New England Section of the American Urological Association
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Robotic Repair of Right External Iliac Vein Injury during Radical Cystectomy & Root Cause Analysis of Injury
Sina Monfared, MD, Utsav Bansal, Kenneth Softness, Philip Kim, Peter Steinberg, Peter Chang, Andrew Wagner
Beth Israel Deaconess Medical Center, Boston, MA, USA

Introduction and Objective
We present the case of a 68-year-old male with a known history of extensive high grade T1 urothelial carcinoma of the bladder with new CT findings concerning for right upper tract disease who presented for robotic nephroureterectomy and radical cystoprostatectomy. During the right pelvic lymph node dissection, sudden monopolar scissor motion created an injury to the right external iliac vein. We performed a repair of the injury as well as a root cause analysis (RCA).
Methods
After completing the right nephroureterectomy, we began the robotic pelvic lymph node dissection. During dissection, the right external iliac vein was punctured through and through by the robotic monopolar scissors during an exchange of the monopolar cautery cords. We gained proximal and distal vessel control using bulldog clamps and repaired both the anterior and posterior defects with 5-0 Prolene suture. We then completed an RCA by speaking with all team members, reviewing case video, performing field testing of Davinci Xi robot arm movement, evaluating raw clutching data from the robot, and comparing the clutching data to the surgery video.
Results
The operative time was 8 hours and 3 minutes with an estimated blood loss of 1.5L. The patient required 2 units of packed red blood cells intraoperatively. Following repair no further complications occurred and the patient was discharged on day 5, after our standard robotic radical cystectomy post-operative pathway. Our RCA showed that an assistant at the bedside unintentionally clutched the arm while placing the monopolar cautery cord with the instrument inside the patient, leading to sudden and unexpected forward scissor movement without resistance.
Conclusions
Robotic repair of near-catastrophic pelvic vessel injury is possible using proximal and distal vascular control and robotic suturing techniques. The available second-by-second robotic motion data can assist with root cause analysis of robotic complications. The bedside assistants should always remove an instrument prior to inserting cautery cords.


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