Early complication of anatomical radical retropubic prostatectomy: lessons from a single-center experience

Rectal Perforation During Pelvic Surgery

Rectal perforations during pelvic surgery are rare but serious complications. The occurrence of rectal involvement is generally lower than that of the involvement of other portions of the bowel. The urologic field is responsible for the majority of iatrogenic rectal injuries from pelvic surgery; general and gynecologic surgeries are prone to the occurrence as well, the latter especially in the case of rectal shaving for deep infiltrating endometriosis. Attention should be posed to the prevention of rectal injuries, especially in case of challenging or salvage procedures; some tricks may be recommended to avoid thermal and mechanical damages and to realize a safe dissection. Intraoperative detection of rectal injuries is of paramount importance; once confirmed, immediate management with the closure of the defect is recommended. In general, rectal injuries diagnosed after surgery are liable to significantly worse outcomes than those detected and managed intraoperatively.

Patient summary

Rectal perforation is a rare but possible complication of pelvic surgeries. The more challenging the procedure (ie, surgery for locally advanced tumors or after radiation therapy), the higher the risk of rectal lesion. Intraoperative management of the injury should be attempted, with direct repair of the defect with or without fecal diversion.

Safety of robotic prostatectomy over time: a national study of in-hospital injury

OBJECTIVE

To assess national trends of iatrogenic complications and associated burden of care among patients undergoing open and minimally invasive prostatectomy using a population-based cohort.

METHODS

Using the nationally representative cohort, we identified patients who were diagnosed with prostate cancer, and underwent prostatectomy during 2001 and 2011. We determined the risk of iatrogenic complication and length of stay (LOS) over time among open and minimally invasive surgery (MIS) patients. Hierarchical multivariable logistic regression was performed to assess the changes over time and elucidate independent predictors of iatrogenic complications.

RESULTS

We identified 556,932 and 219,434 prostate cancer patients undergoing open and minimally invasive prostatectomy. We found that iatrogenic complications for MIS were less frequent in later years (years 09-11 vs. year 01-02 odds ratio (OR), 0.21; 95% confidence intervals (CI), 0.09-0.40). MIS was associated with higher risk of iatrogenic complications in early period (years 01-02 OR, 3.81; 95% CI, 1.72-8.41), but lower risk in late period (years 09-11 OR 0.72 95% CI 0.61-0.86). Patients who experienced iatrogenic complications tended to have longer LOS (Median: Open vs. MIS, 4 days vs. 3 day) than those who didn't (Median: Open vs. MIS, 2 days vs. 1 day), regardless of procedure type.

CONCLUSION

We found that minimally invasive prostatectomy is associated with lower risk of iatrogenic complications when compared with open surgery (OS). However, as "learning curve" is overcome over time, MIS becomes safer than OS. Iatrogenic complications are not benign and seem to be associated with higher burden of inpatient care.

A New Postoperative Predictor of Time to Urinary Continence after Laparoscopic Radical Prostatectomy: The Urine Loss Ratio

OBJECTIVES

To assess the correlation of a newly defined parameter, "urine loss ratio" (ULR), with the time to continence and probability for incontinence after laparoscopic radical prostatectomy (LRP).

MATERIALS AND METHODS

A standardized "micturition protocol" that uses 24-h pad testing to objectively quantify urine loss after removal of the catheter was obtained from 939 patients who underwent LRP and were provided complete follow-up regarding continence. ULR was defined as the weight of urine loss in the pad divided by daily micturition volume, distinguishing between ULR on the first day after catheter removal and the last day of hospital stay. The time to continence was classified as early (0-3 mo), midterm (4-12 mo), and late continence (13-24 mo).

