Complications of Urologic Surgery: Prevention and Management, 4th Edition: with Q&A and Case Studies

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COMPLICATIONS OF UROLOGIC SURGERY

ISBN: 978-1-4160-4572-4

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Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on his or her own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the publisher nor the authors assume any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. The Publisher Library of Congress Cataloging-in-Publication Data Complications of urologic surgery: prevention and management / editor, Samir S. Taneja.—4th ed.      p.  ; cm.   Revised edition of Complications of urologic surgery / edited by Samir S. Taneja, Robert B. Smith and Richard M. Ehrlich. 2001.   Includes bibliographical references and index.   ISBN 978-1-4160-4572-4 (alk. paper)   1.  Genitourinary organs–Surgery–Complications.  I.  Taneja, Samir S.   [DNLM:  1.  Urologic Surgical Procedures, Male.  2.  Postoperative Complications– prevention & control.  3.  Urinary Tract–surgery.  WJ 168 C737 2010]   RD571.C65 2010   617.4′601–dc22       2009018387

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This book is dedicated to the memory of my dear friend and colleague, John P. Stein. When he passed last year, John left a void in the community of urologic oncology, particularly among those of us in the generation of his contemporaries. John’s optimism and energy for life charismatically drew us to him. The fact that so many were deeply affected by his passing coupled with his uncanny ability to make each of us feel special and important reflects his impact. John left an eternal legacy through his unending pursuit of perfection and excellence in the care of patients. Despite his tremendous academic accomplishments, his zeal for scientific inquiry, and his global outreach as an educator, John always placed the care and outcome of his patients first. No matter how good the outcome, he always felt it could and would be made better through his efforts. In this regard, John will always live on as an example to all of us and stands as a wonderful symbol of the spirit of this text. On a personal level, I would like to offer thanks for the love and support given to me by my own family, Uttama, Sorab, and Sabina. The family of every surgeon makes sacrifices through time lost and hours waiting. Without them, the time lost in our work would have little meaning. Through my wife Uttama’s guiding hand, I find life’s balance and meaning, and through the eyes of my children, Sorab and Sabina, I find its promise and discovery. I thank all three of them for the sacrifices they made in the preparation of this text. SST

PREFACE Regardless of the number of years in practice or cases performed, the prevention and management of surgical complications remain primary challenges for any operating surgeon. Although directly impacted by surgical technique, patient selection, and underlying disease processes, some complications inevitably arise even in the perfect candidate receiving the perfect operation. Despite this, the surgeon must continue throughout his or her career to make every effort to reduce the possibility of complication through careful patient selection, methodical preoperative patient optimization, and careful attention to technique. First and foremost, complications take a tremendous emotional and physical toll on our patients, and surgeons must remember this when confronted with a complication. For the patient, the process of surgery is one in which control is given completely to the surgeon. The uncertainty of outcome, the loss of control, and the fear of mortality are tremendously stressful for the patient even in the setting of an uncomplicated surgery. When complications arise, these stresses are magnified and patients and their families are often confused, depressed, or angry. Careful, calm, and comprehensive communication are essential to enable them to understand the nature of the complication, its probable causes, and the planned management. Discussing potential outcomes, concerns going forward, and specific benchmarks for improvement can allow the patient a structured process to mentally cope with the situation. Patients with complications often fear the surgeon will abandon them, and reassurance can go a long way toward maintaining a good relationship. Physical concerns in the setting of complications relate to the patient’s ability to tolerate the stresses and the relative risk of prolonged hospitalization. In patients with pre-existing comorbid conditions, careful attention to management of underlying disease processes, particularly those influencing recovery, will help in avoiding secondary complications. Maintaining nutrition, preventing infection, and carefully monitoring fluids and electrolytes are fundamental surgical principles that directly affect recovery from most intra-abdomenal and intrathoracic surgeries but that can be forgotten in the heat of a stressful complication. Although not all patients recover from complications, the surgeon’s primary goal must be to ensure that the patient’s odds of recovery are optimized by optimizing his or her condition. The balance between action and inaction is a difficult one for surgeons. An underlying desire to make a com-

plication go away often leads to the decision to act quickly through intervention or reoperation. Although sometimes indicated, quick decisions to intervene often result in worsening of the problem or development of secondary complications. At the time of complication, careful diagnostic evaluation to fully understand its nature and extent are critically important before any action is taken. Although stressful for both the patient and surgeon, sometimes waiting it out is the best course of action. It is the intent of this fourth edition of Complications of Urologic Surgery: Prevention and Management to provide both general and specific guidelines for surgeons in the management of most common, and many uncommon, urologic surgery complications. The response to the third edition of the book has been uniformly positive with many commenting on its tremendous utility in preparing for both a urologic career and day to day practice. Using this helpful feedback I have structured the book’s fourth edition. Over the 10 years since I began constructing the third edition, urologic surgery has changed dramatically. The rapid growth and adoption of minimally invasive techniques and surgical technologies have altered the way we perform most common procedures and, in doing so, have changed the way we train urologists in residency. As a direct result, urologists less frequently perform open surgery and conventional transurethral procedures. Understanding complications of these procedures is perhaps of greater importance now because contemporary urologists have less experience with these procedures. As such, in this fourth edition I have tried to balance the content between contemporary and classic techniques by including more chapters that specifically focus on minimally invasive procedures, laparoscopic surgery, and robotic surgery. Open surgical techniques remain a focus of the book with inclusion of additional chapters on specific procedures such as partial nephrectomy, orthotopic neobladder, and transurethral bladder tumor resection. Classic chapters from the third edition such as transurethral resection of the prostate and perineal prostatectomy have been re-printed as little could be added to the work of the previous authors. It is my sincere hope that the additional chapters, along with the online case studies and multiple-choice questions, offer expanded utility for the book and a continued positive response among readers in the decade to come. Samir S. Taneja MD June 2009

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LIST OF CONTRIBUTORS William J. Aronson, MD Clinical Professor, Department of Urology, David Geffen School of Medicine, University of California– Los Angeles, Los Angeles, California Complications of Ureteral Surgery

Dean G. Assimos, MD Professor of Surgical Sciences, Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina Complications of Extracorporeal Shock Wave Lithotripsy

Katie N. Ballert, MD Fellow, Department of Urology, New York University School of Medicine, New York, New York Complications of Surgery for Male Incontinence

Gaurav Bandi, MD Assistant Professor, Department of Urology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania Complications of Lasers in Urologic Surgery

Lionel L. Bañez, MD Assistant Professor of Surgery, Division of Urological Surgery and The Duke Prostate Center, Department of Surgery, Duke University Medical Center, Durham, North Carolina Impact of Host Factors and Comorbid Conditions

Yagil Barazani, MD Resident, Department of Urology, Beth Israel Medical Center, New York, New York Complications of Pediatric Laparoscopy

Laurence S. Baskin, MD Professor and Chief, Pediatric Urology, University of California–San Francisco Children’s Hospital, San Francisco, California Complications of Surgery for Disorders of Sex Development

Aaron P. Bayne, MD Pediatric Urology Fellow, Scott Department of Urology, Baylor College of Medicine; Urology Service, Texas Children’s Hospital, Houston, Texas Complications of Adrenal Surgery; Complications of Hypospadias Repair

Nelson E. Bennett, MD Director, Sexual Medicine and Surgery, Institute of Urology, Lahey Clinic Medical Center, Burlington; Assistant Professor of Urology, Department of Urology, Tufts School of Medicine, Boston, Massachusetts Complications of Surgery for Erectile Dysfunction and Peyronie’s Disease

David A. Berger, MD Fellow in Urologic Oncology, Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri Complications of Radiation Therapy for Urologic Cancer

Bernard H. Bochner, MD Attending Surgeon, Department of Surgery, Urology Service, Memorial Sloan-Kettering Cancer Center, New York, New York Complications of Lymphadenectomy

Donald R. Bodner, MD Professor and Interim Chair, Department of Urology, Case Western Reserve University School of Medicine, Cleveland, Ohio Complications of Renal Stone Surgery

Stephan A. Boorjian, MD Fellow in Urologic Oncology, Department of Urology, Mayo Clinic, Rochester, Minnesota Complications of the Incision and Patient Positioning

Steven B. Brandes, MD Professor of Urologic Surgery, Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri Complications of Radiation Therapy for Urologic Cancer

Maurizio Buscarini, MD Resident, Department of Urology, University of Southern California, Norris Comprehensive Cancer Center, Los Angeles, California Complications of Radical Cystectomy

Jeffrey A. Cadeddu, MD Ralph C. Smith, MD, Distinguished Chair in Minimally Invasive Urologic Surgery; Professor, Department of Urology, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas Complications of Renal Tissue Ablation

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List of Contributors David Canes, MD Assistant Professor of Urology, Tufts University Medical School, Boston, Massachusetts Complications of Renovascular Surgery

Bruce I. Carlin, MD Former Assistant Professor of Urology, Washington University School of Medicine, St. Louis, Missouri Complications of Renal Stone Surgery

Sachiko T. Cochran, MD Professor Emeritus, Division of Abdominal Imaging and Cross Sectional Interventional Radiology, David Geffen School of Medicine, University of California– Los Angeles, Los Angeles, California Complications of Therapeutic Radiologic Procedures

Tasha Cooke, MBBS, DM(Urol) Urologist, The Cornwall Regional Hospital, St. James, Jamaica Pharmacologic Complications

Michael S. Cookson, MD Professor, Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee Complications of Orthotopic Neobladder

John M. Corman, MD Medical Director, Virginia Mason Cancer Institute, Virginia Mason Medical Center; Associate Clinical Professor of Urology, University of Washington School of Medicine, Seattle, Washington Complications of Interstitial Seed Implantation

Rahul A. Desai, MD Surgeon, Urology, The Polyclinic, Seattle, Washington Complications of Extracorporeal Shock Wave Lithotripsy

Matthew D. Dunn, MD Assistant Professor of Urology, Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California Complications of Continent Cutaneous Diversion

Jack S. Elder, MD Clinical Professor of Urology, Case Western Reserve School of Medicine, Cleveland, Ohio; Chief, Department of Urology, Henry Ford Hospital; Associate Director, Vattikuti Urology Institute, Detroit, Michigan Complications of Surgery for Posterior Urethral Valves

William J. Ellis, MD Professor, Department of Urology, University of Washington, Seattle, Washington Complications of Simple Prostatectomy

Christopher P. Evans, MD Professor and Chairman, Department of Urology, University of California–Davis, Sacramento, California Complications of Nephrectomy

David Fenig, MD Associate Director, Male Fertility and Sexuality, Chesapeake Urology Associates, Baltimore, Maryland Complications of Surgery of the Testicle, Vas, Epididymis, and Scrotum

Neil E. Fleshner, FRCSC, MD, MPH Chief of Urology, Princess Margaret Hospital, University Health Network; Associate Professor, University of Toronto, Toronto, Ontario, Canada Complications of Hormonal Treatment for Prostate Cancer

Stephen J. Freedland, MD Associate Professor of Urology and Pathology, Division of Urological Surgery and The Duke Prostate Center, Department of Surgery, Duke University Medical Center, Durham, North Carolina Impact of Host Factors and Comorbid Conditions

Andrew L. Freedman, MD Director, Pediatric Urology, Minimally Invasive Urology Institute, Cedars-Sinai Medical Center, Los Angeles, California Special Considerations in the Pediatric Patient

Rodrigo Frota, MD Fellow, Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio Management of Vascular Complications

Gerhard J. Fuchs, MD Medallion Chair in Minimally Invasive Urology; Director, Minimally Invasive Urology Institute; Vice Chairman, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California Complications of Ureteroscopic Surgery

John P. Gearhart, MD Professor and Chief of Pediatric Urology, Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland Complications of Exstrophy and Epispadias Repair

Joel Gelman, MD Associate Clinical Professor, Department of Urology, University of California, Irvine Medical Center, Orange, California Complications of Urethral Reconstruction

Scott M. Gilbert, MD, MS Assistant Professor, Urologic Oncology, Department of Urology, University of Florida College of Medicine, Gainesville, Florida Complications Following Laparoscopic Robot-Assisted Radical Prostatectomy

List of Contributors David A. Ginsberg, MD Associate Professor of Urology, Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles; Chief of Urology, Rancho Los Amigos National Rehabilitation Center, Downey, California Complications of Bladder Augmentation

Guilherme Godoy, MD Fellow in Urologic Oncology, Bruce and Cynthia Sherman Fellowship in Urologic Oncology, Division of Urologic Oncology, Department of Urology, New York University Langone Medical Center, New York, New York Complications of Partial Nephrectomy; Complications of Radical Retropubic Prostatectomy; Complications of Conduit Urinary Diversion

Sam D. Graham Jr, MD Retired Professor and Chairman, Department of Urology, Emory University, Atlanta, Georgia Complications of Radical Perineal Prostatectomy

H. Albin Gritsch, MD Surgical Director, Renal Transplantation, Kidney and Kidney-Pancreas Transplantation Program, Department of Surgery, University of California–Los Angeles Medical Center; Associate Professor of Urology, David Geffen School of Medicine, University of California–Los Angeles, Los Angeles, California Complications of Renal Transplantation

Gregory R. Hanson, MD Surgeon, Metro Urology, Maple Grove, Minnesota Complications of Interstitial Seed Implantation

David J. Hernandez, MD Assistant Professor, Division of Urology, University of South Florida College of Medicine, Tampa, Florida Complications of Exstrophy and Epispadias Repair

Oscar Joe Hines, MD Professor of Surgery, Department of Surgery, David Geffen School of Medicine, University of California–Los Angeles, Los Angeles, California Management of Bowel Complications

Susie N. Hong, MD Cardiology Fellow, Division of Cardiology, Department of Medicine, New York University Medical Center, New York, New York Cardiac Complications of Urologic Surgery

R. Alex Hsi, MD Section Head, Radiation Oncology, Virginia Mason Medical Center, Seattle, Washington; Adjunct Assistant Professor, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania Complications of Interstitial Seed Implantation

George J. Huang, MD Clinical Instructor, Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California Long-term Outcomes of Radical Prostatectomy

William C. Huang, MD Assistant Professor, Department of Urology, New York University, New York, New York Pulmonary Complications of Urologic Surgery

Elias S. Hyams, MD Resident Physician, Department of Urology, New York University School of Medicine, New York, New York Complications of Minimally Invasive Reconstruction of the Upper Urinary Tract

Brian H. Irwin, MD Assistant Professor of Surgery, Division of Urology, University of Vermont College of Medicine, Burlington, Vermont Complications of Robotic Surgery

Niels-Erik B. Jacobsen, MD, FRCSC Fellow, Urologic Oncology, Department of Urology, Indiana University, Indianapolis, Indiana Metabolic Complications of Urologic Surgery

Sudheer K. Jain, MD Assistant Professor of Clinical Anesthesiology, New York University Medical Center, New York, New York Anesthetic Complications in Urologic Surgery

Eric A. Jones, MD Assistant Professor, Scott Department of Urology, Baylor College of Medicine; Urology Service, Texas Children’s Hospital, Houston, Texas Complications of Hypospadias Repair

Jamie A. Kanofsky, MD Resident in Urology, Department of Urology, New York University Langone Medical Center, New York, New York Complications of Conduit Urinary Diversion

Eric L. Kau, MD Fellow in Endourology, Minimally Invasive Urology Institute, Cedars-Sinai Medical Center, Los Angeles, California Complications of Ureteroscopic Surgery

Jeremy Kaufman, MD Resident, Department of Urology, New York University Langone Medical Center, New York, New York Hematologic Complications

Melissa R. Kaufman, MD, PhD Assistant Professor, Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee Complications of Orthotopic Neobladder

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List of Contributors Adam S. Kibel, MD Professor of Urologic Surgery, Division of Urologic Surgery, Washington University School of Medicine, Alvin J. Siteman Cancer Center, St. Louis, Missouri Complications of Radiation Therapy for Urologic Cancer

Simon P. Kim, MD, MPH Resident, Division of Urologic Health Services Research, Department of Urology, University of Michigan Medical Center, Ann Arbor, Michigan Assessing Quality of Care in Urologic Surgery

Michael O. Koch, MD Professor and Chairman, Department of Urology, Indiana University, Indianapolis, Indiana Metabolic Complications of Urologic Surgery

Venkatesh Krishnamurthi, MD Director, Kidney/Pancreas Transplant Program, Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio Management of Vascular Complications

William Lea, MD Resident, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana Management of Urinary Fistulas

Richard Lee, MD Urology Resident, Weill Medical College of Cornell University, New York, New York Complications of Minimally Invasive Procedures for Benign Prostatic Hyperplasia

Bradley C. Leibovich, MD Associate Professor, Department of Urology, Mayo Clinic, Rochester, Minnesota Complications of the Incision and Patient Positioning

Steven E. Lerman, MD Associate Professor of Urology, Department of Urology, David Geffen School of Medicine, University of California–Los Angeles, Los Angeles, California Complications of Pediatric Laparoscopy

John A. Libertino, MD Chairman, Institute of Urology, Lahey Clinic, Burlington; Professor of Urology, Tufts University Medical School, Boston, Massachusetts Complications of Renovascular Surgery

Daniel W. Lin, MD Associate Professor and Director of Urologic Oncology, Department of Urology, University of Washington/ Seattle Cancer Care Alliance; Attending Physician, Veterans Administration Puget Sound Health Care System, Seattle, Washington Toxicities of Chemotherapy for Genitourinary Malignancies

Michael Lipkin, MD Resident, Department of Urology, New York University Langone Medical Center, New York, New York Complications of Percutaneous Renal Surgery

Surena F. Matin, MD Associate Professor, University of Texas M. D. Anderson Cancer Center, Houston, Texas Special Considerations in Laparoscopy

Jeff M. Michalski, MD Professor of Radiation Oncology, Division of Radiation Oncology, Washington University School of Medicine, Alvin J. Siteman Cancer Center, St. Louis, Missouri Complications of Radiation Therapy for Urologic Cancer

Kiarash Michel, MD Urologist, Cedars-Sinai Medical Center, Los Angeles, California Complications of Transurethral Resection of the Prostate

Rosalia Misseri, MD Assistant Professor, Pediatric Urology, James Whitcomb Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana Complications of Ureteral Reimplantation, Antireflux Surgery, and Megaureter Repair

Bruce Montgomery, MD Associate Professor, Department of Medicine, University of Washington/Seattle Cancer Care Alliance; Attending Physician, Veterans Administration Puget Sound Health Care System, Seattle, Washington Toxicities of Chemotherapy for Genitourinary Malignancies

Patrick W. Mufarrij, MD Chief Resident, Department of Urology, New York University, New York, New York Pulmonary Complications of Urologic Surgery

John P. Mulhall, MD Director, Male Sexual and Reproductive Medicine Program, Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York Complications of Surgery for Erectile Dysfunction and Peyronie’s Disease

Stephen Y. Nakada, MD Professor and Chairman, Division of Urology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin Complications of Lasers in Urologic Surgery

Mischel G. Neill, BHB, MBChB, FRACS Consultant Urologist, North Shore Hospital, Auckland, New Zealand Complications of Hormonal Treatment for Prostate Cancer

List of Contributors Eric C. Nelson, MD Clinical Research Fellow, Department of Urology, University of California–Davis, Sacramento, California Complications of Nephrectomy

Christopher S. Ng, MD Attending, Minimally Invasive Urology Institute, Cedars-Sinai Medical Center, Los Angeles, California Complications of Ureteroscopic Surgery

Alan M. Nieder, MD Associate Professor, Division of Urology, Columbia University, Mount Sinai Medical Center, Miami Beach, Florida Pharmacologic Complications

Victor W. Nitti, MD Professor and Vice Chairman, Department of Urology, New York University School of Medicine, New York, New York Complications of Surgery for Male Incontinence

Rebecca L. O’Malley, MD Resident in Urology, Division of Urologic Oncology, Department of Urology, New York University Langone Medical Center, New York, New York Complications of Partial Nephrectomy

Priya Padmanabhan, MD, MPH Instructor, Department of Urologic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee

Lee Ponsky, MD Assistant Professor, Case Western Reserve University, Cleveland, Ohio Special Considerations in Laparoscopy

Steven S. Raman, MD Associate Professor of Radiology, Division of Abdominal Imaging and Cross Sectional Interventional Radiology, David Geffen School of Medicine, University of California–Los Angeles; Director, Abdominal Imaging Fellowship, Radiological Sciences, University of California– Los Angeles, Los Angeles, California Complications of Therapeutic Radiologic Procedures

Martin I. Resnick, MD† Former Chair, Department of Urology, Case Western Reserve University School of Medicine, Cleveland, Ohio Complications of Renal Stone Surgery

Polina Reyblat, MD Urology Resident, Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California Complications of Bladder Augmentation

Richard C. Rink, MD Professor and Chief, Pediatric Urology, James Whitcomb Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana Complications of Ureteral Reimplantation, Antireflux Surgery, and Megaureter Repair

Management of Urinary Fistulas

Michael Paik, MD Urologist, Private Practice, Northwest Community Hospital, Arlington Heights, Illinois Complications of Renal Stone Surgery

Ganesh S. Palapattu, MD Assistant Professor of Urology, Pathology, and Oncology, University of Rochester School of Medicine, Rochester, New York Complications of Transurethral Resection of Bladder Tumors

Erik Pasin, MD Resident, Department of Urology, University of Southern California, Norris Comprehensive Cancer Center, Los Angeles, California Complications of Radical Cystectomy

David F. Penson, MD, MPH Professor of Urology, Vanderbilt University, Nashville, Tennessee

Eric S. Rovner, MD Professor of Urology, Department of Urology, Medical University of South Carolina, Charleston, South Carolina Complications of Female Incontinence Surgery

Rajiv Saini, MD Clinical Assistant Professor of Urology, Weill Medical College of Cornell University, New York; Attending Urologist, Voiding Dysfunction, Brookdale University Hospital and Medical Center, Brooklyn, New York Complications of Minimally Invasive Procedures for Benign Prostatic Hyperplasia

Harriette Scarpero, MD Associate Professor, Department of Urologic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee Management of Urinary Fistulas

Long-term Outcomes of Radical Prostatectomy

Phuong M. Pham, MD Surgical Resident, Department of Surgery, David Geffen School of Medicine, University of California–Los Angeles, Los Angeles, California Management of Bowel Complications †

Deceased

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List of Contributors Arthur Schwartzbard, MD Director, Non-Invasive Cardiology Lab, Manhattan Campus, New York Harbor Healthcare System; Director, Clinical Lipid Research, New York University Center for Prevention of Cardiovascular Disease; Assistant Professor of Medicine, New York University School of Medicine, New York, New York Cardiac Complications of Urologic Surgery

Ojas Shah, MD Assistant Professor of Urology and Director of Endourology and Stone Disease, Department of Urology, New York University Langone Medical Center, New York, New York Hematologic Complications; Complications of Percutaneous Renal Surgery

Ellen Shapiro, MD Professor of Urology, Director of Pediatric Urology, Department of Urology, New York University School of Medicine, New York, New York Complications of Surgery for Posterior Urethral Valves

Katsuto Shinohara, MD Professor, Department of Urology, University of California–San Francisco, San Francisco, California Complications of Cryosurgical Ablation of Prostate

Elizabeth A. Soll, PhD Research Associate, Division of Urologic Health Services Research, Department of Urology, University of Michigan Medical Center, Ann Arbor, Michigan Assessing Quality of Care in Urologic Surgery

John P. Stein, MD† Professor, Department of Urology, University of Southern California, Norris Comprehensive Cancer Center, Los Angeles, California Complications of Radical Cystectomy

Michael D. Stifelman, MD Director of Robotic Surgery and Minimally Invasive Urology, Department of Urology, New York University School of Medicine, New York, New York Complications of Minimally Invasive Reconstruction of the Upper Urinary Tract

Samir S. Taneja, MD The James M. Neissa and Janet Riha Neissa Associate Professor of Urologic Oncology; Director, Division of Urologic Oncology, Department of Urology and New York University Cancer Institute, New York University Langone Medical Center, New York, New York Hematologic Complications; Complications of Intravesical Therapy; Complications of Partial Nephrectomy; Complications of Radical Retropubic Prostatectomy; Complications of Conduit Urinary Diversion

Eric A. Singer, MD, MA Chief Resident in Urology, University of Rochester School of Medicine, Rochester, New York Complications of Transurethral Resection of Bladder Tumors

Jennifer S. Singer, MD Assistant Professor, Pediatric Urology and Renal Transplantation, Department of Urology, David Geffen School of Medicine, University of California– Los Angeles, Los Angeles, California

Basir Tareen, MD Fellow in Urologic Oncology, Bruce and Cynthia Sherman Fellowship in Urologic Oncology, Division of Urologic Oncology, Department of Urology, New York University Langone Medical Center, New York, New York

Special Considerations in the Pediatric Patient

Eila C. Skinner, MD Professor of Clinical Urology, Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California Complications of Continent Cutaneous Diversion

Robert B. Smith, MD Professor of Urology, David Geffen School of Medicine, University of California–Los Angeles, Los Angeles, California Complications of Transurethral Resection of the Prostate

Mitchell H. Sokoloff, MD Professor of Surgery and Chief, Section of Urology, University of Arizona College of Medicine, Tucson, Arizona

Hematologic Complications; Complications of Intravesical Therapy; Complications of Radical Retropubic Prostatectomy

Alexis E. Te, MD Associate Professor of Urology and Director, Brady Prostate Center, Weill Medical College of Cornell University, New York, New York Complications of Minimally Invasive Procedures for Benign Prostatic Hyperplasia

Matthew K. Tollefson, MD Fellow in Urologic Oncology, Department of Urology, Mayo Clinic, Rochester, Minnesota Complications of the Incision and Patient Positioning

Burak Turna, MD Fellow, Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio Management of Vascular Complications

Complications of Transurethral Resection of the Prostate; Complications of Adrenal Surgery

†

Deceased

List of Contributors George T. Vaida, MD Assistant Professor of Clinical Anesthesiology; Medical Director and Anesthesia Director, Minimally Invasive Urology Unit, New York University Medical Center, New York, New York Anesthetic Complications in Urologic Surgery

Jeffrey L. Veale, MD Assistant Professor, Department of Urology, David Geffen School of Medicine, University of California– Los Angeles, Los Angeles, California Complications of Renal Transplantation

Joseph R. Wagner, MD Director of Robotic Surgery, Connecticut Surgical Group/Hartford Hospital, Hartford, Connecticut Complications of Robotic Surgery

John T. Wei, MD, MS Associate Professor, Division of Urologic Health Services Research, Department of Urology, University of Michigan Medical Center, Ann Arbor, Michigan Assessing Quality of Care in Urologic Surgery

Alon Z. Weizer, MD Assistant Professor, Department of Urology, University of Michigan, Ann Arbor, Michigan Complications of Laparoscopic Renal Surgery

Philip Werthman, MD Director, Center for Male Reproductive Medicine, Los Angeles, California Complications of Surgery of the Testicle, Vas, Epididymis, and Scrotum

Jason M. Wilson, MD Associate Professor, Division of Urology, Department of Surgery, University of New Mexico, Albuquerque, New Mexico Complications of Surgery for Disorders of Sex Development

J. Stuart Wolf Jr, MD David A. Bloom Professor of Urology, Department of Urology, University of Michigan, Ann Arbor, Michigan Complications of Laparoscopic Renal Surgery

David P. Wood, MD Professor of Urology, Division of Urologic Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan Complications Following Laparoscopic Robot-Assisted Radical Prostatectomy

Jonathan L. Wright, MD, MS Assistant Professor, Department of Urology, University of Washington, Seattle, Washington Complications of Simple Prostatectomy

Ofer Yossepowitch, MD Attending Surgeon, Department of Urology, Rabin Medical Center, Petah-Tikva, Israel Complications of Lymphadenectomy

Ilia S. Zeltser, MD Instructor, Department of Urology, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas Complications of Renal Tissue Ablation

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Chapter 

1 

IMPACT OF HOST FACTORS AND COMORBID CONDITIONS Lionel L. Bañez

MD Assistant Professor of Surgery, Division of Urological Surgery and The Duke Prostate Center, Department of Surgery, Duke University Medical Center, Durham, North Carolina

Stephen J. Freedland

MD Associate Professor of Urology and Pathology, Division of Urological Surgery and The Duke Prostate Center, Department of Surgery, Duke University Medical Center, Durham, North Carolina

Every urologist would prefer that any patient who has a consultation for a urologic disease would be solely afflicted with the disease for which he or she seeks medical attention, that every surgical patient would be healthy enough to tolerate the proposed surgical intervention to treat the condition, and that complications would occur with only miniscule probability. Unfortunately, this situation is far removed from reality and certainly is becoming less common in current clinical practice in which medical histories, physical examinations, preoperative laboratory examinations, and imaging scans are likely to reveal coexisting medical problems in the urologic patient. In the present era, with life expectancy ever increasing, the prevalence of comorbid conditions such as obesity, heart disease, and diabetes, which affect urologic diseases and their clinical outcome following management, has congruently reached alarming proportions in the general population. Whether driven by improved medical science, rapid technologic advancement, or an effect of natural selection, men and women are living longer (Fig. 1-1). The medical community recognizes special considerations for elderly patients, and most of these considerations are brought about by medical conditions that are diagnosed in later life and progress with advancing age. In urologic disease entities such as erectile dysfunction in men, pelvic floor disorders in women, and urologic malignant diseases such as prostate and bladder cancer, the predisposition and clinical effects related to advanced age have direct biologic implications for the urologic condition. Moreover, because most of these disease entities are diagnosed in the more mature stages of life, the probability of preexisting medical conditions in these patients at the time of consultation is significantly high.

