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Koc et al. Mini-invasive Surg 2018;2:7 I http://dx.doi.org/10.20517/2574-1225.2017.33 Page 3 of 13

[11]
Hung et al. detected the bowel injury rate as 1.04% in total 288 RARP patients. Before the RARP, all of
the patients were received transurethral resection of the prostate. Rectal injury was detected in 2 cases and
sigmoid colon in 1. Sigmoid colon injury was unrecognized during the course of RARP and therefore could
not be repaired intra-operatively. Peritonitis leading to bowel resection and colostomy was the warning
symptom in this case. In 1 patient with rectal injury, late recto-urethral fistula was detected. Colostomy,
prolonged urethral catheterization, and perineal repair were performed, and colostomy was taken down
subsequently after recovery.

Ileo-colonic injuries primarily present postoperatively with abdominal distention, ileus and absent
peritoneal signs. Nowadays, primary repair is preferred without colostomy in most cases. Typically 2-layer
closure with 2/0 polyglactin is used for repair and the compliance of sutures are tested by air insufflation
through the rectum. Prolonged catheterization is recommended for a mean of 14 days. Failure to recognize
[12]
and immediately treat a bowel injury may result in a high mortality rate up to 3% and high morbidity .
However, careful and sharp dissection by the assistance to hold the rectum posteriorly with a suction
[11]
irrigation tip, and avoiding entry into the perirectal fat prevent rectal injury in RARP .

Urine leakage
[6]
Urine leakage is a prevalent and low-grade surgical complication with the rate of 1.8% . Increased drain
output is the most common sign. Drain creatinine level is used to detect the type of the fluid.

[13]
Jacobsen et al. reported the rate of the urinary leakage as 2.1% in their study including 236 RARP
patients. Age, smoking, diabetes mellitus, hypertension and prostate volume were not found to be
associated with anastomotic leakage. However, obesity and excessive bleeding were associated with
[14]
decreased visibility of the bladder neck, hampering suture placement in urethro-vesical anastomosis . As
[15]
a surgical factor, non-eversion of the mucosa was suggested for tighter anastomosis instead of eversion .
The origin of urine leakage may also be the ureteral injury as well as the urethro-vesical anastomosis.
Urgent management is needed in urethral injury. Cystography should be used to detect the origin of the
leakage. Prolonged catheterization is recommended for a mean of 10 to 14 days. Cystography should be
repeated in case of high volume leakage. If the leakage is observed as minimal, catheter should be removed
one week later with no need for cystography [16,17] .

Uroperitoneum is the most serious short-term complication of the urine leakage, and may lead to
peritonitis, deterioration in renal functions and ileus. Before the reoperation decision, pelvic drain or
[14]
nephrostomy tube can be placed .
Ureteric injuries
Most of the ureteric injuries can be detected in postoperative period. The incidence varies between 0.1%
[18]
and 0.3% during RARP . The injury may be at several different levels of the ureter. The distal ureter
[19]
injury risk increases while performing Montsouris approach . In patients with transurethral resection of
the prostate (TUR-P) history, the ureteral orifice may not be in its typical location. Attention must be at
the highest level to avoid cutting closely to the ureteral orifices during the dorsal dissection of the bladder,
especially in post-TUR-P cases.

The ureter can be mistaken in an extremely lateral dissection to find vas deferens, and therefore may be
ligated, transected or injured thermally. In prevention, tubular structures as the vas deferens must be
divided after being sure of its exact identity. Vas deferens converges in the midline from lateral to medial
in differentiation from ureter.