Robotic urological surgery in patients with prior abdominal operations is not associated with increased complications
K. C. Balaji md frcs, 982360, University of Nebraska Medical Center, Omaha, Nebraska 68198-2360, USA. Email: firstname.lastname@example.org
Background: The da Vinci Surgical Robotic System is being increasingly used to perform complex urological operations by minimally invasive techniques. Prior abdominal surgery associated with intra-abdominal adhesions may complicate robotic surgery.
Methods: We used a cohort of consecutive 49 patients undergoing a variety of robotic urological procedures at our institution to study the impact of prior abdominal operations on early perioperative complications.
Results: A total of 21/49 (43%) patients (Group A) had no history of prior abdominal surgery and the rest 28/49 (57%; Group B) had undergone prior abdominal surgery. The incidence of peritoneal adhesions was significantly higher in patients with prior abdominal surgery compared to the rest of the cohort, 54% versus 10% (P = 0.002). The median operative time, estimated blood loss, postoperative drop in hemoglobin, time to hospital discharge, postoperative narcotic analgesic use and postoperative complication rate between group A and group B were not statistically different. The overall perioperative complication rate for the entire cohort was 14.3%, with 6–8% of complications occurring in each of the two groups (P = 1.0). Comparative subset analysis of 28 patients in Group B, 15 (54%) and 13 (46%) with or without intra-abdominal adhesions did not reveal a significant difference in perioperative complication rates either. However, operative time was longer in patients with intra-abdominal adhesions compared to patients without, median of 590 (281-922) and 434 (153–723) min respectively, although not statistically significant (P = 0.059).
Conclusion: Our study demonstrates that robotic urological surgery can be performed in patients with prior abdominal surgery without increased perioperative complications.
Patients with prior intraperitoneal abdominal operations remain at an increased risk of intra-abdominal adhesions,1 which may complicate successful completion of laparoscopic or robotic procedures. Previous studies have established the safety of performing laparoscopic urologic procedures in patients who have undergone prior abdominal operations.2,3 Recently, the da Vinci Surgical Robotic System (DSRS) has been added to the armamentarium of minimally invasive surgery. The DSRS is being increasingly used to perform complex urological procedures including radical prostatectomy, radical cystectomy and urinary diversions.4,5 Currently there is no published data specifically addressing the issue of performing robotic urological procedures in patients who have undergone prior abdominal surgery.
While there are common technical aspects between laparoscopic and robotic urological procedures, robotic surgery requires distinct attention to details such as location of ports to prevent instrument conflicts and ability to complete the procedure without altering the position of the patient once the robot is docked. Because of these distinct requirements, prior abdominal surgery with subsequent intra-abdominal adhesions may potentially complicate robotic procedures. Therefore, in this study we compared the perioperative outcomes in patients with or without prior abdominal surgery undergoing robotic urological procedures using our prospectively established Laparoscopic and Robotic Urological Surgical Program (LRUSP) institutional database.
All relevant clinical information on patients undergoing robotic urological procedures at our institution is maintained on a Microsoft Access (Microsoft, Redmond, WA, USA) database. An Institutional Review Board (IRB) exempt status was obtained because all patient identifiers were deleted after obtaining pertinent clinical information and subjects are never identified. A total of 49 consecutive patients undergoing robotic urologic procedures since the inception of the LRUSP about 2 years ago were included in this study. Of the forty-nine patients, robotic radical prostatectomy was performed in twenty-five patients (51%), radical cystectomy in eight (18%), radical nephrectomy in six (14%), nephrouretrectomy in one (2%), pyeloplasty in five (10%), ileal conduit urinary diversion in three (4%) and detrusor myotomy in one (2%) patient. A total of 21/49 (43%) patients (Group A) had no history of prior abdominal surgery and the rest 28/49 (57%) (Group B) had undergone prior abdominal surgery.
The two groups were compared using the Wilcoxon rank sum test for the continuous variables and the categorical variables were compared using Fisher's exact test. P-values were compared to a significance level of 0.05.