Notwithstanding the effect of age on comorbid medical conditions in the urologic patient, the past decades have also seen a dramatic rise in the prevalence of disease entities closely linked to harmful lifestyle choices such as smoking and alcohol consumption, unhealthy diets, lack of exercise and physical activity, and intravenous narcotic abuse. These lifestyle choices adversely affect patients of all ages who may seek urologic consultation and who may present with detrimental comorbidities such as childhood obesity, juvenile diabetes, chronic obstructive pulmonary disease, liver disease, and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Although biologic links to known urologic diseases may be less apparent, the overall outcome and incidence of complications following surgical intervention are directly affected by coexisting health problems. Indeed, assessing the urologic patient for preexisting comorbidities is of critical importance because host factors play an important role in postoperative complications. Awareness of comorbidities allows the urologist to institute the proper measures to control preexisting diseases to optimize the overall health status of the individual patient, maximize the likelihood of a good outcome, and minimize the risk of a complication. The urologist also can assess the need for ancillary examinations for a more comprehensive evaluation of comorbid conditions more accurately and can determine the need for intraoperative monitoring and specialized intensive postsurgical care. More importantly, comprehensive knowledge of all concurrent illnesses in the urologic patient aids the urologist in the deciding whether surgical intervention is the optimal treatment option or whether conservative management may be the only viable therapeutic alternative. 3

Section I  Nonurologic Complications of Urologic Surgery 100,000 90,000

Age 65 and up

80,000 70,000 Population (× 1000)

4

60,000 50,000 40,000 30,000 20,000 10,000 0 2000

2010

2020

2030

2040

2050

Year Figure 1-1  Projected population of the United States for adults ≥65 years old (2000-2050). *Based on data from the United States Census Bureau (http://www.census.gov/ipc/www/usinterimproj/)

To serve as an introduction to the succeeding chapters in this section, we tackle host factors that significantly affect the occurrence of nonurologic complications following urologic surgery. We provide an overview of comorbidities in the urologic patient and highlight current prevalent disease entities that influence outcome following definitive surgical management. Comorbidities to which whole chapters are devoted, such as those pertaining to cardiovascular, pulmonary, hematologic, and anesthetic complications, are discussed only briefly here, to leave room for a more detailed discussion of topics of special interest such as obesity that are of major interest in the field of contemporary urology. We also provide insight into clinical tools such as useful comorbidity indices and scoring systems that aim to quantify the severity of comorbidities and predict posttreatment morbidity and mortality.

OBESITY The importance of nutritional status to surgical outcomes and the deleterious effects of obesity are of significant interest in the field of urology. Interest has centered on obesity for two main reasons: (1) the prevalence of obesity has been growing at epidemic proportions worldwide, particularly within the United States1; and (2) scientific evidence suggests a relationship between obesity and multiple urologic conditions including urologic malignant diseases, benign prostatic hyperplasia (BPH), incontinence, erectile dysfunction, and stone disease, to name a few.2

Most of the leading causes of death in the United States are linked to obesity, including heart disease, cancer, stroke, chronic respiratory disease, and diabetes. Viewed as a growing national health crisis, obesity has surpassed tobacco smoking as the leading cause of preventable death; obesity not only results in a potentially avoidable toll in human lives but also incurs a substantial cost in health expenditure for the country.3 Affecting nearly a third of all adults in the United States, obesity is further associated with various comorbidities, such as hypertension, hypercholesterolemia, sleep apnea, cholecystolithiasis, osteoarthritis, and depression, that may aggravate the overall health status of the overweight or obese patient and may contribute to the occurrence of surgical complications. Childhood obesity is also on the rise and would have undesirable consequences for children and adolescents undergoing pediatric urologic procedures.4 Obesity is defined as an excess accumulation of adipose tissue in the body; however, functionally, overweight and obese are labels used to denote ranges of weight that are in excess of what is generally considered healthy for the given height of a person. Because of its simplicity, body mass index (BMI) is a widely accepted method to assess for obesity. BMI is calculated by dividing the weight (in kilograms) of an individual by the height (in meters) squared.5 Figure 1-2 illustrates the standard weight status categories associated with BMI range for adults. Although other anthropometric measurements such as skinfold thickness and midarm circumference may be used for more accurate estimation

Chapter 1  Impact of Host Factors and Comorbid Conditions

BODY MASS INDEX (kg/m2)

6'2" 6'1" 6' 5'11" 5'10"

110 115 120 125 130 135 140 145 150 155 160 165 170 175 180 185 190 195 200 205 210 215 220 225 230 235 240 245 250 14 15 15 16 17 17 18 19 19 20 21 21 22 22 23 24 24 25 26 26 27 28 28 29 30 30 31 31 32 188 15 15 15 16

15 16 16 17

16 16 17 17

16 17 17 18

17 18 18 19

18 18 19 19

18 19 20 20

19 20 20 21

20 20 21 22

20 21 22 22

21 22 22 23

22 22 23 24

22 23 24 24

23 24 24 25

24 24 25 26

24 25 26 27

25 26 26 27

26 26 27 28

26 27 28 29

27 28 29 29

28 28 29 30

28 29 30 31

29 30 31 32

30 31 31 32

30 31 32 33

31 32 33 34

32 33 33 34

32 33 34 35

33 34 35 36

185 183 180 178

5'9" 5'8" 5'7" 5'6"

16 17 17 18

17 17 18 19

18 18 19 19

18 19 20 20

19 20 20 21

20 21 21 22

21 21 22 23

21 22 23 23

22 23 23 24

23 24 24 25

24 24 25 26

24 25 26 27

25 26 27 27

26 27 27 28

27 27 28 29

27 28 29 30

28 29 30 31

29 30 31 31

30 30 31 32

30 31 32 33

31 32 33 34

32 33 34 35

32 33 34 36

33 34 35 36

34 35 36 37

35 36 37 38

35 36 38 39

36 37 38 40

37 38 39 40

175 173 170 168

5'5" 5'4" 5'3" 5'2"

18 19 19 20

19 20 20 21

20 21 21 22

21 21 22 23

22 22 23 24

22 23 24 25

23 24 25 26

24 25 26 27

25 26 27 27

26 27 27 28

27 27 28 29

27 28 29 30

28 29 30 31

29 30 31 32

30 31 32 33

31 32 33 34

31 33 34 35

32 33 35 36

33 34 35 37

34 35 36 37

35 36 37 38

36 37 38 39

37 38 39 40

37 39 40 41

38 39 41 42

39 40 42 43

40 41 43 44

41 42 43 45

42 43 44 46

165 163 160 158

5'1" 5'

21 21 50

22 22 52

23 23 54

24 24 56

25 25 59

26 26 61

26 27 63

27 28 65

28 29 68

29 30 70

30 31 72

31 32 74

32 33 77

33 34 79

34 35 81

35 36 83

36 37 86

37 38 88

38 39 90

39 40 92

40 41 95

41 42 97

42 43 43 44 45 46 47 155 43 44 45 46 47 48 49 152 99 101 104 106 108 110 113

HEIGHT (cm)

HEIGHT (ft / in)

WEIGHT (lbs)

WEIGHT (kg) UNDERWEIGHT (BMI0.2  ng/mL or two values at 0.2  ng/mL).19,22,23 More ominously, increased body weight was found to be associated with an increased risk of death from prostate cancer in a large, prospectively studied population.24 Thus, obesity may well exert a biologic effect on prostate cancer that promotes aggressiveness and disease progression. However, in terms of health-related quality of life after radical prostatectomy, prospective studies have so far

failed to demonstrate large differences between mildly obese men and men of normal weight.25-27 For a more detailed review of obesity and prostate cancer, we recommend the article by Buschemeyer and Freedland in European Urology.28

Kidney Cancer Obesity, particularly in women, has been shown to be associated with renal cell carcinoma (RCC).24,29 A high BMI was found to be a strong risk factor for RCC; several underlying mechanisms were suspected, including higher insulin and estrogen levels, hypertension, hypercholesterolemia, and impaired host immune response.30 Boeing and colleagues31 examined determinants such as smoking, diet, occupational hazards, beverage consumption, medications, and obesity in a case-control cohort of 277 patients with RCC and 286 matched controls and found that specific dietary patterns associated with obesity, such as consumption of fatty foods and meat products, may explain the higher incidence of RCC in industrialized countries relative to developing countries.31 Indeed, in a large retrospective study involving 363,992 men, investigators from the National Institutes of Health found that obese men, especially those with a history of tobacco use and elevated systolic blood pressures, have an increased long-term risk for RCC.32 As in prostate cancer, open surgical procedures for RCC can be technically difficult in patients with severe adiposity. Thus, wide interest exists in prescribing laparoscopic procedures for obese patients because these less invasive approaches have been found to be safe and effective for these subsets of patients.33,34 However, a study of 210 patients who were treated with laparoscopic surgery for RCC revealed that BMI was a significant risk factor for major postoperative complications.35 The investigators further reported that with every unit increase in BMI, the risk of a major complication increased by 14%. Finally, with regard to clinical outcome and cancer-specific mortality, overweight and obese patients have higher risk of death from kidney cancer relative to patients of normal weight.24

Bladder Cancer Compared with prostate and renal cancer, published reports of relationships between bladder cancer and obesity are scarce. In 1994, an epidemiologic study of 514 patients with bladder cancer found that beyond the well-known link with smoking, obesity was also a significant risk factor for bladder cancer.36 However, a large prospective study of nearly 1 million people found no link between BMI and bladder cancer mortality.24 With regard to diet, reports on the association between high fat intake and bladder cancer have been conflicting.37,38 With respect to surgical outcome for radical cystectomy, abundant reports show not only that obesity contributes to the technical challenge of the operation

Chapter 1  Impact of Host Factors and Comorbid Conditions but also that higher BMI increases the risk of perioper­ ative complications. In a retrospective analysis of 304 consecutive patients who underwent radical cystectomy and urinary diversion for bladder cancer, increased BMI was independently associated with higher estimated blood loss.39 This finding was later confirmed in a cohort of 498 patients; the investigators further concluded that, along with greater blood loss, an increased BMI was also independently associated with prolonged operative time and increased rate of complications.40

Obesity and Benign Urologic Conditions Several nonmalignant urologic conditions are also un­favorably affected by an increased BMI and morbid obesity.

Benign Prostatic Hyperplasia and Lower Urinary Tract Symptoms Obesity is a known risk factor for lower urinary tract symptoms (LUTS) and BPH. Indeed, a large-scale, crosssectional study from the Prostate Study Group of the Austrian Society for Urology found a link between BPH and obesity.41 The relationship between obesity and LUTS was further confirmed in a report from Johns Hopkins University in Baltimore on 2797 men from the Third National Health and Nutrition Examination Survey.42 In another confirmatory study, BPH was found to be associated with increased serum insulin levels and abdominal obesity as opposed to BMI itself.43 The biologic link between obesity and BPH likely has its origin in the association of obesity with hyperinsulinemia and the status of insulin as a direct prostate growth factor.44

Erectile Dysfunction Obesity, particularly central obesity, is a known predictor of erectile dysfunction in men.45 Both atherosclerosis and diabetes mellitus, which are associated with obesity, play significant roles in the development of erectile dysfunction. Although the underlying cause for erectile dysfunction is thought to be multifactorial, investigators have suggested that obesity increases the risk of erectile dysfunction of vascular origin as a result of the development of chronic vascular disease.46 Obesity is also known to increase the risk of diabetes. The microvascular complications characteristic of diabetes exert deleterious effects on erectile tissue similar to the pathologic features of diabetic nephropathy, retinopathy, and gastroparesis.47 Furthermore, weight loss is the only known lifestyle intervention that can improve erectile dysfunction.48

Stress Urinary Incontinence Pelvic floor weakness leading to stress urinary incontinence (SUI) in women is aggravated by increased intraabdominal pressure and is closely associated with truncal obesity.49 A report examined the association of

bladder function with smoking, food consumption, and obesity in 6424 women with SUI and found a strong relationship between SUI and obesity.50 These findings were confirmed in a questionnaire-based study conducted in Norway involving 27,936 women.51 The proposed underlying mechanism for the association between high BMI and incontinence is that a high BMI leads to increased intravesical pressures and thus lowers the differential between the detrusor pressure and leak point pressure such that incontinence is more likely to occur.52 With regard to the perioperative effect of obesity in surgical treatment of SUI, a study involving 250 women who underwent retropubic anti-incontinence procedures revealed that operative time was significantly longer for obese women; however, blood loss and major perioperative complications were similar across BMI groups.53

Urolithiasis Urinary stone formation has been linked to obesity, as illustrated by a report on 527 calcium oxalate stone formers wherein an increased BMI was strongly asso­ ciated with an elevated risk of stone formation for both men and women.54 However, a retrospective study of 5492 stone formers revealed that the association between obesity and stone formation was significant only in women.55 In a study conducted at Duke University in North Carolina, the major metabolic abnormalities found in obese stone formers that were possible contributors to recurrent stone formation were hypocitraturia, gouty diathesis, and hyperuricosuria.56 An inverse association between pH and body weight suggests that production of excessively acidic urine promotes urate nephrolithiasis in obese stone formers.57 With respect to urologic procedures to treat stone disease, obesity adversely affects outcome following extracorporeal shock wave lithotripsy (ESWL). In a report examining clinical and radiologic variables associated with poor outcome after ESWL, along with obesity, pelvic ureteral stones, stones >10  mm, and obstruction were independent predictors of unsuccessful outcome.58 Thus, because of the probability of treatment failure, obese patients may be better served by endourologic procedures than by ESWL.

MALNUTRITION At the opposite end of the nutritional spectrum from overnutrition and obesity is malnutrition. With regard to the surgical patient, malnutrition has been associated with an increased incidence of nosocomial infection, poor wound healing, an increased length of hospital stay, multiorgan dysfunction, and mortality.59 Various scientific investigations have demonstrated that deterioration of nutritional status has an invariably deleterious effect on surgical outcome. As early as 1932, Cuthbertson60 reported the association of impaired

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Section I  Nonurologic Complications of Urologic Surgery wound healing with negative nitrogen balance in trauma patients. A more recent prospective study conducted in a cohort of patients who did not have cancer used four clinical parameters to predict perioperative morbidity: 1. Percentage of ideal body weight 2. Preoperative percentage of weight loss 3. Arm muscle circumference 4. Serum albumin Results of the study revealed that patients with at least one abnormal clinical parameter had a significant increase in the incidence of major complications and in length of hospital stay relative to patients with normal preoperative parameters.61 Not only has malnutrition per se been implicated in surgical complications, but also certain types of nutrient deficiency, protein malnutrition in particular, may lead to more severe postoperative problems. Relative to protein-calorie malnutrition, which is characterized by a lack of both proteins and carbohydrates, severe protein malnutrition leads to low serum albumin concentration, edema, and a high prevalence of acute infections.62 Thus, it is evident that nutritional status is a key clinical parameter demanding thorough evaluation in the surgical patient to prevent nutrition-related complications.

NUTRITIONAL STATUS ASSESSMENT Traditionally, clinicians relied on anthropometric measurements, which they compared with tables providing ideal weight-for-height estimates to evaluate the nutritional status of patients.63 Clinicians also determined body mass composition determinants such as lean body mass based on limb skinfold or circumference measurements and used these variables as indicators for adequacy of nutrition. However, problems pertaining to the precision of anthropometric measurements, the wide intraobserver and interobserver variations, and the lack of reliable reference standards have challenged the validity of these methods in ascertaining nutritional health of the surgical patient.59 These issues surrounding the traditional methods of screening for malnutrition led to an interest in studying serum markers for more accurate determination of preoperative nutritional competence. Serum albumin is by far the most commonly used biochemical parameter to assess for nutritional status in the surgical patient. The National Veterans Affairs Surgical Risk Study involved a very large prospective observational investigation of 54,215 patients and found that preoperative serum albumin level was a highly reliable predictor of 30-day operative mortality and morbidity after major noncardiac surgery.64 To validate this finding in urologic surgery, McLaughlin and colleagues65 performed a similar analysis on 643 patients who under-

went major urologic operations, compared preoperative and intraoperative factors, and sought to identify risk factors associated with complications after urologic surgery. Their study revealed that serum albumin was one of the five most significant preoperative determinants associated with 30-day morbidity (along with histories of congestive heart failure, diabetes with end-organ damage, angioplasty, and quadriplegia). Specifically, low serum albumin levels (≤35 g/L) conferred 2.5 times greater risk of incurring a postoperative morbidity in patients undergoing urologic operative procedures. Although serum albumin is emerging as a robust clinical marker of nutritional status with clear advantage over anthropometrics, controversies remain especially with regard to the reliability of the serum marker in more elderly patients.66 Other visceral protein biomarkers of interest to both physicians and nutritionists include prealbumin and retinol-binding protein,67 which are fairly well maintained in the geriatric population compared with albumin. However, the use of these soluble proteins to gauge nutritional insufficiency can be limited by fluid shifts, increased vascular permeability, and altered hepatic protein metabolism in response to stress. Technologic advances such as total body nitrogen measurement, dual radiographic absorptiometry, and bioelectrical impedance may circumvent these limitations68 and become the future standards of care. Until these newer modalities are fully tested and validated in a true patient population, serum albumin determination will remain a simple and readily available applicable test for nutritional assessment in the urologic patient.

INFECTION AND UROSEPSIS Although community-acquired urinary tract infections (UTIs) are very common and are considered relatively easy to treat, complicated UTIs such as those acquired in the hospital setting are a legitimate cause for concern in urology. The term complicated UTI connotes infections brought about by a functional or anatomic abnormality in the urinary tract, but it may also be used to indicate an infection that occurs in a patient with altered defense mechanisms.69 When an infection previously localized to the urinary tract enters the bloodstream and causes a systemic infection, urosepsis ensues. Judicious use of prophylactic antibiotics in surgical procedures has served to minimize the incidence of these preventable yet potentially lethal complications in urologic practice.70 However, the rising incidence of antimicrobial resistance, especially of gram-positive pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), can lead to treatment failure and life-threatening sepsis.71 Moreover, the increasing numbers of patients who are immunocompromised either by an underlying disease (e.g., HIV/AIDS) or through concurrent medical

Chapter 1  Impact of Host Factors and Comorbid Conditions therapy (e.g., steroids, anticancer chemotherapy)72 also lead to greater infection risk. These risk factors are particularly relevant when surgery entails instrumentation and manipulation of the urinary tract. Given that certain host factors predispose the urologic patient to complicated infection, it is necessary to determine the need for antimicrobial prophylaxis preoperatively and to prevent the occurrence of systemic septicemia. Both demographic factors and medical conditions play a role in susceptibility to complicated UTI. Advanced age in a patient should alert the urologist to the possible presence of UTI. The prevalence of UTI increases with age and reaches approximately 3.6% in men ≥70 years old and 7% in women ≥50 years old.73 As previously discussed, nutritional imbalances leading to obesity and malnutrition could impair cellular immunity and thereby predispose patients to UTI. Preexisting local or systemic infections intuitively are associated with complicated UTI. Recent antimicrobial use has been linked to complicated UTI, possibly through two mechanisms: (1) antibiotic therapy fails, and the initial infection, either systemic or local, progresses to complicated UTI or frank urosepsis; or (2) antibiotics used to eliminate competing pathogens promote the growth of resistant strains and lead to infection with a more virulent strain.74 Diabetes mellitus not only increases the incidence of UTI in adults but also contributes to a complicated course despite antibiotic prophylaxis and treatment. This situation is the result of defects in the secretion of urinary cytokines and increased adherence of microorganisms to the uroepithelial cells in diabetic patients.75 Not surprisingly, many urologic and medical renal conditions are associated with an increased incidence of complicated UTIs and urosepsis. One of the most consistent contributors to complicated UTI is obstruction of the urinary tract.76 This underlying mechanism encompasses the following: intrinsic disorders of the kidney, renal pelvis, and ureters (e.g., congenital anomalies including vesicoureteral reflux, renal or ureteral calculi, neoplasms, strictures); extrinsic abnormalities of the upper urinary tract (e.g., aberrant vessels, retroperitoneal hematomas or fibrosis, nonurologic neoplasms); and disorders of the bladder and bladder neck (e.g., BPH, prostate and bladder cancer, cystolithiasis, bladder neck contracture) and urethra (e.g., valves, strictures). Functional impairment of the bladder, as seen in spastic or atonic neurogenic bladder, may have the same consequences as conditions causing physical obstruction.77 Renal diseases, whether unilateral, bilateral, or segmental, may also complicate UTI and include conditions such as azotemia, polycystic kidney disease, and papillary necrosis, as well as nephropathies brought about by abuse of analgesics such as nonsteroidal antiinflammatory drugs.78 Immunosuppressed urologic patients present a unique problem with regard to susceptibility to compli-

cated UTI. Whether impairment of immunologic response was brought about iatrogenically (e.g., patients with cancer who are undergoing chemotherapy, transplant recipients receiving steroids) or is the result of a disease process (e.g., HIV/AIDS, persistent neutropenia or granulocytopenia),72 avid use of broad-spectrum antibiotics not only for common infections but also for opportunistic organisms should be considered by the urologist for an optimal clinical outcome. Finally, urologic instrumentation leads to an increased probability of introducing microorganisms into an otherwise sterile urinary tract and thus predisposes patients to infections. The same principle applies to urologic procedures in which foreign bodies are purposefully left in the human body (e.g., ureteral stents, penile prostheses).79 Although intended to elicit only a minimal inflammatory response, any foreign body can serve as a nidus of infection and must be removed promptly when it is determined to be the source of infection or when its presence in the body contributes to a complicated UTI.

QUANTIFYING COMORBIDITY In medicine, comorbidity is defined as the effect of all other pathologic conditions an individual patient may have other than the primary disease of interest. The very nature of comorbidities, as secondary or lesser diseases of interest, has led to some indifference among practicing clinicians and research investigators regarding the significance of these illnesses in treatment decision making and survival outcomes. Because of the significant correlation between advanced age and increased prevalence of preexisting comorbidities at the time of surgery, physicians have traditionally used age as a surrogate for the effects of concurrent medical conditions, especially in elderly urologic patients.80 Although no one can discount the value of age in treatment decisions,80 the use of age as a strict criterion that may deny appropriate curative therapy to healthy older patients is unacceptable and may even have litigious consequences. The impact of comorbidities is substantial in the field of urology, particularly in urologic oncology. An analysis of 34,294 newly diagnosed cases of cancer in patients from the Netherlands Eindhoven cancer registry showed that, aside from lung cancer (58%) and stomach cancer (53%), the crude prevalence of comorbidities was highest in malignant diseases of the kidney (54%), bladder (53%), and prostate (51%).81 In terms of prognosis, Post and colleagues82 acknowledged that comorbidity was the most important prognostic factor for 3-year survival in a population-based study of 1337 patients with localized prostate cancer. In a series of 1023 consecutive radical nephrectomies and nephronsparing surgical procedures for RCC in Dresden, Germany, comorbidities were closely associated with overall morbidity and mortality.83 With regard to treat-

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Section I  Nonurologic Complications of Urologic Surgery ment-related side effects, both peripheral vascular disease and diabetes have been shown to be significant risk factors for development of impotence following external beam radiation for prostate cancer as well as for gastrointestinal and genitourinary toxicities.84 Thus, comorbidities can affect almost all aspects of urologic disease but most importantly the incidence of posttreatment morbidity and all-cause death. Up until the late 1980s, the effects of comorbidities were largely unquantifiable and subjective. As a result, certain beliefs and attitudes in clinical practice were based mostly on anecdotal data rather than on appropriate evidence-based information. This need for methods to quantify the effects of comorbidities adequately led to the development of comorbidity scoring systems, which are gaining utility for both research and clinical purposes. The most extensively studied and most commonly used comorbidity scoring scheme in medicine is the Charlson Index score.85 Dr. Mary E. Charlson, a clinical epidemiologist and methodologist who was interested in improving clinical outcome in both medical and surgical patients, first published the index in 1987 at Cornell University in Ithaca, New York. The Charlson Index is a list of 19 pathologic conditions (Table 1-1). Based on the proportional hazards regression model that Charlson constructed from clinical data, each condition is an assigned a weight from 1 to 6. The Charlson TABLE 1-1  Weighted Index of Comorbidity [Defined by the Charlson Index] Assigned Weights for Diseases

Conditions

1

Myocardial infarct Congestive heart failure Peripheral vascular disease Cerebrovascular disease Dementia Chronic pulmonary disease Connective tissue disease Ulcer disease Mild liver disease Diabetes

2

Hemiplegia Moderate or severe renal disease Diabetes with end organ damage Any tumor Leukemia Lymphoma

3

Moderate or severe liver disease

6

Metastatic solid tumor AIDS

Assigned weights for each condition that a patient has. The total equals the score. Example: chronic pulmonary (1) and lymphoma (2) = total score (3). From Charlson ME, Pompei P, Ales K, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373-383.

