Formosan Journal of Surgery

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 52  |  Issue : 6  |  Page : 207--211

Management of postoperative ileus after robot-assisted radical prostatectomy


Shu-Chi Wang1, Cheng-Kuang Yang1, Chen-Li Cheng1, Yen-Chuan Ou2,  
1 Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
2 Division of Urology, Department of Surgery, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan

Correspondence Address:
Dr. Yen-Chuan Ou
Division of Urology, Department of Surgery, Tungs' Taichung MetroHarbor Hospital, No.699, Sec. 8, Taiwan Blvd., Taichung City 435
Taiwan

Abstract

Introduction: The use of robot-assisted radical prostatectomy (RARP) for localized prostate cancer has increased in recent years. Postoperative ileus (POI) is the most common perioperative complication leading to delayed discharge after RARP. The incidence and management of prolonged POI from at our institution were reviewed. Materials and Methods: A total of 958 RARPs were reviewed. Prolonged POI was defined as intolerance of an oral diet that continued until the postoperative day 6 and beyond. All data including the patients' characteristics, comorbidities, perioperative outcome, and management of prolonged POI were assessed. Results: Seven patients experienced prolonged POI. Four of these seven patients (57%) recovered under conservative treatment. Three patients (43%) needed surgical reexploration were identified by abdominal computed tomography (CT) scan, including one adhesive intestinal obstruction and two incarcerated inguinal hernias. The laparoscopic reexplorations were successfully performed for the three patients. Conclusion: For patients with prolonged POI failing initial conservative treatment, a prompt CT survey is crucial for early detection of patients requiring surgical intervention, helps to avoid intra-abdominal adhesion during the exploratory laparotomy and reduces associated surgical complications.



How to cite this article:
Wang SC, Yang CK, Cheng CL, Ou YC. Management of postoperative ileus after robot-assisted radical prostatectomy.Formos J Surg 2019;52:207-211


How to cite this URL:
Wang SC, Yang CK, Cheng CL, Ou YC. Management of postoperative ileus after robot-assisted radical prostatectomy. Formos J Surg [serial online] 2019 [cited 2020 Aug 13 ];52:207-211
Available from: http://www.e-fjs.org/text.asp?2019/52/6/207/272321


Full Text



 Introduction



Prostate cancer is one of the most common cancers in men. The use of robot-assisted radical prostatectomy (RARP) for localized prostate cancer has increased in recent years. Coelho et al. reviewed 2500 patients received RARP and found postoperative ileus (POI) was the most common perioperative complications after RARP.[1] The incidence of POI after RARP has been reported from 0.4% to 2%.[2],[3],[4] Although not a life-threatening complication, POI prolonged hospitalization, prolonged disability, and impaired quality of life and was reported as the most common reason for delayed discharge.[4],[5] Proper management of POI is of paramount importance. To our knowledge, only a few studies have investigated this issue, specifically POI after RARP. The incidence and management of prolonged POI among 958 RARPs in our institution were reviewed.

 Materials and Methods



After approval by the institutional review board of Taichung Veterans General Hospital (IRB No. CE13240A-2 obtained on July 28th, 2015) with the need of obtaining informed consents from the study participants, we reviewed patients who underwent RARP from December 2005 to April 2015. A total of 958 RARPs were performed by a single surgeon. According to our preoperative preparation protocol, all patients received a clear liquid diet the day before RARP and Fleet Enema the night before the scheduled surgery. RARP was carried out as previously described using Patel's technique with minor modifications.[5] We usually performed bilateral pelvic lymph node dissection. Neurovascular bundle (NVB) preservation procedures were performed based on the tumor status (including findings on preoperative digital rectal examination, prostate-specific antigen [PSA], Gleason score, magnetic resonance imaging). Preservation of NVB was performed using the Vattikuti Institute Prostatectomy technique.[6] Urethrovesical anastomosis was completed with two 3-0 monocryl continuous stitches.

In all cases, a nasogastric (NG) tube was inserted before the operation and was kept in decompression status overnight. NG tube was removed on the morning of the postoperative day (POD) 1. Patients were allowed to try water and resumed a regular diet gradually. Early ambulation was also encouraged. The drainage tube was removed when daily drainage amount was <100 ml, usually POD 2–4. Most patients were discharged on POD 3–5.

