Материал: Oxford American Handbook of Urology ( PDFDrive )

572 CHAPTER 16 Urological surgery and equipment

Preparation of the patient for urological surgery

The degree of preparation is related to the complexity of the procedure. Certain aspects of examination (pulse rate, blood pressure) and certain tests (hemoglobin, electrolytes, and creatinine) are important not only to assess fitness for surgery but also as a baseline against which changes in the postoperative period may be measured.

•Assess cardiac status (angina, arrhythmias, previous myocardial infarction [MI], blood pressure, electrocardiogram [ECG], chest X-ray [CXR]). We assess respiratory function by pulmonary function tests (forced vital capacity [FVC], forced expiratory volume in 1 second

[FEV1]) for all major surgery and for any surgery where the patient has symptoms of respiratory problems or a history of chronic airways disease (e.g., asthma).

•Arrange an anesthetic review when there is, for example, cardiac or respiratory comorbidity.

•Culture urine, treat active (symptomatic) infection with an appropriate antibiotic starting a week before surgery, and give prophylactic antibiotics at the induction of anesthesia.

•Stop aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) 10 days prior to surgery.

•Obtain consent (see p. 608).

•Measure hemoglobin and serum creatinine and investigate and correct anemia, electrolyte disturbance, and abnormal renal function. If blood loss is anticipated, group and save a sample of serum or cross-match several units of blood, the precise number depending on the speed with which your blood bank can deliver blood if needed. Recommendations on blood products are as follows:

• The patient may choose to store his or her own blood prior to the procedure.

Bowel preparation

This is indicated if bowel is to be used (ileal conduit, bladder reconstruction). Use a mechanical prep (Fleets phosphasoda or polyethelen glycol 3350) and antimicrobial prep (neomycin and erythromycin base), starting at noon the day before surgery, with a clear fluid-only diet for the rest of the day.

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574 CHAPTER 16 Urological surgery and equipment

Antibiotic prophylaxis in urological surgery

The precise antibiotic prophylaxis policy that you use will depend on your local microbiological flora. Your local microbiology department will provide regular advice and updates on which antibiotics should be used, both for prophylaxis and treatment. The policy shown below and in Table 16.1 is just a recommendation.

Culture urine before any procedure, and use specific prophylaxis (based on sensitivities) if culture positive.

We avoid ciprofloxacin in inpatients because it is secreted onto the skin and causes methicillin-resistant Staphylococcus aureus (MRSA) colonization. For most purposes, nitrofurantoin provides equivalent coverage without being secreted onto the skin.

We do use ciprofloxacin if there is known Proteus infection (all Proteus species are resistant to nitrofurantoin).

Patients with artificial heart valves

Patients with heart murmurs and those with prosthetic heart valves should be given 1 g IV amoxycillin with 80 mg gentamycin at induction of anesthesia, with an additional dose of oral amoxycillin, 500 mg 6 hours later (substituting vancomycin 1 g for those who are penicillin allergic).

Patients with joint replacements

The advice is conflicting.

AAOS/AUA advice

Joint advice of the American Academy of Orthopedic Surgeons (AAOS) and the American Urological Association (AUA) is that antibiotic prophylaxis is not indicated for urological patients with pins, plates, or screws, nor for most patients with total joint replacements.

It is recommended for all patients undergoing urological procedures, including TURP, within 2 years of a prosthetic joint replacement, for those who are immunocompromised (e.g., rheumatoid patients, those with systemic lupus erythematosus [SLE], drug-induced immunosuppression, including steroids), and for those with a history of previous joint infection, hemophilia, HIV infection, diabetes, or malignancy.

Antibiotic regime

Give a single dose of a quinolone, such as 500 mg of ciprofloxacin, 1–2 hours preoperatively + ampicillin 2 g IV + gentamicin 1.5 mg/kg 30–60 minutes preoperatively (substituting vancomycin 1 g IV for penicillin-allergic patients).

576 CHAPTER 16 Urological surgery and equipment

Complications of surgery in general: DVT and PE

While venous thromboembolism (VTE) is uncommon after urological surgery, it is considered the most important nonsurgical complication of major urological procedures. Following TURP, 0.1–0.2% of patients experience a pulmonary embolus (PE)1 and 1–5% of patients undergoing major urological surgery experience symptomatic VTE.2

The mortality of PE is on the order of 1%.3

Risk factors for DVT and PE

Increased risk for deep venous thromboembolism (DVT) and PE is with open (versus endoscopic) procedures, malignancy, and increasing age and depends on the duration of the procedure.

Categorization of VTE risk

American College of Chest Physicians (ACCP) Guidelines on prevention of venous thromboembolism2 categorize the risk of VTE are as follows:

•Low-risk patients—those <40 years undergoing minor surgery (surgery lasting <30 minutes) and with no additional risk factors. No specific measures to prevent DVT are required in such patients other than early mobilization. Increasing age and duration of surgery increases risk of VTE.

•High-risk patients—include those undergoing non-major surgery (surgery lasting >30 minutes) who are age >60 years

Prevention of DVT and PE

See Box 16.1.

Diagnosis of DVT

Signs of DVT are nonspecific (i.e., cellulitis and DVT share common signs—low-grade fever, calf swelling and tenderness). If you suspect a DVT, arrange for a Doppler ultrasound. If the ultrasound probe can compress the popliteal and femoral veins, there is no DVT; if it can’t, there is a DVT.

Diagnosis of PE

Small PEs may be asymptomatic.

Symptoms include breathlessness, pleuritic chest pain, and hemoptysis. Signs include tachycardia, tachypnea, raised jugular venous pressure

(JVP), hypotension, and pleural rubs pleural effusion.

1 Donat R, Mancey–Jones B (2002). Incidence of thromboembolism after transurethral resection of the prostate (TURP). Scan J Urol Nephrol 36:119–123.

2 Geerts WH, Heit JA, Clagett PG, et al. (2001). Prevention of venous thromboembolism. (American College of Chest Physicians [ACCP] Guidelines on prevention of venous thromboembolism) Chest 119:132S–175S.

3 Quinlan DJ, McQuillan A, Eikelboom JW (2004). Low molecular weight heparin compared with intravenous unfractionated heparin for treatment of pulmonary embolism. Ann Intern Med 140:175–183.