Index score is the sum of the weights for all concurrent diseases aside from the primary disease of interest. Thus, for example, in men with prostate cancer, although cancer is generally assigned a score of 2, in this case, men are assigned no points for prostate cancer because it is the primary index disease. In a cohort of 685 patients with breast cancer in the original study, the Charlson Index score showed a strong association of a 2.3-fold increase in the 10-year risk of mortality per 1-point increment in the comorbidity level. The Charlson Index score provides a simple means to quantify the effect of comorbid illnesses, incorporate the severity of a particular disease (diabetes without complications versus diabetes with end-organ damage), and account for the aggregate effect of multiple concurrent disease processes on clinical outcome, most often mortality. In prostate cancer research, the Charlson Index score has been avidly evaluated as a predictor of both cause-specific mortality and all-cause mortality. Albertsen and colleagues86 showed that the Charlson Index score provided significant predictive information on cancer-specific and all-cause survival independent of age, Gleason score, or clinical stage in a cohort of 451 patients with Jewett-Whitmore stage A1-B prostate cancer treated with hormonal ablation. In 2002, a competing risk analysis of 751 men who were undergoing radical prostatectomy for clinically localized prostate cancer at the Mayo Clinic in Rochester, Minnesota showed that whereas the Gleason score emerged as the only significant predictor of prostate cancer–specific mortality, both the Charlson Index score and the Gleason score were predictive of overall mortality.87 Comparable results were reported by other groups who performed similar analyses using Charlson Index scores in prostate cancer out`come studies.82,88,89 The clinical utility of the Charlson Index score extends to other urologic diseases as well. With regard to bladder cancer, the Charlson Index score was evaluated in predicting adverse pathologic characteristics, cancer-specific death, and overall survival following radical cystectomy.90 Logistic regression revealed that the Charlson Index score was independently associated with an increased risk of extravesical disease. Cox regression models further revealed that the index was significantly associated with decreased cancer-specific survival. In 302 men undergoing transurethral resection of the prostate (TURP) or simple prostatectomy for BPH, the Charlson Index score correlated with 5-year mortality.91 Thus, even for nononcologic urologic operations, comorbidity indices have demonstrated power for predicting mortality following surgery. Aside from being scientifically validated for use in urologic surgery, the Charlson Index has other notable advantages in urologic practice and clinical research. Administrative database codes known as International Classification of Diseases codes, ninth revision with or without clinical modification (ICD-9/ICD-9CM) and imple-

Chapter 1  Impact of Host Factors and Comorbid Conditions mented by almost all hospitals in the United States can be used to calculate the Charlson Index score for a particular patient.92 Ideally, meticulous chart review for each individual patient should be done to ensure a completely accurate Charlson Index score because the ICD-9 codes may not be up to date for that particular patient. However, studies have shown that the predictive properties of indices computed using either ICD-9 codes alone or detailed chart review are comparable.93 The Dartmouth-Manitoba version was the first adaptation of the Charlson Index score to use ICD-9 diag­ noses.94 Other adaptations published by Deyo and associates,95 D’Hoore and colleagues,96 and Ghali and associates97 further simplified the translations from ICD-9 to Charlson Index score while maintaining validity and relevance for prediction of clinical end points such as 1-year mortality, in-hospital mortality, or postoperative death. Limitations to the Charlson Index score, as previously alluded to, include coding errors (particularly when relying on ICD-9 codes), incomplete medical histories, and determination of whether a diagnosis is a comorbidity at hospital admission or a complication arising during the hospital stay.98 Furthermore, because of the lack of definitive comorbidity studies for all urologic diseases, the correlations of the comorbidity index to outcome may vary among disease entities and surgical procedures. Other indices of comorbidity are available but have not been as broadly used as the Charlson Index. Three prime examples are the Index of Co-Existent Disease (ICED),99 the Kaplan-Feinstein Index (KFI),100 and the Cumulative Illness Rating Scale (CIRS).101 Similar to the Charlson Index, the ICED, KFI, and CIRS are designed to measure the impact of concurrent diseases on prognosis. Because of the lack of definitive head-to-head comparisons of the various methods of comorbidity assessments, no clear-cut evidence exists to establish the advantage of one scale over the other.102 In fact, in a study in which Charlson Index scores were shown to be predictive of 5-year mortality following TURP for BPH, similar analysis using the KFI and ICED demonstrated comparable predictive power.91 Although the Charlson Index is the most widely used, its role as a robust prognostic indicator for many disease entities remains unclear. Given the upswing in interest in this field, we anticipate that future validation of this and other indices will be forthcoming.

CONCLUSION It is the ultimate goal of every urologist to provide the best possible care for the urologic patient. The projected surge in life expectancy in this new millennium translates into an analogous increase in urologic patients who will potentially present with various comorbid diseases. These patients will require thorough evaluation including addressing of associated comorbidities to

obtain an excellent outcome. The impact of host factors and comorbidities cannot be taken lightly because more and more scientific evidence points to associations of these pretreatment parameters with a heightened risk for undesirable posttreatment complications. In particular, obesity, which is associated with other significant comorbidities and has been found to affect both the urologic disease process and consequent complications, must be investigated comprehensively. Furthermore, adequate assessment of nutritional status to ensure sufficient nutritional support in the surgical patient is also warranted. Patients with host factors that predispose them to infections may require prophylactic antibiotic coverage and must be closely monitored to anticipate the need for further antimicrobial treatment to prevent urosepsis. Finally, various comorbidity scoring systems are being investigated for their clinical value and may further provide urologists and other clinicians with more accurate predictive models for assessing the risk of complications among patients with urologic diseases. As subsequent chapters in this book delve into more organspecific, urologic disease–specific, or procedure-specific complications, we encourage the readers to make every effort in taking a broad, encompassing approach when evaluating urologic patients by diligently considering the effects of comorbid conditions in each individual person.

KEY POINTS 1. With increasing life expectancy in the general population, the prevalence of comorbid conditions such as obesity, heart disease, and diabetes has increased to alarming proportions. 2. Awareness of comorbidities allows the urologist to institute the proper measures to control pre­ existing diseases to optimize the overall health status of the individual patient, maximize the likelihood of a good outcome, and minimize the risk of a complication. 3. Obesity can directly influence surgical outcome because of certain proposed biologic linkages with urologic malignant diseases. 4. Nutritional status is a key clinical parameter demanding thorough evaluation in the surgical patient to prevent nutrition-related complications. 5. Given that certain host factors predispose the urologic patient to complicated infection, it is necessary to determine the need for antimicrobial prophylaxis preoperatively and to prevent the occurrence of systemic septicemia.

REFERENCES Please see www.expertconsult.com

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Chapter 

2 

PULMONARY COMPLICATIONS OF UROLOGIC SURGERY Patrick W. Mufarrij

MD Chief Resident, Department of Urology, New York University, New York, New York

William C. Huang

MD Assistant Professor, Department of Urology, New York University, New York, New York

Some say we can get along on only 20 percent of our lung capacity, but that dragging sort of existence is a poor substitute for the vitality we enjoy when the twin bellows of our lungs are taking in great drafts of oxygen. —Gene Tunney World heavyweight boxing champion, 1926 to 1928

Indeed, the lungs are the essential respiratory organ of air-breathing vertebrates and sustain the fire of life by absorbing oxygen into the body and excreting carbon dioxide into the atmosphere. For surgical patients, safe airway management and the maintenance of optimal perioperative pulmonary function are instrumental to a successful recovery. Unfortunately, pulmonary complications do occur on multiple levels and at varying rates of clinical urgency. Although these complications have a wide range of causes, all affect either oxygenation or ventilation of the patient. Postoperative pulmonary complications are a major cause of morbidity and mortality, and they result in prolonged hospital stays and increased health care costs. The risks of such complications depend on the susceptibility of the patient and on the type of pro­ cedure undertaken. Although definitions and analytical methods vary throughout the literature, the incidence of postoperative pulmonary complications, ranging from clinically significant atelectasis to respiratory failure, following abdominal or pelvic surgery has been reported to be between 20% and 30%.1-4 We define respiratory complication as any pulmonary abnormality that produces identifiable disease or dysfunction that is clinically significant and impairs a patient’s clinical course.5

PREOPERATIVE PULMONARY ASSESSMENT AND POSTOPERATIVE PULMONARY REHABILITATION Patients who are at risk for developing pulmonary complications need to be identified preoperatively so that

special measures can be undertaken in the perioperative period either to avoid or to mitigate these potential setbacks. As outlined by Smetana and coworkers,5 definite risk factors for developing postoperative pulmonary complications are as follows: 1. Chronic obstructive pulmonary disease (COPD) 2. Active tobacco smoking history 3. Cessation of smoking 2 5. Serum albumin concentration 30 mg/dL 7. Surgical procedures lasting >3 hours Smoking tobacco is a well-known risk factor for postoperative pulmonary complications that increases the relative risk of these events among smokers as compared with nonsmokers by an odds ratio of 1.4 to 4.3.2,3 In their prospective study of 200 patients undergoing coronary artery bypass surgery, Warner and associates6 demonstrated that patients who had stopped smoking ≥8 weeks preoperatively had a significantly lower risk of pulmonary complications than did patients who were active smokers (14.5% versus 33%). Moreover, patients who had stopped smoking for >6 months had pulmonary complication rates similar to those patients who had never smoked (11.1% versus 11.9%). Surprisingly, patients who had quit smoking 3 hours.

ATELECTASIS AND RESPIRATORY INFECTION Atelectasis is the reversible collapse of alveoli in dependent lung areas. Studies suggest that atelectasis could also represent alveoli that are filled with fluid and foam.12 Ninety percent of anesthetized patients develop atelectasis, a complication believed to result from surfactant inhibition, gas resorption, or lung compression.13 Atelectasis occurs with both intravenous (IV) and inhalational anesthesia regimens, regardless of whether the patient is breathing spontaneously or is mechanically ventilated. Surgical patients are also predisposed to atelectasis because of the rapid, shallow breathing pattern and the inhibiting effect of analgesia on spontaneous sighing that is commonly seen in the postoperative setting.14 Although increased age was once thought to be a risk factor, it has not been shown to increase the propensity for development of atelectasis.15 Atelectasis is associated with the development of several pathophysiologic respiratory effects, including decreased compliance, impairment of oxygenation, increased pulmonary vascular resistance, and development of lung injury.16 Impairment of gas exchange, often the most obvious effect of atelectasis, leads to worsened arterial oxygenation in the absence of supplemental oxygen. The consequences of impaired oxygenation are frequently insignificant in a healthy lung, but they may necessitate the application of higher inspired oxygen concentration in a diseased lung. The diagnosis of atelectasis is usually suspected when the alterations in lung physiology consistent with this entity (described earlier) occur in a likely setting, such as the postoperative period. Clinical findings such as dyspnea, tachypnea, or hypoxemia usually confirm this suspicion, but imaging with chest radiography or computed tomography (CT) often reliably confirms the diagnosis.17 Reversing or preventing atelectasis is possible in many patients in the postoperative period and is of proven benefit in preventing pulmonary complications.18 The most clinically important techniques or devices are those that encourage patients to inspire deeply and thus to produce a large and sustained increase in transpulmonary pressure to distend the lung and to reexpand collapsed lungs. Although some controversy exists regarding the routine use of prophylactic pulmonary physical therapy following abdominal surgical procedures, we strongly encourage the practice. Postoperative pulmonary infections have an incidence in the literature widely ranging from 2.8% to 50% depending on the type of anesthesia, type of surgery, and patient risk factors.19 Infectious respiratory complications are not surprisingly more common in patients with risk factors such as COPD, altered lung defenses, and active smoking. Postoperative pneumonia delays

Chapter 2  Pulmonary Complications of Urologic Surgery recovery from the surgical procedure, and the resulting impairment of tissue oxygenation can delay wound healing. Rodgers and coworkers20 reported that patients who developed postoperative pneumonia had a 10% mortality rate, which was substantially higher when systemic sepsis ensued. Another large study of patients undergoing major noncardiac surgical procedures found that 1.5% developed postoperative pneumonia, and this cohort of patients had a 10-fold higher 30-day mortality rate did than patients who did not develop this complication.21 The two types of pneumonia most frequently encountered in the postoperative patient are aspiration and nosocomial. Aspiration pneumonia occurs after abnormal entry of fluid, particulate matter, or gastrointestinal secretions into the respiratory tract and can result in pulmonary complications by way of chemical pneumonitis, bacterial infection, or mechanical obstruction.22 Pneumonia resulting from aspiration is caused primarily by anaerobic bacteria that comprise the normal flora of the patient. Treatment of aspiration pneumonia involves antibiotics, supportive care, and removal of any aspirated material that is obstructing the respiratory tree. Nosocomial pneumonia is acquired in the hospital and manifests ≥48 hours after admission; the definition of this condition excludes any infection present or incubating at the time of hospital admission.23 Unlike aspiration pneumonias, nosocomial infections of the lung are frequently polymicrobial and result from highly virulent bacteria, with gram-negative bacilli the predominant organism in 60% of cases.23 Treatment entails supportive care and empirical antibiotic coverage, with specific attention paid to frequent pathogens of a particular institution, such as methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, or Acinetobacter baumannii.24 Ventilatorassociated pneumonia, a specific subset of nosocomial pneumonia, is bacterial pneumonia in patients with acute respiratory failure who have been intubated for >48 hours.23 Treatment of ventilator-associated pneumonia is similar to that for nosocomial pneumonia. Mortality rates of ≤40% have been reported for ventilator-associated pneumonia, and grave complications such as acute respiratory distress syndrome (ARDS) can develop.24 ARDS, a severe lung disease characterized by inflammation of the lung parenchyma that leads to impaired gas exchange with concomitant systemic release of inflammatory mediators, causes inflammation and hypoxemia, and frequently results in multisystem organ failure.25 Essentially, the pathophysiology of ARDS involves massive capillary leak resulting from excessive inflammatory response in the host’s lung tissue. Treatment of ARDS involves mechanical ventilation, treatment of underlying causes, supportive care, and antibiotic coverage if indicated.

PULMONARY EMBOLISM Pulmonary embolism (PE) has historically been reported in ≤10% of patients following urologic surgical procedures, and with deep vein thrombosis (DVT) has been observed in ≤30% of patients who do not receive prophylaxis.26 One prospective observational study suggested a marked decrease in the incidence of PE, largely because of the institution of routine DVT prophylaxis, such as early ambulation, use of graduated compression stockings, and intermittent pneumatic compression.27 In this study, urologic patients, 40% of whom underwent open surgical procedures, had an overall PE rate of 0.87%. At our institution, we routinely use non­ pharmacologic methods of thromboprophylaxis, such as compression stockings or pneumatic compression devices placed before induction of general anesthesia and then in the early postoperative period, particularly if the patient is not ambulatory. The 3-month mortality of PE has been reported to be 15%, despite current aggressive treatment guidelines.28 The use of anticoagulation treatment for venous thromboembolism (VTE), the clinical entity that comprises both DVT and PE, must be weighed against the risk of bleeding, especially in the postsurgical patient. The statistically significant risk factors for postoperative DVT include the following29: 1. Increased age 2. Obesity 3. Previous history of VTE 4. Varicose veins 5. Oral contraceptive therapy 6. Malignant disease 7. General anesthesia 8. Orthopedic surgery 9. Factor V Leiden gene mutation (a thrombophilia) Regional and spinal anesthetic regimens have been associated with a decreased risk of PE when compared with general anesthesia, purportedly as a result of the vasodilation of the lower extremities afforded by sympathetic blockade.30 This finding is of particular interest because many endoscopic urologic procedures can be performed with spinal anesthesia. The most common symptoms of PE, according to two large prospective studies, are dyspnea (73%), pleuritic chest pain (63%), and cough (37%).31,32 More than 97% of patients with confirmed PE complain of at least one of these symptoms.31 Clinical decision models have been created to help in the diagnosis of PE.33,34 According to one such model developed by Kruip and coworkers,33 patients are stratified according to a points system. Patients who are considered “unlikely” to have PE should undergo D-dimer serum testing; if test results are negative, the diagnosis of PE is excluded.33 All other

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Section I  Nonurologic Complications of Urologic Surgery patients considered “likely” to have PE and patients with an abnormal serum D-dimer test results should undergo spiral CT of the chest. The spiral chest CT scan is the prevailing imaging modality used in the diagnosis of PE because it is readily available and safe. It cannot, however, be used in patients with renal insufficiency or an allergy to contrast dye. In these patients, a ventilation-perfusion scan is preferred, but many clinicians would rather treat patients with suspected PE empirically rather than rely on the poor sensitivity (41%) and specificity (10%) of this scan.31 A negative result on the spiral CT scan of the chest excludes the diagnosis of PE, whereas patients with positive scan results proceed to appropriate therapy.35 Anticoagulation therapy is the treatment of PE in patients without signs of cardiogenic shock or right ventricular dysfunction. Patients with evidence of rightsided cardiac dysfunction (submassive PE) or with signs of shock (massive PE) may also benefit from more aggressive therapies, such as fibrinolysis or embolectomy.36 The addition of thrombolytic therapy causes faster clot lysis than does heparin therapy alone, but the 12% incidence of major hemorrhage requires careful patient selection.36,37 The decision to use thrombolytic therapy should be made in consultation with a cardiologist. Inpatient anticoagulation therapy is initiated with IV heparin, which accelerates the actions of antithrombin III, helps to prevent the formation of additional clots, and promotes fibrinolysis of the existing clot. Therapeutic partial thromboplastin times (PTT) while patients are receiving IV heparin should be reached within 24 hours of treatment initiation; failure to do so has been associated with higher rates of further embolic episodes.38 Patients receiving heparin should have daily hemograms to monitor for the rare development of heparin-induced thrombocytopenia, which necessitates immediate cessation of heparin therapy and possible initiation of alternative forms of anticoagulation. Absolute contraindications to heparin therapy are active bleeding, severe bleeding diathesis, a platelet count ≤20,000/mm3, neurosurgical or ocular surgical procedures performed within the past 10 days, or intracranial bleeding within the past 10 days.39 The placement of an inferior vena cava filter is indicated in patients with a contraindication to anticoagulation therapy or with recurrent VTE despite maximal medical anticoagulation therapy. Warfarin sodium, an oral vitamin K antagonist, remains the mainstay of outpatient anticoagulation therapy, although patients can also be maintained on subcutaneous injections of heparin or low-molecular-weight heparin. The seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy made recommendations for the use of antithrombotic and thrombolytic therapy in urologic patients.40 For patients undergoing transurethral, lapa-

roscopic, or low-risk procedures, early and persistent mobilization is recommended. Recommendations for patients undergoing major open urologic procedures include intermittent pneumatic compression, use of graduated compression stockings, and early ambulation. These recommendations in combination with the identification of VTE risk factors offer reasonable guidelines for urologic thromboprophylaxis.

PULMONARY COMPLICATIONS OF OPEN AND LAPAROSCOPIC UROLOGIC SURGERY Given the anatomic proximity of the kidneys and adrenal glands to the costodiaphragmatic pleural spaces, inadvertent violation of the thoracic cavity during open or laparoscopic surgical procedures is possible. Pleural entry during surgical procedures of the flank can result from the intimate association between the pleura and lower ribs: the pleura extends down to the 11th rib in the posterior axillary line and to just below the 12th rib in the area of the vertebral column. Riehle and Lavengood41 observed that pleural violation usually occurs while the surgeon attempts to separate the pleura and diaphragm during dissection within the intercostal space or because of failure to mobilize the diaphragm sufficiently before retractor placement. Entry into the pleural space is sometimes expected during a flank incision, especially if a rib resection is necessary. Investigators have also reported cases of a kidney tumor invading the diaphragm and necessitating resection of that tissue with subsequent repair.42 Open flank surgical procedures for nephrectomy are associated with a risk of pleural injury in >23% of cases, and pneumothorax is a known complication of this surgical approach.43 In reports by Shaffer and associates44 and by Stephenson and colleagues,45 pneumothorax incidence after open nephrectomy ranged from 1% to 10%; 1% of patients undergoing open nephrectomy required postoperative chest tube placement. Most pleural injuries during flank surgical procedures are recognized intraoperatively, and 99% of pneumothoraces are found in patients who sustained an intraoperative injury.46 Modifications of the traditional flank incision, such as the supra-11th mini-flank incision, help to prevent pleural injury during open surgical procedures of the kidney.47 Pleurotomies recognized intraoperatively during open flank surgical procedures can usually be repaired without difficulty or sequelae.48 Adequate mobilization of the diaphragm is usually paramount to facilitate these closures. A 12-Fr rubber catheter is initially placed through the defect and into the pleural cavity, and the pleura is closed with absorbable or nonabsorbable suture in a running pattern. Next, the lung is expanded with positive pressure ventilation; this maneuver forces out the remaining air within the pleural cavity through the end of the catheter, which

Chapter 2  Pulmonary Complications of Urologic Surgery has been submerged in a container of fluid. The catheter is removed when air ceases to bubble out of its submersed tip. At the same time the catheter is removed from the pleural space, the running suture is tied while the lung remains expanded. Compared with open flank surgical procedures, diaphragmatic injury during laparoscopic nephrectomy or adrenalectomy is rare, with a reported incidence as low as 0.6%.49,50 Unlike its open counterpart, laparoscopic urologic surgical procedures are performed during insufflation of the peritoneum or retroperitoneum with carbon dioxide. This gas can seep into the pleural space through small diaphragmatic injuries and can cause sudden collapse of the ipsilateral lung. The resulting pneumothorax can be catastrophic if it is not recognized quickly. The diaphragm may also begin to billow into the surgical field, the so-called floppy diaphragm sign of pleural injury.51 These injuries can also result from endoscopic instruments, such as retractors, that are not in view of the laparoscope, and recognition of the problem may be delayed until the patient begins to show signs of decompensation. Because laparoscopic diaphragmatic injuries may not be as obvious as in open surgical procedures, they manifest more commonly as emergencies. As in open surgical procedures, suspected diaphragmatic tears during laparoscopy should be repaired primarily, if possible. Depending on the severity of the injury and the clinical status of the anesthetized patient, these repairs can be performed either immediately or after the specimen has been removed. Delaying repair until after specimen extraction may provide better visualization of the injury; however, unstable patients require immediate attention to this complication. In a review of 1765 laparoscopic renal procedures, Del Pizzo and colleagues50 noted that diaphragmatic injury was able to be addressed at the end of the case when the patient remained hemodynamically stable without acute respiratory decompensation.50 If repair can be delayed, then it is advised to decrease the pneumoperitoneum to 10 mm Hg to limit the extent of any present pneumothorax, to facilitate patient ventilation, and to allow for tension-free anastomosis.52 In repairing large diaphragmatic injuries, the laparoscope can be used to inspect the pleural cavity for any direct pulmonary injuries. Laparoscopic suturing devices or needle drivers are used to close the injury with interrupted figure-of-eight nonabsorbable sutures.50 Before complete closure of the injury, the laparoscopic suction device is inserted through the rent into the pleural cavity to evacuate any residual air, while a large inspiratory breath is given to the patient by the anesthesiologist. Then the final stitch is secured as the suction device is removed from the pleural cavity. For smaller diaphragmatic insults, such as cautery burns, simply oversewing the area of injury usually suffices, as in open surgical procedures.50

Other techniques have been described for repair of diaphragmatic injuries during laparoscopy. These include the use of nonabsorbable sutures with pledgets for tenuous closures, polyglactin mesh stapled over the defect or gelatin thrombin matrix for small defects, and placement of allogenic material, such as polytetrafluoroethylene (PTFE), for large defects.52-55 Insertion of a chest tube is generally unnecessary unless there is pleural bleeding, injury to the visceral pleura, or failure of the foregoing techniques.50 If a thoracostomy tube is indicated, it can be placed under vision by passing the laparoscope through the diaphragmatic opening before inserting the chest tube. Postoperatively, patient hemodynamic or respiratory decompensation would certainly justify thoracic surgical consultation and chest tube insertion. Historically, it had been the standard of care to obtain a chest radiograph after every open flank surgical procedure regardless of the index of suspicion for pleural injury. Latchemsetty and colleagues46 concluded that postoperative chest radiographs are not routinely needed after open nephrectomy unless they are clinically indicated by, for example, one of the following: 1. Central line placement 2. Intraoperative diaphragmatic injury 3. Respiratory distress 4. Abnormal physical examination findings Similarly, investigators have noted that postoperative chest radiographs are not useful in patients who undergo uncomplicated laparoscopic surgical procedures.56

PULMONARY COMPLICATIONS OF PERCUTANEOUS NEPHROLITHOTOMY Percutaneous nephrolithotomy (PCNL) is generally a safe treatment option. Most of the complications and injuries to surrounding organs develop from the initial puncture. Total complication rates, including insignificant bleeding and fever, are reported to be as high as 83%.57,58 The rates of significant bleeding requiring transfusion and of sepsis are 5% to 18% and 1% to 4.7%, respectively.59 Regarding pleural injuries, complication rates have been reported to range from 2.3% to 23%, depending on the definition of injury.58-60 Anatomically, the lower border of the pleural reflection crosses the 10th rib in the midaxillary line and crosses the 12th rib posteriorly at the lateral border of sacrospinal muscle.61 The posterior portion of the diaphragm arises from the tips of the 10th to 12th ribs and from the lateral and medial arcuate ligaments. Meanwhile, the 11th and 12th ribs cross the upper pole of the kidney. Thus, all supracostal nephrostomy tracts traverse the diaphragm, and in many cases also the pleural space, but the lung may be avoided.62

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Section I  Nonurologic Complications of Urologic Surgery Not surprisingly, the rates of thoracic complications are higher with the supracostal approach for PCNL.60,63 Subcostal punctures are associated with fewer complications, but under certain circumstances, such as scoliosis, high kidney position, staghorn calculi, upper calyx stone, stone in proximal ureter or pelvis, or duplicated collecting systems, the optimal access route is through a supracostal approach to the upper pole of the kidney.64 Decreased pulmonary complications have been reported under C-arm fluoroscopic guidance, a technique that also helps to prevent injury to the spleen, liver, bowl, and renal hilum.65 In addition, punctures should be performed after maximal exhalation, when the lungs are smallest. Hopper and Yakes66 observed that at end expiration, the likelihood of violating the pleura with supracostal access was 29% on the right and 14% on the left. Nonetheless, a 16-fold greater risk of pleural injury is reported when the puncture is made above the 11th rib as compared with supra-12th rib access.60 Thus, many urologists avoid supra-11th rib access if possible. The use of an adequately sized working sheath during supracostal PCNL seals the pleural opening and prevents pneumothorax and hydrothorax while allowing for stone removal and irrigation.60 During PCNL, maintaining low pressure within the irrigation system minimizes the chances of fluid and air entering the pleural space through the pleural opening from a supracostal approach. Postprocedurally, the drainage catheter should be large enough to tamponade the tract.65 Intrathoracic complications, most of which are hydropneumothoraces, following supracostal access for PCNL occur at rates between 3.1% and 12.5%.60,67 Many urologists routinely obtain postoperative upright chest radiographs to evaluate for these possible injuries. Ogan and coworkers68 prospectively noted that intraoperative chest fluoroscopic examination during PCNL is sufficient to detect clinically significant hydropneumothoraces and recommended that routine immediate, postoperative chest radiographs are not necessary unless postoperative clinical symptoms become suspicious. These investigators found that both fluoroscopic examinations and upright chest radiographs yielded high false-negative rates when compared with chest CT scans; however, most missed fluid collections were clinically insignificant. Pleural fluid that becomes clinically significant most likely accumulates later in the post­ operative period, at which time the development of symptoms or signs warrants imaging and possible intervention.68 Golijanin and coworkers63 reported a 3.5% incidence of thoracostomy tube placement in 115 patients who underwent supracostal PCNL. The incidence of pulmonary complications that necessitate surgical intervention after a supra-12th rib approach ranges from 3% to 23%.65,68 To avoid painful chest tube placement postoperatively by a thoracic surgeon, Ogan and Pearle69

described inserting an 8- to 10-Fr loop nephrostomy tube intraoperatively using real-time fluoroscopic guidance into the pleural space of patients who had developed significant hydropneumothorax following supracostal PCNL. These investigators detected significant hydropneumothoraces using intraoperative fluoroscopy and believed that an advantage of this procedure is maintained drainage in cases requiring second-look flexible nephroscopy, which could introduce additional fluid and air into the pleural space. Traditional thoracostomy tube placement is recommended when significant drainage, blood, or parenchymal injury to the lung is detected. A rare pulmonary complication of PCNL is nephropleural fistula. Lallas and colleagues70 retrospectively reported rates of nephropleural fistulas following supracostal PCNL as 2.3% (2 of 87 cases) in supra-12th rib access and 6.3% (2 of 32 cases) in supra-11th rib access. These fistulas were managed with decompression of the collecting system with ureteral stent, endourologic treatment of any obstruction resulting from residual stone fragments, and decompression of the pleural space with a thoracostomy tube. Refractory cases of intra-thoracic fluid accumulation may require decortication with pleural sclerosis via a thoracic surgical procedure. This group also suggested obtaining antegrade nephrostograms before removing the nephrostomy tube in patients to aid in the diagnosis of this uncommon fistula; however, the cost-effectiveness of this practice is admittedly unknown. To reduce the probability of this relatively rare complication further, Lingeman and associates71 suggested removing all tubes from the upper pole access site and placing a nephrostomy tube in a remote lower pole location. This method, however, requires an additional puncture and trauma to the kidney and therefore may not be worth the risk reduction of an already infrequent complication.