RESULTS

Early continence was attained in 69.8% (n=655) of patients, midterm continence in 18.4% (n=173), and late continence in 3.5% (n=33). Of 939 patients in whom first-day ULR was quantified, 495 patients were not discharged immediately and their last-day ULR was quantified (2.3 d following catheter removal). There was a linear correlation between time to continence and ULR, which was more significant for last- than first-day ULR (p<0.001). A cutoff point of more than 15% of urine loss indicates a high risk of incontinence (ie, 8-fold for first-day ULR, 55-fold for last-day ULR).

CONCLUSION

ULR predicts the time to continence and may be used to select patients for specific rehabilitation programs and early adjuvant medical therapy, particularly when urine loss exceeds 15%.

[Radical prostatectomy. A review of our series between 1997-2003]

OBJECTIVE

To evaluate the complications and results of our series of 398 radical retropubic prostatectomies as an elective treatment for clinically localized prostate cancer.

PATIENTS AND METHODS

Between January 1997 and June 2003, a total of 398 radical retropubic prostatectomies have been performed. Mean age was 63.8 years (45.8-78.2), mean PSA at diagnosis 9.32 ng/ml (0.9-129.7). Mean surgical time was 141.6 minutes (70-280), and mean hospitalization was 6.75 days (2-37).

RESULTS

Mean follow-up was 65.18 months. We report as peroperatory complications: rectal injury 1.8%, lymphatic leakage 0.3%, urinary fistula 5%. As delay complications: uretrovesical junction stenosis 6%. We observed 49.1% of patients with positive surgical margins. We don't report any peroperatory death. The overall survival rate is 98.5%, the cancer specific survival rate is 99.75%, and the recurrence-free survival rate is 84.97%.

CONCLUSIONS

Radical retropubic prostatectomy is an excellent treatment form for patients with clinically localized prostate cancer. A strict selection of patients candidates is important to obtain good results.

Rupture of vesicourethral anastomosis following radical retropubic prostatectomy

OBJECTIVE

Rupture of vesicourethral anastomosis following radical retropubic prostatectomy is a complication that requires immediate management. We evaluated the morbidity of this rare complication.

MATERIALS AND METHODS

We analyzed retrospectively 5 cases of disruption of vesicourethral anastomosis during post-operative period in a consecutive series of 1,600 radical retropubic prostatectomies, performed by a single surgeon.

RESULTS

It occurred in a ratio of 1:320 prostatectomies (0,3%). Management was conservative in all the cases with an average catheter permanence time of 28 days, being its removal preceded by cystography. Two cases were secondary to bleeding, 1 followed the change of vesical catheter and 2 by unknown causes after removing the Foley catheter. Only one patient evolved with urethral stenosis, in the period ranging from 6 to 120 months.

CONCLUSION

Rupture of vesicourethral anastomosis is not related to the surgeon's experience, and conservative treatment has shown to be effective.

Laparoscopic radical prostatectomy: functional and oncological outcomes

PURPOSE OF REVIEW

Laparoscopic radical prostatectomy has become an accepted alternative to open surgery, however data on the functional and oncological outcome are still lacking. In this study we present an analysis based on a survey of the current literature and the first 500 patients treated with the Heilbronn technique. Additionally, we compare the results of laparoscopy with those of open radical prostatectomy.

RECENT FINDINGS

We conducted an extensive MEDLINE search of laparoscopic and open radical prostatectomy from 1999 through 2003, focusing on the last 3 years. The articles as well as our own results were analyzed with respect to continence, potency, positive margins, prostatic specific antigen failure, and clinical progression. No significant differences were found between the laparoscopic and open approach with respect to overall continence at 12 months (60-94% versus 61-98%) or at 3 months (51-63% versus 62-69%), varying from 4.1% at pT2, 12% at pT3 to 19% at pT4 stages. We found no significant differences between the two techniques in the recovery of potency (34-67% versus 31-79%), if one excludes the selected series of Walsh with a mean age of 57 years. Furthermore, we did not detect any significant differences in positive margins and short-term prostatic specific antigen recurrence (3 years).

SUMMARY

At centers of expertise, laparoscopic radical prostatectomy is able to provide similar functional and oncological results as its open counterpart, however with the advantages of minimally invasive surgery.

