title: Prevention and Management of Complications During Robotic-assisted Laparoscopic Radical Prostatectomy Following Comprehensive Planning: A Large Series Involving a Single Surgeon.
abstract: OBJECTIVE
  To report a series of 1,000 patients treated by a single surgeon using robotic-assisted laparoscopic radical prostatectomy (RALP) and to show how to prevent and manage complications of the procedure.
  
  
  METHODS
  Complication rates were prospectively assessed in a series of 1,000 consecutive patients who underwent RALP (group I, cases 1-200; IIa, 201-400; IIb, 401-600; IIIa, 601-800; and IIIb, 801-1000). Preoperative evaluation focused on patients' history of gout, use of drugs that can influence clotting time, and cardiopulmonary problems. Magnetic resonance imaging (MRI) was routinely performed. Operative difficulty was assessed based on the following variables: neoadjuvant hormonal therapy (NHT), obesity [body mass index (BMI) >30 kg/m(2)], prostate volume >70 g, presence of a large median lobe with intravesical protrusion >1 cm, previous transurethral resection of the prostate, previous pelvic surgery, previous extended pelvic lymph node dissection (EPLND), and salvage robotic radical prostatectomy (SRP).
  
  
  RESULTS
  Operative difficulty tended to increase significantly with greater age, higher American Society of Anesthesiologists' anesthetic/surgical risk class scores, increased BMI, and more advanced clinical stage. The number of cases with NHT, obesity, previous pelvic surgery, EPLND, and SRP significantly increased from early to later groups of patients. Conversely, significantly less blood loss occurred in later groups of patients (group I, 179 ml to 97 ml in group IIIb; p<0.001). The need for blood transfusions gradually reduced from 3.5% to 0.5% in groups I and IIIb, respectively (p=0.022). The total complication rate was 6.4% (64/1,000; surgical/medical=5%/1.4%). Complication rates decreased significantly: 12%, 6%, 6%, 4%, and 4% in groups I, IIa, IIb, IIIa, and IIIb, respectively (p=0.003). The most common complications were blood transfusion and bowel problems (11/1,000=1.1%).
  
  
  CONCLUSIONS
  Assessed in terms of groups of 200 cases, the surgeon's learning curve for RALP showed significantly fewer complications even as the operative difficulty of cases increased. The keys to preventing complications were meticulous preoperative evaluation of patients, MRI planning, and a dedicated robotic team for performing RALP. Early diagnosis and management of complications are paramount in patients who present any deviation from the normal postoperative course and clinical care pathway.
authors.affiliation: Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C Department of Research, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C School of Medicine, National Yang-Ming University, Taipei, Taiwan, R.O.C ycou228@gmail.com.
authors.forename: Yen-Chuan
authors.initials: YC
authors.lastname: Ou
authors.affiliation: Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C School of Medicine, National Yang-Ming University, Taipei, Taiwan, R.O.C.
authors.forename: Chun-Kuang
authors.initials: CK
authors.lastname: Yang
authors.affiliation: Department of Research, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C School of Medicine, National Yang-Ming University, Taipei, Taiwan, R.O.C.
authors.forename: Kuangh-Si
authors.initials: KS
authors.lastname: Chang
authors.affiliation: Department of Pathology, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C School of Medicine, National Yang-Ming University, Taipei, Taiwan, R.O.C.
authors.forename: John
authors.initials: J
authors.lastname: Wang
authors.affiliation: Department of Radiation, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C School of Medicine, National Yang-Ming University, Taipei, Taiwan, R.O.C.
authors.forename: Siu-Wan
authors.initials: SW
authors.lastname: Hung
authors.affiliation: Division of Urology, Department of Surgery, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan, R.O.C School of Medicine, National Yang-Ming University, Taipei, Taiwan, R.O.C.
authors.forename: Min-Che
authors.initials: MC
authors.lastname: Tung
authors.affiliation: Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, U.S.A.
authors.forename: Ashutosh K
authors.initials: AK
authors.lastname: Tewari
authors.affiliation: Global Robotics Institute, Florida Hospital, Orlando, FL, U.S.A.
authors.forename: Vipul R
authors.initials: VR
authors.lastname: Patel
mesh_terms: D000368:Aged; D006073:Gout / Q000517:prevention & control; D006470:Hemorrhage / Q000517:prevention & control; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000517:prevention & control*; D011468:Prostatectomy / Q000009:adverse effects*; D011471:Prostatic Neoplasms / Q000601:surgery*; D012371:Robotics; D066231:Surgeons / Q000706:statistics & numerical data
keywords: Prostate cancer; laparoscopy; radical prostatectomy; robotic surgery; surgical complications