PATIENTS WITH PRIOR BLEOMYCIN CHEMOTHERAPY Fortunately for patients with testicular cancer, chemotherapy offers durable responses in almost all patients including those with widely disseminated disease. The current standard of treatment for patients with metastatic germ cell tumors is the following regimen: 1. Bleomycin, an antibiotic with antineoplastic activity 2. Etoposide, a DNA topoisomerase inhibitor 3. Cisplatin, an alkylating agent This multidrug chemotherapeutic regimen is commonly referred to as BEP. Although patients with goodrisk disease can avoid treatment with bleomycin,72 many patients including those with poor-risk or intermediate-risk disease are subjected to bleomycin.

Chapter 2  Pulmonary Complications of Urologic Surgery Urologists should be well aware of potential complications associated with administration of bleomycin. Bleomycin-related toxicities include interstitial pneumonitis (bleomycin-induced pneumonitis [BIP]), which can result in pulmonary fibrosis (2%-40%).73 In a few patients, this complication may eventually result in death.74 Toxicity is believed to be related to multiple factors including cumulative bleomycin dose, increasing age, thoracic radiation, poor renal function, exposure to high inspired oxygen concentrations, and a history of smoking.75 BIP typically begins gradually and manifests in the first few months of therapy but may develop even 6 months following discontinuation of therapy. Initial symptoms of BIP include nonproductive cough, dyspnea with exertion, and fever. Symptoms may progress to dyspnea at rest and cyanosis.75 Because of similarities in symptoms, a diagnosis of infectious pneumonitis is excluded before the drug is discontinued. Patients undergoing surgical procedures such as retroperitoneal lymph node dissection after BEP therapy should have a thorough preoperative evaluation. This assessment should include pulmonary function testing because pulmonary fibrosis may result in significant perioperative complications. In a retrospective study of patients undergoing retroperitoneal lymph node dissection after chemotherapy, Baniel and associates76 identified pulmonary complications as the largest contributors to severe postoperative complications. The conclusion from this study was that conservative fluid adminis­ tration and limited inspired oxygen concentrations minimized pulmonary complications in patients with bleomycin exposure.76 Subsequent studies confirmed the importance of meticulous fluid management, although they raised questions regarding the significance of high inspired oxygen concentrations.77

KEY POINTS 1. Patients who are at risk for developing pulmonary complications need to be identified preoperatively so that special measures can be undertaken in the perioperative period either to avoid or to mitigate complications. 2. For any patient receiving anesthesia, and especially for those undergoing urologic surgical procedures involving an incision that breaches muscles used during respiration, pulmonary rehabilitation is critical in preventing complications and in fostering the recuperation of normal respiratory status. 3. Surgical patients are also predisposed to atelectasis because of the rapid, shallow breathing pattern and the inhibiting effect of analgesia on spontaneous sighing that is commonly seen in the postoperative setting. 4. Infectious respiratory complications are more common in patients with risk factors such as COPD, altered lung defenses, and active smoking. 5. In preventing PE in patients undergoing transurethral, laparoscopic, or low-risk procedures, early and persistent mobilization is recommended. 6. Recommendations for patients undergoing major open urologic procedures include intermittent pneumatic compression, use of graduated compression stockings, and early ambulation, in addition to VTE prophylaxis when indicated based on risk factors.

REFERENCES Please see www.expertconsult.com

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3 

CARDIAC COMPLICATIONS OF UROLOGIC SURGERY Susie N. Hong

MD Cardiology Fellow, Division of Cardiology, Department of Medicine, New York University Medical Center, New York, New York

Arthur Schwartzbard

MD Director, Non-Invasive Cardiology Lab, Manhattan Campus, New York Harbor Healthcare System; Director, Clinical Lipid Research, New York University Center for Prevention of Cardiovascular Disease; Assistant Professor of Medicine, New York University School of Medicine, New York, New York

Cardiac complications can pose significant risks to patients undergoing urologic surgical procedures. Several strategies and guidelines have evolved to help identify patients at greatest risk and therapies have been developed to help modify and minimize cardiac surgical complications. In this chapter, we review the general approach to preoperative assessment as well as perioperative management of cardiovascular disease states that are often encountered.

GENERAL APPROACH TO THE PATIENT A detailed history and physical examination combined with a baseline electrocardiogram (ECG) can elucidate cardiac disease states, such as coronary artery disease (CAD), congestive heart failure, valvular abnormalities, or arrhythmias. If a cardiac disease state is identified or known, it is important to know the degree, stability, and severity of the condition. Information about previous management and treatment for the condition is helpful in optimizing the patient’s preoperative, perioperative, and postoperative course. Additionally, assessments of the patient’s baseline functional capacity, comorbid conditions (e.g., diabetes, renal failure), and type of surgical procedure required are important in assessing overall cardiac risk.

PREOPERATIVE CLINICAL EVALUATION Multiple algorithms have been devised to assess perioperative risk. In this chapter, we review the American College of Cardiology/American Heart Association (ACC/AHA) 2007 guidelines,1 which incorporate the elements of the Revised Cardiac Risk Index2 in an algorithm to assess cardiac risk before noncardiac surgical procedures.

American College of Cardiology/ American Heart Association 2007 Guidelines The ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation for noncardiac surgical procedures concluded that identifying patients with active cardiac conditions, by careful history taking and clinical assessment, is crucial before elective surgical procedures. Terminology such as cleared for surgery as a preoperative assessment is not recommended by the ACC/AHA1 because such statements may not accurately assess a patient’s overall cardiac risk during surgery and can possibly be misleading. The ACC/AHA 2007 guidelines recommend obtaining at least four components from a patient’s history and physical examination to assess whether a patient can safely proceed to surgery, the patient’s overall cardiac risk, and whether additional testing is needed. Additionally, these variables are needed to navigate the stepwise approach algorithm devised by the 2007 ACC/AHA guidelines. These components are as follows: 1. Clinical risk factors (Box 3-1) 2. Cardiac risk assessment: identification of active cardiac conditions requiring evaluation and treatment (Table 3-1) 3. Functional capacity (Table 3-2) 4. Surgery-specific risk (Table 3-3)

Clinical Risk Factors The ACC/AHA 2007 guidelines incorporate several elements of the Revised Cardiac Risk Index,2 one of the most widely used risk indices for preoperative evaluation for noncardiac surgery, into its assessment of clinical risk factors for preoperative assessment before noncardiac surgical procedures (see Box 3-1). Active cardiac disease indicates a major clinical risk. The pres21

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Section I  Nonurologic Complications of Urologic Surgery BOX 3-1 Clinical Cardiac Risk Factors •  History of ischemic heart disease* •  History of compensated or prior heart failure† •  History of cerebrovascular disease‡ •  Diabetes mellitus (insulin treated) •  Renal insufficiency (creatinine >2 mg/dL) *Ischemic heart disease is defined as history of myocardial infarction, history of positive treadmill test result, use of nitroglycerin, chronic stable angina, or electrocardiogram with abnormal Q waves. † Congestive heart failure is defined as history of heart failure, pulmonary edema, paroxysmal nocturnal dyspnea, peripheral edema, bilateral rales, S3, or radiograph with pulmonary vascular redistribution. ‡ Cerebrovascular disease (history of transient ischemic attack or stroke).

ence of one or more active cardiac conditions (see Table 3-1) mandates intensive management and may result in the delay or cancellation of the operation unless it is an emergency. The ACC/AHA chose to replace the intermediate-risk category with the clinical risk factors from the index, with the exclusion of the type of surgery, which is incorporated elsewhere in the approach to the patient. Clinical risk factors include the following: 1. History of ischemic heart disease 2. History of compensated or prior heart failure 3. History of cerebrovascular disease 4. Diabetes mellitus 5. Renal insufficiency Ischemic heart disease is defined as history of myocardial infarction (MI), a history of a positive treadmill test result, use of nitroglycerin, chronic stable angina, or an ECG with abnormal Q waves. Congestive heart failure is defined as a history of heart failure, pulmonary edema, paroxysmal nocturnal dyspnea, peripheral edema, bilateral rales, S3, or a radiograph showing pulmonary vascular redistribution cerebrovascular disease (history of transient ischemic attack or stroke). Diabetes mellitus is defined as preoperative insulin treatment for diabetes mellitus, and renal insufficiency is defined as a preoperative creatinine concentration of >2  mg/dL. Increasing numbers of risk factors correlate with increased risk. Although no adequate clinical trials on which to base firm recommendations have been conducted, it appears reasonable to wait 4 to 6 weeks after MI to perform elective surgical procedures.1

TABLE 3-1  Active Cardiac Conditions for Which the Patient Should Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I, Level of Evidence: B) Condition

Examples

Unstable coronary syndromes

Unstable or severe angina* (CCS class III or IV)† Recent MI‡

Decompensated HF (NYHA functional class IV; worsening or new-onset HF) Significant arrhythmias

High-grade atrioventricular block Mobitz II atrioventricular block Third-degree atrioventricular heart block Symptomatic ventricular arrhythmias Supraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR >100 bpm at rest) Symptomatic bradycardia Newly recognized ventricular tachycardia

Severe valvular disease

Severe aortic stenosis (mean pressure gradient >40 mm Hg, aortic valve area 7 days but ≤1 month (≤30 days). From Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation. 2007;116(17):e418-e499.

management and may result in delay or cancellation of a surgical procedure unless it is an emergency.

Cardiac Risk Assessment

Exercise Capacity

Identifying the highest-risk patient is critical to avoid serious complications and adverse outcomes in elective noncardiac surgery. History taking should attempt to identify serious cardiac conditions such as unstable coronary syndromes, prior angina, recent or past MI, decompensated heart failure, significant arrhythmias, and severe valvular disease (see Table 3-1). The presence of one or more of these conditions mandates intensive

The assessment of functional capacity provides important prognostic information, since patients with good functional status have a lower risk of complications. Functional status can be expressed in metabolic equivalents (MET). Perioperative cardiac and long-term risks are increased in patients unable to meet a 4-MET demand during most normal daily activities. Various activity scales provide the clinician with a set of ques-

Chapter 3  Cardiac Complications of Urologic Surgery tions to determine a patient’s functional capacity. See Table 3-2 for a functional status assessment and estimated energy requirements for various activities. Confounding factors in assessing functional capacity include a history of arthritis or peripheral vascular disease. If ambulation cannot be assessed because of these limitations, a careful history of other METs (e.g., household chores not involving walking, upper extremity activities) can be helpful in evaluating a patient’s functional capacity.

Surgery-specific Risk Urologic procedures are generally considered intermediate-risk procedures. However, the timing of surgery (emergency versus elective) can alter the patient’s risk significantly. Additionally, urologic procedures involving large volume shifts, as well as procedures in elderly patients, can increase cardiac risk. Cardiac risk stratification is listed in Table 3-3. Intermediate-risk procedures are generally associated with a 1% to 5% cardiac risk. Care should be taken in optimizing a patient preoperatively and perioperatively to minimize risk and to maximize medical therapy based on overall cardiac risk. In emergency surgery, which generally is associated with substantial risk, risk indices do not necessarily TABLE 3-2  Estimated Energy Requirements for Various Activities Can you …

Can you …

1 MET

Take care of yourself?

↓

Eat, dress, or ↓ use the toilet?

Walk on level ground at 4 mph (6.4 kph)?

Walk indoors around the house?

Run a short distance?

Walk a block or 2 on level ground at 2-3 mph (3.2-4.8 kph)?

Do heavy work around the house such as scrubbing floors or lifting or moving heavy furniture?

Do light work around the house like dusting or washing dishes?

Participate in moderate recreational activities like golfing, bowling, dancing, playing doubles tennis, or throwing a baseball or football?

4 METs

4 METs

>10 METs

Climb a flight of stairs or walk up a hill?

Participate in strenuous sports like swimming, singles tennis, football, basketball, or skiing?

kph, kilometers per hour; MET, metabolic equivalent; mph, miles per hour. Modified from Hlatky MA, Boineau RE, Higgenbotham MB, et al. A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol. 1989;64:651-654.

apply because these indices are derived mostly from elective procedures,. However, these algorithms can assist in providing an estimate of the patient’s minimal risk. Further testing and interventions are likely not very beneficial given that patients are usually better off proceeding directly to surgery. In general, emergency surgical procedures should be assumed to be high risk, and much care should be taken in optimizing the medical management of these patients. If a patient has a known cardiac condition, medical therapy should be targeted to the specific disease state to optimize medical care and to minimize complications (see “Management of Specific Preoperative Cardiac Conditions”). Urgent surgery (need for a procedure during the same admission but able to be delayed a few days without significant patient compromise) is another category that likely increases cardiac risk.3 With urgent surgery, initial risk estimates should be made preoperatively. However, additional testing and subsequent therapies are often limited, except for identifying and stabilizing patients with unstable cardiac disease.

Overall Risk Assessment A stepwise approach generalizing cardiac risk assessment can be seen in Figure 3-1, which combines the

TABLE 3-3  Cardiac Risk* Stratification for Noncardiac Surgical Procedures Risk Stratification

Procedure Examples

Vascular (reported cardiac risk often >5%)

Aortic and other major vascular surgery Peripheral vascular surgery

Intermediate (reported cardiac risk generally 1%-5%)

Intraperitoneal and intrathoracic surgery Carotid endarterectomy Head and neck surgery Orthopedic surgery Prostate surgery

Low† (reported cardiac risk generally 0.1 mV Persistent ischemic response >1-3 minutes after exertion 3-4 abnormal leads

Low

No ischemia or ischemia induced at high-level exercise (>7 METs or heart rate >130 bpm [>85% of age-predicted heart rate]) manifested by: Horizontal or downsloping ST-segment depression >0.1 mV 1 or 2 abnormal leads

Inadequate Test

Inability to reach adequate target workload or heart rate response for age without an ischemic response; for patients undergoing noncardiac surgery, the inability to exercise to at least the intermediate-risk level without ischemia should be considered an inadequate test

bpm, beats per min; CAD, coronary artery disease; MET, metabolic equivalent. *Workload and heart rate estimates for risk severity require adjustment for patient age. Maximum target heart rates for 40- and 80-year-old subjects taking no cardioactive medication are 180 and 140 bpm, respectively. From Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation. 2007;116(17):e418-e499.

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Section I  Nonurologic Complications of Urologic Surgery

β-Blockers β-Blockers may be beneficial in higher-risk patients who are undergoing major noncardiac surgery.5 However, a 2006 ACC/AHA guideline update on perioperative β-blocker therapy noted major limitations in the published literature regarding this issue.6 More recently, a large randomized controlled trial of patients undergoing noncardiac surgery with risk factors found that although β-blockade decreases the risk of MI, it may increase the risk of stroke and overall mortality.7 As a result of newer evidence and questionable benefit of perioperative β-blocker treatment for noncardiac surgery, we recommend the following:

If surgery is more urgent, rapid-acting agents can be administered that allow effective blood pressure control in a matter of minutes or hours. β-Blockers are parti­ cularly effective agents and may reduce perioperative complications in high-risk patients. Most important, continuation of preoperative antihypertensive treatment through the perioperative period is critical, and a patient’s medical antihypertensive regimen must be ascertained before the procedure. Because of potential heart rate or blood pressure rebound, particular care should be taken to avoid withdrawal of β-blockers and clonidine.

Ischemic Heart Disease 1. β-Blockers should be continued in patients undergoing surgery who are already receiving β-blockers to treat angina, symptomatic arrhythmias, hypertension, or other ACC/AHA class I guideline indications. 2. β-Blockers are probably recommended for patients in whom preoperative assessment for high-risk surgery (e.g., vascular surgery) identifies high cardiac risk owing to the findings of ischemia on preoperative testing. We do not recommend using β-blockers in patients at low to intermediate risk who are not already being treated with a β-blocker. However, β-blockers should not be withdrawn before noncardiac surgical procedures from patients already receiving β-blocker therapy for other indications.

Statins Among patients who are undergoing major vascular surgery or those with known CAD, we recommend continuing statin therapy in patients already being treated and, in previously untreated patients, initiating statin therapy before elective vascular surgical procedures. Among patients not previously treated with statins who are undergoing urgent or emergency major vascular surgical procedures, we suggest initiating statin therapy in the perioperative period and, if possible, preoperatively. Over the long term, we recommend that statin therapy be titrated to recommended goals.

MANAGEMENT OF SPECIFIC PREOPERATIVE CARDIAC CONDITIONS Hypertension Known hypertension, particularly stage 3 hypertension (systolic blood pressure ≥180  mm  Hg and diastolic blood pressure ≥110 mm Hg) should be controlled preoperatively. In most cases, an effective medical regimen can be achieved over several days to weeks of preoperative outpatient treatment.

Evaluation for Coronary Artery Disease One of the most important historical assessments of patients with known CAD is to determine whether the patient is experiencing angina. If the patient is asymptomatic and receiving an effective cardiac regimen, medical optimization without further testing for CAD is generally recommended. However, if a patient experences symptoms, great care should be taken in determining whether the angina is stable or unstable. Patients with chronic stable angina (chest pain worsened by exercise and relieved by rest or sublingual nitrogen) should be managed with optimal medical therapy before surgical procedures. Preoperative non­ invasive or invasive cardiac testing is generally not recommended. Unstable angina (chest pain that occurs at rest or sleep and is unrelieved by rest or sublingual nitroglycerin) should be evaluated further before surgical procedures. If a patient is experiencing symptoms of unstable angina or an MI, medical optimization, a baseline ECG, and referral to a cardiologist for further testing or cardiac catheterization are highly recommended. Cardiac revascularization may delay the patient’s surgical procedure, especially if percutaneous intervention (PCI) with stenting is performed. Given evidence regarding the limited value of coronary revascularization before noncardiac surgical procedures,8 the indication for preoperative testing is limited to patients with active cardiac disease and groups in whom coronary revascularization may be beneficial independent of noncardiac surgical procedures. Noninvasive Testing  Exercise ECG testing is the preferred stress test given the importance of exercise tolerance as a predictor of outcome. Exercise ECG testing is usually performed with perfusion imaging or echocardiography because imaging can better identify high-risk features that would warrant referral for angiography. For patients who cannot exercise, adenosine/dipyridamole stress testing and dobutamine echocardiography are other options for noninvasive cardiac testing to assess CAD.

Chapter 3  Cardiac Complications of Urologic Surgery We recommend the following patients for noninvasive testing: 1. Patients with active cardiac conditions (see Table 3-1) in whom noncardiac surgical procedures are planned; these patients should be evaluated and treated by a cardiologist preoperatively 2. Patients with three or more clinical risk factors and poor functional capacity (10 g/dL. Although lower intraop­ erative hemoglobin levels can generally be tolerated by most patients, these values are associated with an increased risk of morbidity and mortality. Additionally, anemia may reflect a previously unsuspected coexisting disease process that could have a significant effect on the perioperative course. Because anemia can be a primary disorder or can occur secondary to other sys­ temic processes, a careful history and physical examina­ tion are essential and can provide extensive information about the underlying cause.5 Initial diagnostic studies should include reticulocyte count, mean corpuscular volume (MCV), examination of the peripheral blood smear, and a fecal occult blood test.5 Many urologic conditions can be associated with anemia, including malignant disease and chronic renal failure. Iron deficiency anemia has been associated with states of renal cell carcinoma. Direct involvement of the bone marrow by cancer may result in myelofibrosis and subse­ quent anemia, most often seen in metastatic prostate cancer.6 Radiation therapy can lead to bone marrow sup­ pression or vitamin B12 deficiency secondary to radiation ileitis.7 Many chemotherapeutic agents can cause myelo­ suppression. Commonly used antibiotics in urology, such as nitrofurantoin, sulfa compounds, and quino­ lones, can produce hemolytic anemia in patients with glucose-6-phosphate dehydrogenase deficiency. Hemo­ lytic anemia has also been reported in association with renal cell carcinoma and seminoma.8,9 Finally hematuria itself can cause anemia if it is chronic or severe. Understanding the cause of the anemia can dictate the appropriate perioperative course of action to mini­ mize operative morbidity. For patients with a correct­ able underlying cause of anemia who are judged to be at risk for functional compromise, therapy consists of transfusion. In patients who are undergoing surgical procedures that are deemed elective, it is advisable to proceed after correcting the underlying cause of anemia preoperatively and thereby avoiding transfusion. In certain conditions, recombinant erythropoietin can be used to elevate the hemoglobin level, and this agent is often used in the preoperative period. Preoperative transfusions should ideally be performed 24 hours in advance to allow regeneration of 2,3-diphosphoglycer­ ate, which shifts the oxygen dissociation curve to increase oxygen availability to the tissues. Transfusions incur a potential risk of morbidity, including hemolytic reactions, allergic reactions, and transmission of viral diseases (Table 4-1).11 Elevation of the hematocrit level significantly higher than normal (erythrocytosis) increases blood viscosity and decreases oxygen transport. A significant increase in surgical morbidity and mortality occurs, particularly related to thromboembolic complications. This increase in red blood cell (RBC) mass can be primary, as in poly­ cythemia vera, or secondary. Common causes of sec­ ondary erythrocytosis are hypoxic states or paraneoplastic syndromes (as seen in renal cell carcinoma and Wilms’

TABLE 4-1  Complications of Transfusions Per Unit Transfused Complications

Frequency

Immune Acute hemolysis Delayed hemolysis Febrile nonhemolytic Allergic cutaneous Anaphylactic Alloimmunization (RBC) Alloimmunization (HLA)

1/12,000 1/1500 1-4/100 1-4/100 1/150,000 1/100 1/10

Nonimmune Hepatitis C Hepatitis B HIV-1 HIV-2 Malaria Bacterial sepsis Hypothermia

1/103,000 1/200,000 1/490,000 None reported 1/4,000,000 Rare Rare

HIV, human immunodeficiency virus; HLA, human leukocyte antigen; RBC, red blood cell. Adapted from Dzieczkowski JS, Anderson KC. Transfusion biology and therapy. In: Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison’s Principles on Internal Medicine, 14th ed. New York: McGraw-Hill; 1998:718-724.

tumor) likely resulting in increased production of erythropoietin. Patients with polycythemia vera should undergo preoperative phlebotomy to lower hematocrit levels to 15% of normal levels should be adequate for surgery and can be achieved with fresh frozen plasma (FFP). Factor V deficiency is also a very rare disorder in which the PT and APTT are prolonged. Approximately 25% of normal activity is maintained for surgery. Factor VII deficiency is uncommon and is inherited as an autosomal gene with intermediate penetrance. The PT is prolonged and the APTT is normal. Replacement is achieved by transfusing plasma or factor VII replacement. Inherited factor X deficiency is autosomal recessive. Maintenance of levels >40% of normal may be achieved with plasma transfusion in preparation for surgery. Factor XI deficiency is uncommon as well and is inherited in an autosomal dominant fashion. A higher frequency of this deficiency is noted in the Ashkenazi Jewish popu­ lation. These patients may not have bleeding histories but often present with epistaxis. Severe bleeding may occur with trauma or major surgery. Patients can suc­ cessfully undergo urologic surgical procedures with adequate FFP therapy. Factor XII deficiency is not usually associated with bleeding manifestations, although the APTT is pro­ longed. Therapy is not needed for this deficiency. Factor XIII stabilizes fibrin into a covalent network, and in factor XIII deficiency coagulation studies are normal except fibrin stability. Abnormal clot solubility and spe­ cific factor XIII assay establish the diagnosis, and trans­ fusion of FFP is sufficient for hemostasis.17 Fibrinogen deficiency, or dysfibrinogenemia, is uncommon and FFP or cryoprecipitate may be given to maintain a level ade­ quate for normal hemostasis.

DISORDERS OF INCREASED BLEEDING Coagulation and bleeding abnormalities are among the major problems encountered in the surgical or criti­ cally ill patient. Although most of these patients have no intrinsic abnormalities of hemostasis, either their underlying disease or the therapy of the disease may produce clinically significant bleeding problems. The urologist must be able to recognize these abnormalities quickly and address them before clinically significant problems arise. Failure to do so may result in a signifi­ cant increase in morbidity and mortality in the acutely ill patient or the surgical patient. In this section, we discuss the major critical disorders that may lead to increased bleeding.

Renal Failure Renal disease can be associated with functional defects in RBCs, platelets, leukocytes, and coagulation factors. Significant bleeding conditions can occur in the uremic patient, most commonly the result of impaired platelet

function. Investigations of the hemorrhagic tendency associated with uremia have mostly been performed in patients with chronic renal failure, and whether these findings can be extrapolated to acute renal failure is unclear.19 Uremic bleeding is multifactorial in origin and is mainly the result of impaired platelet–vessel wall inter­ action. Increased prostacyclin and nitric oxide produc­ tion by the endothelium, abnormalities in vWF, and several biochemical and functional abnormalities of uremic platelets have also been described.20 The finding that acquired platelet dysfunction is at least partially corrected by hemodialysis suggests that accumulation of uremic toxins in the blood may contribute to the observed effects. Despite the hemorrhagic tendency, activation of coagulation has been demonstrated in uremic patients and is more prominent in those who are treated with hemodialysis. The safest treatment to relieve uremic bleeding is administration of DDAVP, but its effect is often short-lived. High-dose intravenous (IV) conjugated estrogens can significantly improve the bleeding time and have a longer duration of action.21-24

Disseminated Intravascular Coagulation DIC is an acquired coagulopathy and is the most com­ monly entertained diagnosis in a bleeding, critically ill patient. Of all acute causes of coagulopathy, it is poten­ tially the most life-threatening. DIC is not a single entity, but rather a clinicopathologic syndrome that is the end product of a variety of underlying disorders, most commonly bacterial sepsis and malignant disease in the urologic patient.25-28 Central to the pathogenesis of DIC is the unregulated and excessive generation of thrombin.26 Normally, the cumulative effect of clot production, clot dissolution (fibrinolysis), and inhibition of clot activation is to produce the steady-state equilibrium of hemostasis. In DIC, however, excess thrombin is generated, resulting in the inappropriate activation of fibrinolysis and the shifting of the steady state to excessive clot dissolution. A secondary result is that fibrin thrombi are formed in the microvasculature, and platelets and RBCs are trapped and consumed. As the cycle continues, platelets, fibrin­ ogen, and other clotting factors are consumed beyond the body’s ability to compensate, and excessive bleed­ ing ensues. It should be clear from this description that DIC is initially a thrombotic process with secondary hemorrhage occurring only when platelets and clotting factors are sufficiently consumed and depleted. Approx­ imately 10% of patients with DIC present with only thrombotic manifestations.28 Patients in whom DIC is suspected generally present with diffuse bleeding from several sites, petechiae or ecchymoses, hypoxemia, hypotension, or oliguria. In acute DIC, laboratory evaluation demonstrates variable

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36

Section I  Nonurologic Complications of Urologic Surgery degrees of thrombocytopenia, hypofibrinogenemia, and prolongation of PT and APTT. Assays for fibrin split products (FSPs), fibrin degradation products (FDPs), or the D-dimer fragment of fibrin are generally markedly elevated. The D-dimer assay is theoretically more spe­ cific for DIC because this fragment is produced by the action of plasmin on polymerized fibrin.32 Patients with malignant disease often have chronic, compensated DIC in which bleeding is minimal in the steady state, and these patients often present with normal PT/PTT, platelet, and fibrinogen test results. Patients in this subset demonstrate an elevation of FDPs, FSPs, or D-dimer. These patients are also at increased risk for significant bleeding following anything that may acti­ vate their clotting system, such as relatively minor sur­ gical procedures.28-30 The diagnosis of DIC relies heavily on laboratory results, but one must also consider the clinical picture. Of all the laboratory findings, thrombocytopenia, hypo­ fibrinogenemia, and D-dimer fragments appear to be the most sensitive in making a laboratory diagno­ sis.28,29,32 In addition to the coagulation abnormalities, microangiopathic hemolytic anemia is present with fragmented RBCs (schistocytes) on the peripheral blood smear.28 The primary management strategy in patients with DIC consists of aggressive basic support measures and prompt treatment of the underlying process causing the DIC.25,28,33 When this is not possible, when treatment of the underlying disease accentuates the DIC, or when the DIC is progressing despite appropriate treatment of the underlying process, the general approach is to support the patient’s hemostatic system with the trans­ fusion of FFP, cryoprecipitate, or platelets.28 The idea that this approach will add to the consumption coagu­ lopathy has never been clinically proven. If hemorrhage is excessive, replacement with packed RBCs is advised. When the underlying process is not immediately con­ trollable, or when intensive blood replacement therapy does not improve clinical parameters, heparin infusion may be beneficial.34

Primary Fibrinogenolysis Primary fibrinogenolysis is the condition in which the fibrinolytic pathway is activated independent of the activation of coagulation. This process results in the pathologic degradation of fibrinogen and fibrin by plasmin. Urologic conditions associated with abnormal activation of fibrinolysis are metastatic malignant disease (primarily prostate cancer) and infections.35 In patients with metastatic carcinoma, the tumor cells are presumed to release a substance that directly activates fibrinolysis.27 Patients do not typically present with gross bleeding but are at significant risk for hemorrhage resulting from hypofibrinogenemia. Marked thrombocytopenia should

raise the suspicion of the development of DIC. The major laboratory discriminant between primary fibrino­ genolysis and DIC is the absence of an elevated level of D-dimer. Once active bleeding develops, it is very dif­ ficult to distinguish the two entities because fibrin is generated through the action of thrombin and lysis of fibrin produces D-dimers.27 Unlike in DIC, the treatment of choice of primary fibrinogenolysis is the use of antifibrinolytic agents, such as ε-aminocaproic acid or tranexamic acid.27,35,36 Transfusion support with cryoprecipitate may also be given for severe hypofibrinogenemia. If DIC has devel­ oped, the use of antifibrinolytic agents in the absence of systemic anticoagulation (heparin) is contraindicated because of the risk of increased microvascular throm­ bosis. The best approach in individuals with primary hyperfibrinogenolysis secondary to malignant disease is often aggressive treatment of the underlying malignant condition. Caution should be used in balancing chemotherapy-related bone marrow suppres­ sion with bleeding complications resulting from fibrinogenolysis.