Operative management of rectal injuries during laparoscopic radical prostatectomy

OBJECTIVES

To present our experience in the management of rectal injuries during laparoscopic radical prostatectomy.

METHODS

All patients underwent bowel preparation and received perioperative antibiotics. If rectal injury was suspected, digital rectal examination was performed, aided by bubbling air into the rectum if required. When the diagnosis was confirmed, the hole was closed in two layers of absorbable sutures. A fat flap was developed from the omentum (in the transperitoneal approach) or the perirectal fat (in the extraperitoneal approach) and placed on the suture line. Anal dilation was performed. After surgery, broad-spectrum antibiotics and a low-residue diet were prescribed.

RESULTS

Of 300 patients who underwent surgery between May 1998 and June 2002, 6 (2%) had a rectal injury. The first patient had received neoadjuvant hormonal therapy. Five cases were in the transperitoneal approach and were closed using omental fat and 1 was in the extraperitoneal approach with a perirectal fat flap. The first patient presented with a rectourethral fistula and was treated with catheterization for 1 month and a diverting colostomy. The others were detected intraoperatively and were treated laparoscopically. In the second patient, a diverting colostomy was performed at the end of surgery using a separate incision. Patients resumed oral intake within 2 to 7 days and were discharged from the hospital between 6 and 18 days postoperatively. No wound infection was noted.

CONCLUSIONS

Rectal injuries during laparoscopic radical prostatectomy can be identified and managed intraoperatively without requiring conversion. Double-layered closure reinforced by a fat flap resulted in an uneventful recovery.

Intraoperative and perioperative morbidity of contemporary radical retropubic prostatectomy in a consecutive series of 1243 patients: results of a single center between 1999 and 2002

OBJECTIVES

To up date counselling of patients in an experienced center, we assessed intraoperative and perioperative complications in a consecutive series of contemporary radical retropubic prostatectomy for localized prostate cancer.

METHODS

In a prospective study, we analyzed all intraoperative and perioperative complications within 30 days in a consecutive series of 1243 patients undergoing radical prostatectomy between January 1999 and February 2002. All adverse events were graduated in major and minor complications by their severity and sequel.

RESULTS

There were no deaths. Overall, 996 patients (80.2%) were not affected by any complication. Major complications were observed in 50 patients (4.0%), minor complications in 197 (15.8%). Pelvic lymphadenectomy was performed in 861 (69.3%) patients. This procedure was associated with a significantly higher rate of lymphoceles requiring a drainage, 4.2% versus 0.3% (p<0.006) and a higher rate of deep venous thrombosis, 1.4% versus 0.5% (p<0.2), respectively.

CONCLUSION

Radical retropubic prostatectomy is a safe surgical procedure. Postoperatively the majority of our patients was not compromised by any complication within 30 days. Furthermore, due to a higher rate of lymphoceles and thromboembolic events the indication for pelvic lymphadenectomy should be considered carefully.

Validation of a biopsy-based pathologic algorithm for predicting lymph node metastases in patients with clinically localized prostate carcinoma

BACKGROUND

The authors validated an algorithm for the preoperative prediction of lymph node (LN) metastases in patients with clinically localized prostate carcinoma. The algorithm was applied to sextant biopsy material and radical retropubic prostatectomy (RRP) stage obtained from a cohort of men who were treated at the authors' institution.

METHODS

Four hundred forty-three patients underwent systematic sextant biopsy and RRP with staging lymphadenectomy. The original algorithm was based on systematic sextant biopsy data and classified patients into three risk groups for LN metastases based on the biopsy result. If > or = 4 of 6 biopsies contained any Gleason Pattern 4 disease, then the patient was at high risk for LN metastases (45%). Patients with > or = 1 of 6 biopsies with dominant Gleason Pattern 4 disease (excluding high-risk patients) had an intermediate predicted risk (19%) of LN metastases. All other patients had a low predicted risk of LN metastases (2.2%). The authors assed the percentage of patients who were positive and negative for LN metastases and calculated the specificity and negative predictive value in the series when patients were classified according to the original algorithm.