We defined prolonged POI as intolerance of an oral diet which continued until POD 6 and beyond. According to our protocol, once a patient presented POI, conservative treatment with intravenous hydration, bowel rest with nothing by mouth, and NG decompression was applied immediately. Patients' clinical conditions and daily changes in intestinal gas on the plain abdominal X-ray were closely monitored. For those failing initial conservative treatment, an abdominal computed tomography (CT) scan was arranged. If mechanical intestinal obstruction detected by CT scan, laparoscopic reexploration was performed.

 Results



Among the 958 cases that were reviewed, we identified seven patients (0.87%) with the complication of prolonged POI [Figure 1]. All data including the patients' characteristics, comorbidities, operative course, and perioperative outcome are shown in [Table 1]. The mean age of these cases was 65.5 years old (range, 55–76 years) and the mean PSA was 11.38 ng/ml (range, 5.33–20.67). Six of the seven cases had adenocarcinoma of the prostate, which was proven by transrectal ultrasound-guided (TRUS) biopsy. One received RARP for benign prostatic hyperplasia with progressive elevated PSA without TRUS biopsy. The mean preoperative Gleason score was 7.5 (range 6–10), clinical stage was ranged from T1c to T3b, mean blood loss was 81.4 ml (range 50–200), and mean operative time was 157 min (range 120–240). None of the seven patients underwent an intra-abdominal operation before RARP.{Figure 1}{Table 1}

Two patients with POI recovered under initial conservative treatment. Abdominal CT scan was arranged for the five patients failing conservative treatment. Mechanical intestinal obstruction was detected by CT scan in three patients. These three patients received laparoscopic reexploration and the perioperative outcomes are shown in [Table 2]. In Case #2 and Case #6, postoperative CT revealed unilateral incarcerated inguinal hernia. Both these two patients underwent laparoscopic adhesiolysis with nonprosthetic hernia repair uneventfully on POD 11 and POD 6, respectively [Figure 2]. In Case #3, abdominal CT showed hematoma at the pelvis and terminal ileum adhesion to the right perivesical space causing mechanical intestinal obstruction [Figure 3]. Laparoscopic adhesiolysis was performed on POD 19. In this case, we found more severe intra-abdominal adhesion, and there were several serosa tears during adhesiolysis. None of the three cases was converted to open procedure.{Table 2}{Figure 2}{Figure 3}

 Discussion



POI after abdominal surgery usually resolves spontaneously after 2–3 days.[7] Currently, there is no consistent definition of prolonged POI. Artinyan et al. recommended that an ileus lasting more than 6 days was a better clinical definition of prolonged POI.[8]

Minimally invasive surgery is superior to conventional open surgery in less pain medication required, faster postoperative recovery, and a better cosmetic result.[9] However, there is still debate about which is better with respect to postoperative bowel obstruction. In the field of urologic surgery, POI is the main complication following cystectomy, but it occurs less frequently after other minimally invasive surgery. Current evidence suggesting that higher body mass index, greater estimated blood loss, urinary extravasation, existence of a major complication, procedures involving bowel resection, increasing operative time, and transperitoneal approach are risk factors for POI.[10] Pierorazio et al. found RARP was associated with higher POI leading to “off-clinical care pathway,” compared to open radical prostatectomy and laparoscopic prostatectomy.[4]

