Bleeding and subsequent haematoma formation can be a troublesome problem during and after radical prostatectomy, whichever way it is performed. The recent advent of laparoscopic radical prostatectomy, with or without robotic assistance, has significantly reduced intra-operative blood loss; however, after surgery haematomata may still develop, most often in the prostatic bed between the bladder and the rectum. In this location a sizeable blood clot may cause pain and tenesmus and discharge through the anastomosis into the bladder, resulting in haematuria, often with troublesome clots. It may also distort or even disrupt the anastomosis and significantly delay healing and hence time to catheter removal and the restoration of normal voiding.
Meticulous technique can minimize the risk of haematoma formation and other complications after robot-assisted radical prostatectomy  and significant bleeding that requires blood transfusion is <1% in high volume centres . The use of clips to secure the pedicles is important to prevent arterial bleeding from branches of the internal iliac artery (so-called ‘arteries of Flocks’). Careful haemostasis is required in relation to both neurovascular bundles, however, this should be achieved without recourse to diathermy if at all possible, in order to reduce the risks of postoperative erectile dysfunction. The Rocco suture , which aims to approximate peri-urethral tissue to sub-trigonal fascia, not only facilitates the vesico-urethral anastomosis, but also reduces the potential space in the prostatic bed in which a haematoma may form. In our experience of >1000 cases of robot-assisted radical prostatectomy, the use of the Rocco suture in more recent cases has in part contributed to the reduced incidence of this complication.
In addition, immediately before the insertion of the Rocco suture we deploy 7 mL fibrin sealant solution such as Evicel® (Ethicon, Johnson & Johnson, New Brunswick, NJ, USA) or Tisseel® (Baxter Internation Inc, Deerfield, IL, USA) using a spray applicator along both neurovascular bundles and across the surface of the anterior rectal wall. The remaining 3 ccs can be used to help seal the urethra-vesical anastomosis, once this has been completed and the catheter inserted. This step is intended to reduce the risk of anastomotic leakage, which can result in large quantities of urine appearing in the drain or even in urinary peritonitis. Alternatives include the haemostatic matrices Floseal (Baxter) or Surgiflo (Ethicon), which are flowable thrombin – gelatin combinations, and cellulose-based products such as Surgicel® (Ethicon) and Fibrillar (Ethicon), which may provide physical haemostatic tamponade in confined spaces. There is no evidence contraindicating the use of these products during radical prostatectomy and Floseal has been shown not to adversely affect cavernous nerve function in animal studies .
The mechanism of action of fibrin sealants mimics the last step of the physiological coagulation cascade (Fig. 1), an advantage over the haemostatic matrices which require normal clotting parameters to already exist. Both Evicel® and Tisseel® contain plasma-derived fibrinogen, thrombin and calcium chloride. The fibrinogen component contains fibronectin, assisting collagen adherence, and the thrombin component contains calcium ions, aiding activation . Both products are subject to vigorous virus inactivation and removal procedures; to date there have been no reported cases of virus transmission resulting from the use of fibrin sealants. The products do differ importantly, in that Tisseel® also contains bovine aprotinin, which is used as an antifibrinolytic agent intended to slow fibrinolysis at the site of the application. A recent comparison of the mechanical, kinetic and biochemical properties of fibrin clots formed with Tisseel® and Evicel® concluded that the latter product not only formed clots faster, but also formed clots of a higher tensile strength . The authors associate the ‘superior’ clot strength of Evicel® to the covalent (bond to self) Factor XIII cross-linking, because both contain similar amounts of fibrinogen.
In many other branches of surgery, including liver resection, neurosurgery and other areas of urology, fibrin sealants have been found to be of value in stopping bleeding and preventing haematoma formation, and are increasingly employed [7–11]. The haemostatic agents, although slightly cheaper than the fibrin sealants, tend to swell up after coming into contact with blood, take longer to be broken down (4–8 weeks vs 7–14 days), and come in smaller quantities (5 mL vs 10 mL) of active product.
Even with the deployment of the Rocco suture and the use of a fibrin sealant, occasionally a significant haematoma will develop during the early postoperative period. The clinical signs are those of acute blood loss including tachycardia and hypotension. The haemoglobin will usually drop. The patient will often also complain of lower abdominal pain and tenesmus, because of the pressure effect on the bladder and rectum. CT scanning will establish the diagnosis and will provide an estimation of the size and location of the haematoma. At this stage a difficult decision has to be made whether to re-establish the pneumoperitoneum and replace the ports to evacuate the clot and establish haemostasis, or to rely on natural fibrinolysis to gradually dissolve the haematoma over a matter of weeks. Obviously the cardiovascular stability of the patient and the size of the haematoma will influence this decision.
If the haematoma is managed nonoperatively then a longer period of urethral catheterization is recommended to ensure adequate healing of the urethra-vesical anastomosis (2–3 vs 1 week). Similarly, significant haematuria in a patient who initially had clear urine usually indicates a delayed presentation of pelvic haematoma and should be managed as such. A cystogram will provide good evidence for anastomotic integrity before catheter removal in these cases. If repeated cystograms continue to indicate significant anastomotic disruption after several weeks, a flexible cystoscopy and guidewire insertion of a urethral catheter may be required to assess the degree of separation and ensure the correct placement of the catheter balloon.
In conclusion, as in all branches of surgery, prevention of complications is far preferable to their cure. In laparoscopic and robot-assisted radical prostatectomy there is no substitute for proper training and careful mentoring, as well as accumulated surgical experience, to develop the best possible surgical technique. The use of the Rocco suture and the deployment of fibrin sealants have, in our hands, reduced the very troublesome incidence of haematoma formation between the bladder and the rectum. When this problem has occurred on rare occasions, we have found that re-establishing the robotic ports, taking down the anastomosis and evacuating the clot has resolved the problem effectively, without significant morbidity. This, however, is disruptive to the patient, his relatives and theatre staff, not to mention the surgeon, and therefore much better avoided if at all possible. The manoeuvres described above are designed to help laparoscopic and robotic surgeons achieve just that.