Page 46 - Read Online

Page 6 of 13 Koc et al. Mini-invasive Surg 2018;2:7 I http://dx.doi.org/10.20517/2574-1225.2017.33

The absolute mechanism of PION is unknown, but might be the result of optic nerve ischemia. Multiple
factors have been proposed as underlying mechanisms of PION but the PION cases after open radical
prostatectomy is found to be associated with prolonged hypotension as the result of excessive blood
loss [43,44] . Urologists should immediately consult such patients to ophthalmologists.

Secondary corneal abrasions may be seen due to positional eye edema related with Trendelenburg
positioning. Foam-based safety goggles should be placed over the patient’s eyes before the operation and
should stay throughout 90 min postoperatively in the recovery room, until the patient is oriented enough
[45]
not to rub his eyes. The use of these goggles presents significant decrease in corneal abrasion rates .

Shoulder braces are used commonly to prevent cephalad migration but may lead to brachial plexus injuries
[46]
if apply excessive pressure on the upper roots and trunks of the brachial plexus .
The surgeon should be cautious about the potential for trauma during the docking of the robot and set
the arms to minimize the risk. Besides, increased surgeon comfort may protract the operative time, thus
increase the risk of neuropraxia and compartment syndrome [41,42] .

Compartment syndrome
Lower limb compartment syndrome (LLCS) is a serious complication occurs in RARP but its incidence
is low. In a multicenter study, LLCS was developed at 9 cases with the incidence of 0.29%. The prevalent
factors were console time > 4 h in 8 cases, to be at early steps of learning curve (less than 20 cases) in
3 cases, obesity (body mass index > 30 kg/m ) in 5 cases, peripheral vascular disease in 2/9 cases and
2
incorrect positioning in 1 case. Fasciotomy was required in 7 cases, and primarily closed at 5 patients.
However, 2 patients required graft to cover the skin defect and were treated with intravenous (i.v.) fluids
and analgesia. No amputations and/or deaths were reported.

Correct positioning of the patient is essential to prevent LLCS. Legs should be replaced to the appropriate
position just after the robot undocked. Decompressive fasciotomy outcomes become poorer by the time
passing. Urologist should be cautious about patients with leg pain in recovery period and early refer the
suspected cases to a specialist. During the learning curve, careful case selection and active mentorship is
[47]
recommended to keep console time < 4 h .
Obturator nerve injury
Obturator nerve injury (ONI) is a rarely seen complication of RARP. Besides, the most common nerve
injury during RARP is the obturator nerve injury with 0.4% frequency [48,49] . The injury may be in the form
of stretching, entrapment by clips, transection or burning of the nerve during PLND. Even though ONI is
rare, it is essential to take precaution and recognize promptly for immediate repair to avoid the significant
morbidities such as loss of motor and sensory adductor functions. A full knowledge of pelvic anatomy and
careful dissection are essential for both prevention and repair of the ONI.

In prevention, optimal visualization of the nerve should be provided. Obturator lymph nodes should be
pulled medially for observation of the nerve. Clips must be placed carefully and parallel to the nerve. To
prevent electrofulguration effects, we should better prefer bipolar cautery. In case of a total transection, if
recognized during the RARP procedure, the transected nerve edges should be sutured to prevent persistant
[50]
disfunction and ensuing atrophy of the adductor muscles .

[51]
Ghazi et al. reported their complication rates as 3 of total 1503 RARP cases in terms of ONI. Inadvertent
clipping was hold responsible for the complication. They recognized and removed the clips intra-
operatively and they observed the patients postoperatively.