle (NVB) preservation and other operative details, could be refined prior to RALP.[5]

Surgical techniques

For RALP and other robotic-assisted surgeries, a dedicated robotic team was assembled. The patient was placed in a steep Trendelenburg position of 25°–30° while under general anesthesia. Six trocar ports on a four-arm da Vinci Robotic System were used for a transperitoneal approach (Intuitive Surgical, Sunnyvale, CA, USA). [Table 1] shows the criteria for NVB preservation. NVB preservation was carried out after careful consideration of various parameters, such as the D'Amico risk classification, biopsy tumor percentage, and preoperative MRI. RALP was carried out as described previously.[4],[10],[11]{Table 1}

Postoperative care

The postoperative care protocol was carried out on a routine basis in accordance with the postoperative date and as described herein. Early ambulation was encouraged on the first postoperative day (POD 1). First, the patient would try to drink some water. If there was no discomfort, they were encouraged to eat a regular diet on POD 1–2. On PODs 1–3, the drainage tube would be removed. If there were no complications, the patient was discharged on PODs 2–5. The patient would visit the urology outpatient department on PODs 7–14 for evaluation and Foley catheter removal.[4] All patients were followed up on a regular basis at the outpatient department, and the surgical complication rate was assessed for at least 6 months after surgery.

The protocol was approved by the Taichung Veterans General Hospital's Institutional Review Board (IRB) (IRB Number: CE 15215B) and Tungs' Taichung Metroharbor Hospital (IRB Number: 109007). The IRB waived informed consent.

Statistical analyses

The mean and standard deviation are used to express all data. For biostatistical calculations, IBM SPSS 20.0 for Windows (Chicago, IL, USA) was used. Statistical analyses were carried out using one-way analysis of variance and the Chi-squared test, as appropriate. P < 0.05 was considered statistically significant.

  Results Top

Complications occurred in 120 of the 2000 RALP cases reviewed. The perioperative surgical complications in Group I are shown in [Table 2]. In Group I, 72 cases developed complications: 26 were classified as Clavien–Dindo Grade I, 29 as Clavien–Dindo Grade II, 12 as Clavien–Dindo Grade III, and 4 as Clavien–Dindo Grade IV. In Group II, the number of cases with complications was lower at 48: there were 15 Clavien–Dindo Grade I cases, 17 Clavien–Dindo Grade II cases, 15 Clavien–Dindo Grade III cases, and 1 Clavien–Dindo Grade IV case.{Table 2}

[Table 3] shows that the minor Clavien–Dindo Grade (I–II) group (P = 0.0416) had a significantly lower complication rate. The transfusion rate in Group I was 1.1%, but it dropped significantly to 0.1% in Group II (P = 0.0151). Blood transfusions were the most common complication (0.6%, 12/2,000). The gastrointestinal (GI) complications observed ranged in severity from Clavien–Dindo Grades I to VI and included intraoperatively repaired intestinal tears, rectal injuries, prolonged ileus, incarcerated inguinal hernias requiring laparoscopic hernioplasty, intestinal obstructions requiring laparoscopic enterolysis, and colorectal injuries requiring transient colostomy and subsequent colostomy closure.[8] Ureteral injuries, GI bleeding, urine leakage, internal bleeding, and incisional hernia were among the other complications discovered [Table 2] and [Table 4]. The minor Clavien–Dindo Grade (I–II) group (P = 0.0416) was the only complication group with a statistically significant decrease in events. Our findings clearly show a decreasing trend in the number of complications after 1000 cases of experience.{Table 3}{Table 4}


  Discussion Top

The urology community considers RALP to be the most preferred surgical therapeutic treatment for localized prostate cancer. Martin et al.[12] proposed ten criteria for the accurate and thorough reporting of surgical complications. The method of data collection, duration of follow-up, definitions of complications, outpatient information, mortality rates and causes of death, morbidity rates and total complications, procedure-specific complications, severity grading system, length of stay, and risk factors in the analysis are among these elements. Patel et al. examined related articles as well as individual outcomes. In reporting the outcomes after RALP, they proposed the pentafecta, which adds no postoperative complications and negative surgical margins to the traditional trifecta outcomes (continence, potency, and no biochemical recurrence).