Vitamin K–related Disorders Liver disease and vitamin K deficiency are common causes of abnormal coagulation tests and clinical coagulopa­ thies. The pathophysiology of these disorders is the decreased production of vitamin K–dependent clotting factors (factors II, VII, IX, X) and of proteins C and S. Of all these changes, a decrease in factor VII is the most common because of its short half-life (6-10 hours). The liver is the major source of all coagulation proteins except factor VIII and vWF. Liver disorders may also produce abnormalities in fibrinolysis.37,38 Primary vitamin K deficiency is extremely rare in healthy people. A wide variety of animal and plant sources can provide sufficient vitamin K, and the bacterial flora in the intes­ tine is able to synthesize a significant portion of the required dietary vitamin K. Vitamin K is fat soluble, and therefore adequate bile salt circulation is necessary for absorption. Vitamin K deficiencies can result from a wide range of conditions. These include, but are not limited to, the following: 1. Newborns, owing to poor transfer of vitamin K by the placenta and lack of vitamin K synthesis in the initially sterile intestine 2. Severe malnutrition or total parenteral nutrition 3. Extrahepatic biliary obstruction 4. Intestinal malabsorption syndromes 5. Broad-spectrum antibiotic use The liver also synthesizes factor V, which plays a critical role in fibrin generation. Significant impairment of hepatic synthetic function may result in the decreased

Chapter 4  Hematologic Complications production of any of these clotting factors despite normal vitamin K status. Patients with liver disease or vitamin K deficiency initially have isolated prolongation of the PT resulting from a depletion of factor VII without any signs of clini­ cally significant bleeding. In more severe deficiencies, the PTT can also be elevated because of depletion of factors II, IX, and X. A marked reduction in fibrinogen solely on the basis of decreased synthesis is an ominous sign and suggests very severe liver disease. Patients with long-standing liver disease develop portal hypertension, which may result in splenic pooling of platelets. A valu­ able assessment of liver synthetic function is the mea­ surement of albumin or cholesterol. In a patient with vitamin K deficiency and no evi­ dence of active bleeding, observation with repletion of vitamin K is indicated. Vitamin K may be administered orally, subcutaneously, intramuscularly, or intrave­ nously. Of these routes of administration, the safest and most reliable is subcutaneous injection as long as the patient’s cutaneous perfusion is adequate. However, this route may take 12 to 36 hours for PT correction. Studies have assessed the risk of anaphylactic reaction when vitamin K is given intravenously, and although the actual number of reports is low, prudent administration is recommended.39 The response to vitamin K may be poor in the presence of liver disease. Patients who fail to respond to vitamin K, who demonstrate increasing abnormalities of PT or PTT, or who are to undergo an invasive procedure may be treated with FFP infusions. Given the short half-life of factor VII, aggressive support with FFP every 6 hours in the perioperative period is generally necessary to produce sustained correction in clotting.40

Massive Transfusion Syndrome Massive transfusion syndrome results from replacement of total blood volume in 5  U of blood. The key element in making the diagnosis is the transfusion history. Treatment of this disorder is replacement of clotting factors by FFP and of platelets with platelet transfusions. However, the best treatment is avoiding the situation, and this can be achieved by transfusion of 1  U of FFP and platelets for every 5 U of packed RBCs transfused. In individuals with continued or excessive blood loss, empirical treatment with FFP or platelets may be advis­ able. In the absence of uncontrolled or continued bleed­

ing, it is acceptable to hold the use of FFP and platelets unless they are clinically indicated for postoperative bleeding.

ANTICOAGULATED PATIENT Patients receiving chronic anticoagulation therapy who require a urologic procedure represent a challenge to the urologist. Perioperative management of these patients should be aimed at minimizing both surgical and medical risks. To accomplish this goal, the urologist must have an understanding of the indication for anti­ coagulation therapy, the consequence of withholding the therapy, and the pharmacologic mechanism of action of the particular anticoagulation medication.42 The most common indications for chronic antico­ agulation include venous thromboembolism (VTE), mechanical prosthetic heart valves, and chronic atrial fibrillation. In addition, the urologist is seeing more and more patients who are managed on antiplatelet therapy following the placement of metallic cardiac stents, particularly drug-eluting stents. Discussion of VTE is addressed later in this chapter. Mechanical prosthetic heart valves require anticoagulation secondary to the risk of thrombotic complications including systemic embolization and occlusive thrombosis. Patients with atrial fibrillation require anticoagulation because of their six times normal increased rate of stroke.42 A discussion of commonly used anticoagulation agents should include aspirin (acetylsalicylic acid [ASA]), warfarin, heparin, and now clopidogrel (Plavix). ASA exerts its anticoagulant effect by inhibiting platelet aggregation by inhibiting thromboxane A production. This effect is irreversible and lasts for the life of the platelet, which is approximately 7 to 10 days. Therefore, patients taking ASA who are undergoing an elective procedure should discontinue ASA for approximately 10 days before the procedure. In theory, if the platelet count is normal and 20% of the platelets are ASA free, near-normal hemostasis can be achieved, and it has been suggested that ASA can be discontinued 3 days before the procedure. Typical patients taking ASA include those with coronary artery disease, those with a history of stroke, and some patients with atrial fibril­ lation. Discontinuing ASA in these patients for a uro­ logic procedure is often of minimal risk, and ASA treatment can be restarted as soon as reasonable after the procedure. Although the urologist now faces an aging popula­ tion of patients, many of whom are taking clopidogrel as a result of prior cardiac stent placement, guidelines have yet to be established regarding the safety of cessa­ tion of this drug, even for a short time. Most patients who have had a drug-eluting cardiac stent placed are advised to take lifelong antiplatelet therapy. Each case needs to be addressed individually, however, and the risk-to-benefit ratio of stopping the medication must be

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38

Section I  Nonurologic Complications of Urologic Surgery weighed against the necessary planned procedure. In any event, this decision needs to involve the urologist, the cardiologist, and often a hematologist. Warfarin exerts its anticoagulant effect by inhibiting vitamin K–dependent procoagulation factors II, VII, IX, and X and anticoagulant proteins C and S. Warfarin’s effect usually occurs 2 to 3 days after initiation of therapy because of the prolonged half-life of the differ­ ent procoagulant factors; factor II has the longest halflife (72 hours). In the past, the PT was used to measure the effect of warfarin, but because of variability in PT measurements the INR (international normalized ratio) is currently used. The therapeutic range for all antico­ agulant indications is 2 to 3, except for prosthetic mechanical heart valves for which an INR of 2.5 to 3.5 is recommended. Most procedures can be performed safely when the INR is 1.4 or less. Warfarin is used in patients with prosthetic heart valves, atrial fibrillation, and a history of stroke as well as in preventing recurrent myocardial infarction and death in patients with an acute myocardial infarction.43 However, the most common indication for warfarin therapy is manage­ ment of patients with VTE. The management of patients taking warfarin who require an invasive procedure depends on the proce­ dure, the risk of bleeding, and the risk of thromboem­ bolism once the warfarin is stopped. Patients who are at lower risk such as those with atrial fibrillation can often discontinue the warfarin, allow the INR to correct, and restart therapy when it is clinically safe following the procedure. For those patients at higher risk for a thromboembolic event, including patients with a mechanical prosthetic mitral valve and patients with a mechanical prosthetic valve and atrial fibrillation or left ventricular dysfunction, should discontinue warfarin 3 to 5 days before admission and start heparin therapy once the INR is 90% for detecting proximal vein thrombosis.77,78 It is less invasive than the gold standard diagnostic test, contrast venography, and is more accurate than imped­ ance plethysmography.67 If the initial ultrasound finding is abnormal, then a diagnosis of DVT can be comfortably made. Conversely, when the test result is normal, one cannot completely rule out the possibility of a DVT. Ginsberg, in a review of DVT management, recom­ mended a repeat ultrasound study for those patients with clinically suspected DVT who had normal findings on their initial ultrasound examination.67 Because of the difficulty of definitively diagnosing DVT definitively, attempts have been made to develop strategies to accomplish this without the need for repeat testing. One investigated strategy involves measuring plasma D-dimers, often in combination with imped­ ance plethysmography or other assays.78 More extensive work needs to be conducted in this area before this approach can become standard practice. The diagnosis of acute PE is also difficult given the wide range of presentation (see Chapter 2).59,79,80 More recent approaches, such as use of the Wells score, have suggested using a D-dimer test and categorizing patients as having a low, intermediate, or high probability of PE.81 When the index of suspicious is high, particularly in patients in the postoperative period, a spiral com­ puted tomography (CT) scan is warranted and is con­ sidered by most clinicians to be the standard initial diagnostic test. At present, we often employ spiral chest CT as a first test for PE. If results are negative, then we proceed with pulmonary angiography only if a strong clinical suspi­ cion still exists for PE. A potential shortcoming of both spiral CT and pulmonary angiography is the need for a large bolus of IV or intra-arterial contrast material. In individuals with preexisting renal compromise, a venti­ lation-perfusion scan is clearly the best first test to consider. Newer modalities for diagnosis and exclusion of PE have been evaluated. These techniques include ventila­ tion-perfusion single photon emission CT (SPECT), single-detected and multi-detected CT, and magnetic resonance angiography (MRA) with gadolinium enhancement and perfusion magnetic resonance imaging (MRI).82 Real-time MRI has been suggested for patients in whom contrast studies should be avoided or who have renal failure.82 MRA may be used more in the future as techniques are improved and more data become available.

Management The goals of treating thromboembolic disease are to prevent further propagation of the thrombus, to prevent embolization of the thrombus, and in certain situations

to promote fibrinolysis. Once the diagnosis is made, then anticoagulation therapy should be instituted unless a contraindication exists. If the patient is hemo­ dynamically unstable or has extensive ileofemoral DVT, thrombolytic therapy may be considered. This therapy usually entails the use of streptokinase (SK), urokinase (UK), or tissue plasminogen activator (tPA). The use of thrombolytic therapy is limited by the associated increased risk in major bleeding, especially in the post­ operative patient. The Food and Drug Administration currently recommends two regimens for thrombolytic therapy: (1) IV SK with a bolus of 250,000 U followed by an infusion of 100,000 U/hour for ≤72 hours for the treatment of DVT; and (2) 100 mg IV tPA over 2 hours for the treatment PE.67,67a Again, thrombolytic therapy should be reserved for those patients with hemody­ namic instability, extensive disease, and low risk of bleeding. If the patient is not hemodynamically unstable, then heparin therapy should be instituted immediately on confirmation of DVT. Various regimens for the admin­ istration of IV unfractionated heparin have been devel­ oped, are based on weight or dose titration nomograms.67 An APTT of 1.5 to 2.5 times the control is recommended. Furthermore, attempts should be made to achieve thera­ peutic APTT values as rapidly as possible because persis­ tent subtherapeutic values likely increase the risk of DVT recurrence. Heparin therapy is usually maintained for 4 to 7 days. Warfarin therapy is started 24 hours after heparin therapy and is monitored by INR with a goal of 2.0 to 3.0 times control. The clinician should confirm that the patient has no evidence of major bleeding with a therapeutic APTT before warfarin therapy is instituted. Heparin therapy can be discontinued once therapeutic levels of INR have been achieved for 2 days. The dura­ tion of treatment is determined by the risk for future thromboembolic disease. Patients with a first episode of thromboembolic disease and a reversible risk factor such as surgery should be treated for 6 weeks to 3 months (depending on the severity of the episode). As described later, patients with idiopathic thromboem­ bolic disease should be treated for 3 to 6 months. Longer and, in certain instances, indefinite treatment is recom­ mended in patients with a predisposition for recurrent venous thrombus. Complications of heparin therapy include bleeding, thrombocytopenia with and without thrombosis, osteo­ porosis, skin necrosis, and less common complications including anaphylaxis, hypoaldosteronism, and alope­ cia.59,83 Similar complications are associated with warfa­ rin therapy; bleeding is the most common. Particular attention should be paid to concomitant medications that may interact with warfarin and affect INR, the most prevalent of which are fluoroquinolones, macrolides, and sulfonamides in the treatment of urologic patients.84,85

Chapter 4  Hematologic Complications Because of potential complications, alternative anti­ coagulation regimens have been sought. Several studies have been conducted in the past 2 decades to evaluate LMWH. LMWHs are synthesized from larger unfraction­ ated heparin molecules by enzymatic or chemical de­polymerization.86-89 The advantages of LMWH include superior bioavailability, lower incidence of bleeding, lower incidence of heparin-induced thrombocytopenia, ease of administration and monitoring (subcutaneous once or twice daily), and the availability of outpatient use.86,87 Several trials comparing LMWH with unfrac­ tionated heparin concluded that LMWH significantly reduced recurrence, had a superior relative risk reduc­ tion of thromboembolic complications, and incurred a statistically significant reduction in bleeding.87,90 Although the actual cost of LMWH is 10 to 20 times that of unfractionated heparin, the potential lower complication rates, the reduced need for laboratory and hospital monitoring, and the availability of outpatient treatment may make LMWH a more cost-effective alter­ native. For these reasons, LMWH is preferable to unfrac­ tionated heparin in most settings.87 For those patients with a contraindication to antico­ agulation therapy, an inferior vena caval filter can be considered. However, no definitive evidence confirms the efficacy of these devices in preventing PE. Surgical intervention (i.e., thrombectomy) has been replaced by thrombolytic therapy. The only definitive indication for surgical thrombectomy is in a patient with chronic thromboembolic pulmonary hypertension or in a patient with a massive PE and a contraindication to thrombolytic therapy. Because of the significant morbidity and mortality associated with thromboembolic disease, prevention is critical, especially in the surgical patient. Radical pelvic surgery is considered to be a serious risk factor for post­ operative DVT; it is associated with a DVT rate of approximately 30% and PE rate of 10% in patients without prophylaxis.65 With prophylaxis, these rates decrease to 10%, and 1.5% respectively. However, cur­ rently no large, randomized prospective studies have examined various methods of prophylaxis in the uro­ logic patient. Chandhoke and colleagues91 conducted a prospective randomized study comparing warfarin and intermittent pneumatic leg compression as prophylaxis for postoperative DVT in the urologic patient and con­ cluded that low-dose warfarin is as effective as is inter­ mittent pneumatic leg compression. Unfortunately, this study involved only 100 patients. Based on data in general and orthopedic surgical patients, Clagget and associates91a developed a general strategy for prevention based on a patient’s risk. For the low-risk patient (40 years old; undergoing major surgical procedures; no other risk factors) should receive low-dose unfractionated heparin

at a dose of 5000 U subcutaneously 2 hours preoperatively and then postoperatively every 8 hours or intermittent pneumatic compression (IPC) stockings during and after surgery. IPC stockings not only increase blood flow but also promote fibrinolysis. Low-dose unfractionated heparin, LMWH, or use of IPC stockings is recommended for high-risk patients (>40 years old; undergoing major surgical procedures; and additional risk factors). High-risk patients with a history of previous VTE, malignant disease, orthopedic surgery, hip fracture, stroke, or spinal cord injury should receive LMWH, oral anticoagulation, IPC stockings, or adjusted-dose heparin given at a dose of 3500 U three times a day beginning 2 days preoperatively to maintain an APTT at the upper limit of normal. We routinely use IPC stockings in all patients under­ going open pelvic surgery, particularly for malignant disease. Individuals with bulky pelvic malignant tumors should be evaluated preoperatively for the presence of a preexisting DVT before the placement of IPC stock­ ings. IPC stockings are placed before the induction of anesthetic and muscle relaxation and are maintained until the patient is ambulating on a regular basis post­ operatively. In patients undergoing flank surgery, the decision to use IPC stockings is based on the anticipated length of the procedure. Given the position of the patient during flank surgery, we generally employ IPC stockings in most patients. A review of 5900 patients undergoing laparoscopic prostatectomy showed that only 31 developed symp­ tomatic VTE within 90 days of the surgical procedure. The investigators found that prior DVT, current tobacco smoking, larger prostate volume, longer operative time, and longer hospital stay were associated with VTE in univariate analysis. The data did not support the routine use of heparin prophylaxis in this multi-institution study.92 A topic of concern is late thromboembolic complica­ tions. In the past, it was believed that DVT occurred in the first 3 postoperative days and that prophylaxis was indicated during that period. More recent studies, however, suggested that significant numbers of DVT and PE cases occur after hospital discharge. Huber and associates93 determined that ≤25% of DVT and 16% of PE occurred after hospital discharge. This finding of late DVT has been noted in urologic patients as well. In a series reviewing postoperative complications in patients undergoing radical retropubic prostatectomy, investiga­ tors noted that DVT was diagnosed an average of 12 days postoperatively.73 Late thromboembolism is thought to result from a prolonged hypercoagulable state that extends beyond the period of prophylaxis. Such prolonged states may be of particular concern in patients at prolonged bed rest or with concurrent malig­ nant disease. Unfortunately, the trend toward mini­ mally invasive surgical procedures and earlier hospital discharge may make addressing this question more difficult.

43

44

Section I  Nonurologic Complications of Urologic Surgery

KEY POINTS 1. Although routine preoperative coagulation defect screening is not shown to be cost effective, we have continued its use in patients at risk of sig­ nificant bleeding during a planned procedure. 2. Anemia can affect surgical outcomes and should be corrected whenever possible before elective surgical procedures. 3. Individuals undergoing elective surgical proce­ dures should discontinue the use of ASA, clopi­ dogrel, or NSAIDs a full 7 to 10 days preoperatively to allow normalization of platelet function. 4. In patients with drug-eluting coronary stents, or specific indications for anticoagulation, the risk of stopping anticoagulation should be weighed against the risk of intraoperative bleeding, depending on the planned procedure. 5. Patients with an abnormal preoperative PTT value and no history of anticoagulation should undergo careful evaluation for clotting factor deficiency. 6. The distinction between DIC and primary fibri­ nogenolysis is essential because treatments are

REFERENCES Please see www.expertconsult.com

distinct and antifibrinolytic therapies are contra­ indicated in DIC. 7. In patients with certain risk factors for a hyper­ coagulable state, and in patients at risk for venous thrombosis, evaluation for factor deficiency or lupus anticoagulant is indicated. 8. The risk factors for venous thrombosis can be thought of in the context of Virchow’s triad for the pathophysiology of thrombus formation (stasis, hypercoagulability, and intimal injury). 9. VTE prophylaxis recommendations should be risk adjusted. 10. High-risk patients with a history of previous VTE, malignant disease, orthopedic surgery, hip frac­ ture, stroke, or spinal cord injury should receive VTE prophylaxis in the form of LMWH, oral anticoagulation, IPC stockings, or adjusted-dose heparin given at a dose of 3500 U three times a day beginning 2 days preoperatively to maintain an APTT at the upper limit of normal.

Chapter 

5 

METABOLIC COMPLICATIONS OF UROLOGIC SURGERY Niels-Erik B. Jacobsen

MD, FRCSC Fellow, Urologic Oncology, Department of Urology, Indiana University, Indianapolis, Indiana

Michael O. Koch

MD Professor and Chairman, Department of Urology, Indiana University, Indianapolis, Indiana

Implicit with the medical and surgical management of genitourinary disorders, metabolic complications are commonly encountered in urologic practice. To facilitate the diagnosis, management, and prevention of such complications, the urologist must maintain a firm understanding of the pathophysiology involved. This chapter provides an in-depth discussion of metabolic complications commonly encountered as sequelae of urologic surgery, including transurethral resection (TUR) syndrome, post-obstructive diuresis (POD), and metabolic complications of urinary diversion. Additionally, special consideration is given to the perioperative management of patients with chronic kidney disease (CKD).

PERIOPERATIVE MANAGEMENT OF THE PATIENT WITH CHRONIC KIDNEY DISEASE CKD affects an estimated 35% of adults over the age of 20 years in the United States.1,2 It is associated with numerous complications and comorbid conditions that, together, pose a definite morbidity and mortality risk. Fortunately, adverse outcomes from renal insufficiency can be delayed or prevented through appropriate monitoring and early treatment. As such, it is essential that the urologist maintains a basic understanding of the pathophysiology of CKD, particularly as it applies to perioperative management.

Definition of Chronic Kidney Disease In 2002 the Kidney Disease Outcome Quality Initiative (K/DOQI) Working Group of the National Kidney Foundation defined CKD according to the presence of objective renal damage (e.g., proteinuria >300 mg/day) or a glomerular filtration rate (GFR) below 60  mL/min/1.73 m2 for >3 months.2 GFR, the best measure of overall renal function, represents the product of the number of functioning nephrons and single-nephron

GFR. GFR can be estimated using the Cockcroft-Gault equation for creatinine clearance. Normal reference levels of GFR vary with age, gender, and body size. A GFR of 60 mL/min/1.73 m2 represents roughly half the normal adult GFR. The K/DOQI definition makes allowance for the normal age-related decline in GFR (~1 mL/min/1.73 m2 per year) that occurs after the age of 20 or 30 years. Irrespective of GFR, all patients with objective evidence of kidney damage are considered to have CKD because they remain at risk for progressive loss of renal function and related complications (Table 5-1). CKD is classified into five stages according to GFR (Table 5-2). Although the cut-off values between stages are arbitrary, the prevalence and severity of complications associated with CKD worsen as GFR declines.

Management of Comorbidities and Complications The numerous complications and comorbid conditions associated with CKD may negatively impact patient outcome independent of the renal dysfunction itself (see Table 5-1). Each deserves individual consideration and management so as to minimize the potential for adverse events in the perioperative period. Diabetes mellitus and hypertension represent the first and third leading causes of end-stage renal disease (ESRD), respectively.3 New-onset or worsening hypertension, secondary to hypervolemia and stimulation of the renin angiotensin system, also represents a common complication of CKD.4 Strict glycemic control and optimization of blood pressure are obvious goals in the perioperative period. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) are first-line anti-hypertensive agents used in this setting; their use is based on studies that demonstrate effective blood pressure control and reduced risk of progression to ESRD in both diabetic and nondiabetic CKD patients.5,6 Diuretics, followed by calcium 45

46

Section I  Nonurologic Complications of Urologic Surgery channel or beta-blocking agents, may be added if blood pressure remains high despite ACE inhibitors or ARBs.7 Loop diuretics are preferred over thiazides if the GFR is 7 + bother

Medical therapy (α-blockers, 5α-reductase inhibitors) Surgical treatment (radical prostatectomy, transurethral prostatic resection)

AUASI, American Urological Association Symptom Index. Adapted from Shekelle PG, MacLean CH, Morton SC, et al. Assessing care of vulnerable elders: methods for developing quality indicators. Ann Intern Med. 2001;185(8 Pt 2):647-652.

gators stressed the importance of establishing a validated relationship between process and outcome as well as the use of prospectively collected data to augment that of clinical databases. According to Peskin,109 QOC assessment has been particularly difficult for surgeons. The importance of understanding relationships among structure, process, and outcome to creating a valid quality indicator is well understood. However, most researchers have not yet established the strength of such associations when measuring surgical care quality. Structure and process indicators have been largely ignored, whereas outcomes based on morbidity and mortality have been the primary QOC measures for surgical procedures.109 Hammermeis-

Chapter 19  Assessing Quality of Care in Urologic Surgery ter and associates110 noted the inadequacies of relying solely on outcome-based quality indicators, mortality in particular, in assessing quality of surgical care, including the small number of deaths providing limited power for statistical analyses, the difficulty in measuring nonfatal outcomes, and the chance of failing to capture longterm outcomes. Nevertheless, most QOC research to date in urology has focused only on hospital and surgeon volume indicators. With the current exponential growth of health care costs, we should anticipate that interest in health services delivery, as a major cost center, will only increase. By participating in larger efforts such as PCPI and PQRI, urologists will have greater input on national policies related to health care delivery. Failure by urologists to participate in the development and implementation of QOC programs could result in significant financial penalties to individual physicians and institutions. More importantly, if urology as a specialty ignores the impending QOC trends and national efforts, it is likely that other nonurologic specialty interests will prevail and will increasingly dictate urologic care.

KEY POINTS 1. Decreased mortality rates and fewer complications have been well documented in hospitals with high surgical volume, a finding that supports the concept of centers for excellence. 2. Outcome is the presumed result of core processes and is often considered the quality indicator of most value to the patient. 3. Studies using administrative databases have generally found relationships between hospital or surgeon volume and outcome. 4. The general paucity of level I clinical evidence for various definitive therapies has resulted in significant variations in the utilization of RP, a finding that raises important questions regarding quality discrepancies. 5. BPH treatment decisions are typically driven by quality of life considerations.

REFERENCES Please see www.expertconsult.com

223

Chapter 

20

COMPLICATIONS OF THE INCISION AND PATIENT POSITIONING Matthew K. Tollefson

MD Fellow in Urologic Oncology, Department of Urology, Mayo Clinic, Rochester, Minnesota

Stephen A. Boorjian

MD Fellow in Urologic Oncology, Department of Urology, Mayo Clinic, Rochester, Minnesota

Bradley C. Leibovich

MD Associate Professor, Department of Urology, Mayo Clinic, Rochester, Minnesota

Successful surgical therapy depends on proper healing of the surgical wound. Problems with wound healing can lead to seromas, hematomas, surgical site infections (SSIs), dehiscence, and incisional hernias. In addition, nerve injuries related to patient positioning or retractor placement may affect postoperative mobility. All these complications increase morbidity and can contribute to mortality in surgical patients. Complications related to the incision are important for all surgeons to be aware of because they are among the most common complications following operative procedures. Often, these complications are relatively minor and may resolve with conservative management (e.g., simple wound seromas or hematomas). However, at times they may be expensive and time-consuming (e.g., complicated wound infection), may require additional surgical procedures (e.g., incisional hernia), or may cause permanent disability (e.g., postoperative neurapraxia). Therefore, management of these complications is focused on prevention, as well as prompt recognition and appropriate treatment. The objective of this chapter is to review common complications of the incision with respect to their pathogenesis, clinical features, prevention, and management.

