Материал: Oxford American Handbook of Urology ( PDFDrive )

632 CHAPTER 16 Urological surgery and equipment

Nephrectomy and nephroureterectomy

Indications

•Renal cell cancer

•Nonfunctioning kidney containing a staghorn calculus

•Persistent hemorrhage following renal trauma

Anesthesia

General anesthesia is used.

Postoperative care

Nephrectomy

Cardiovascular status and urine output should be carefully monitored in the immediate postoperative period. Hemorrhage from the renal pedicle or, for left-sided nephrectomy, the spleen, is rare, but will present with an increasing tachycardia, cool peripheries, falling urine output, and eventually a drop in blood pressure.

A drain is usually not left in place, but if it is, there may be excessive drainage of blood from the drain. However, do not be lulled into a false sense of security by the absence of drainage—this does not mean that hemorrhage is not occurring, as the drain may be blocked but hemorrhage may be ongoing.

For nephrectomy via a posterolateral (rib-based) incision, watch for pneumothorax. Arrange for a CXR on return from the recovery room. Arrange routine chest physiotherapy to reduce the risk of chest infection. Regular chest examination is important, looking specifically for pneumothorax and pleural effusion.

Mobilize the patient as quickly as possible, to reduce the risk of DVT and PE.

Nephroureterectomy

Where the ureter has been excised from the bladder, a urethral catheter is left in place at the end of the procedure, to allow the hole in the bladder to heal. This is usually removed 10–14 days after surgery.

Common postoperative complications and their management

•Hemorrhage—see above.

•Wound infection is rare. If superficial, treat with antibiotics. If an underlying collection of pus is suspected, open the wound to allow free drainage, and pack the wound daily.

•Pancreatic injury is rare, but would be indicated by excessive drainage of fluid from the drain, if present, which will have a high amylase level. If no drain is present, an abdominal collection will develop, which may be manifested by a prolonged ileus.

NEPHRECTOMY AND NEPHROURETERECTOMY 633

Procedure-specific consent form—recommended discussion of adverse events

Serious or frequently occurring complications of nephrectomy or nephroureterectomy

Simple nephrectomy Common

•Temporary insertion of a bladder catheter

•Occasional insertion of a wound drain

Occasional

•Bleeding requiring further surgery or transfusion

•Entry into lung requiring temporary insertion of a drainage tube

Rare

•Involvement or injury to nearby structures—blood vessels, spleen, lung, liver, pancreas, bowel, requiring further extensive surgery

•Infection, pain, or hernia of incision, requiring further treatment

•Anesthetic or cardiovascular problems, possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack)

Alternative therapy includes observation, laparoscopic approach.

Radical nephrectomy

Complications are as above plus the following:

•Occasional: need for further therapy for cancer

•Rare: may be an abnormality other than cancer on microscopic analysis

Alternative therapy includes observation, embolization, immunotherapy, and laparoscopic approach.

Nephroureterectomy

Complications are the same as those listed above.

634 CHAPTER 16 Urological surgery and equipment

Radical prostatectomy

Indications

This is performed for localized prostate cancer.

Anesthesia

General or regional anesthesia is required.

Postoperative care

Mobilize the patient as quickly as possible and continue subcutaneous heparin and use of AK-TEDS until discharge to reduce the risk of DVT and PE. Remove the drains when drainage is minimal.

If there is persistent leak of fluid from the drains, send a sample for urea and creatinine, and if it is urine, get a cystogram to determine the size of the leak at the vesicourethral junction.

Urethral catheters are left in situ after radical prostatectomy for a variable time depending on the surgeon who performs the operation. Some surgeons leave a catheter for 3 weeks and others for just 1 week.

Common postoperative complications and their management

Hemorrhage

This is managed in the usual way (transfusion; return to surgery when bleeding persists or when there is cardiovascular compromise).

Ureteric obstruction

This usually results from edema of the bladder, obstructing the ureteric orifices. Retrograde ureteric catheterization is rarely possible (this would require urethral catheter removal and it is difficult to see the ureteric orifices because of the edema).

Arrange for placement of percutaneous nephrostomies.

