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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 9 of 13

[65]
Chiong et al. reported the incidence of TSH as 0.66%, all occurring at sites of 12 mm trocars, even
though with the use of bladeless, blunt trocars. Furthermore, they suggested to insert the trocar at least
40°-60° to the abdominal wall to reduce the TSH occurrence risk [65,72] .

Routine fascial closure is not recommended as the TSH incidence is rare in 8 mm robotic trocar sites.
Instead, removal of ports under direct visualization is recommended at the end of the procedure to make
sure that bowel segments are not unawarely pulled into the port sites during the port removal and to assess
[69]
the degree of peritoneal defect .

Vesicourethral anastomotic strictures
Vesicourethral anastomotic strictures (VUAS) are fibrotic narrowing of the vesicourethral anastomosis.
The incidence is less than 1.4% in RARC series [73,74] . The mostly seen comorbid conditions related with
anastomotic stenosis are older age, cigarette smoking, hypertension, coronaryartery disease, obesity, prior
bladder surgery, diabetes mellitus that affect vascular health, increase the tissue ischemia and result in
poor healing. Anastomotic urine leakage, foreign body in urinary bladder, increased estimated blood loss
and increased operative time that result in poor anastomotic mucosal apposition were also found as related
[75]
with VUAS .

VUAS generally becomes symptomatic within 6 months following prostatectomy and the duration rarely
[76]
prolongs up to 24 months . Complaints related with voiding are primarily in obstructive pattern such
as straining to void, weak stream, incomplete bladder emptying and hesitancy. Urinary retention and
recurrent urinary tract infections may also indicate VUAS. Besides, the patients with radiotheraphy history
often complain of urinary urgency and frequency, and dysuria.

[77]
Sandhu et al. found VUAS rate as 4% (n = 198) in overall 4500 radical prostatectomy cases performed
at Memorial Sloan-Kettering hospital. They detected the VUAS cases at an average of 3.5 months after
prostatectomy. They were also found that the VUAS risk increased 10-folds in open procedures compared
[77]
with minimal invasive methods .
In the management of VUAS, no consensus exists. Conservative management and open or minimally
invasive surgical procedures may be a choice in the treatment plan. Patient preference is also important
in decision. First-line management includes various endoscopic procedures, and complex reconstructive
procedures may be applied in case of failure.

High-risk disease
[78]
D’Amico et al. defined the high-risk disease as prostate-specific antigen level ≥ 20 ng/mL, preoperative
[79]
Gleason grade ≥ 8 or clinical stage ≥ T2c by considering oncologic outcomes. Srougi et al. performed
RARP in 199 high-risk PCa cases and found their complication rate as 12.1% (4.5% as major complications).
[80]
Jayram et al. performed RARP in 148 PCa cases diagnosed as high-risk disease. They reported excellent
complication rates as 0.6% in terms of minor complications (Clavien 1-2; urethral stricture) and 3.4% in
terms of major complications (Clavien 3; lymphocele, hematoma/clot retantion and incisional hernia).

CONCLUSION
RARP can be routinely performed with a relatively low risk of complications. Surgical experience,
cancer characteristics and clinical patient characteristics determine the risk of complications. Increased
perioperative complications rates are significantly associated with low surgeon volume, low hospital
volume and extended lymph node dissection. True patients selection, proper positioning, mentorship
in the learning curve and avoiding prolonged procedures are important points in preventing RARP-