There was no difference in the types of surgery performed between the two groups (data not shown). The comparative perioperative outcomes of the two groups are tabulated in Table 1. Group A consisted of 20 men and 1 woman compared to 22 men and 6 women in Group B. There was no significant difference in the baseline patient characteristics with regard to age, sex and BMI between the two groups. None of the cases were converted to open and there was no perioperative mortality. The incidence of peritoneal adhesions was significantly higher in patients with prior abdominal surgery compared to the rest of the cohort, 54% versus 10% (P = 0.002). The median operative time, estimated blood loss, postoperative drop in hemoglobin, time to hospital discharge, postoperative narcotic analgesic use and postoperative complication rate between group A and group B were not statistically different. The overall perioperative complication rate for the entire cohort was 14.3%, with 6–8% of complications occurring in each of the two groups (P = 1.0). The list of complications is tabulated in Table 2. Of the 28 patients in Group B with history of prior abdominal surgery, 15 (54%) of patients had intra-abdominal adhesions. Further comparative subset analysis within Group B of patients with or without adhesions did not demonstrate a significant difference in any of the variables studied (Table 3), providing additional evidence that intra-abdominal adhesions do not contribute to increased morbidity in patients undergoing robotic urological procedures. However, the operative time in patients with prior abdominal surgery who developed intra-abdominal adhesions was longer than in patients who did not have adhesions, median of 434 (153–723) and 590 (281–922) min, respectively, although not statistically significant (P-value = 0.059).
Table 1. Comparison of perioperative results from robotic urological procedures in patients with or without intra-abdominal adhesions
|Age at surgery (years)||Median|| 55.7|| 66.3||0.18|
|Range|| 17.1–88.0|| 27.3–83.8|
|Sex||Male|| 20 (95%)|| 22 (79%)||0.21|
|Female|| 1 (5%)|| 6 (21%)|
|BMI||Median|| 28.7|| 25.4||0.094|
|Range|| 18.8–37.0|| 19.0–37.5|
|Morphine equivalent (mg)||Median|| 22|| 16||0.86|
|Range|| 2–164|| 0–240|
|Decrease in postoperative hemoglobin (g)||Median|| 3.4|| 2.8||0.73|
|Range|| 0.2–8.1|| 1.2–6.8|
|Estimated blood loss (mL)||Median||400||200||0.088|
|Range|| 25–1500|| 10–4000|
|Hospital stay (days)||Median|| 4|| 3||0.43|
|Range|| 1–24|| 1–10|
|Adhesions||Present|| 2 (10%)|| 15 (54%)||0.002|
|No|| 19 (90%)|| 13 (46%)|
|Complications|| || 3 (14%)|| 4 (14%)||1.00|
Table 2. List of perioperative complications in patients undergoing robotic urological procedures
|Abscess, A-fib||Prolonged urethrovesical anastomotic leak|
|Recto-Neo bladder fistula, bowel obstruction||Rectovesical fistula|
|Acute renal failure: resolved||Rectourethral fistula|
|Pressure sore with radial nerve palsy|
Table 3. Comparison of perioperative results from robotic urological procedures in patients with or without intra-abdominal adhesions following prior abdominal surgery
|Age at surgery (years)||Median|| 66.9|| 63.1||0.82|
|Range|| 27.3–83.8|| 32.5–79.1|
|Sex||Male|| 12 (92%)|| 10 (67%)||0.17|
|Female|| 1 (8%)|| 5 (33%)|
|BMI||Median|| 25.2|| 27.3||0.60|
|Range|| 20.7–32.1|| 19.0–37.5|
|Operative time (min)||Median||434||590||0.059|
|Morphine equivalent (mg)||Median|| 30|| 11||0.37|
|Range|| 0–240|| 0–188|
|Postoperative drop in hemaglobin (g/dL)||Median|| 2.8|| 2.8||0.98|
|Range|| 1.2–5.4|| 1.2–6.8|
|Estimated blood loss (mL)||Median||200||200||0.43|
|Range|| 1–1000|| 1–4000|
|Hospital stay (days)||Median|| 3|| 4||0.29|
|Range|| 1–8|| 1–10|
|Complications||yes|| 1 (8%)|| 3 (20%)||0.60|
Because increasing numbers of complex urological procedures are currently being performed using robotic and laparoscopic techniques, the number of patients with a prior history of abdominal operations undergoing such procedures is also likely to increase.4 Patients undergoing abdominal surgery remain at an increased risk of intraperitoneal adhesions, which may complicate future abdominal surgery, including robotic surgery.3 Although some studies have showed a trend toward higher postoperative and total complication rates in patients undergoing transperitoneal laparoscopy into a previously operated abdomen, others have demonstrated that laparoscopic renal surgery could be successfully performed without increased complications in patients who have had a history of open abdominal or prior renal surgery.3,6
Robotic surgery requires distinct attention to details such as location of ports to prevent instrument conflicts, and ability to complete the procedure without altering the position of the patient once the robot is docked. Any increased peritoneal adhesion can potentially complicate completion of robotic urological procedures because of the confinements of the working space, lack of freedom to operate in a distant surgical field and limitation of field of view. The use of the da Vinci Surgical Robotic System requires three to four ports dedicated to the robotic arms with an additional one or more working ports to use conventional laparoscopic instruments. Because of the additional ports required to complete robotic surgery compared to a similar procedure performed by laparoscopic surgery, intraperitoneal adhesions may become an increasing confounding variable in the successful completion of robotic urological procedures.