Potential RALP complications should be discussed with surgeons before the procedure. The Clavien–Dindo grading system is recommended by the European Association of Urology Guidelines to assess RALP complications. According to Patel et al., the median RALP complication rate was 12.6%, with a range of 3.1%–42%. The most frequently reported Clavien–Dindo Grade (I–II) complications were minor. Most complications can be avoidable by the surgeon with a focused approach, experience, awareness, and strict adherence to safe surgical skills. Under the supervision of an experienced surgeon, RALP is a safe and repeatable procedure.[1]

Only a few studies with a sample size of over 2000 patients have been conducted. Coelho et al.[7] described 2500 robotic-assisted radical prostatectomies performed by a single surgeon at a busy center. Significant overall complication rates (P = 0.0034) and the number of anastomotic leaks (P < 0.001) decreased with increasing surgeon experience. The overall complication rate was 5.08%. The rate was 9.3% in the first 300 cases and 3.3% in the final 300 cases. Other studies that looked into the complications of RALP used fewer than 2000 cases. In 2013, Liss et al.[13] reported an overall complication rate of 10.8% in 1000 RALP cases. The complication rate was 18% in the first 200 cases and 5% in the last 200 cases. Furthermore, the rate of major complications (Grades III and IV) fell from 12.5% to 2.5%. In 2017, Kočárek et al.[14] examined 1500 RALP cases, 20 (1.3%) of which had intraoperative complications based on the Clavien–Dindo classification. Within 3 months of surgery, 127 (8.5%) of the patients experienced complications.

[Table 5] contains some pointers and tips to deal with problems that may arise at various stages of RALP. In addition to the experience shared in [Table 5], preoperative MRI mapping was used in our study to collect anatomical information on the prostate, pelvis, and other nearby structures. We reviewed current articles and found that comprehensive preoperative MRI can make prostate dissection precise, preserve the NVB, and make vesicourethral anastomosis safer, resulting in a shorter operative time, fewer complications, better prediction of the high-risk site of tumor extracapsular extension, a smaller positive surgical margin, and improved outcomes.[27],[28],[29],[30],[31] MRI can also alert surgeons to subclinical inguinal hernias, which can be repaired intraoperatively. Anomalies in the accessory pudendal arteries were identified and preserved in some cases.[27],[32]{Table 5}

The use of neoadjuvant hormone therapy (NHT) prior to RALP may have an impact on surgical outcomes. Hou et al.[33] studied 28 patients with high-risk prostate cancer. Following NHT, the mean operative time for RALP was longer. Patients who received NHT had the same perioperative morbidity as non-NHT patients. Anticoagulants, Chinese herbal medicine, hyperuricemia, and gouty arthritis medications were among the other preoperative medications. In our practice, anticoagulants were withheld 1 week before RALP, and Chinese herbs were withheld 3 weeks before RALP. According to Mantz et al.,[34] aspirin did not increase major thrombotic or bleeding events in at-risk patients undergoing urological surgery. Some Chinese herbal medications, on the other hand, have the potential to disrupt the coagulation cascade and increase the likelihood of bleeding. Patients who use traditional Chinese medicine may experience drug–drug interactions or other serious side effects. Cordier and Steenkamp proposed that Chinese herbal medication be stopped prior to surgery.[35],[36]

Gout attacks occurred in 4.2% of 359 patients with prostate cancer who underwent radical prostatectomy (open, laparoscopic, or robotic).[37] The incidence rate of gouty arthritis in the current study was 1.5% in the first 200 cases and decreased to 0.375% in cases 201–800. The administration of antihyperuricemic medication may have contributed to the improvement.[4]