SEROMA Pathogenesis and Clinical Features One of the most common and likely underreported complications following operative procedures is the development of a wound seroma. Although typically a benign finding, when not treated, seromas may lead to more serious wound infections, wound breakdown, or potentially skin necrosis. A seroma is a collection of

sterile, clear, ultrafiltrated serum, lymphatic fluid, or liquified fat.1 The fluid is usually clear, amber, and slightly viscous. Seromas are located under the incision, above the fascial layer, and directly beneath the dermis of the skin. They are more likely to occur when large tissue flaps are mobilized or when extensive lymphadenectomy is performed, such as during axillary2 or inguinal lymph node dissection.3 Thus, efforts to limit the extent of dissection where feasible without compromising cancer control such as sentinal lymph node procedures4 or preservation of the saphenous vein during inguinal lymphadenectomy5,6 may reduce the risk of seroma formation.

Prevention and Management Most postoperative seromas are discovered incidentally and require no active intervention. However, when large or symptomatic, seromas can be evacuated by opening the overlying skin edges, packing the wound with sterile saline-soaked gauze, and allowing the wound to heal by second intention. Seromas that develop under flaps (i.e., after inguinal lymph node dissection), however, may be more difficult to manage because these have the potential to damage the delicate vascular supply to the flap. Therefore, in incisions that involve extensive skin flaps, placement of closed-suction drains is typically performed and recommended. These drains are left in place until their output decreases to a minimal amount (typically 2 weeks postoperatively may often be watched with delayed repair of the resultant incisional hernia, because the risk of evisceration is very low in such patients. Unfortunately, wound dehiscence frequently occurs without warning. Up to 80% of the time, it manifests as sudden, dramatic drainage of a large volume of clear, serous fluid from the incision. Patients may also note a pulling or ripping sensation. This often occurs when the patient is standing or changing positions, because the pressure on the incision is greatest at these times. The diagnosis is then confirmed by gently probing the incision with a sterile, cotton-tipped applicator to determine the integrity of the fascia. If clinical suspicion remains despite equivocal physical examination findings, imaging studies such as ultrasound or computed tomography can be used. When a large segment of the incision is open, immediate plans for closure in the operating room should be made. In the event of evisceration, the eviscerated intraperitoneal contents should be covered with a sterile saline moistened towel until an emergency operation can be performed.

Preoperative Risk Factors

Intraoperative and Postoperative Risk Factors

Malnutrition

Technical error with fascial closure

Anemia

Emergency procedures

Hypoproteinemia

Wound complications (infection, seroma, hematoma)

Obesity Comorbid disease (e.g., diabetes, renal failure, chemotherapy, irradiation) Increased intra-abdominal pressure (e.g., coughing, straining, ascites)

Numerous factors can contribute to wound dehiscence (Table 20-3). However, despite advances in suture material and perioperative care, the incidence of abdominal fascial dehiscence has remained steady at nearly 1% of abdominal wounds.42,43 Other factors that contribute to wound dehiscence remain. Obesity, for example, is associated with increased difficulty in identifying the fascia and in closing the incision. Corticosteroids, over long periods, can decrease the tensile strength of healing wounds.44 Patients with cancer are more likely to have problems with wound healing, because these patients are more likely to have a contaminated wound and have undergone previous irradiation or chemotherapy.45 Radiation causes obliterative sclerosing endarteritis that can decrease the microvascular arterial supply to the wound.46 Malnourished patients nearly uniformly have decreased protein synthesis and turnover, which lead to poorer fascial integrity. Finally, diabetic patients encounter more healing problems than do patients without diabetes and have a greater risk of wound dehiscence.41 The likely reason is that diabetic patients have less collagen synthesis and deposition, decreased wound breaking strength, and impaired leukocyte function.

Suture Selection and Technique Wounds have 70 years, operative time >180 minutes, and improper positioning were cited as risk factors for neurologic injury.103 These findings were supported by a separate investigation, which noted lower extremity neuropathies in 1.5% of 991 patients undergoing procedures in the lithotomy position and found that prolonged (>2 hours) positioning in the lithotomy position was a risk factor for injury.105 A previous study reported postoperative neurapraxia in 21% of patients undergoing perineal prostatectomy using the exaggerated lithotomy position.106 Positioning-related nerve injuries in the lithotomy position have been attributed to overflexion of the hips and knees, which causes stretching and compression of the nerves. For example, hyperabduction of the thighs with external rotation of the hips may lead to injury of the femoral nerve secondary to ischemia from compression of the nerve beneath the inguinal ligament. Presentation, management, and prevention of femoral nerve injuries have been discussed. The sciatic nerve, meanwhile, is the largest nerve in the body and arises from the fourth lumbar through the third sacral nerve roots of the lumbosacral plexus. The sciatic nerve then exits the pelvis through the sciatic foramen and travels through the thigh before dividing in the popliteal fossa into the common peroneal and tibial nerves. The sciatic nerve functions to provide cutaneous innervation to the foot and leg, as well as motor innervation of the biceps femoris (hamstring muscle), leg, and foot.107 Excessive stretching of the sciatic nerve by overflexion of the hip and extension of the knee during establishment of the lithotomy position or by shifting of the patient during the procedure may result in injury. In particular, investigators have suggested that excessive hip flexion in the lithotomy position may compress the nerve as it passes through the sciatic notch, thus potentially resulting in ischemic neuropathy.108,109 The potential sequelae of sciatic depend on the location of the insult along the course of the nerve. Injury to the thigh portion of the sciatic nerve, for example, results in difficulties with flexion of the leg, whereas disruption of the tibial nerve abolishes the ankle jerk reflex. The common peroneal nerve, meanwhile, arises from the sciatic nerve behind the knee and then wraps around

the head of the fibula before separating into the superficial peroneal, which provides sensory innervation to the lateral leg, and the deep peroneal, which provides motor innervation to the tibialis anterior that allows dorsiflexion of the foot. Because this nerve is very superficial when it crosses the head of the fibula, it may easily be compressed and injured at this point (i.e., by direct contact of the leg against an immobile, hard support). Therefore, padding the lateral leg supports during positioning for lithotomy procedures is recommended. Injury to the peroneal nerve most commonly manifests as foot drop, resulting from an inability to dorsiflex the foot. In addition, patients may experience numbness of the lateral aspect of the lower leg and dorsum of the foot.109 Overall, nerve injuries during procedures in the lithotomy position may be minimized by careful attention to proper patient positioning, including padding of exposed peripheral nerves, avoiding unnecessary tension on the hips and knees by checking to see that the muscles of the lower extremity are not taut after the lithotomy position is established, and minimizing operative times. Modifications in stirrup design have also been proposed to help minimize the complications of lithotomy positioning.110

KEY POINTS   1. Large hematomas that collect in the retroperitoneum or rectus sheath may cause paralytic ileus, anemia, and ongoing bleeding resulting from the consumption of coagulation factors.   2. Wounds that involve large skin flaps or those with large potential spaces in which blood could collect should be drained with a closed-suction surgical drain until the output of these drains decreases.   3. Intraoperative strategies to prevent wound infection include aseptic technique to reduce the microbial inoculum as well as good surgical practice to minimize dead space and devitalized tissue.   4. Antibiotic prophylaxis is recommended for all class II (clean-contaminated) wounds and for class ID (clean) wounds in which prosthetic material or a vascular graft is implanted because the consequences of infection are serious in these instances.   5. Severe infections, such as necrotizing fasciitis, represent surgical emergencies and patients should be taken immediately back to the operating room for wide débridement.   6. The use of vacuum-assisted closure should be limited when wounds are near conduits, anastomoses, and neobladders because this technique may be associated with an increased rate of cutaneous fistula formation.

235

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Section IV  Common Surgical Considerations

  7. If clinical suspicion of dehiscence remains despite equivocal physical examination findings, imaging studies such as ultrasound or computed tomography can be used.   8. Investigators have demonstrated that wounds that have been closed with a suture length that is twice as long as the wound have a higher rate of wound dehiscence than do wounds closed with suture that is four times the length of the wound.   9. Although brachial plexus injuries have been reported to result from excessive extension and

REFERENCES Please see www.expertconsult.com

external rotation during surgical procedures in the supine position, including radical prostatectomy, most brachial plexus injuries occur during procedures in the flank position, which is commonly used for procedures involving the kidney and retroperitoneum. 10. Retractor injuries to the femoral nerve occur when the blades of the retractor are placed directly on the psoas muscle, where they may compress the nerve directly or indirectly by trapping the nerve against the lateral pelvic wall.

Chapter 

21

MANAGEMENT OF VASCULAR COMPLICATIONS Venkatesh Krishnamurthi

MD Director, Kidney/Pancreas Transplant Program, Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio

Rodrigo Frota

MD Fellow, Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio

Burak Turna

MD Fellow, Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio

Knowledge of the management of vascular problems is a fundamental requirement for all surgeons. Although most urologic operations are not performed to correct vascular conditions, familiarity with the specific vascular complications that can arise during abdominal and pelvic surgery is essential. The best approach to managing vascular complications is to prevent them. This principle is best accomplished by thorough knowledge of the operation, relevant anatomy, and application of precise surgical technique. Occasionally, unexpected vascular complications arise and require intraoperative attention and correction. The objective of this chapter is to review the common vascular complications that occur during abdominal and pelvic urologic procedures and their respective management. The techniques described herein are not the only available methods but are chosen based on our (Krishnamurthi’s) personal observations and experiences in practice in urologic and transplantation surgery.

VASCULAR INSTRUMENTATION Proper instruments and fine suture needles are paramount to the performance of successful vascular reconstruction. Although the specific instrument is a matter of individual preference, instrumentation for vascular surgical procedures should include the following: 1. Noncrushing vascular clamps designed for blood vessel occlusion 2. Forceps with fine tips designed to atraumatically grasp vessel walls as well as suture needles 3. Needle holders with fine tips to grasp small needles, yet, prevent unwanted needle movement

4. An assortment of Silastic vessel loops and umbilical tapes for atraumatic vessel manipulation Vascular clamps are designed to occlude blood vessels in a noncrushing, atraumatic fashion. They are manufactured in a variety of shapes and sizes, and their selection depends on the size of the vessel to be occluded and the desired direction of vessel wall occlusion (longitudinal, transverse, or oblique). The jaws of vascular clamps should have rows of interdigitating teeth that allow vessel wall apposition without endothelial damage. Vascular clamps should be applied by compressing the jaws only to the point necessary for blood flow cessation. Overaggressive application can result in endothelial damage and subsequent dissection. For small, delicate vessels or relatively inaccessible areas, spring-loaded (Bulldog) clamps are useful devices. These also come in a variety of sizes, strengths, and shapes. Additionally, plastic varieties with soft padded jaws may be useful for extremely delicate vessels. Vascular forceps must have tines that are in direct apposition, and the tips should be fine enough to grasp the vascular adventitia as well as a suture needle. Forceps with rows of interdigitating teeth serve to accomplish both of these purposes. In contrast, forceps designed for stable needle grasp such as diamond jaw forceps do not allow for reliable manipulation of tissue. Vascular needle holders should have fine tips to grasp fine suture needles. The two common choices in vascular needle holders are a ring-handled type (Scanlan or Ryder) needle holder and the spring-loaded type (Castroviejo or Jacobson needle holder) (Fig. 21-1). Needle holder selection, again, is a matter of individual preference; however, spring-loaded needle holders generally allow for precise needle placement without large degrees 237

238

Section IV  Common Surgical Considerations

BASIC VASCULAR TECHNIQUES General Principles of Vascular Dissection

Figure 21-1  Needle holders commonly used for vascular repairs.

of wrist rotation. Ring-handled needle holders enable a more stable needle grasp and facilitate accurate placement in deep structures or through densely calcified vessels. To some degree, the selection of vascular suture is also matter of individual preference. The caliber of the suture should be as fine as possible, without risking suture line disruption, to minimize bleeding through suture holes. In most cases, suture sizes ranging between 2-0 and 7-0 are applicable for vascular procedures in the abdomen and pelvis. At the level of the aorta, 2-0 or 3-0 suture should suffice, and 4-0 is almost always suitable for the inferior vena cava (IVC). As one progresses to smaller vessels, including the common and external iliac arteries and veins, 5-0 and 6-0 suture is most often satisfactory. Repair of small vessels, such as segmental renal arteries, may require 7-0 suture. Nonabsorbable sutures are most often selected for vascular procedures. Although silk suture has favorable handling and tying characteristics, its popularity waned with the development of synthetic, nonabsorbable sutures such as polypropylene. In comparison with silk, synthetic monofilament sutures are relatively inert in tissue, have a low coefficient of friction thereby resulting in less tissue drag, and tend to retain a greater amount of tensile strength over time. Vascular sutures are swaged onto fine, one-half–circle or threeeighths–circle needles. The vascular needle should be large enough to penetrate tissue yet small enough not to cause hemorrhage from the needle holes. A common practice in vascular repair is to use a continuous suture with needles swaged onto both ends. This construction allows for greater flexibility in accomplishing the repair (e.g., closure from both directions). In select instances, specifically in pediatric vascular surgery, absorbable monofilament suture with a long half-life (e.g., polydioxanone suture) can be used to allow anastomotic growth.

In planned vascular operations, exposure and control of blood vessels are typically the first orders of business. Both electrocautery and sharp dissection can successfully be used to expose blood vessels. Knowledge of the vascular anatomy and of the characteristic appearance of the correct dissection plane greatly facilitates proper vascular exposure. Blood vessels are enwrapped in a loose periadventitial sheath. Separation of this sheath from the vessel wall, which is identified by the characteristic vasa vasorum on the arterial wall, allows for circumferential dissection of the artery. In general, arteries should be exposed along the anterior surface because major branches are unlikely to arise from this direction. The artery can then be circumferentially exposed, and encirclement with a vessel loop will permit atraumatic mobilization of the vessel for division of its posterior attachments. While handling arteries, it is advisable to grasp only the adventitial tissues with forceps rather than compressing the part or all of the lumen. Traumatic application of forceps to the arterial lumen may result in intimal disruption with dissection or distal embolization of loose atheromatous plaques. Major veins often run adjacent to arteries and can be dissected in similar fashion. Grasping part (or all) of the vein wall is, in general, a safe maneuver and can greatly facilitate dissection of the vein from the surrounding tissues.

Control of Hemorrhage Unlike planned vascular operations, urologic procedures during which vascular complications occur require exposure of blood vessels in unplanned situations. Perhaps the most important principle in managing unexpected bleeding is that properly applied digital pressure can control virtually all abdominal and pelvic bleeding. Multiple attempts to use instruments, such as vascular clamps and hemostats, in a poorly exposed operative field carry significant risks of causing additional vascular injury and worsening the ongoing hemorrhage. Digital pressure should be applied by the first assistant while the primary surgeon and others obtain improved exposure by suctioning the field, focusing the lights, extending the incision, and repositioning the retractor. Once exposure has been improved, attention should be directed toward obtaining proximal and distal vascular control. After inflow and outflow vessels are identified and are suitably exposed, vascular clamps should be placed, and digital pressure on the area of hemorrhage should be slowly released such that the site of vessel wall injury can be inspected. If hemostasis has not been satisfactorily achieved to allow for suitable inspection, these steps should be

Chapter 21  Management of Vascular Complications repeated until the site of injury can be fully examined. Attempts to place suture through poorly exposed tissues pose the risk of inadvertent injury to adjacent structures. If hemostasis is satisfactory and the site of vessel wall injury can be directly examined, irregular tissue should be excised and the type of vascular repair required should be determined. Two principles should be considered when conducting vascular repairs: (1) hemostasis and (2) preservation of the normal luminal caliber to maintain flow. Before conducting the vascular repair, the surgeon should determine the need for systemic anticoagulation and proximal and distal embolectomy. Following prolonged occlusion (>30 minutes), thrombi may form along the occluded end of major vessels. Therefore, the surgeon should anticipate the length of time between vessel occlusion and restoration of flow and accordingly administer systemic anticoagulation and/or perform proximal and distal thromboembolectomy. These issues are not a consideration when the vessel is simply ligated and distal flow is terminated. Systemic anticoagulation is achieved with the administration of intravenous heparin. The anticoagulant effect of heparin generally occurs within 5 minutes and reaches peak activity at approximately 90 minutes following administration. Restoration of a normal coagulation profile can be accomplished by administering protamine sulfate at a milligram for milligram equivalent dose, thus allowing for the temporal decay of heparin that was given earlier. Caution must be exercised with the administration of protamine because it (1) may cause hypotension if it is injected too rapidly and (2) may result in hypocoagulability if it is administered in excessively high doses. In general, because most repairs of vascular complications can be accomplished fairly quickly, a safer practice is to administer smaller doses of heparin (60-70 U/kg) and to allow enough time for the effects simply to dissipate. It is essential to remove intravascular thrombus before restoring the flow. Failure to do so may result in distal embolization and distal ischemia, with potentially catastrophic consequences. Thrombi within the arterial system can be removed with an Edwards Fogarty arterial embolectomy catheter (Edwards Life Sciences, Irvine, California). These catheters range in length from 40 to 100  cm. The diameter of the inflated balloon should approximate that of the vessel in which the catheter is inserted. Inflated balloon diameters range from 4  mm (2-Fr catheter) to 14  mm (7-Fr catheter). After selecting the smallest balloon that will accomplish the task required, the catheter should be advanced with the balloon deflated. Should resistance be met, further advancement should not be attempted. The balloon should then be inflated using “only” the volume of liquid required to inflate the balloon and the catheter should be withdrawn.

During catheter withdrawal, if the surgeon meets resistance, the balloon should be allowed to deflate slightly before another attempt is made to withdraw again. Should clot be removed, additional passes should be accomplished until no further clot remains. It is essential to consider embolectomy in both the proximal and distal circulations. Additionally, overinflation of the balloon and forcible withdrawal of the catheter may result in intimal damage and extraction of intima that will leave a segment of vessel with a denuded endothelium. Attempts to remove thrombi in the venous system can also be made using a Fogarty venous thrombectomy catheter. These 80-cm catheters have balloons ranging in inflated diameters of 12 to 19 mm (6-Fr to 8-Fr catheter). From the standpoint of urologic procedures, venous thrombectomy is relevant in the setting of thrombus formation in the infrarenal IVC or common and external iliac veins. Simple ligation of these vessels may be a satisfactory consideration, rather than potentially incomplete thrombectomy. As mentioned previously, vascular repairs may involve simple ligation or vessel wall closure with maintenance of luminal patency. When restoration of flow is not required, as in the pelvis, which has a rich collateral circulation, vessels can be ligated with ties or clips. For larger vessels (>4 mm), a transfixion technique such as suture ligature or oversewing of the vessel walls effects a more reliable closure than does simple ligature. When restoration of flow is intended, the vessel should be repaired such that the ≥50% of the original luminal diameter is maintained. Greater reductions are likely to result in flow disturbances with hemodynamically significant consequences. Short lacerations (≤4  mm) in the vessel wall can be repaired by direct closure with continuous or interrupted suture. In general, transverse closure (perpendicular to the direction of blood flow) preserves the luminal diameter better than does longitudinal closure. For arterial lacerations >4 mm, luminal diameter can be maintained by closing the defect with an elliptical autogenous (usually venous) or synthetic vascular patch. The patch is trimmed to match the size of the defect. One apex of the patch is then anchored, and the sides of the patch are approximated to the arterial wall. The opposite end of the patch can be trimmed or the arteriotomy can be extended to complete the patch closure. In the setting of vascular disruption or significant luminal compromise by a ligature or a clamp, excision and reanastomosis of the vessel may be required. As with other anastomoses, the fundamental principle of constructing a relaxed, tension-free anastomosis should be followed. When the ends of the vessel can be reapproximated in this manner, a simple end-to-end anastomosis can be constructed using either interrupted or continuous suture.

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Section IV  Common Surgical Considerations Our preference has been to perform this procedure with a double-armed suture placed along the posterior aspect of the anastomosis. We then use each needle to sew along both sides of the vessel walls. Concerns that this technique will result in purse-string–type narrowing of the anastomosis can be minimized by purposefully tying a small air knot. An alternative is to complete the anastomosis and just before tying the suture, gently open the clamps (distal followed by proximal) to allow for expansion of the anastomosis. The clamps can then be reapplied and the suture can be tied. Placement of interrupted sutures has a theoretical advantage of avoiding a purse-string type constriction; however, this is generally not a clinically relevant problem for larger abdominal and pelvic vessels. When the two vessel ends cannot be reapproximated in a tension-free manner, an interposition graft must be used. The selection of autogenous versus synthetic conduits is discussed later in this chapter. In general, when using a synthetic conduit, synthetic monofilament nonabsorbable suture (polypropylene) should be used for the anastomosis. When constructing an end-to-end anastomosis between small vessels (2 cm is generally an indication for vascular interposition. In cases of partial loss of a vessel wall, an appropriately

sized and shaped patch preserves luminal patency over primary closure. Vascular substitutes may be derived from synthetic materials or from autogenous tissues. Expanded poly­ tetrafluoroethylene (ePTFE) is the primary component of vascular substitutes used for arteriovenous access. ePTFE offers the advantages of strength, resistance to significant dilatation, ability to be implanted without pre­clotting, and theoretical advantage of being less thrombogenic.1 ePTFE grafts may also be more resistant to infection than textile grafts because of their smoother surface, which makes bacterial adherence difficult.2 Dacron grafts are textile grafts composed of yarn, which is either woven or knitted to form the fabric. Woven grafts, tighter and less porous than knitted grafts, are recommended for situations in which hemostasis, without time consuming preclotting, is required. Knitted grafts require preclotting and are believed to promote faster and more complete healing and incorporation. Dacron grafts have very high patency rates for large vessel reconstruction. The selection of a suitable vascular substitute depends largely on the clinical situation. Substitution of arterial defects with native arteries is preferential. For large arteries, such as the aorta and the common iliac and external iliac arteries, autogenous vessels are generally not readily available, and therefore Dacron and ePTFE are most often employed. For smaller arteries, such as the main or segmental renal artery, a suitable arterial conduit is the hypogastric artery. This vessel can be harvested, with its terminal branches, as a free graft and can be fashioned as an interposition graft or patch. For small segmental renal arteries, the inferior epigastric artery may be similarly used. In patients with advanced atherosclerosis that precludes the use of an autogenous arterial substitute, autogenous veins can serve as acceptable conduits. When a vein is used as an arterial conduit, it is imperative to check for venous valves and accordingly reverse the direction of the vein. The saphenous vein is readily available in most patients and has been used extensively as a bypass conduit for patients with renal artery disease.3 Although the gonadal vein is similar in diameter to the renal artery, the thin wall of the gonadal vein predisposes it to aneurysmal degeneration when it is used as a bypass graft. Substitution of larger-caliber arteries, such as the aorta and iliac vessels, can be accomplished by using the superficial femoral vein.4 Nearly any vein that can serve as an arterial conduit can function well as a patch.5 The presence of collateral venous drainage greatly minimizes the need for venous substitutes. When substitutes are required, however, autogenous veins are preferred but are hampered by mismatches in size. Common clinical situations that may require preservation of venous drainage involve the renal vein (particu-

Chapter 21  Management of Vascular Complications larly the right renal vein), the IVC, and the iliac veins. The saphenous vein can be fashioned as a spiral graft and matched to the main renal vein.6 For patients with IVC tumor thrombi that extend to the right atrium, autogenous pericardium is an excellent caval substitute.7 If use of an autogenous vein for venous replacement is not feasible, externally supported (ring-reinforced) ePTFE grafts may function acceptably. These grafts are preferred over Dacron secondary to their ability to resist respiratory compression and thus avoid graft collapse. The graft should have a diameter slightly smaller than that of the native vessel so the blood flow velocity is increased, thereby potentially decreasing the risk of thrombosis. Eight- to 12-mm grafts are suitable for iliofemoral replacement, and 16- to 20-mm grafts serve well as IVC grafts. A PTFE patch can function well for partial replacement of the IVC (Fig. 21-2). The need for longterm anticoagulation with synthetic venous grafts and patches remains unclear. When neither autogenous vessels nor synthetic materials are suitable as vascular replacements, cadaveric vessels have been routinely used in organ transplantation. An assortment of arterial and venous conduits should always be procured with liver and pancreas grafts. If not used at the time of transplant, these grafts can be kept in cold storage in preservation solution (4°C) for ≤1 week and used in the intended recipient if necessary. As a final effort, third-party vascular grafts have been used to salvage kidneys for transplantation.8 Extension of this practice beyond the transplant recipient is inadvisable because of the need for immunosuppression and the risk of viral transmission. Additionally, blood group compatibility and viral serologic status must be verified before implantation of cadaveric vessels.

Figure 21-2  Polytetrafluoroethylene patch replacement of the infrarenal inferior vena cava.

MANAGEMENT OF SPECIFIC VASCULAR COMPLICATIONS This section is devoted to the management of complications that occur along anatomically distinct vascular structures. Although specific urologic procedures may be associated with injuries to specific vessels, this relationship is not absolute because numerous operations can have the same vascular complication.

Arterial System Aortic Injury Injuries to the aorta can occur during operations for large retroperitoneal masses. Most cases of aortic injury involve left-sided procedures (retroperitoneal lymphadenectomy, left nephrectomy, or left adrenalectomy) and are undoubtedly the result of proximity of the operative disease to the aorta. Almost all cases of aortic injury occur during excision of a mass that is closely adherent to the aortic adventitia. With current computed tomography imaging, the relationship between the mass and the aortic wall should be appreciated by careful review of preoperative computed tomography scans. If aortic involvement or adherence is suspected on preoperative imaging, consideration should be given to concomitant aortic replacement during mass excision. Intraoperative determination for the potential of aortic injury should occur when the “normal” aortic wall is not apparent. As mentioned previously, the surgeon should appreciate the vasa vasorum that identify the correct periadventitial layer. As is commonly noted in postchemotherapy retroperitoneal lymphadenectomy, a subadventitial plane can be easily developed; this plane results in a weakened aortic wall with the potential for catastrophic hemorrhage. Another situation in which aortic injury can occur is during left nephrectomy, particularly if the renal artery is ligated and divided in an extreme proximal location. The mistake in this situation is to maintain the dissection too close to the aorta, and the result is too little proximal renal artery after ligation and division. When significant hemorrhage from the juxtarenal aorta is encountered, initial treatment attempts should not include clamping the aorta. The suprarenal aorta is covered by a thick network of neural and lymphatic tissue and the overlying diaphragmatic crural fibers. Attempts to divide this tissue to identify the aorta just above the renal artery are fraught with difficulty and risk the potential of additional injury. The first attempt to control aortic hemorrhage along this location should be directed toward compressing the aorta at the level of the esophageal (diaphragmatic) hiatus. At this location the distal thoracic aorta can be accessed by retracting the stomach caudally and the left lateral segment of the liver toward the patient’s right; then, by opening

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Figure 21-3  Schematic depicting compression of the distal thoracic/supraceliac aorta.

the lesser omentum, the aorta can be compressed in this location (Fig. 21-3). Once the aorta is compressed and the site of hemorrhage is identified, the previously described methods can be employed to control bleeding.