Lymphocele

Drain by radiologically assisted drain placement. If the lymphocele recurs after drain removal, create a window from the lymph collection into the peritoneal cavity so the lymph drains into the peritoneum from which it is absorbed.

Displaced catheter post radical prostatectomy

If the catheter falls out a week after surgery, the patient may well void successfully, and in this situation no further action need be taken. If, however, the catheter inadvertently falls out the day after surgery, gently attempt to replace it with a 12 Fr. catheter that has been well lubricated.

If this fails, pass a flexible cystoscope, under local anesthetic, into the bulbar urethra and attempt to pass a guide wire into the bladder, over which a catheter can then safely be passed. If this is not possible, another option is to hope that the patient voids spontaneously and does not leak urine at the site of the anastomosis.

An ascending urethrogram may provide reassurance that there is no leak of contrast and that the anastomosis is watertight. If there is a leak

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or the patient is unable to void, a suprapubic catheter can be placed (percutaneously or under general anesthetic via an open cystostomy).

Fecal fistula

This is due to rectal injury, either recognized and repaired at the time of surgery and later breaking down, or not immediately recognized. Formal closure is often required.

Contracture at the vesicourethral anastomosis

Gentle dilatation may be tried. If the stricture recurs, instruct the patient in ISC, in an attempt to keep the stricture open. If this fails, a bladder neck incision may be tried.

Procedure-specific consent form—recommended discussion of adverse events

Serious or frequently occurring complications of radical prostatectomy

Common

•Temporary insertion of a bladder catheter and wound drain

•High chance of impotence due to unavoidable nerve damage

•No semen is produced during orgasm, causing infertility

Occasional

•Blood loss requiring transfusion or repeat surgery

•Urinary incontinence—temporary or permanent, requiring pads or further surgery

•Discovery that cancer cells are already outside the prostate, needing observation or further treatment at a later date if required, including radiotherapy or hormonal therapy

Rare

•Anesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack)

•Pain, infection, or hernia in area of incision

•Rectal injury, very rarely needing temporary colostomy

Alternative therapy includes watchful waiting, radiotherapy, brachytherapy, hormonal therapy, and perineal or laparoscopic removal.

636 CHAPTER 16 Urological surgery and equipment

Radical cystectomy

Indications

•Muscle-invasive bladder cancer

•Adenocarcinoma of bladder (radioresistant)

•Squamous carcinoma of bladder (relatively radioresistant)

•Non-muscle-invasive TCC bladder that has failed to respond to intravesical chemotherapy or immunotherapy

•Recurrent TCC bladder post-radiotherapy

Combined with urethrectomy if

•There are multiple bladder tumors

•There is involvement of the bladder neck or prostatic urethra

Anesthesia

General anesthesia is used.

Postoperative care and common post-operative complications and their management

Monitor cardiovascular status, urine output, and respiratory status carefully in the first 48 hours. Routine chest physiotherapy is started early in the postoperative period to reduce the chance of chest infection. Mobilize the patient as early as possible to minimize the risk of DVT and PE.

Drains are removed when they stop draining. Some surgeons prefer to leave them for a week or so, so that late leaks (urine, intestinal contents) will drain via the drain track and not cause peritonitis.

Try to remove the nasogastric tube, if used, as soon as possible to assist respiration and reduce the risks of chest infection. The patient usually starts to resume their diet within a week or so. If the ileus is prolonged, start parenteral nutrition.

Hemorrhage

Persistent bleeding that fails to respond to transfusion should be managed by re-exploration.

Wound dehiscence requires resuturing under general anesthetic.

Ileus is common. It usually resolves spontaneously within a few days.

Small bowel obstruction

This occurs from herniation of small bowel through the mesenteric defect created at the junction between the two bowel ends. Continue nasogastric aspiration. The obstruction will usually resolve spontaneously.

Reoperation is occasionally required when the obstruction persists or when there are signs of bowel ischemia.

Leakage from the intestinal anastomosis

This can lead to the following:

•Peritonitis—requiring reoperation and repair or refashioning of the anastomosis

•An enterocutaneous fistula—bowel contents leak from the intestine and through a fistulous track onto the skin. A low-volume leak (<500