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Page 4 of 13 Koc et al. Mini-invasive Surg 2018;2:7 I http://dx.doi.org/10.20517/2574-1225.2017.33

Medial ureteral injury usually occurs during the extended pelvic lymph node dissection (PLND) at the
level of the iliac vessels. Ureters should be visualized clearly to avoid any type of injury. The safety distance
increases by pulling the ureter away with the help of robotic arms.

Any type of ureteral injury can be corrected during the course of robotic surgery. In non-transecting
injuries, ureteral stent should be placed through the bladder opening. Repair with 5/0 Monocryl (Ethicon)
suture after stent placement allows the correction of partially or fully transected ureters. Transverse closure
of longitudinal defects prevents narrowing of the ureter. In case of wide injury in the ureter or ureteral
[20]
orifice, ureteral reimplantation may the treatment choice .
Bleeding
Postoperative bleeding rate was reported as 0.5%-2.0% according to various definitions after radical
prostatectomy. Most papers reported blood loss between 100 and 300 mL [21-26] .

It is possible to cope with the bleeding that occurs during the operation. However, bleeds that are not seen
due to the increased intra-abdominal pressure may cause bleeding afterwards. Bleeding is most often seen
at the dorsal vein complex, lateral pedicles and port sites. Therefore, the intra-abdominal pressure should
be reduced after the operation even if it is expected to decrease for a while, and then the hemostasis should
be repeated. After the ports are removed, it should be checked whether any bleeds exist arising from the
port sites.

[27]
In a case report, Lorenzo et al. reported a small perforation at iliac vein during their PLND performance,
and they denoted that bleeding was stopped by the bipolar forceps and 5 mm metal clipping.

[28]
In a study consisted of 1000 RARP patients, Ahmed et al. reported that blood transfusion was needed
for 15 (1.5%) patients for approximately 4.4 units per patient. The transfusion indication was based on
tachycardia and hypotension except 6 patients who needed transfusion due to significant cardiac disease
[28]
history to maintain hematocrit level > 30% .
[29]
Patel et al. indicated complication rates as 4.3% in a series of 1500 patients including 8 hemorrhages,
5 of which required blood transfusion due to decrease in hemoglobin levels at postoperative 5th hour.
Bleeding stopped at post-operative 3rd-4th days and hemoglobin levels stabilized. All patients were treated
[30]
[29]
successfully without surgical exploration . Controversy, Murphy et al. reported complication rates as
high as 15.7% in their 400 patient series in which 1 of the 15 complicated cases (3.75% of total) were re-
operated due to bleeding.

[31]
Postoperative hematomas may also be seen but often resolve spontaneously. Fischer et al. also
reported urinary retention due to retrovesical hematoma as a rarely observed complication that resolved
spontaneously.

[32]
Tasci et al. reported a total of 5 postoperative transfusion-requiring bleedings among their 317 patient
series of RARP. In postoperative 5th hour, hemoglobin levels were found as reduced in these 5 cases.
However, vital findings and general status were stable. Subsequent hemoglobin and hematocrit levels
continued to fall. Blood and the blood products were transfused. In postoperative 2nd day, ecchymosis was
detected on posterior and lateral walls of abdomen, scrotum, and spread up to the legs. Hemorrhage was
minimal in abdomen drainage and no bleeding was detected in the abdomen in computed tomography
during the follow-up period. However, there was severe hemorrhage sourcing from abdominal walls.
Nevertheless, bleeding stopped on the 3rd or 4th day without surgical exploration, and hemoglobin became
[32]
stable .