Материал: Oxford American Handbook of Urology ( PDFDrive )

RADICAL CYSTECTOMY 637

mL/24 hr) will usually heal spontaneously. Normal (enteral) nutrition may be maintained until the fistula closes (which usually occurs within a matter of days or a few weeks). If the leak is high volume, spontaneous closure is less likely and reoperation to close the fistula may be required.

Pelvic abscess

Formal surgical (open) exploration of the pelvis is indicated with drainage of the abscess and careful inspection to see if the underlying cause is a rectal injury, in which case a defunctioning colostomy should be performed.

Partial cystectomy

Indications

This is done to remove primary, solitary bladder tumors at a site that allows 2 cm of normal tissue around it in a bladder that will have adequate capacity and compliance after operation.

There should be the following:

•No prior history of bladder cancer

•No carcinoma in situ

•A solitary muscle-invasive tumor located well away from the ureteral orifices which includes 2 cm of normal surrounding bladder

High-grade tumors should not be excluded if these criteria are met. The lesions most commonly amenable to partial cystectomy are G2 or G3 TCCs or adenocarcinomas located on the posterior wall or dome.

Contraindications

These include associated carcinoma in situ, deeply invasive tumors, and tumors at the bladder base (i.e., near the ureteric orifices).

Procedure-specific consent form—recommended discussion of adverse events

Serious or frequently occurring complications of radical cystectomy

See also consent for ileal conduit if this is the planned form of urinary diversion.

Common

•Temporary insertion of a nasal tube, drain, and stent

•High chance of impotence (lack of erections) due to unavoidable nerve damage

•No semen is produced during orgasm (dry orgasm), causing infertility.

•Blood loss requiring transfusion or repeat surgery

•In women, pain or difficulty with sexual intercourse from narrowing or shortening of vagina and need for removal of uterus and ovaries (causing premature menopause in those not at menopause)

Occasional

•Cancer may not be cured with surgery alone.

•Need to remove penile urinary pipe as part of procedure

Rare

• Infection or hernia of incision, requiring further treatment

638CHAPTER 16 Urological surgery and equipment

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

•Decreased renal function with time

Very rarely

•Rectal injury, very rarely needing temporary colostomy

•Diarrhea due to shortened bowel, vitamin deficiency requiring treatment

•Bowel and urine leak, requiring reoperation

•Scarring of bowel or ureters, requiring operation in the future

•Scarring, narrowing, or hernia formation around stomal opening, requiring revision

Alternative treatment includes radiotherapy, neobladder formation rather than ileal conduit urinary diversion.

Formation of neobladder with bowel

Common

•Need to perform intermittent self-catheterization if bladder fails to empty.

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640 CHAPTER 16 Urological surgery and equipment

Ileal conduit

Indications

•For urinary diversion following radical cystectomy

•Intractable incontinence for which anti-incontinence surgery has failed or is not appropriate

Postoperative care and common postoperative complications and their management

Oliguria or anuria: Try a fluid challenge.

Wound infection: Treat with antibiotics and wound care. Open the superficial layers of the wound to release pus.

Wound dehiscence is rare. It requires resuturing in the operating room, 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 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 mL/24 hr) will usually heal spontaneously. Normal (enteral) nutrition may be maintained until the fistula closes (which usually occurs within a matter of days or a few weeks). If high volume, spontaneous closure is less likely, and reoperation to close the fistula may be required.

Leakage from the ureteroileal junction

Leakage may be suspected because of a persistently high output of fluid from the drain. Test this for urea. Urine will have a higher urea and creatinine concentration than serum. If the fluid is lymph, the urea and creatinine concentration will be the same as that of serum.

Arrange for a loopogram. This will confirm the leak. Place a soft, small catheter (12 Fr) into the conduit to encourage antegrade flow of urine and assist healing of the ureteroileal anastomosis. If the leakage continues, arrange for bilateral nephrostomies to divert the flow of urine away from the area and encourage wound healing.

Occasionally, a ureteroileal leak will present as a urinoma (this causes a persistent ileus). Radiologically assisted drain insertion can result in a dramatic resolution of the ileus, with subsequent healing of the ureteroileal leak.