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Page 2 of 13 Koc et al. Mini-invasive Surg 2018;2:7 I http://dx.doi.org/10.20517/2574-1225.2017.33

[1]
Clavien-Dindo classification has been used as a standardized classification in general surgical literature .
[2]
Martin et al. proposed a report in 2002, to standardize the classification criteria that should be
incorporated into surgical complication reports including definitions of general and procedure-specific
complications, data accrual, and follow-up period, inclusion of length of stay and outpatient information,
identification of mortality and morbidity rates, application of a grading system for complications, and
analysis of risk stratification. However, they reported hepatectomy, pancreatectomy, and esophagectomy
[2]
[3]
as specific examples . Donat modified these criteria in 2007, to include procedure-specific complications
concerning urology such as inadvertent visceral injury, bleeding and transfusion rates, urine leakage, and
lymphocele formation.

This paper aimed to present the commonly seen and serious surgical complications of robot-assisted radical
prostatectomy (RARP) as the most frequently performed robot-assisted procedure in urology practice, and
their prevention and management.

METHODS
A systematic search was performed in PubMed database. Studies that referred to RARP complications are
detected and evaluated. Papers were identified through database screening and after initial screening. Only
the full text available articles in English, published between 2000 and 2017 were included. The keywords
comprised “urology, robot-assisted surgery, prostatectomy, complication”. Most commonly seen robot-
assisted surgery complications and radical prostatectomy complications were individually researched. As
the result, an overview of most commonly seen RARP-related complication topics that should be useful in
robotic urology.

RARP COMPLICATIONS
The number of robot-assisted procedures increases gradually in urology practice. In USA, 67% of
[4]
prostatectomies have been performed robotically . Even though, open radical cystectomy has higher
[5]
complication rates compared to RARP , a great number of surgeons have been in their learning curve in
terms of robotic urologic surgery practice thus may explain the most of the robotic surgery complications.

Rectum and bowel injuries
Rectal injury is a rare but devastating complication of RARP. In a recent systematic review and meta-
[6]
analysis, the incidence of rectal injury was reported as low as 0.2% . Patient history of prostate or rectal
surgery, hormonal therapy, radiotherapy, periprostatic fibrosis and infection constitute the risk factors for
rectal injury. Besides, the ill-defined plane between the rectum and prostate, and the difficulty in dissection
[7,8]
of locally advanced tumors also may be responsible for rectal injuries .
[9]
Novara et al. analyzed 415 clinically localized PCa patients who underwent RARP. Five cases were
complicated with rectal injury, and all of them were detected intra-operatively (1.5%). The lesions were
sutured the lesions immediately in 2 or 3 planes, and patients used broad-spectrum antibiotics for
7 days and took liquid diet for 4 days. The bladder catheter was removed after a median of 9 days. The
[9]
postoperative course was uneventful for all cases .
[10]
Wedmid et al. reported 11 rectal injury cases out of a totally 6650 RARP patients. Rectal injury was
recognized in 8 of 11 patients intra-operatively and repaired in the same session. Primary repair was
performed in 7 cases by the robotic surgeon. Diverting colostomy with primary repair was performed in
[10]
only 1 patient. Two and three-layer closure was applied for the full thickness lacerations .