Most of our RARP were performed via the transperitoneal approach, including the seven patients developing prolonged ileus. Only five of the 958 patients underwent extra-peritoneal RARP due to severe intra-abdominal adhesion. The transperitoneal approach has the advantages of larger working space, a reduced risk of lymphocele, and better luminosity. The extraperitoneal approach caused a lower prevalence of bowel complication and was superior in the recovery of postoperative intestinal function.[11] In our practice, we usually performed limited pelvic lymph node dissection in our RARPs. Yuh et al. reviewed 406 consecutive RARPs and found extended lymph node dissections were associated with longer operation time, higher positive lymph node rates, similar blood loss, similar symptomatic lymphocele, and similar major complication rates compared with limited lymph node dissection.[12] Increased blood may potentially have a negative impact on the neural and endocrine system, which can make intestinal peristalsis worse.[8] Most blood loss in our RARPs fell in the range 50–200 ml. The seven patients had a comparable mean blood loss of 81.4 ml (range from 50 to 200 ml). As blood loss during the robotic surgery was low, the relationship between blood loss and POI was hard to be confirmed in robotic surgery. Diabetes mellitus (DM) has a negative effect on the nervous system, the inflammatory response, and the hormone system of the human body. Ozdemir et al. reported that DM was as a risk factor for developing POI after RARP and five of the six patients (83.3%) developing POI had DM in their series.[3] However, the coincidence of DM and POI was much lower in our study (14.2%).

Conservative treatment with bowel reset and NG decompression was usually a useful strategy for managing POI. If ileus persists despite conservative treatment and lasts more than 6 days, abdominal CT scan might offer a rapid diagnosis. CT scan is a valuable tool in patients with bowel obstruction. It can not only distinguish bowel obstruction from paralytic ileus but also help identify the cause of the obstruction.[13] Extrinsic causes of small bowel obstruction include adhesion, hematoma, hernia, and endometriosis. By identifying the transition point on the CT scan, where a caliber change between the dilated proximal and collapsed distal bowel loops occurs, physicians can find the cause of the obstruction.[14] With these findings, clinicians can decide to treat patients surgically or medically. Although the best timing of CT scan for POI has not been established, we suggested a prompt rather than delayed CT scan for early identification of bowel obstruction necessitating surgical exploration and avoid intra-abdominal adhesion occurring in the late postoperative period.

One of our patients with adhesive intestinal obstruction underwent laparoscopic adhesiolysis. Risk factors for developing postoperative hematoma include increased intraoperative blood loss[15] and coagulopathy from medical diseases or anticoagulants.[16] Pelvic hematoma formation is a risk factor of developing adhesive intestinal obstruction after RARP. Due to the increased intra-abdominal pressure of pneumoperitoneum, some bleeders may be easily missed. These vessels can ooze after releasing the pneumoperitoneum. Meticulous hemostasis and properly positioned drainage tube are of paramount importance for avoiding hematoma formation.

In a review of a total 2500 RARPs, one trocar-site bowel herniation (0.04%) and one bowel obstruction (0.04%) requiring surgical intervention were reported. None of the incarcerated inguinal hernia was reported in their review.[1] Soto-Palou and Sánchez-Ortiz reported that the risk of encountering a hernia at the time of prostatectomy was 22.4% in patients with a preoperative International Prostate Symptom Score of 15 or greater.[17] Concurrent inguinal hernia repair during RARP was advocated for preventing postoperative complication.[18] We usually performed nonprosthetic inguinal hernia repair during our RARPs. However, there are still two patients complicated by incarcerated inguinal hernia and required laparoscopic hernioplasty. Dissection of the space of Retzius during prostatectomy may expose asymptomatic abdominal wall defect plugged with fat. An unrecognized and unrepaired hernia may lead to incarcerated hernia postoperatively, especially when the integrity of the peritoneum has been disrupted.

Laparoscopic adhesiolysis had been shown to be effective for postoperative bowel obstruction.[19] Li et al. reported a comparable efficacy and a reduced overall complication rate in laparoscopic adhesiolysis compared with open adhesiolysis.[20] We preferred the laparoscopic approach, using previous trocar wounds and placing the patient in the Trendelenburg position. No more extra wounds needed to be created and the head-down tilt position facilitated identification the site of bowel obstruction.

