INTRAOPERATIVE, PERIOPERATIVE, AND LONG-TERM COMPLICATIONS

OF RADICAL PROSTATECTOMY
Urol Clin N Am August 2001

INTRAOPERATIVE COMPLICATIONS

specific intraoperative complications of radical prostatectomy include

haemorrhage
rectal injury (<1%)
ureteric injury (<1%)
nerve (obturator, femoral) injury

Haemorrhage

improved understanding of the anatomy of the superficial and deep dorsal vein complex of Santorini and its
trifurcation has resulted in an anatomic approach to hemostasis
average blood loss in most recent series has been 1000 mL or less
haemorrhage requiring blood transfusion most common intraoperative complication of radical prostatectomy
nerve-sparing approach is associated with a higher rate of blood loss
decrease in intraoperative blood loss and transfusion rates with increasing experience
need for autologous blood donation has been debated

Rectal Injury

uncommon complication occurring in 0-5.3% of cases

predisposing factors
prior radiation, transurethral resection of the prostate, and rectal surgery
stage of the disease did not seem to impact on the risk for rectal injury
management
if adequate bowel preparation, a two-layer repair of the rectal injury is the primary mode of management
omental flap mobilized through an opening in the peritoneum and placed through the rectovesical cul-desac to cover the suture line may decrease the chance of a rectourethral fistula or leak
temporary loop or end colostomy has been recommended in cases of previous radiotherapy
additional measures
broad-spectrum antibiotic coverage
prolonged NBM status
dilatation of the anal sphincter at the time of injury

Ureteric Injury

0.05-1.6% of cases in recent series

may occur
if an extended dissection above the iliac bifurcation is performed
while dissecting the posterior aspect of the bladder neck
failure to identify the correct plane between the bladder and seminal vesicles
intraoperative recognition is the most important factor in the management of ureteric injury
5mL of indigo carmine during surgery will delineate any site of urinary leakage outside the bladder
if ureteric injury occurs, a nonrefluxing ureteroneocystostomy usually is required

Nerve Injury

obturator nerve injury

rare complication during pelvic lymphadenectomy that may occur with sharp transection or secondary to
positioning of retractors
if recognized, primary repair of the severed nerve should be carried out with nonabsorbable sutures
femoral neuropathy

may occur owing to direct trauma; however, the most common mechanism is palsy occurring as a
consequence of a self-retaining retractor injury if the blades used are too long and rest on the psoas
muscle where the femoral nerve travels within the substance of the muscle
may result in quadriceps weakness and paresthesia of the anteromedial aspect of thigh

PERIOPERATIVE COMPLICATIONS
Medical Complications

general perioperative complications (contemporary series)

respiratory failure secondary to atelectasis
pulmonary emboli (1-2%)
deep venous thrombosis (1-2%)
myocardial infarction/arrhythmia (1%)
postoperative ileus

DVT/PE are the most common early surgical complications, and fatal pulmonary embolism is the most
common cause of mortality in contemporary series
various methods have been used in an attempt to decrease these complications, including low-dose heparin,
warfarin, and sequential compression devices

Surgical Complications

wound-related problems, such as dehiscence, seroma, and infection ~1%

specific early complications
delayed haemorrhage
catheter dislodgment
lymphocele formation 1-2%
anastomotic leak

Delayed Haemorrhage

larger hematomas may result in anastomotic disruption or may become infected

Catheter Dislodgment

safest approach is to perform flexible cystoscopy with placement of a guidewire under direct vision to replace
the Foley catheter
if catheter dislodgment occurs 5 days after surgery, can safely observe without reinsertion

Anastomotic Leakage

true incidence uncertain because most small urinary leaks resolve spontaneously with adequate drainage
and remain undiagnosed
urinary leakage after radical prostatectomy is related directly to the quality of the anastomosis
if high output from the pelvic drains, the creatinine level of the fluid should be determined
if identical to serum there is no urine leakage so, the drain can be taken off suction and withdrawn when
the drainage ceases
high creatinine level is diagnostic of urinary leakage
site of the urinary leak and its relationship to the drain and Foley catheter should be determined by a
cystogram
prolonged catheter drainage usually will result in spontaneous resolution of urinary leakage in most cases
large urinary leaks ultimately may result in a urinoma and abscess formation that requires percutaneous
drainage

Lymphocele

extent of lymphadenectomy has a role in the incidence of lymphatic leakage

meticulous lymphatic control using hemoclips or suture ligation helps to prevent this complication
most lymphoceles remain asymptomatic and resolve spontaneously

symptomatic lymphoceles may present with lower-extremity swelling and scrotal edema and, if infected, with
fever
initial management of a symptomatic lymphocele consists of percutaneous drainage under CT scan or
ultrasonography guidance
if the drainage persists, sclerotherapy with agents such as tetracycline or povidone-iodine has been
recommended
if fails or infected then surgical drainage/marsupialization

LONG-TERM COMPLICATIONS

bladder neck contracture (10-20%)

urinary incontinence (total ~2%, stress 10-20%)
impotence (40-80%)

Bladder Neck Contracture

eversion of the bladder neck with fine absorbable suture for a precise mucosa-to-mucosa anastomosis is
probably most important factor resulting in a decreased rate of anastomotic strictures in most recent series
urinary extravasation has been thought to result in periurethral scarring, which may contribute to stricture
formation and incontinence

Urinary Incontinence

recent study of 1800 radical prostatectomies found age >70 years to be the only factor associated with
worse continence
intrinsic sphincter deficiency is the main cause of incontinence after radical prostatectomy
every effort should be made to preserve as much urethral length as possible
importance of bladder neck preservation for incontinence has been debated
in patients with significant urinary incontinence, urodynamic evaluation should be performed before any
invasive treatment to assess the etiology of urinary incontinence
although sphincteric dysfunction is the cause of incontinence in most cases, bladder instability may
contribute to incontinence in some patients
endoscopic collagen injection and placement of an artificial urinary sphincter are available options for
significant stress incontinence

Impotence

before the introduction of the anatomic radical prostatectomy, the impotence rate was almost 100%
age, stage of the disease, and the extent of the nerve-sparing (unilateral or bilateral) procedure were
significant factors for preservation of potency
rates variable , impotence 40-80%
one reason for differences between results may be the method of assessment of sexual function
sildenafil has revolutionized the management of postprostatectomy impotence
reported response rate to sildenafil has been as high as 50% after nerve-sparing procedures

COMPARISON OF RADICAL PERINEAL AND RETROPUBIC PROSTATECTOMY

retropubic associated with a higher rate of respiratory and miscellaneous medical complications
overall risk for genitourinary complications identical
specific differences
exaggerated lithotomy position in the perineal approach may be a limiting factor in patients with joint
problems
transient lower-extremity neurapraxia related to this positioning may occur
lower rates of blood loss using the perineal approach
perineal prostatectomy associated with a higher rate of rectal injury
excellent continence and potency rates have been reported using the perineal approach