Visceral Artery Injury Superior mesenteric artery (SMA) and celiac artery injuries likely occur more often than the few reported cases in the literature. The highest reported incidence was that seen by Ritchey and colleagues,9 in which approximately 2% of children undergoing nephrectomy for Wilms’ tumor with venous involvement had SMA injury. Other sporadic cases of SMA injury have been reported, but these undoubtedly are an extremely small proportion of all (unreported) SMA injuries.5,10 Nearly all cases of inadvertent SMA ligation or division involve the resection of large left-sided tumors. These neoplasms may displace structures from their expected position and distort the normal anatomic relationships. The close proximity of the SMA and left renal vein is well known and clearly plays a role in the mistaking of the SMA for the renal artery. In the majority of reported cases of SMA injury, the injury was recognized intraoperatively either after direct visualization of the transected SMA or by recognition of ischemicappearing small intestine. Once the injury is recognized, immediate attempts to revascularize the SMA should be undertaken, through direct reanastomosis, placement

of an interposition graft, reimplantation into the aorta, bypass with the splenic artery, or construction of patch angioplasty following thromboembolectomy.5,9,10 Several points deserve mention to avoid inadvertent SMA injury. First, the surgeon should be certain to stay on the (left) lateral aspect of the aorta. This relationship can become distorted, particularly when the patient is placed in a left thoracoabdominal or left flank position. However, reassessment and recognition of the lateral aspect of the aorta are imperative to avoid visceral artery injury. Second, nearly all major arteries to the left kidney lie posterior to the left renal vein (with the exception of a retroaortic left renal vein). Before ligating any large (>2 mm) artery during excision of a left-sided mass, the relationship of this artery and the left renal vein should be verified, and the previously mentioned relationship should be noted. Inadvertent ligation of a large vessel anterior to the renal vein carries the risk of visceral artery ligation. Third, and particularly when the two prior principles are not apparent, the renal artery can be approached from a posterior direction. The entire kidney can be mobilized and rotated medially (toward the patient’s right), and the major renal vessels can be palpated from the posterior location. Following identification and verification that these vessels are posterior to the main renal vein, these arteries can be ligated. In cases of anomalous venous drainage, such as a circumaortic or retroaortic vein, the major renal artery may in fact be anterior to the renal vein. This relationship should be noted from careful review of the preoperative imaging, and the principle of staying on the left lateral aspect of the aorta should be followed. Injuries to the celiac axis are also rare; only one has been reported in the literature.10 The celiac axis arises only a few millimeters proximal to the SMA, and injuries to this vessel occur in a manner identical to SMA injuries. Inadvertent ligation of both the SMA and celiac axis is extremely poorly tolerated because it likely results in loss of collateral vessels to the distal SMA through the splenic artery and intrapancreatic collateral vessels. The presence of thick fibrous tissue (neural and lymphatic tissue) surrounding a major artery should suggest inadvertent dissection of the SMA or celiac axis. These vessels are surrounded by thick neural and lymphatic tissue much more so than the renal artery, and recognition of this anatomic relationship should aid in avoiding inadvertent ligation.

Lumbar Artery Hemorrhage from lumbar arteries can occur during resection of lymphatic tissue posterior to the aorta. The important principle when dissecting lumbar arteries is to avoid keeping the dissection too close to the aorta. In this case, inadvertent bleeding from the lumbar artery can be controlled by simply grasping each end and applying an effective hemostatic maneuver. When bleeding occurs from the origin of the lumbar artery,

Chapter 21  Management of Vascular Complications one often has insufficient vessel to grasp, and hemostasis involves directly suturing the aorta. The important principle in this situation is to mobilize the posterior surface of the aorta adequately so that the sutures can be placed with good visualization.

External Iliac Artery Injuries to the external iliac artery can occur during pelvic lymphadenectomy procedures or organ transplantation procedures. Because the external iliac artery is an end artery, the surgeon should always attempt to maintain prograde blood flow when repairing this vessel. If this is not feasible, vascular surgical consultation for construction of an extra-anatomic bypass (femoral-femoral or axillofemoral bypass) should be pursued as soon as possible. Techniques to control hemorrhage from the external iliac artery are identical to those previously mentioned in this chapter. Two special considerations deserve mention. If the displacement between the two ends of the external iliac artery necessitates placement of an interposition graft, a native hypogastric artery may be a suitable and readily available conduit. This vessel can be procured and fashioned as a free interposition graft or patch, or conversely, prograde blood flow can be restored by ligation of the distal hypogastric artery and anastomosis of the proximal hypogastric artery to the distal external iliac artery.11 In most cases, the hypogastric artery provides only a short interposition graft and generally does not meet the caliber of the external iliac artery. For long disruptions of the external iliac artery, a synthetic interposition graft may be used. One other option is use of the patient’s external iliac vein, which can be procured and then placed in a reversed configuration as a vascular conduit.

Venous System Significant hemorrhage during urologic procedures is much more likely to occur from venous structures.

Renal

Infrahepatic

Malignant renal diseases induce the formation of new blood vessels, and most urologists have encountered large renal tumors with a parasitizing network of veins. Additionally, many of these veins are extremely thin walled and fragile. Tumor extension into the major renal veins from adrenal veins and the IVC is seen with malignant tumors of the kidney and adrenal gland, and knowledge of the management of tumors involving the venous system is essential during procedures on the kidney.

Renal Vein/Interior Vena Cava Thrombus Extraction Malignant renal diseases involve the renal vein and IVC in approximately 5% to 10% of cases. These tumors can extend within the lumen of the venous system up to the level of the right atrium. Although locally advanced, renal cell cancers with venous involvement are considered localized disease, and surgical resection of these cancers is intended to be curative. The surgical technique for management of cancers involving the renal veins or IVC directly depends on the level of extension. The techniques presented in this chapter are based on the classification scheme proposed by Neves and Zincke (Fig. 21-4).12 Tumor thrombi involving the renal vein and those protruding just into the IVC through the renal vein orifice can be managed without complete IVC occlusion. Our approach is to mobilize the entire kidney after early arterial ligation. Following this maneuver, the renal vein is circumferentially dissected. As a result of renal vein obstruction from the tumor thrombus, the development of thin-walled venous collateral vessels may pose challenges to obtaining circumferential control. Once the renal vein has been isolated, the surgeon should carefully palpate the tumor thrombus within the vein and determine whether it can be safely retracted back toward the kidney. With the thrombus retracted toward the kidney, a tangentially occluding clamp, such

Intrahepatic

Atrial

Figure 21-4  Inferior vena cava tumor thrombus classification scheme. (Adapted from Neves RJ, Zincke H. Surgical treatment of renal cancer with vena cava extension. Br J Urol. 1987;59:390-395.)

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Section IV  Common Surgical Considerations as a Cooley clamp or a Satinsky clamp, can be placed partially across the IVC. It is important to mobilize the posterior aspect of the IVC before placing the clamp so that the walls of the IVC can be reapproximated without undue tension. Once the clamp has been placed, a small cuff of the IVC can be resected with the renal vein. The surgeon can inspect the portion of the IVC within the clamp to ensure adequate tumor resection. If tumor resection is incomplete, the clamp should be left in place and the kidney should be removed. Circumferential control of the IVC and left renal vein, which are reviewed subsequently, is then required for further tumor extraction. During removal of a renal cell carcinoma with level I thrombus, we tend to leave the division of the vein as the final step. In this setting, the entire kidney has been mobilized, thus allowing for maximum retraction of the kidney and unobstructed placement of the partially occluding clamp. Another caveat is that by leaving the venous dissection for the last step, one ensures that all sources of inflow have been ligated and divided. In the event that arterial inflow to the kidney remains, placement of the clamp will potentially result in outflow obstruction, venous hypertension, and new areas of venous bleeding. Closure of the vena cava can be performed with 4-0 or 5-0 polypropylene suture. In most instances, the IVC walls are fairly thick and are satisfactorily apposed with 4-0 suture. Our preference is to begin a suture at each apex of the vena cavotomy and run these continuously to the midpoint where the sutures are secured. We have not found that an overand-back technique is necessary for low-pressure venous systems. Management of level II and level III tumor thrombi requires control of the infrarenal and suprarenal IVC as well as all tributaries, such as the contralateral renal vein, lumbar veins, and adrenal veins. Our approach is to encircle the contralateral renal vein and infrarenal vena cava and then address the suprarenal vena cava. From an operative perspective, the principal distinction between a level II and a level III thrombus is the need to mobilize the liver so that the IVC can be encircled above (cephalad to) the level of the thrombus. For level II thrombi, the liver does not need to be mobilized and the caudate lobe can be retracted cephalad, thereby exposing a greater length of the suprarenal IVC. Occasionally, small venous branches that drain the caudate lobe directly into the IVC need to be divided. These veins tend to be short, wide, and occasionally fragile. Our approach is to ligate both sides of these small veins before division; however, occasionally, the very short nature of the vein does not permit double ligation, and small clips can be placed on the hepatic side of these veins before division. If one encounters hemorrhage from the hepatic side, a suture ligature (polypropylene or silk) can often control the hemorrhage. These small veins tend to retract into the liver parenchyma and thus

hemostasis is best accomplished by incorporating some of the surrounding hepatic parenchyma. Once the IVC cephalad to the thrombus is exposed, it can be encircled with a vessel loop or umbilical tape. Our preference is to use umbilical tapes because their relative inelasticity allows for better upward retraction of the IVC. For level II thrombi, once all segments of the IVC have been encircled, the kidney can be addressed with the standard approach to a radical nephrectomy. We typically attempt to gain early arterial control and then completely mobilize the entire kidney in a perifascial manner. All attachments except for the tumor-filled renal vein should be divided. At this point, control of the IVC is obtained by first occluding the contralateral renal vein, then the infrarenal IVC followed by the suprarenal (cephalad to the thrombus) IVC. The IVC is carefully palpated, and if the occluded segment becomes distended, the surgeon needs to consider the possibility of uncontrolled venous tributaries. The clamps should be released and additional dissection of the IVC should be conducted. In most instances, the uncontrolled tributaries are posteriorly inserting lumbar veins. In our experience, we have not encountered lumbar veins along the suprarenal IVC. The only significant posterior branch above the level of the renal vein is the right adrenal vein. Once the caval segment is satisfactorily occluded, a vena cavotomy is made along the renal vein ostium. We generally prefer to make the vena cavotomy along the anterolateral aspect of the IVC and extend this to a degree that allows complete visualization of the caval lumen at the level of the tumor thrombus. Most often, the vena cavotomy should be made only large enough to allow extraction of the thrombus. Once the thrombus has been extracted, the lumen of the IVC can be inspected and the vena cavotomy can be enlarged accordingly. At this point, the entire lumen of the cava should be both visually and digitally inspected. Any adherent areas of tumor should be managed with resection of the IVC wall. The remaining IVC can be reapproximated with 4-0 polypropylene suture. As stated previously, we prefer to place one suture at each apex and run this continuously until the midpoint is reached. Controversy exists regarding the need to vent the IVC. We do attempt to avoid entrapping a large amount of air in the IVC before unclamping. Any entrapped air can be expelled by releasing the clamps before tying the suture. The clamps are released in the following sequence: suprarenal IVC, contralateral renal vein. The retrograde flow of blood within the IVC generally expels any entrapped air and the suture can be tied. At this point, the clamp on the infrarenal IVC can be released, thereby restoring prograde blood flow. With level III thrombi, more extensive liver mobilization is necessary for suprarenal caval control. For thrombi near the level of the hepatic veins or just above

Chapter 21  Management of Vascular Complications the hepatic veins, we completely mobilize the liver. Following standard exposure of the retroperitoneum, we divide the falciform ligament and left triangular ligament to expose the suprahepatic IVC. We then mobilize the right lobe of the liver. Initially, several small venous branches that drain the caudate lobe can be divided in the manner described previously. The posterior aspect of the right hepatic lobe should then be carefully freed from the kidney. In many instances, right-sided tumors can result in dense adherence to the posterior aspect of the right hepatic lobe, and the correct plane of separation is identified by gently retracting on the liver and kidney. Vigorous retraction on the liver can result in a laceration to the liver that will be accompanied by troublesome bleeding. Once the attachments between the liver and kidney are completely divided, the right triangular ligament can be addressed. In our experience, the best approach to releasing the right hepatic lobe is to have the surgeon stand on the left side of the patient and gently retract the right lobe of the liver toward the patient’s left. The assistant can then free the attachments between the right lobe and the diaphragm (right triangular ligament), which can be divided with the electrocautery. Anterior and posterior leaflets to the right triangular ligament are present, and each needs to be divided to release the liver from the diaphragm. Division of the triangular ligament should generally proceed in a lateral to medial direction. Once the right hepatic lobe is completely mobilized off the diaphragm, the right hepatic vein and right aspect of the suprahepatic vena cava become visible. With progressive release of the right hepatic lobe, retraction on the right lobe displays additional veins draining directly into the IVC. As one proceeds up the IVC

toward the major hepatic veins, the tributaries draining the caudate and right lobe tend to become wider and more difficult to control with simple ties. For veins >5 mm in width, we prefer to divide these vessels after placing small vascular clamps such as a spoon clamp or angled or straight DeBakey clamp on each side of the vein. After placing these clamps, the vein is divided, and the venous stump can be oversewn with a polypropylene suture. We leave more vein on the IVC side so that a suitable portion of the vein wall remains to reapproximate. For the hepatic end of the vein, a figure-of-eight–type stitch that incorporates some hepatic parenchyma can be placed around the clamp and secured just after releasing the clamp. Full mobilization of the liver enables reliable control of the suprahepatic IVC. We make every attempt to mobilize the liver off the IVC all the way to the level of the hepatic veins. The IVC just below the hepatic veins is palpated, and if this segment appears free of thrombus, we encircle the IVC in this location. In many instances, the cephalad extent of the thrombus can be retracted below the portion of the IVC to be clamped (Fig. 21-5). The advantage of clamping below the hepatic veins is that hepatic outflow is not obstructed, thus making control of the hepatic inflow unnecessary. In the setting of thrombi above the level of the hepatic veins but still below the diaphragm, the IVC must be occluded along its suprahepatic segment. The inflow to the liver must also be occluded by clamping the porta hepatis (portal vein and hepatic artery) with an atraumatic vascular clamp (Pringle’s maneuver). Level III thrombi are addressed identically to level II in that the relevant segment of the IVC and all significant tributaries are isolated and controlled. The kidney is then mobilized by dividing all attachments except for

Tumor in IVC

Tumor

Clamp Finger

Hepatic vein

A

B

Figure 21-5  A, Echocardiographic images of the inferior vena cava with level III tumor thrombus. B, The tumor thrombus is being retracted by the surgeon’s fingers just before application of the clamp.

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Section IV  Common Surgical Considerations the thrombus-filled renal vein. The IVC is then controlled and opened, the tumor is extracted, the IVC is closed, and flow is reestablished as described previously. Two points deserve special mention. In our experience, left-sided tumors require a slightly different approach. For left-sided tumors with vena caval thrombi (levels II-IV), we complete the left nephrectomy before addressing the IVC. The renal vein is divided and we close the renal vein stump, which is filled with tumor thrombus, with a running polypropylene suture. Occasionally, the renal vein stump is expanded with tumor and is difficult to close. In this situation, we sew a small section of a surgical sponge over the vein end. Because this vein will subsequently be resected, the closure needs only to be hemostatic to prevent overt tumor spillage. We then expose the IVC by turning our attention to the right side of the retroperitoneum. The duodenum is mobilized through a standard Kocher maneuver. The left renal vein stump is then dissected and is brought over toward the patient’s right. The usual landmark of the aorta posterior to the left renal vein serves as a consistent reminder that no significant posterior branches to the left renal vein are present at this level. Once the renal vein stump has been brought over to the patient’s right side, additional mobilization can be gained on the left lateral and left posterior aspect of the IVC, and the caval portion of the operation can proceed in the previously described manner. Another important distinction between right-sided and left-sided tumors is the need for arterial inflow control to the contralateral kidney. For right-sided tumors, occlusion of the left renal vein at its entry into the IVC generally does not result in venous hypertension because the left renal vein has collateral drainage through adrenal, gonadal, and lumbar branches. For left-sided tumors, occlusion of the right renal vein may result in venous hypertension, acute tubular necrosis, and renal insufficiency. Occlusion of the right renal vein without inflow control can be tolerated if the caval portion of the operation is fairly short. However, if the thrombus is adherent to the IVC wall and removal of the tumor from within the IVC is protracted, it is helpful to occlude the right renal artery as well. In the majority of the cases, the right renal artery rises from the aorta just posterior to the left renal vein. As the left renal vein stump is mobilized toward the patient’s right, the lymphatic tissue posterior to renal vein is carefully divided, thus enabling identification of the proximal aspect of the right renal artery. The artery is encircled with a vessel loop and isolated for later occlusion. It is imperative to dissect the right renal artery very gently because, in most cases, it supplies the only functioning kidney. One final point in the management of IVC tumor thrombi relates to the placement of the suprarenal IVC

Figure 21-6  Schematic depicting the direction of clamp application along the suprarenal IVC. The thrombus can be retracted inferiorly and the clamp is applied so that the anterior wall of the IVC is compressed against the posterior wall.

clamp. We prefer to occlude the suprarenal IVC with a clamp that is placed in an anterior to posterior direction. The anterior aspect of the IVC is compressed against the posterior aspect of the IVC (Fig. 21-6). The clamp is best applied by the surgeon, standing on the right side of the table, and is done by retracting the thrombus with the left hand and then applying the clamp with the right hand. The importance of placing the clamp in this direction relates to the possibility of needing to place a vascular graft should IVC resection become necessary. If the IVC is resected, the suprarenal portion can be transected by leaving a suitable cuff of tissue within the clamp. The anterior and posterior walls are more easily identified and approximated to a tube graft than are the lateral walls, as would be seen with a clamp placed in a straight up-and-down manner. Because the thrombus generally does not involve the infrarenal IVC, the clamp along this portion of the IVC can be placed further from the cut edge, thereby making an anastomosis more straightforward. Level IV (supradiaphragmatic or atrial) thrombi are approached in conjunction with a cardiothoracic surgical team. Because the tumor is controlled from within the chest, extensive mobilization of the liver is not necessary. The caudate lobe of the liver should be mobilized off the IVC enough to allow for a vena cavotomy of adequate length. Similar to the situation described previously, we complete the nephrectomy and mobilize the IVC and control all tributaries before the institution of cardiopulmonary bypass (CPB). Because the patient will be maximally anticoagulated while undergoing

Chapter 21  Management of Vascular Complications CPB, it is imperative to have meticulous hemostasis following the nephrectomy. Once the patient has been placed on CPB, the cardiothoracic and urologic surgeons can work simultaneously to open the IVC and atrium and extract the tumor thrombus from both directions. We previously preferred to use deep hypothermic circulatory arrest (DHCA) to aid in resection of level IV thrombi.13 However, this technique can be associated with significant perioperative complications. More recently, we prefer to extract atrial thrombi with a cardiopulmonary bypass type approach. Venous blood from the infrarenal IVC and superior vena cava is directed toward the CPB circuit, which is then returned through an aortic cannula. When the IVC is opened and the tumor thrombus is extracted, the surgeon encounters significant bleeding from the hepatic venous return, but this bleeding can be controlled and returned to the bypass circuit with vacuum-assisted venous drainage. The suction rate can be set to match the rate of bleeding from the liver, to enable the surgeon to inspect the IVC lumen adequately. The advantage of cardiopulmonary bypass (over DHCA) lies in the ability to resect intracaval tumors adequately under normothermic CPB and without needing to arrest the heart. DHCA may still be required for massive tumors within the atrium.

Inferior Vena Cava Hemorrhage As many urologists may have encountered, hemorrhage from the IVC can be associated with massive blood loss. In our experience, the best way to prevent significant IVC hemorrhage is first to obtain control of the IVC and significant tributaries, as described previously. Once control has been obtained, bleeding from the IVC can easily be terminated by occluding the isolated segment. For small lacerations in the IVC, we prefer to obtain immediate control simply with digital pressure. After the adjacent cava has been adequately mobilized, a small clamp (e.g., a spoon-type clamp) can be placed such that the IVC is atraumatically apposed in this location. Lacerations can be closed in the previously described manners. Other surgeons have had success with Allis clamps in these situations, and we think this technique is acceptable for surgeons experienced with placing these clamps. Occasionally the IVC or renal vein can become very thin, and attempts at placing Allis clamps can result in tearing and more vigorous bleeding. Whenever possible, we prefer to decrease the pressure within the IVC by controlling inflow and outflow before we attempt to close a laceration. It is difficult to control flow at the IVC bifurcation, and injuries to this extremely thin-walled location can result in catastrophic hemorrhage. Dissection in this area must be undertaken with extreme care and is ill-advised without obtaining control of the iliac veins as well as the IVC. Despite control of the external iliac veins and infrarenal IVC, several large

posterior branches along the common iliac segment can cause significant bleeding. If significant bleeding from posteriorly located branches persists during attempts to close an injury to the caval bifurcation, closure of the injury can be attempted; however, this may be fraught with additional tearing. In this situation, it is best to close the laceration with the aid of pledget. Lacerations to the IVC bifurcation that extend under the common iliac arteries can be very difficult to visualize because of the overlying arteries. These vessels can be mobilized and retracted; however, these maneuvers may still limit visualization of the full extent of the laceration. Occasionally, intentional division and subsequent reanastomosis of the artery are necessary to fully appreciate hemorrhage from the IVC bifurcation.

Lumbar Vein Hemorrhage Lumbar vein hemorrhage can also occur during operations on the IVC. In our experience, the best method for controlled division of lumbar veins involves first obtaining control of the IVC. We prefer to encircle the IVC with umbilical tape, and with upward traction, the posteriorly draining lumbar veins can be identified. These veins can then be dissected and doubly ligated before dividing. Occasionally, the veins are too short to place two ties and therefore the distal aspect of the vein can be controlled with clips. We prefer to place a tie on the IVC side and leave a reasonable cuff on this side. If hemorrhage occurs from the IVC side, the previously obtained control of the IVC can aid to decrease bleeding. Hemorrhage from the distal side (lumbar side) can be troublesome because the vein tends to retract into the posterior body wall musculature. The bleeding from this location can be controlled with a fingertip, and then a long, slender instrument, such as a tonsil clamp, can be used to grasp the vein edges after the digital pressure has been slowly released. Once the edges are grasped, the vein can be occluded by twisting the clamp. If the vein cannot be grasped, a figure-of-8 stitch (2-0 or 3-0 polypropylene on a large half-circle needle) incorporating some of the posterior body wall musculature can also be successful in controlling the bleeding.

Hypogastric (Internal Iliac) Venous Hemorrhage Hemorrhage from the hypogastric or internal iliac veins can be encountered during renal transplantation or pelvic lymphadenectomy procedures. Injuries to these large veins can result in substantial hemorrhage. Often, three hypogastric veins insert posteriorly into the external iliac vein. At least one of these veins is fairly wide, a feature that can make dissection and subsequent ligature placement fairly difficult. In comparison with lumbar vein hemorrhage, bleeding from the hypogastric veins tends to be more severe and more difficult to control. Accordingly, dissection of these veins should be approached in a very meticulous manner.

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Section IV  Common Surgical Considerations Our approach to exposing and dividing the hypogastric veins starts with mobilizing the common, external, and (proximal) internal iliac arteries and retracting these vessels medially. The external iliac vein is then circumferentially mobilized all the way to the insertion of the first hypogastric branch. We then circumferentially dissect the common iliac vein and encircle this with an umbilical tape or vessel loop. Again, if substantial bleeding from the hypogastric veins occurs, the inflow and outflow of the iliac veins can be controlled. We now dissect the hypogastric veins after retracting up on the vascular loops on the common and external iliac veins. Additionally, the hypogastric veins can most often be exposed from a lateral direction. With the artery mobilized medially, the vein can be further mobilized to a medial direction that allows a somewhat unobstructed access to the hypogastric veins. The psoas muscle can be retracted laterally with a handheld-type retractor to provide improved exposure. Each hypogastric vein is circumferentially dissected, doubly ligated, and divided. Similar to lumbar veins, these veins can be very short, and placement of two separate ligatures can be difficult. In these situations, we have found that clips placed on the distal aspect (segment of vein away from the iliac vein) can accomplish satisfactory hemostasis. After each internal iliac vein is divided, the iliac vein is now completely mobilized and can be placed lateral to the iliac artery. Occasionally, the ligature on the iliac vein side cannot be placed. In these cases, we control the distal vein and then gain control of the iliac vein by occluding proximally and distally. The hypogastric veins can then be divided, leaving the portion of the vein entering the external iliac vein uncontrolled. If the external iliac vein has been fully mobilized, this vein can be readily flipped over and the uncontrolled branches on the posterior aspect can be sutured. Given that the external iliac and common iliac veins have been previously controlled, no bleeding should occur during this maneuver. Hemorrhage from the hypogastric or internal iliac vein can be considerable, and bleeding from the distal end is particularly is very difficult to control. The approach to controlling the distal end is similar to that

described for control of lumbar vein hemorrhage. Immediate control is gained with digital pressure, and a long, slender instrument or suture ligature that incorporates adjacent tissue can establish more definitive control.

External Iliac Vein Hemorrhage In relative terms, hemorrhage from the external iliac vein is more readily controlled than is hemorrhage from the vena cava or internal iliac vein. The reason is the lack of branches and relative ease in which to encircle the external iliac vein. Occasionally, an obturator branch can insert along the posterior aspect and can result in troublesome bleeding. The external iliac vein can be grasped with forceps and flipped over, and the branch point of a tributary can be suture ligated.

Renal Vein Hemorrhage Hemorrhage from the renal veins can be associated with large quantities of blood loss. The right renal vein, in particular, can be extremely thin walled. Occasionally, while encircling this vein, a posteriorly inserting branch (infrequent) or the posterior wall can be injured. Bleeding from the renal vein can be immediately controlled with digital pressure. Once this is applied, the next steps relate to the intended operation. If the injury occurs during nephrectomy, pressure can be maintained on the vein until the renal artery is ligated, after which the vein can be ligated and divided. If the artery cannot be readily controlled, attempts to fix the laceration in the renal vein while the kidney is perfused are extremely difficult and will undoubtedly result in large volumes of blood loss. An alternative approach is to place a large clamp across the renal pedicle and remove the kidney. The transected edges of the renal artery and vein are then identified and suture ligated with fine polypropylene suture (4-0 or 5-0). Placement of a pedicle-type clamp on the right side must be done with the appreciation of the short right renal vein. The hilum must be transected in a manner that maintains tissue within the clamp. If this is not considered, the tissue within the jaws of the clamp may retract, thereby resulting in ongoing bleeding.

Chapter 21  Management of Vascular Complications

KEY POINTS 1. In general, arteries should be exposed along the anterior surface because major branches are unlikely to arise from this direction. 2. Perhaps the most important principle in managing unexpected bleeding is that properly applied digital pressure can control virtually all abdominal and pelvic bleeding. 3. Two principles should be considered when conducting vascular repairs: hemostasis and preservation of the normal luminal caliber to maintain flow. 4. Before conducting vascular repair, the surgeon should determine the need for systemic anti­ coagulation and proximal and distal embolectomy. 5. The close proximity of the SMA and left renal vein is well known and clearly plays a role in mistaking the SMA for the renal artery.

REFERENCES Please see www.expertconsult.com

6. Nearly all major arteries to the left kidney lie posterior to the left renal vein (with the exception of a retroaortic left renal vein). 7. Occlusion of the left renal vein at its entry into the IVC generally does not result in venous hypertension because the left renal vein has collateral drainage through adrenal, gonadal, and lumbar branches. 8. Occlusion of the right renal vein may result in venous hypertension, acute tubular necrosis, and renal insufficiency. If ligation or resection of the suprarenal vena cava is required, reconstruction of the right renal vein is required. 9. The best way to prevent significant vena caval hemorrhage is to first obtain control of the IVC and significant tributaries.

