Postoperative Hemorrhagic Shock 7 Days After Robot-Assisted Radical Prostatectomy

Abstract

Background: Delayed postoperative bleeding after robot-assisted radical prostatectomy (RARP) is a rare lifethreatening condition. We present such a case wherein a patient developed hemorrhagic shock from a ruptured pseudoaneurysm arising from the epigastric artery and discuss its management. Case Presentation: A 71-year-old man with prostate cancer underwent RARP. The urethral catheter was removed on postoperative day 7; 80 minutes later, the patient suddenly lost consciousness and went into shock. Enhanced CT revealed intra-abdominal bleeding; however, the cause was unknown. Intraoperatively, bleeding was observed from the anterior abdominal wall, which likely corresponded to the epigastric artery. However, this was controlled with monopolar electrocautery. Because of unstable hemodynamics, hemostasis was immediately performed by laparotomy, and bleeding was noted from the previously coagulated right inferior epigastric artery. Therefore, the cause was considered to be the rupture of a pseudoaneurysm. Conclusion: Our experience suggests that monopolar electrocautery may be inadequate for controlling bleeding that may be encountered during RARP, possibly leading to pseudoaneurysm formation, which may cause a delayed life-threatening hemorrhage. Meticulous and precise hemostasis is key to avoiding this complication.

Prostatic Fossa Pseudoaneurysm After Robot-Assisted Radical Prostatectomy (RARP): A Case Report

“…Postprostatectomy pseudoaneurysms (PPP) are a very rare complication, with the most recent series showing only 23 cases described in the literature [ 3 ]. They occur because of infections, trauma, malignancies, or iatrogenic causes, such as intraoperative arterial wall damage [ 6 ]. In our patient, arterial wall damage was the probable cause; it can result from small bleeding left behind in dissection when using a nerve-sparing approach.…”

“…In our patient, arterial wall damage was the probable cause; it can result from small bleeding left behind in dissection when using a nerve-sparing approach. Another explanation may be in-block artery and veins ligature using clips or direct artery damage using mono-polar scissors [ 6 , 7 ]. As a result, the vascular anomaly is predis-posed to bleeding and the intermittent bleeding accumulated in the Retzius space drained through the vesicourethral anastomosis, leading to hematuria [ 7 ].…”

Pseudoaneurysm after Radical Prostatectomy: A Case Report and Narrative Literature Review

“…The main causes of a pseudoaneurysm are endovascular procedures, surgical procedures, biopsies and drainages [7]. Monopolar electrocautery, if applied on an arterial wall, could lead to pseudoaneurysm formation [3], as a consequence of arterial wall injury [8], every time LND is performed during RARP; it does not require any other apparent risk factor to cause vascular damage [9].…”

“…Delayed postoperative bleeding is a serious complication of RP, although rare [3]. Iatrogenic pelvic pseudo-aneurysms following open, robotic or laparoscopic procedures have been rarely reported in the past.…”

“…Iatrogenic pelvic pseudo-aneurysms following open, robotic or laparoscopic procedures have been rarely reported in the past. The clinical presentation of a bleeding pseudoaneurysm can be diversified [3] and the clinical management of hemorrhage after RP has not been well-described, despite wide institutional and anecdotal experiences. Several case series have described postoperative hemorrhage management through minimally invasive exploration as well as angioembolization, although decision-making criteria or decisional algorithms have not been well established [4].…”