RESULTS

Twenty of 443 patients had intraoperative LN metastases. When applied to the current data, the Hamburg algorithm classified 404 patients in the low-risk group, 30 patients in the intermediate-risk group, and 9 patients in the high risk group. The incidence of LN metastases was 2.47% in the low-risk group, 20% in the intermediate-risk group, and 44.4% in the high-risk group. The negative predictive value for the low-risk group was 97.52%, and the specificity was 94.14%.

CONCLUSIONS

The Hamburg algorithm proved a valid tool for the prediction of lymphatic spread in this validation study on data from the authors' institution. The algorithm may serve as a tool to select patients who do not need to undergo pelvic lymphadenectomy at the time they undergo RRP, hence reducing morbidity and expense. More importantly, with the increasing numbers of men undergoing treatment options in whom LN dissection is not performed, this validated algorithm provides an important selection basis regarding the appropriateness of a therapy that does not routinely include LN staging.

Variations in morbidity after radical prostatectomy

BACKGROUND

Recent studies of surgery for cancer have demonstrated variations in outcomes among hospitals and among surgeons. We sought to examine variations in morbidity after radical prostatectomy for prostate cancer.

METHODS

We used the Surveillance, Epidemiology, and End Results-Medicare linked data base to evaluate health-related outcomes after radical prostatectomy. The rates of postoperative complications, late urinary complications (strictures or fistulas 31 to 365 days after the procedure), and long-term incontinence (more than 1 year after the procedure) were inferred from the Medicare claims records of 11,522 patients who underwent prostatectomy between 1992 and 1996. These rates were analyzed in relation to hospital volume and surgeon volume (the number of procedures performed at individual hospitals and by individual surgeons, respectively).

RESULTS

Neither hospital volume nor surgeon volume was significantly associated with surgery-related death. Significant trends in the relation between volume and outcome were observed with respect to postoperative complications and late urinary complications. Postoperative morbidity was lower in very-high-volume hospitals than in low-volume hospitals (27 percent vs. 32 percent, P=0.03) and was also lower when the prostatectomy was performed by very-high-volume surgeons than when it was performed by low-volume surgeons (26 percent vs. 32 percent, P<0.001). The rates of late urinary complications followed a similar pattern. Results for long-term preservation of continence were less clear-cut. In a detailed analysis of the 159 surgeons who had a high or very high volume of procedures, wide surgeon-to-surgeon variations in these clinical outcomes were observed, and they were much greater than would be predicted on the basis of chance or observed variations in the case mix.

CONCLUSIONS

In men undergoing prostatectomy, the rates of postoperative and late urinary complications are significantly reduced if the procedure is performed in a high-volume hospital and by a surgeon who performs a high number of such procedures.

[Complications in a consecutive series of 133 cases of radical prostatectomy]

OBJECTIVE

To evaluate the surgical complications of radical prostatectomy in our hospital.

PATIENTS AND METHOD

From august 1991 to december 1999, 138 patients with clinically localized prostate cancer underwent Walsh technique radical prostatectomy. The follow-up is known from 133 patients with a mean age of 64.8% and a mean PSA of 17.6 ng/ml.

RESULTS

The mean follow-up is 43 months. Urinary fistula (9%), lymphatic leakage (5.22%) and rectal injury (2.2%) are the most common early complications. Urinary incontinence (27%), erectile dysfunction (98%) and urethrovesical junction stenosis (12%) are the delay complications. Only three patients have died due to prostate cancer. Our results are compared with another series.

CONCLUSIONS

The morbidity of radical prostatectomy is very similar to the compared series. Urinary incontinence and erectile dysfunction are the most worrying complications which the patient must know to have the opportunity to choose another therapeutic option.