Our data suggests that robotic urological procedures can be performed without increased perioperative complications in patients with prior abdominal surgery, and there were no conversions to open in either group. We analysed the incidence of the adhesions based on the type of the prior surgery. A total of 42 abdominal surgeries were performed in 28 patients. A vast majority of these procedures included appendectomy and ventral/inguinal hernia repair. The incidence of peritoneal adhesions was significantly higher in patients with prior abdominal surgery compared to the rest of the cohort, 54% versus 10% (P = 0.002). A successful pneumoperitoneum was established in all of these patients either using one-step Veress needle or open technique of placement of the first intra-abdominal port. Following successful insertion of access the adhesions were taken down either laparoscopically or robotically, which accounted for the increased operative time in this group.
Rectal fistula occurred in 3/49 (6%) patients in this series of patients, 1 in Group A and 2 in Group B. The incidence of rectal fistula is higher in the current study compared to published incidence of 1.1–2.3% in patients undergoing laparoscopic or open radical prostatectomy.7 In two patients with a prior history of extraperitoneal bladder perforations at the transurethral resection of bladder tumors, the anterior rectal wall was deliberately incised to free the bladder specimen due to dense scarring between the posterior bladder wall and the rectum. In another patient with a large volume prostate and history of neoadjuvant hormone therapy for prostate cancer, the anterior rectal wall was incised at radical prostatectomy due to obliteration of the tissue plane between the prostate and the rectum. In all patients, the rectal incision was repaired primarily in an airtight two layer fashion, and a proximal loop colostomy was done in one patient. Postoperative rectal fistula developed in all three patients, which resolved with conservative treatment in two patients. Another patient underwent open repair of vesicorectal fistula. While prior bladder perforations at bladder tumor resections may have contributed to the increased incidence of rectal fistula, history of other prior abdominal surgery does not seem to increase the risk of rectal fistulae or other forms of bowel injury.
While the various technical aspects and outcomes of urological procedures such as radical prostatectomy either by conventional open or laparoscopic or robotic methods are being debated, most studies demonstrate that minimally invasive methods clearly result in decreased blood loss compared to their respective open methods.8 The major advantage of decreased blood loss by robotic surgery may be offset by increased peritoneal adhesions from prior surgery because of an increase in operative time as well as blood loss from adhesiolysis. Our data confirms that there is a trend towards increased operative time in patients with a history of prior abdominal surgery, but this is not statistically significant. Median blood loss was surprisingly higher in group which had no prior surgery, but was not statistically significant. A larger cohort of patients may be needed to resolve the issue.
The lack of statistical difference in any of the variables of interest between the two study groups may be because of the inadequately powered small sample size. Although our LRUSP database was set up prospectively, we did not specifically analyse the type of prior abdominal surgery, extent and location of adhesions, time to adhesiolysis or associated blood loss. Because there were only seven complications reportable as events, further detailed univariate or multivariate analysis is beyond the scope of the dataset. Although the study is neither randomized nor prospectively carried out to evaluate the specific impact of prior abdominal operations on robotic surgery, the study was carried out using prospectively established LRUSP institutional database that provides all the necessary information to generate reliable preliminary results. Nevertheless, the study has generated a hypothesis that robotic urological procedures can be performed in patients with prior abdominal surgery without significantly increased complications, which may be validated using a larger cohort.
Our results suggest that robotic urological procedures can be performed in patients with prior abdominal surgery without significantly increased morbidity. There was a trend towards increased median operative time patients with history of prior abdominal surgery. A study using a larger cohort of patients is necessary to further validate our findings.