Editing Open Radical Prostatectomy (section)

== Complications ==

* '''Intraoperative'''
** '''Hemorrhage'''
*** '''<1% require intraoperative transfusion'''
*** If there is troublesome bleeding from the dorsal vein complex at any point, completely divide the dorsal vein complex over the urethra and oversew the end. This is the single best means to control bleeding from the dorsal vein complex.
** '''Obturator nerve injury'''
*** Can occur during the pelvic lymphadenectomy
*** '''An attempt should be made at reanastomosis with fine non-absorbable sutures'''
*** '''When a tension-free primary nerve repair is not feasible, nerve grafting can be performed by a cutaneous or genitofemoral nerve graft.'''
*** '''Even without a nerve repair, conservative management with physical therapy can compensate for the deficit, and therefore many patients do not have a significant thigh aDDuctor deficit after the injury'''
** '''Rectal injury'''
*** '''An infrequent (<0.3%) but serious complication'''
**** '''Occurs more commonly in salvage prostatectomy setting'''
***** '''Rates of rectal injury with salvage prostatectomy have decreased with increasing experience'''
*** Occurs during apical dissection while attempting to develop the plane between the rectum and Denonvilliers fascia
*** '''Methods to detect rectal injury:'''
**** '''Insert gloved finger through anus and look for rectal defect'''
**** '''Fill pelvis with saline and inject air through rectum'''
*** '''When rectal injury occurs, the prostatectomy should be completed, the bladder neck should be reconstructed, and hemostasis should be excellent.'''
*** '''Principles of Rectal Injury Repair'''
***# '''General surgery consultation'''
***# '''Copious irrigation of wound with antibiotic solution'''
***# '''Excellent visualization of the extent of rectal injury''' and freshen edges of the rectal wound
***# '''Multi-layer closure'''
***# '''Interpose omentum between the rectal closure and the vesicourethral anastomosis to reduce the possibility of a rectourethral fistula'''.
***#* Can be accomplished by making a small opening in the peritoneum; finding the omentum and fashioning a slender, well-vascularized pedicle that will be long enough to reach the pelvic floor; dividing the peritoneum in the rectovesical cul-de-sac; and feeding the end of an omental pedicle through this opening. The anal sphincter is digitally dilated widely by an assistant, and the rectal injury is clearly delineated.
***#* The vesicourethral anastomosis is performed after suturing the omental pedicle in place.
***# '''Post-operative antibiotics'''
***** '''Several days on broad-spectrum antibiotics for both aerobic and anaerobic bacteria.'''
*** '''Indications to consider a diverting colostomy (3):'''
***# '''Large rectal defect'''
***# '''History of pelvic radiotherapy'''
***# '''Long-term pre-operative glucocorticoid therapy'''
** '''Ureteral injury'''
*** Very rare
*** Usually occurs secondary to inadvertent dissection within the layers of the trigone while attempting to identify the proper cleavage plane between the bladder and seminal vesicles.
*** If this injury occurs, ureteral reimplantation should be undertaken.
* '''Early post-operative complications'''
** '''Ileus, wound infection, UTI'''
** '''Thromboembolic events'''
*** DVT with PE is a major cause of mortality after RP.
*** Highest likelihood 14-28 days after the procedure.
*** Support stockings and early ambulation are recommended.
**** Prophylactic anticoagulation and sequential compression devices are advisable in patients at high risk for thromboembolic complications. However, perioperative subcutaneous heparin injection may predispose to lymphoceles, and many surgeons reserve pharmacologic prophylaxis for high-risk patients
** '''Lymphocele'''
*** '''Pelvic lymphoceles can cause compression of the bladder resulting in reduced capacity and increased urinary frequency and urgency.'''
**** The possibility of a pelvic lymphocele should be ruled-out in patients who present with new onset, worsening irritative voiding symptoms and incontinence following uneventful robotic prostatectomy. These patients can often be misdiagnosed as experiencing normal post-operative recovery of urinary continence and be prescribed pelvic physiotherapy and anticholinergic medications.
** '''Urine leak'''
** '''Life-threatening delayed hemorrhage'''
*** Rare
*** '''Patients requiring acute transfusions for severe hypotension after radical prostatectomy should be explored early to evacuate the pelvic hematoma.'''
**** '''In patients managed non-operatively, the pelvic hematoma may drain through the urethrovesical anastomosis, resulting in symptomatic bladder neck contractures and long-term problems with continence.'''
* '''Late post-operative complications'''
** '''Bladder neck contracture'''
*** Arises from inadequate coaptation of the mucosal surfaces.
*** '''May be due to (3):'''
***# '''Inadequate approximation at the time of surgery'''
***# '''Urinary extravasation'''
***# '''Distraction of the bladder neck from a hematoma.'''
*** '''Should be considered in any patient who complains of a poor urinary stream or in patients who have prolonged unexplained incontinence'''
*** Management:
**** Options:
***** Simple cystoscopic dilation
***** Direct cold-knife incision of the bladder neck at 3-, 6-, and 9-o’clock followed by intermittent self-catheterization for a limited time.
***** Injection of triamcinolone acetonide (200 mg in 5 mL) at the bladder neck after cold-knife incision may be useful in patients with recalcitrant bladder neck contractures.
** '''Urinary Incontinence'''
*** '''Generally good outcomes'''
**** Relatively few require implantation of an artificial urinary sphincter or a sling procedure for stress urinary incontinence.
*** '''Varies according to (2):'''
***# '''Patient age'''
***#* '''Mostly closed associated with continence'''
***#** ≈95% of males < 60 years can attain pad-free urinary continence after surgery
***#** 85% of males > 70 years regain continence
***# '''Experience and skill of the surgeon'''
**** '''A 2014 meta-analysis found that nerve-sparing in patients undergoing radical prostatectomy was associated with improved time to continence but not long-term continence rates'''§
**** A 2015 meta-analysis found that nerve-sparing technique, not nerve-sparing, was associated with improved long-term continence§
** '''Erectile Dysfunction''':
*** '''Factors predicting recovery of erectile function after radical prostatectomy:'''
***# '''Age of the patient (younger than 65 years)'''
***# '''Status of potency pre-operatively'''
***# '''Extent of nerve-sparing surgery'''
***** '''≈26% of males who underwent bilateral sural nerve grafting demonstrated full erections (sufficient for penetration). Sural grafts are placed in reverse to the natural position (proximal to distal and distal to proximal).'''
***** Up to 70% of the patients were potent postoperatively in a series of radical perineal prostatectomy patients.
***** Pharmacotherapy has been demonstrated to improve potency outcomes.
*** '''Erections usually begin to return as partial erections 3-6 months after surgery and may continue to improve for up to 3 years or more'''
*** In those who maintain erectile function following radical prostatectomy, the erection is generally less firm than it was preoperatively
*** Patients should be encouraged to use erectile aids postoperatively, including PDE5 inhibitors, intraurethral suppositories, intracavernosal injections, or vacuum erection devices. Erection rehabilitation programs using intracavernosal injection therapy or PDE5 inhibitors might hasten the return of erections and increase the proportion of men who recover erections
*** “On-demand,” rather than nightly, administration of PDE5 inhibitors may be more efficacious in men with erectile dysfunction after bilateral nerve-sparing radical prostatectomy
** '''Urethral stricture'''
** '''Hernia'''