During the last decade, the number of robot-assisted prostatectomies performed in the United States has risen steadily throughout the country. Several factors have led to more complex patients being offered surgery for organ-confined prostate cancer, including refined surgical techniques, a better understanding of anatomy, and more experience. Robot-assisted procedures help surgeons better visualize anatomy and control bleeding with the added benefit of increased dexterity. This has enabled surgeons to treat prostate cancers more effectively with fewer complications than was previously possible with traditional open surgery.

Although rare, several studies have reported on complication rates associated with robot-assisted prostatectomy. However, few data exist when evaluating ureteral injuries that are sustained during these procedures. Further complicating matters is that there is no standardized universal criteria for reporting and grading of complications. “Identifying patient characteristics that may forewarn surgeons of such damage may further improve our ability to reduce complications,” says Jay K. Jhaveri, MD, MPH.

Low Rates Observed

In the Journal of Endourology, Dr. Jhaveri and colleagues had a study published that focused on 6,442 patients who underwent robotic prostatectomy by one of five surgeons over a 12-year period. Under the guidance of Mani Menon, MD, and James Peabody, MD, the study team found that three patients—operated on by two of the five surgeons—sustained complete transection of the ureter. One of the patients required readmission for further treatment.

Robotic-Prostatectomy-Callout

The study authors identified several risk factors that predisposed these patients to ureteral injury, including a history of:

• Infection.
• Abdominal surgery.
• Radiation treatment.
• Enlarged prostate glands.
• Prior transurethral prostatic resection.

Overall, the study group found a 0.046% rate of ureteral injury during robotic prostatectomy, which compares favorably with other similar studies and published data for this topic, according to Dr. Jhaveri.

Taking Precautions

“It’s important to note that these events occurred despite surgeons in the study being highly experienced,” says Dr. Jhaveri. “The surgeons performed more than 1,000 robotic prostatectomies, a rate that is well beyond the accepted learning curve of 100 cases. This shows that even in the most experienced hands, untoward complications can still occur. Determining risk factors can help us identify high-risk patients and allow us to take measures either before or during surgery to reduce the probability of these injuries.”

Beyond the clear benefits to patients, the study shows that preventive measures may also help avoid prolonged, expensive hospitalizations. “In addition, these measures may reduce the need for additional treatments or surgery and cut down the potentially expensive costs of follow-up treatments,” Dr. Jhaveri says. “Ultimately, taking precautions preoperatively or intraoperatively can reduce the probability of ureteral injuries and improve patient outcomes even further.”

References

Jhaveri JK, Penna FJ, Diaz-Insua M, Jeong W, Menon M, Peabody JO. Ureteral injuries sustained during robot-assisted radical prostatectomy. J Endourol. 2013 Dec 10 [Epub ahead of print]. Available at: http://online.liebertpub.com/doi/abs/10.1089/end.2013.0564.

Ahmed F, Rhee J, Sutherland D, Benjamin C, Engel J, Frazier H 2nd. Surgical complications after robot-assisted laparoscopic radical prostatectomy: the initial 1000 cases stratified by the clavien classification system. J Endourol. 2012;26:135-139.

Musch M, Hohenhorst L, Pailliart A, Loewen H, Davoudi Y, Kroepfl D. Robot-assisted reconstructive surgery of the distal ureter: single institution experience in 16 patients. BJU Int. 2013;111:773-783.

Nelson B, Kaufman M, Broughton G, et al. Comparison of length of hospital stay between radical retropubic prostatectomy and robotic assisted laparoscopic prostatectomy. J Urol. 2007;177:929-931.

Ficarra V, Novara G, Rosen RC, et al. Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol. 2012;62:405-417.

Teber D, Gözen AS, Cresswell J, Canda AE, Yencilek F, Rassweiler J. Prevention and management of ureteral injuries occurring during laparoscopic radical prostatectomy: the Heilbronn experience and a review of the literature. World J Urol. 2009;27:613-618.