Robotic prostatectomy is the most frequent oncologic surgery performed in urology. As a result of its frequency, it’s also the most likely to result in complications unless the surgeon prevents them before they happen and minimizes them when they occur.
“Robotic prostatectomy is not a new procedure, but many urologists are new to the technology. And even the most experienced surgeon is always training,” said Rene Sotelo, MD, professor of Clinical Urology at the Keck School of Medicine at the University of Southern California.
During Friday morning’s Prime Time plenary session, Dr. Sotelo will moderate a 30-minute panel discussion on Setbacks and Operative Solutions: Robotic Prostatectomy, which begins at 9 am in the Esplanade Ballroom at Moscone South. The four panelists are Vipul Patel, MD, FACS, Medical Director of the Global Robotics Institute and professor of Urology at the University of Central Florida College of Medicine; Christopher Porter, MD, FACS, Medical Director of Clinical Research at Virginia Mason Medical Center; Thomas Ahlering, MD, Chief of Urologic Oncology at the University of California, Irvine; and Rosalia Viterbo, MD, FACS, associate professor of Surgical Oncology, and Director of Robotic Surgery and Operations at Fox Chase Cancer Center.
“Our faculty understands robotic prostatectomy inside and out,” Dr. Sotelo said. “We are going to be drawing on the combined expertise of the faculty of well over 10,000 cases. They know what can go wrong and how to keep it from happening.”
Complications will never be completely eliminated from surgery, he noted, but it is possible to reduce the frequency and severity of complications with the appropriate preparation for surgery and certain approaches to the procedure.
And nothing beats robotic surgery as a learning tool, Dr. Sotelo added. Recording of surgical procedures using high-definition video is now routine, allowing for more complete and accurate documentation and analysis of successful surgeries and complications.
“We are utilizing videos to show very precisely how things went off the track,” Dr. Sotelo said. “Complications can start as simply as patient position that is not ideal, such as a patient sliding during the procedure or shoulders and arms that are not padded properly. If you do not position the patient properly, you can have complications to the prostatectomy itself and complications that injure other parts of the body, such as the brachial plexus, and complications that can be mistaken for other diseases.”
Procedural complications start with initial access. The Veress needle is inserted blindly, which can result in injury to intra-abdominal structures, most often intestine or large vascular structures.
Trocar placement is similarly subject to misadventure. Skin incisions that are too small are a common problem because they require excessive force to insert the trocar, which increases the risk of injury.
Accidental instrument contact during the procedure is another familiar problem. Instrument insertion can also be a problem. The solution is to ensure that the surgeon has a direct view of every instrument insertion.
Pelvic nerve and rectal injuries are other familiar complications. The risk of both injuries can be minimized with good visualization of the surgical field and a high degree of alertness.
Salvage prostatectomy carries a higher risk of rectal injury, Dr. Sotelo noted, and should be avoided early in the learning curve. Ureter injuries are not common, but most are detected after surgery, not during the procedure. Better awareness of the risk can help reduce their occurrence.
“We are going to be showing real cases with video showing how to prevent the problem, and how to recognize it and fix it when something does go wrong,” Dr. Sotelo said. “As you learn how to recognize these complications, you can do a better job of repair and prevention in the future. If you recognize a complication early, you can deal with it earlier and more easily.”