Steve Waxman, MD, JD
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Robotic technology has undoubtedly had a profound impact on the field of urology. In particular, robot-assisted laparoscopic
prostatectomy (RALP) is growing in popularity worldwide. It is now the most commonly performed surgical approach for radical
prostatectomy in the United States, accounting for nearly 50,000 cases annually (Curr Opin Urol 2008; 18:173-9).
While the procedure is popular with patients and urologists alike, it is not without its share of risk. As with any surgical
procedure, patients can and do suffer complications and injuries from RALP, some of which result in claims of medical malpractice
against the urologist.
This article reviews the most common risks, complications, injuries, and claims associated with RALP and other robotic procedures.
Tempering expectations The da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) has had phenomenal penetration into hospital markets
worldwide over the past 8 years (Minerva Urol Nefrol 2007; 59:191-8). Urologic procedures account for a large portion of the robotic workload at most hospitals, and RALP is the
most commonly performed robotic procedure of any kind in the world (Minerva Urol Nefrol 2007; 59:191-8).
There are several reasons for the groundswell of enthusiasm for robot-assisted laparoscopy. The technical advantages of the
robot include 3-D and 10X magnified vision coupled with precise instrument control (Curr Opin Urol 2008; 18:173-9). These attributes have allowed urologists young and old to incorporate RALP into their surgical armamentarium.
Editorial Comment
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Patients and surgeons are always looking for minimally invasive surgery that provides results that are comparable or better
than those of open surgery. Several large, published robotic series have shown results comparable to those of open radical
prostatectomy with regard to oncologic, continence, and potency outcomes (Curr Opin Urol 2008; 18:173-9, Cancer 2007; 110:1951-8). Proponents of RALP cite the method's improved exposure, along with the tamponade effect of pneumoperitoneum
to allow for decreased blood loss and less morbidity and mortality associated with the procedure (Curr Opin Urol 2008; 18:173-9). Patients see the potential for improved comfort and convalescence postoperatively and often steer the preoperative
discussion toward RALP.
Patient expectations can lead to serious problems if they are not met, however. Although patients may experience a shorter
convalescence and decreased pain following RALP, guaranteeing such a result is inadvisable, as not all procedures and postoperative
courses go as planned. Urologists must counsel their patients preoperatively on the potential benefits and risks along with
their own experience with RALP. Quoting outcomes from centers of excellence can backfire if one's personal results are significantly
different.
Some series have shown similar postoperative hospital stays for RALP and open radical prostatectomy (J Urol 2007; 177:929-31). Although an extended hospital stay or increased pain beyond anticipation is not reason enough for a lawsuit,
complications and/or injuries, coupled with failed expectations, can lead to patient dissatisfaction and may potentially result
in a claim.
Pneumoperitoneum
Although technically separate from the actual robotic portion of the operation, laparoscopic access and establishment of
the pneumoperitoneum are crucial. The risks of vascular and bowel injury during this portion of the procedure can necessitate
open conversion or result in complications similar to any other laparoscopic operation (World J Urol 2008; 26:595-602).
Due to the location of the ports, the epigastric vessels can be injured at the time of placement.
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