A dedicated and experienced robotic team is critical to the success of robotic-assisted surgeries in terms of lowering complication rates and in many other factors. Preoperative preparation, patient positioning, patient safety and protection, docking, surgery instrument preparation and usage, wound treatment, and postoperative patient care are skills of a skilled robotic team at every step of RALP. A professional robotic team benefits both novices and experienced surgeons by facilitating learning and improving outcomes. The robotic team and surgeon are both growing and gaining experience at the same time.[4]

An ocular complication after RALP has been reported,[38] but it was not observed in this study. As a result of the increased intraocular pressure and other physiologic changes induced within the eye, the unusual steep Trendelenburg positioning during RALP may cause ocular complications. Kan et al. reported ocular complications, such as corneal abrasion and ischemic optic neuropathy, following RALP. Corneal abrasions frequently heal on their own without causing permanent damage, scarring, vision loss, or other complications. Ischemic optic neuropathy, on the other hand, is far more severe and can result in permanent vision loss.

Clinical decision-making should be supported by evidence from the clinical care pathway.[39] For difficult operations, such as RALP, an experienced surgeon and a surgical team require a stable clinical care pathway that includes early diagnosis, subsequent management, and a low plication rate. The most common complications identified in our study were blood transfusions and GI issues. However, as surgeon experience increased, the rate of blood transfusions decreased.

In our study, urine leaks occurred in four of the first 1000 cases, then decreased to two of the next 1000 cases. Urine leaks were one of the most common complications, with an incidence rate of 0.3%–15.4%.[3],[40] Urine leaks may be followed by vesicourethral anastomotic strictures and incontinence. There are numerous methods of vesicourethral anastomosis for urine leak prevention. Our method was posterior rhabdosphincter reconstruction, which was also used by Coelho et al.[41] They enrolled 803 RALP patients, 473 of whom received modified posterior reconstruction of the rhabdosphincter, achieving a 0.4% anastomotic leakage rate and early recovery of continence. Three hundred and thirty patients did not receive posterior reconstruction after RALP, resulting in early continence recovery in 2.1% of patients. In our practice, intraoperative normal saline bladder instillation (200 mL) was used to confirm watertight vesicourethral anastomosis. Postoperative cystography prior to Foley removal was not required in our experience.[42]

Complication reduction is the ultimate lifelong goal for all surgeons. Beginners typically have a higher complication rate. Minor complications were significantly reduced in our study after 1,000 cases of RALP. However, there was no statistically significant difference in the incidence of major (Clavien–Dindo Grades III–IV) complications between the two cohorts. We hypothesized that the reason was the accumulation of experience by the surgeon and surgical team, as well as the maturation of the clinical care pathway. Most surgeons, including beginners, were aware of the potential critical steps for major complications. Minor complications, on the other hand, necessitate more experience accumulation for prevention.

Our study found a downward trend in the complication rates of a high-volume RALP surgeon. Our findings, however, may not apply to the experiences of all surgeons in case series involving multiple surgeons, limiting the generalizability of the findings. Another limitation of our study is that the majority of the patients enrolled received the same surgical method, which was then adjusted based on individual anatomical variations or situations encountered during the operation. The Montessori technique, which involves first performing seminal vesicle dissection, dropping the bladder directly, or the Retzius space-saving radical prostatectomy are all surgical options. The Montessori technique was the most commonly performed technique in our case series. In a few cases, other methods were used. We did not weigh the pros and cons of these approaches.

Our study's strengths were in standardizing reporting using the Clavien–Dindo complication reporting system, and we met 9 of the 10 criteria defined by Martin et al.[12] Our study adds to the body of knowledge about the relationship between surgical experience and complication rates among RALP surgeons and broadens the base of comparison for future RALP research.

  Conclusion Top

Our analysis of 2000 RALP cases shows that complication rates decrease with surgical experience, with significantly fewer minor Clavien–Dindo Grade (I–II) complications and blood transfusion rates. We discussed some of the solutions to problems we encountered during RALP.

Financial support and sponsorship


Conflicts of interest

Prof. Yen-Chuan Ou, an editorial board member at Urological Science, had no role in the peer review process of or decision to publish this article. The other authors declared no conflicts of interest in writing this paper.

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