Complications - pelvic lymphadenectomy on both sides, laparoscopic, robot-assisted laparoscopy (DaVinci)

Bleeding

Incidence: 2–10% of cases, depending on the surgeon's experience and the extensive venous plexus in the pelvic area.

Origin of bleeding:

• Arterial: Common iliac artery, internal, external, or branches (e.g., obturator artery, uterine artery, lateral sacral artery).
• Venous: External/internal iliac vein, deep circumflex iliac vein, obturator vein, paravesical venous plexus.
• Capillary bleeding: Diffuse oozing from lymph node tissue or smaller perforating vessels.

Management:

• Minor bleeding:
  • Bipolar coagulation or hemostatic agents (e.g., Surgicel, fibrin glue).
• Vascular injury:
  • Immediate compression with a gauze roll to locate the bleeding source.
  • Ligature of smaller vessels with absorbable suture material (e.g., Vicryl 3-0, PDS 5-0).
  • If a larger artery or vein is involved: Vascular suture with monofilament suture material (Prolene 5-0) or clipping.
• Massive bleeding:
  • Application of a temporary vascular clamp to stabilize the patient.
  • If necessary: Conversion to open surgery for better vascular exposure.
  • Transfusion management: Administration of packed red blood cells (PRBCs), fresh frozen plasma (FFP), and possibly tranexamic acid to reduce bleeding.

Injury to Adjacent Structures

The anatomical proximity of the ureters, bladder, bowel structures, and nerves requires careful dissection.

Ureteral Injury (1–3% of cases)

Causes:

• Direct mechanical damage from dissection.
• Thermal damage from coagulation.
• Strangulation or ischemia from traction or ligature.

Diagnosis:

• Visible damage or transection of the ureter.
• Methylene blue test or intraoperative ureteral catheterization to detect leaks.

Therapy:

• Small lesions (<50% of ureter circumference): Direct suture with PDS 5-0 and DJ stent for 6 weeks.
• Complete ureteral transection:
  • Uretero-ureterostomy (end-to-end anastomosis).
  • If necessary: Ureteroneocystostomy, Boari flap, or nephrostomy.

Bladder Injury (up to 5% of cases)

Causes:

• Direct bladder damage during lymph node mobilization.
• Iatrogenic perforation from excessive retraction.

Diagnosis:

• Visible bladder perforation.
• Positive methylene blue test or intraoperative cystoscopy.

Therapy:

• Small defects: Primary closure in two layers with absorbable suture material (Vicryl 4-0, 2-0). Transurethral bladder catheter for 5-7 days followed by cystogram.
• Larger defects: Primary closure and transurethral bladder catheter for 10–14 days, followed by cystogram.

Nerve Injuries

Obturator nerve (up to 2% of cases):

• Cause: Direct dissection in the obturator fossa.
• Consequences: Weakness in leg adduction, sensory loss medially on the thigh.
• Therapy: Immediate microsurgical suture or nerve transfer in case of complete transection.

Inferior hypogastric plexus:

• Consequences: Bladder emptying disorders, sexual dysfunction.
• Management: Preventive careful preservation of autonomic nerves.

Bleeding and Hematomas

Symptoms:

• Tachycardia, hypotension, pale skin.
• Drop in hemoglobin level.
• Pelvic tenderness or palpable hematoma.

Management:

• Close monitoring of vital signs.
• For small hematoma: Wait for spontaneous resorption.
• For larger hematoma: CT-guided drainage or surgical revision.

Lymphoceles (up to 20% of cases)

Symptoms:

• Mostly asymptomatic.
• Larger lymphoceles possible with pressure sensation, pain, infection.

Therapy:

• Small lymphoceles → Observation.
• Larger, symptomatic lymphoceles → Ultrasound- CT-guided drainage.
• Infected lymphoceles → Antibiotic therapy and drainage.

Urological Complications

• Ureteral stricture or leakage:
  • Diagnostics: Sonography, CT urogram, cystoscopy.
  • Therapy:
    • DJ catheter for 6 weeks.
    • If persistent: Surgical ureteral reimplantation.
• Bladder emptying disorder:
  • Management: Intermittent self-catheterization.