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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 7 of 13

[52]
Gözen et al. reported 2 cases with obturator nerve transection in their total 1027 RARP cases. All
injuries were detected at the proximal part of the obturator nerve. They recognized the both cases during
the RARP and immediately removed the clips by dissectors. They repaired the transected nerve edges with
6/0 polypropylene suture. One of the ONI cases needed to administer a neurotropic drug, and the other
one also received physiotherapy besides the neurotropic drug. In a mean follow-up period of 19 months,
[52]
they observed a successful recovery in the both cases .
Lymphocele
A lymphocele is lymphatic fluid collection as a consequence of surgical dissection and insufficient closure
of afferent lymphatic vessels. Lymphocele is the most frequent complication after PLND. Lymphoceles are
generally subclinical. Pelvic pressure, urinary frequency, deep venous thrombosis, ileus, infection and
edema are the common symptoms.

In PCa cases, PLND is the most effective procedure for accurate cancer staging and removes all tumor
deposits. Intraoperative complications related with PLND include ureteral, obturator nerve (sensory/motor
neuropraxia) and major vascular injury.

[53]
Its incidence changes from 0% to 8% according to different reports. In a subgroup analysis, Davis et al.
found the rate of the symptomatic lymphoceles as 19% after extraperitoneal RARP, but 0% after
transperitoneal RARP. The incidence of the PLND associated grade 3 and grade 4 complications during
RARP vary from 0% to 5%. Only PLND related complications are rare. Any vascular injury necessitating
[54]
[53]
transfusion or conversion to open surgery related with PLND were not reported yet . Van der Poel et al.
observed no significant difference among the complication incidences between men undergoing PLND or
not.
[55]
In a recent report, Briganti et al. revealed that the rate of lymphocele was significantly increased (10.3%)
[56]
in extended PLND as compared with limited PLND (4.6%). Accordingly, Naselli et al. reported that the
number of LNs retrieved was an independent and statistically significant predictor of the symptomatic
lymphocele occurrence.

[57]
Keskin et al. reported the lymphocele rate as 9% in 521 patients RARP series. The number of the
symptomatic lymphoceles was 13. All lymphocele cases were detected by ultrasound at the routine follow-
up at the end of the postoperative 1st month. Lymphocele was unilateral in 43 patients and bilateral in 3. At
the end of the postoperative 6th month, ultrasonographic findings regressed in only 11 of 46 cases (24%).

Percutaneous external drainage was performed to 7 patients. As the history of the patients assessed, 5 of
the 7 patients who presented an infected lymphocele were the cases with diabetes mellitus. A patient who
was diagnosed before the routine first month follow-up was also diabetic, and presented new-onset bilateral
leg edema, urinary incontinence and fever at the postoperative 3rd week. Bilateral lymphoceles and deep
venous thrombosis were detected by ultrasonography and immediately treated with antibiotics, bilateral
drainage, bed rest and high dose of low molecular weight heparin. The symptomatic lymphocele incidence
was as low as 2.5% in this study. Infection was the most common sign. Hydrocele, leg edema, incontinence,
[58]
deep venous thrombosis and superficial phlebitis were rarely observed .
[59]
Taniguchi et al. presented a patient with delayed lymphocele infection after RARP and PLND in a recent
case report. The patient who did not have known risk factors for lymphocele, applied with the complaint of
fever and fatigue after 6 months from the operation. Pelvic ultrasonography and computed tomography (CT)
showed an 80 mm cystic lesion leading to displacement of the urinary bladder. Blood markers of infection
were increased. Fluid collection was drained and drainage tube was placed. Methicillin-susceptible