 Conclusion



In our experience, prolonged POI after RARP and had an incidence of 0.73%. When a patient developed POI, conservative treatment with bowel rest and NG decompression were usually effective. A prompt abdominal CT survey should be arranged for those failing initial conservative treatment. In our review, up to three of seven patients (43%) with prolonged POI need surgical reexploration. With early identification of patients who require surgical intervention, intra-abdominal adhesion during the second exploratory, and associated surgical complications can be avoided.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Coelho RF, Palmer KJ, Rocco B, Moniz RR, Chauhan S, Orvieto MA, et al. Early complication rates in a single-surgeon series of 2500 robotic-assisted radical prostatectomies: Report applying a standardized grading system. Eur Urol 2010;57:945-52.
2Liss MA, Skarecky D, Morales B, Osann K, Eichel L, Ahlering TE. Preventing perioperative complications of robotic-assisted radical prostatectomy. Urology 2013;81:319-23.
3Ozdemir AT, Altinova S, Koyuncu H, Serefoglu EC, Cimen IH, Balbay DM. The incidence of postoperative ileus in patients who underwent robotic assisted radical prostatectomy. Cent European J Urol 2014;67:19-24.
4Pierorazio PM, Mullins JK, Ross AE, Hyams ES, Partin AW, Han M, et al. Trends in immediate perioperative morbidity and delay in discharge after open and minimally invasive radical prostatectomy (RP): A 20-year institutional experience. BJU Int 2013;112:45-53.
5Gonzalgo ML, Pavlovich CP, Trock BJ, Link RE, Sullivan W, Su LM. Classification and trends of perioperative morbidities following laparoscopic radical prostatectomy. J Urol 2005;174:135-9.
6Menon M, Tewari A, Peabody J; VIP Team. Vattikuti institute prostatectomy: Technique. J Urol 2003;169:2289-92.
7Livingston EH, Passaro EP Jr. Postoperative ileus. Dig Dis Sci 1990;35:121-32.
8Artinyan A, Nunoo-Mensah JW, Balasubramaniam S, Gauderman J, Essani R, Gonzalez-Ruiz C, et al. Prolonged postoperative ileus-definition, risk factors, and predictors after surgery. World J Surg 2008;32:1495-500.
9Mohiuddin K, Swanson SJ. Maximizing the benefit of minimally invasive surgery. J Surg Oncol 2013;108:315-9.
10Aoun F, Zanaty M, Peltier A, Velthoven RV. Minimal invasive urologic surgery and postoperative ileus. Open Access J Sci Technol 2015;3.
11Liu LH, Zhang T, He SH, Wu ZY, Zhang HB, Chen FZ, et al. Transperitoneal versus extraperitoneal laparoscopic radical prostatectomy for localized prostate cancer: A meta analysis. Zhonghua Nan Ke Xue 2013;19:1020-6.
12Yuh BE, Ruel NH, Mejia R, Novara G, Wilson TG. Standardized comparison of robot-assisted limited and extended pelvic lymphadenectomy for prostate cancer. BJU Int 2013;112:81-8.
13Taourel PG, Fabre JM, Pradel JA, Seneterre EJ, Megibow AJ, Bruel JM. Value of CT in the diagnosis and management of patients with suspected acute small-bowel obstruction. AJR Am J Roentgenol 1995;165:1187-92.
14Silva AC, Pimenta M, Guimarães LS. Small bowel obstruction: What to look for. Radiographics 2009;29:423-39.
15Zetterling M, Ronne-Engström E. High intraoperative blood loss may be a risk factor for postoperative hematoma. J Neurosurg Anesthesiol 2004;16:151-5.
16Yi S, Yoon DH, Kim KN, Kim SH, Shin HC. Postoperative spinal epidural hematoma: Risk factor and clinical outcome. Yonsei Med J 2006;47:326-32.
17Soto-Palou FG, Sánchez-Ortiz RF. Outcomes of minimally invasive inguinal hernia repair at the time of robotic radical prostatectomy. Curr Urol Rep 2017;18:43.
18Mourmouris P, Argun OB, Tufek I, Obek C, Skolarikos A, Tuna MB, et al. Nonprosthetic direct inguinal hernia repair during robotic radical prostatectomy. J Endourol 2016;30:218-22.
19Borzellino G, Tasselli S, Zerman G, Pedrazzani C, Manzoni G. Laparoscopic approach to postoperative adhesive obstruction. Surg Endosc 2004;18:686-90.
20Li MZ, Lian L, Xiao LB, Wu WH, He YL, Song XM. Laparoscopic versus open adhesiolysis in patients with adhesive small bowel obstruction: A systematic review and meta-analysis. Am J Surg 2012;204:779-86.