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MANAGEMENT OF BOWEL COMPLICATIONS Phuong M. Pham

MD Surgical Resident, Department of Surgery, David Geffen School of Medicine, University of California– Los Angeles, Los Angeles, California

Oscar Joe Hines

MD Professor of Surgery, Department of Surgery, David Geffen School of Medicine, University of California– Los Angeles, Los Angeles, California

Urologists are often faced with clinical and operative decisions that involve the bowel. The bowel can be invaded by urologic tumors, may be used as a urinary conduit, and simply may be in the way of complex urologic procedures. The approach to some common problems associated with operating in the abdominal cavity and the management of potential complications associated with the gastrointestinal (GI) tract are outlined in this chapter.

ILEUS Ileus, or intestinal paralysis, is experienced by most patients following an intraperitoneal procedure and can also be exhibited following an extraperitoneal procedure. This condition is a normal physiologic response of diminished bowel motility and function following an operation and is characterized by abdominal distention, lack of bowel sounds, delayed passage of flatus and defecation, and accumulation of gas and fluids in the bowel that may result in nausea and vomiting. However, prolonged ileus lengthens the patient’s discomfort, increases the need for parenteral nutritional support, and constitutes the most common reason for delayed discharge after abdominal surgery. The economic impact of ileus is estimated to be $750 million to $1 billion in the United States annually.1 The pathophysiologic mechanism of ileus is incompletely understood but appears multifactorial involving neurogenic, inflammatory, and pharmacologic mechanisms. Increased sympathetic outflow inhibits bowel motility by preventing the release of acetylcholine from excitatory fibers located in the myenteric plexus. In addition, catecholamines released during an operation are associated with inhibited motility,2 and β-adrenergic blockade improves motility in animals.3 Intestinal manipulation elicits a local inflammatory response with the release of nitric oxide, prostaglandins, and

interleukins by macrophages.4 It appears that these inflammatory mediators interact with numerous neurotransmitters and hormones such as vasoactive intestinal polypeptide, calcitonin gene–related peptide, substance P, and corticotropin-releasing factor to result in ileus.5 Pharmacologically, opioids used postoperatively contribute to ileus by their depressant effects on GI transit.4 Following abdominal surgical procedures, each section of the GI tract recovers at a different rate. The small intestine first regains function within 24 hours, the stomach in 24 to 48 hours, and the colon in 3 to 5 days. Therefore, once the patient has experienced flatus following an operation, the physician can assume that the colon and the remaining GI tract have recovered. During this period, it is unlikely the patient will want to take anything by mouth, and in fact this may prolong the ileus. The bowel should be given a period of rest before starting oral intake. The mainstay of treatment for postoperative ileus has been nasogastric decompression. However, the use of this technique during this period has become somewhat controversial. In fact, a meta-analysis of 26 studies concluded that routine nasogastric decompression after elective laparotomy results in significantly increased rates of pulmonary complications such as fever, atelectasis, and pneumonia.6 The same study also found that selective decompression resulted in fewer wound complications and shorter hospital stay. Thus, nasogastric decompression may benefit the patient in selected cases. If bowel anastomosis was performed, it probably shows good judgment to use a nasogastric tube. However, many colorectal surgeons have successfully stopped using a nasogastric tube for left colonic anastomoses. If no bowel anastomosis is performed, one can reliably not use a nasogastric tube. If the patient does become distended, experience nausea or vomiting, or complains of heartburn (a sign of poor gastric function, reflux, and 251

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Section IV  Common Surgical Considerations a prodrome of vomiting in the postoperative patient), a nasogastric tube should be placed. Several abnormalities can initiate and propagate ileus. Simple electrolyte abnormalities including hyponatremia, hypokalemia, and hypo-osmolarity can usually be corrected and may aid in correction of this motility problem. Excessive use of narcotic analgesia prolongs ileus, and a non-narcotic approach to pain relief should be considered. Ileus, however, can be a sign of more severe conditions including sepsis and acute blood loss. If postoperative bowel function is not progressing as one would expect, the clinician should look for sources of infection including intra-abdominal abscess, bowel leak, urinary tract infection, or pulmonary infection. Finally, the acute withdrawal or accelerated taper of steroids in the postoperative period is known to prolong or even precipitate ileus and is corrected with bolus steroid administration.7 After these problems have been corrected, the ileus should resolve without much delay. In some patients, ileus may last significantly longer than normal. In such a case, the use of a nasogastric tube is advised. Parenteral nutrition should be started if it is anticipated that prolonged ileus will continue (>710 days). Once bowel obstruction has been ruled out and the correctable abnormalities listed earlier have been addressed, a trial of prokinetic agents may be started. Several agents are available including cisapride, metoclopramide, bethanechol, and erythromycin. Some investigators have attempted to improve problems of ileus by the use of prokinetic agents in the immediate postoperative period. Unfortunately, the use of metoclopramide or cisapride in a prospective manner does not appear to shorten the length of ileus or discharge to home.8,9 Erythromycin is a motilin receptor agonist in human GI smooth muscle and induces migrating motor complexes,10 but studies have shown mixed results with regard to its effects on ileus. One study showed that erythromycin shortened the time to oral intake and hospital stay following pancreaticoduodenectomy,11 whereas another study showed that the drug did not alter clinically important outcomes related to postoperative ileus in patients undergoing resection for colorectal cancer.12 The most appropriate treatment for ileus maybe a multimodal approach because of the multifactorial origin of this condition. The use of nonsteroidal antiinflammatory drugs may help improve ileus by reducing the amount of opioid given postoperatively. Thoracic epidural blocks with bupivacaine hydrochloride have been shown to reduce ileus significantly as opposed to systemic opioid therapy in patients undergoing abdominal surgical procedures.13 Early postoperative ambulation has not been shown to expedite GI tract function recovery, but it is encouraged for its benefits in reducing thromboembolism and pulmonary complications. Laparoscopic procedures have been shown to decrease the

duration of ileus because of reduced tissue trauma, which results in the release of lower levels of inflammatory cytokines. Finally, the most important factor determining correction of ileus may be the power of suggestion and the doctor-patient relationship. Autonomic activity, the major mediator of ileus, is subject to control by suggestion. One study examined the effect of preoperative instructions for the early return of GI motility and compared this group of patients with a group who received an equal-length of interview offering reassurance and nonspecific instructions. The group receiving the specific preoperative instruction returned to normal intestinal motility in 2.6 versus 4.1 days and had a 1.5-day shorter hospital stay and a $1,200.00 cost savings.14 This simple 5-minute intervention may significantly affect your practice.

BOWEL OBSTRUCTION Intra-abdominal adhesions are the most common cause of bowel obstruction in the United States. Other potential causes include both internal and external herniation, carcinomatosis, and radiation. The incidence of postoperative obstruction varies with the approach and procedure performed. The percentage of obstruction ranges from 0.7% to 14.9%15,16 for ureteroileal conduit diversion and 5%17 for retroperitoneal lymph node dissection. In general, bowel obstruction rates are higher for pelvic procedures. Trocar site intestinal herniation must also be considered for patients who have undergone a laparoscopic procedure. Intestinal obstruction in the early postoperative period must be distinguished from ileus. Ileus is associated with many intra-abdominal and extra-abdominal processes that interfere with normal bowel motility, and it resolves spontaneously once the provoking source has been abolished. Most patients with bowel obstruction exhibit abdominal pain, nausea, vomiting, obstipation, and abdominal distention. Alternatively, if bowel function never returns postoperatively, the patient may also have a bowel obstruction. Pain is usually intermittent and may become constant if the bowel becomes compromised. However, pain severity may decrease over time as a result of bowel fatigue and atony. The periodicity of pain can be a clue to the level of obstruction: pain from proximal intestinal obstruction has short periodicity (3-4 minutes), and distal small bowel or colonic pain has longer intervals (15-20 minutes) between episodes of nausea, cramping, and vomiting. When pain and tenderness begin to localize in a more somatic pattern, one should be concerned with bowel ischemia and peritonitis with attendant parietal peritoneal irritation. Vomiting is earlier and more bilious if the obstruction is high, and later and more feculent if the obstruction is low. Abdominal distention may be prominent if the

Chapter 22  Management of Bowel Complications

Figure 22-1  Supine plain film of the abdomen demonstrating dilated loops of small and large intestine and a large bowel obstruction.

Figure 22-2  Upright plain film of the abdomen demonstrating air-fluid levels of the large intestine and a large bowel obstruction.

obstruction is low and minimal if the obstruction is high. Patients usually become profoundly intravascularly depleted manifested by orthostatic hypotension, tachycardia, and low urinary output. In addition, laboratory findings may include an elevated hematocrit and blood urea nitrogen. Eventually, patients manifest hypokalemic, hypochloremic metabolic alkalosis secondary to gastric loss of hydrogen and chloride and the renal compensation of potassium wasting. The essential test in diagnosing bowel obstruction is supine and upright radiographic views of the abdomen. A chest radiograph should also be obtained to exclude a pneumonic process and to look for subdiaphragmatic air. Supine views demonstrate distended loops of bowel (Fig. 22-1). Upright views characteristically show multiple air-fluid levels (Fig. 22-2). In contradistinction to ileus, which may also produce air-fluid levels, gas is not seen through the entire GI tract, especially distal to the point of obstruction. In early or partial bowel obstruction, gas can be seen distal to the point of obstruction. In addition, if the patient has had a rectal examination, gas may be identified in the rectal vault. The use of contrast studies to diagnose or confirm bowel obstruction is sometimes useful. If the bowel is massively distended with air and it appears that large bowel obstruction is present, a barium enema is indicated. It is rare, however, for a patient with an obstruction in the immediate postoperative period to harbor a large bowel obstruction.

In patients with suspected bowel obstruction and equivocal abdominal films, other radiologic modalities are indicated. Multiple studies have demonstrated computed tomography (CT) scanning to have sensitivity and specificity of >90% for small bowel obstruction18. In addition, CT scanning is capable of detecting the cause as well as the presence of closed-loop obstruction and strangulation and therefore usually the first radiologic examination performed. The use of upper GI contrast studies to establish the diagnosis of small bowel obstruction is more controversial. Many published series in the radiologic literature have documented the accuracy of this approach. Again, barium should be used because Gastrografin dilutes as it travels through the GI tract and makes this medium less reliable. However, some physicians believe that an upper GI series can lead to overdiagnosis or underdiagnosis of obstruction and does not predict which patients will ultimately need reoperation. An upper GI series is indicated, however, if the diagnosis of bowel obstruction is unclear. The most important initial step in treating a patient with bowel obstruction is to replace intravascular volume. Balanced salt solutions of normal saline or lactated Ringer’s may be used. The patient may require several liters of fluid before rehydration is complete. Rehydration should be monitored with a Foley catheter and, if indicated, measurement of central venous pressure or Swan-Ganz perimeters. In addition, serum electrolytes should be monitored and adjusted as indicated.

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Section IV  Common Surgical Considerations Antibiotics should not be used unless the patient is to go to the operating room or ischemic bowel is contemplated. Finally, a nasogastric tube should be placed to decompress the stomach and prevent aspiration. Differentiating partial from complete bowel obstruction is important. Complete bowel obstruction is defined by the complete lack of passage of stool or flatus and the absence of evidence of gas distal to the site of obstruction on plain abdominal films. Some patients with early complete bowel obstruction are still passing some gas but soon this ceases. Many cases of partial obstruction resolve with conservative management; however, most cases of complete obstruction will not. Nearly 80% of patients with complete obstruction will require an operation. Therefore, surgical intervention should occur earlier in patients with complete bowel obstruction. Similarly, in approximately 80% of patients, partial bowel obstruction resolves on its own.19 Some physicians have used a long intestinal tube or Levin tube to decompress to bowel. This approach is believed to be more effective than that using an ordinary nasogastric tube because it decompresses the bowel directly at the site of the obstruction, improves circulation, and leads to faster resolution. Unfortunately, the studies examining the utility of this approach have found that patients treated with a Levin tube have a longer period of preoperative treatment, a higher incidence of ischemic bowel, and a longer period of postoperative care.20-22 Therefore, the routine use of Levin tubes cannot be advocated, and in most cases, decompression with a standard nasogastric tube is sufficient. Strangulation of the bowel is a potential complication of obstruction and must be quickly corrected to avoid a poor outcome because it carries a much higher mortality rate than does simple obstruction. The diagnosis of bowel strangulation is made by a combination of signs and laboratory findings. The patient may have a fever, unexplained tachycardia, nausea, and vomiting. Physical examination reveals localized tenderness. Laboratory findings corroborating strangulation include a rising white blood cell count and elevated serum lactic acid or amylase levels. Some clinicians have attempted to correlate specific findings with the diagnosis of strangulated bowel, without much success.23 Even the use of formulas to predict the presence of compromised bowel based on preoperative data has failed to reach sufficient predictive ability.24 If fever, tachycardia, localized pain, and leukocytosis are all absent, the likelihood that the patient is harboring ischemic bowel is near zero.25 When strangulated bowel is suspected, an expedited trip to the operating room is mandatory following adequate resuscitation. Bowel obstruction in the immediate postoperative period almost always resolves with conservative treatment. The initially aggressive nature of adhesions usually improves and leads to resolution of symptoms.

In nearly 90% of these patients, the condition resolves with nasogastric decompression. Two thirds of these bowel obstructions resolve within 7 days and the remainder resolve within 14 days.26 During this period, parenteral nutrition should be considered. If the condition has not resolved after 2 weeks of conservative measures, reoperation is likely indicated.

Reoperation Once a determination has been made that reoperation is necessary to relieve obstruction, the patient should be prepared with perioperative antibiotics and careful induction of general anesthesia to avoid aspiration. The incision is best made away from any previous incision because adhesions are likely present in the undersurface of the previous incision. A midline incision is preferable for adequate exposure. Special care should be taken while entering the abdomen to avoid injury to the intestine. On entering the abdomen, the surgeon should note the character of the peritoneal fluid. Turbid or dark fluid is an indication of ischemic bowel. The entire intestine should be freed of adhesions using sharp dissection from the ligament of Treitz to the sigmoid colon. Blunt dissection tends to remove serosa from the bowel. The bowel should be repaired if the mucosa is visible. A point of transition between proximal dilated and distal decompressed bowel should be identified and the inciting cause corrected. If one determines that completely dissecting the bowel free of adhesions is dangerous, a bypass of the segment should be considered. Determining the viability of the intestine can be difficult. The intestine should be examined for coloration, presence of motility, and arterial pulsations. In addition, Doppler examination can be used to identify arterial flow. If the viability is still in question, one ampule of intravenous fluorescein can be administered. Viable bowel will glow with the use of Wood’s lamp. If dead bowel is identified, a segmental resection should be performed as well as primary anastomosis. Alternatively, the bowel maybe left in place if the suspected bowel segment is long and there is concern of short gut syndrome after resection. However, these patients should undergo repeat exploration within 24 hours and any nonviable bowel should be removed. Milking the bowel to remove the intraoperative contents should be avoided. Sometimes it is necessary to perform this maneuver to close the abdomen. If the bowel is milked, the surgeon can be assured that this will cause transient bacteremia and the potential complications of infection. The abdomen should be closed in a standard fashion. The skin may be closed in most circumstances unless significant contamination is present. Occasionally, the abdomen cannot be closed because of edema. In this circumstance, a piece of prosthetic material (Gore-

Chapter 22  Management of Bowel Complications Tex) should be placed. The patient can undergo reoperation for primary fascial closure once the edema has resolved. Laparoscopy offers the potential for minimally invasive approach for diagnostic as well as therapeutic intervention. Several clinical studies have demonstrated that patients with bowel obstruction who underwent laparoscopic management of bowel obstruction had fewer postoperative complications, quicker recovery of bowel movements, and a shorter hospital stay than those who underwent conventional laparotomy.27-29 However, complications such as perforations were more common overall in the laparoscopic group, and patients with two or more previous laparotomies had higher rates of these complications.29 Thus, when perform by a skilled surgeon on selected patients, laparoscopic management is both feasible and safe.

Prevention Unfortunately, current surgical practices are not very effective in preventing adhesions. Careful surgical technique, avoidance of tissue ischemia, minimization of the use of foreign material, and minimal manipulation of the bowel are recommended. Many substances have been investigated in an attempt to prevent adhesions. Heparin, kinases, fibrinolysin, steroids, nonsteroidal prostaglandin antagonists, and dextran have all been used in animal models and in some patients. In addition, the use of prokinetics, especially cisapride, has been tried.30 None of these agents seem to prevent adhesion formation reliably. Newer products have been developed that show some value and are now commercially available. Seprafilm (Genzyme, Cambridge, Massachusetts) and INTERCEED (Ethicon, Cincinnati, Ohio) are two absorbable physical barriers that are approved by the U.S. Food and Drug Administration for the prevention of adhesions. Seprafilm is a membrane made of hyaluronate and carboxymethylcellulose and is applied intraoperatively. The application of Seprafilm was demonstrated by several randomized trials to reduce the incidence and severity of adhesions after surgery.31-33 INTERCEED, a membrane composed of oxidized regenerated cellulose, has also been shown to reduce the incidence, extent, and severity of postoperative adhesions significantly.34-35 However, its effectiveness is reduced in the presence of blood.36 Whether the application of these absorbable barriers will translate into a lower rate of bowel obstructions has yet to be determined, but the initial results are promising.

ENTEROCUTANEOUS FISTULA An enterocutaneous fistula is defined as an abnormal communication between the bowel and skin. This is a serious condition with a mortality rate still ≤15%. The

approach to a patient who develops an enterocutaneous fistula requires stringent attention to detail and patience. Enterocutaneous fistulas can generally be classified as spontaneous or postoperative. Most enterocutaneous fistulas (75%-85%) result from operative intervention, whereas spontaneous enterocutaneous fistulas account for the remainder and are associated with inflammatory bowel disease.37 The most common operations leading to enterocutaneous fistulas include procedures performed for malignant disease, inflammatory bowel disease, or adhesiolysis. The major risk factor appears to be poor nutritional status of the patient. Patients who have lost 10% to 15% of body weight over a short period of time, have a serum albumin level of 2 cm

Fistula tract 3 days, the colon should be decompressed colonoscopically with placement of a long rectal compression tube.53 Surgical management is indicated in patients with ischemia or perforation or when pharmacologic methods and decompression have failed. Cecal perforation is reported in approximately 10%. The mortality rate is approximately 50%. According to Laplace’s law, the most tension in a hollow viscus occurs in the portion of the colon with the greatest diameter: the cecum. Tension on the bowel wall diminishes blood flow and leads to necrosis and perforation. In the case of perforation, the entire segment of diseased colon is resected. Alternatively, tube cecostomy can be performed in patients without ischemia or perforation. This procedure can be performed using local anesthesia with high success and relatively low morbidity.

STAPLING COMPLICATIONS Hungarian surgeon Hültl first conceived of the concept of stapling as an alternative to suturing tissues in 1908. These devices were not generally accepted until the 1950s, when surgeons in the Soviet Union began using them more frequently for all types of procedures. Today, stapling devices are widely used in the United States, especially for GI tract surgery and creation of urinary conduits and for reconstitution of GI continuity if resection is required for en bloc excision of tumors. Numerous staplers exist and, when used properly, provide an anastomosis as reliable as that of hand-sewn reconstruction. The most commonly used staplers are the GI anastomosis stapler and the thoracoabdominal stapler. In addition, the end-to-end anastomosis stapler has been used for construction of the intestinal conduit stoma.54 This type fires two circular rings of staples creating an anastomosis between two lumina. All these staplers fire a thin wire through two intestinal walls and are compressed to form a B shape. The shank length of the staple determines the thickness of the tissue after application of the instrument. Thus, a longer staple shank should be chosen for thicker tissue. Small vessels may course through the eye of the B, thereby allowing excellent vascular supply but sometimes poor hemostasis. When the same principles of hand-sewn anastomosis, including adequate blood supply, lack of tension, and well prepared intestine, are applied, a stapled anastomosis appears as safe as that of a sewn one55,56

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Section IV  Common Surgical Considerations TABLE 22-4  Sewn Versus Stapled Anastomosis Complications Sewn (%)

Reference

Stapled (%)

VESICOENTERIC FISTULA

Mortality Sewn (%)

Stapled (%)

Hedberg and Helmy55 (1984)

15

4

2

0

Reiling et al56 (1980)

16

18

0

5

TABLE 22-5  Sewn Versus Stapled Anastomosis Operating Room Time (min) Reference Didolkar et al57 (1986) 59

Cajozzo et al

60

Seufert et al

(1990)

(1990)

Anastomotic Time (min)

Sewn

Stapled

Sewn

Stapled

154

170

19

9

—

—

14

14.3

194

180

—

—

(Table 22-4). This is true despite carcinomatosis, adhesions, prior chemotherapy and radiation therapy, bowel obstruction, anemia, and low leukocyte count or albumin value.57 Some surgeons avoid a stapled anastomosis in the patient who has edematous, thickened, or attenuated bowel or who is taking steroids. Most clinicians would agree that at the time of the anastomosis, an attempt at inspection for hemostasis along the staple line should be performed both inside and outside the bowel. This is especially true because a well-placed staple line on the intestine should not be completely hemostatic. Unrecognized massive bleeding has been reported and may require repeat exploration.58 The surgeon should be sure to inspect the inside of a side-to-side anastomosis performed with an anastomosis stapler before it is closed. Many surgeons have claimed that the use of stapling devices save time. Nonetheless, studies that specifically addressed this issue found the operative times to be quite similar (Table 22-5).58-60 Certainly, the cost associated with the use of disposable devices is higher. Allergic reactions to skin staples have been reported, including dermatitis from nickel allergies or chronic urticaria from tantalum staples, but allergies do not appear to be a issue for anastomotic staple application. A unique potential complication in urology appears to be the formation of calculi around a staple nidus.61,62 Brenner and Johnson62 noted a 4.2% incidence in patients who had ileal conduit diversions. The management of such stones is discussed in detail in a separate chapter. These few incidents of calculi formation appear to occur early after surgery and require no intervention.

Vesicoenteric fistula, or the abnormal communication between bladder and bowel, is rare. Most of these fistulas are a consequence of inflammatory and neoplastic processes of the bowel. Diverticulitis alone accounts for ≤50% of these fistulas, whereas colonic malignant disease, granulomatous bowel disease, and radiation therapy make up the majority of the remainder.63 Patients with vesicoenteric fistulas primarily present with urologic symptoms rather than with symptoms related to the bowel. The presence of pneumaturia (passage of gas) and fecaluria (passage of feces) per urethra is pathognomonic and occurs in ≤83% of cases.63 Patients may also exhibit bladder irritation, frequency, urgency, dysuria, and hematuria. Abdominal symptoms such as abdominal pain, diarrhea, constipation, intestinal obstruction, and acute abdomen also occur, but to a much lesser extent. Because of higher colonic pressure, passage of urine per rectum is not seen unless the patient has severe bladder obstruction or a diverting colostomy. The diagnosis of vesicoenteric fistula is sometimes difficult to make on clinical grounds alone, and confirmatory studies are necessary. The most sensitive diagnostic modality is cystoscopy, which may show mucosal abnormalities, feces, and particulate matters. In a series64 of 76 patients diagnosed and treated for vesicoenteric fistulas, investigators found that cystoscopy was sensitive in 60% of the cases. Alternatively, one can perform cystography to document the presence of contrast material in the bowel. CT scan, magnetic resonance imaging, and barium enema are not sensitive when used alone and are commonly used in combination with cystoscopy and cystography. CT scan before bladder instrumentation can provide evidence of air in the bladder, thereby confirming the presence of an enteric fistula, although it may not define the location in the absence of associated phlegmon. In this regard CT scan is the most sensitive modality for confirmation of a fistula, and cystoscopy may allow localization. Once the diagnosis of vesicoenteric fistula is made, surgical therapy is the management of choice in most cases. Whether the approach is a one-stage or two-stage procedure is controversial, and the surgeon must make that decision based on the individual patient. In general, a one-stage repair is indicated in patients with the following factors: younger age, good general condition, small fistula, no involvement of a third organ, and absence of pericolonic or peri-intestinal abscess. In contrast, patients who have larger fistulas with possible involvement of a third organ and who may not tolerate the long surgical procedure well should undergo a twostage repair. In a one-stage repair, the surgeon resects the diseased bowel and portion of the involved bladder then primary bowel anastomosis is achieved and the bladder closed.

Chapter 22  Management of Bowel Complications During the procedure, urinary diversion can be attained by a urethral catheter or a suprapubic catheter. A twostage repair involves creating a diverting colostomy to control the inflammatory process and avoid infection and sepsis. A second operation is then performed weeks later in which the diseased bowel and involved bladder are resected follow by bowel anastomosis, bladder closure, and closure of the colostomy. To promote healing, it is advisable to fill the potential dead space between the bladder and bowel with vascularized tissue. This can be accomplished with an omental flap by fixing it between the bladder and bowel or creating a pedicle flap.

INTERNAL HERNIAS Internal hernias are protrusions of a viscus through a normal or abnormal peritoneal or mesenteric aperture within the confines of the peritoneal cavity. Their overall incidence is 12 cm, colon size is increasing rapidly, or the duration is >3 days, the colon should be decompressed colonoscopically with placement of a long rectal compression tube. 8. Patients with vesicoenteric fistulas primarily present with urologic symptoms rather than with symptoms related to the bowel.

REFERENCES Please see www.expertconsult.com

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Chapter 

23

MANAGEMENT OF URINARY FISTULAS Priya Padmanabhan

MD, MPH Instructor, Department of Urologic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee

William Lea

MD Resident, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana

Harriette Scarpero

MD Associate Professor, Department of Urologic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee

Descriptions of urinary fistulas exist in the ancient writings of Hippocrates and Rufus. Today, surgeons in the Western world encounter fistulas as a result of surgery or radiation for other medical conditions. Repair can be challenging but success is common. The World Health Organization estimates that in developing regions such as West Africa, approximately 2 million women suffer from obstetric fistula, and 50,000 to 100,000 new cases occur annually around the world. The prevention and correction of obstetric fistula are therefore humanitarian issues of significant proportion. Despite differences in origin and patient demographics, optimal fistula repair adheres to several basic surgical tenets (Box 23-1).

URETHROVAGINAL FISTULA Etiology Urethrovaginal fistula is an uncommon disorder that may be the consequence of various pathologic situations. Historically, dystocia was one of the chief contributory factors. Cephalopelvic disproportion can cause ischemic necrosis of the bladder and urethra from prolonged intense pressure of the fetus or forceps pressure on the symphysis pubis. With the avoidance of traumatic vaginal deliveries and prolonged labor in the developed world, obstetric trauma is now a much less common cause of urethrovaginal fistulas. Young women in the developing world, particularly in Africa, are still at high risk of developing urethrovaginal fistula because of inadequate obstetric care.1 In Nigeria, 350 of every 100,000 deliveries are complicated by fistula formation. These patients suffer from the obstructive labor delivery complex, including complex urethrovesical fistulas, rectal injuries (17%), foot drop (20%), and amenorrhea with infertility (63%).2 Today, the most common cause of urethrovaginal fistulas is iatrogenic, from a surgical procedure in the area of the

urethra, such as urethral diverticulectomy or anterior colporrhaphy. These two procedures contribute 15% to 45% of reported urethrovaginal fistulas.3-7 Other surgical procedures that confer risk for urethrovaginal fistula include bladder neck suspension, Kelly plication, vulvectomy, and anti-incontinence surgery (periurethral injection, pubovaginal sling). Significant nonsurgical risk factors are radiation therapy, trauma, genital tumors, and congenital conditions.1,8

Presentation Urethrovaginal fistulas can manifest with vaginal voiding from a pinpoint lesion or total incontinence from complete loss of the urethra (Fig. 23-1). The clinical presentation depends on the location and size of the fistula and the competency of the bladder neck. Distal fistulas are usually asymptomatic but can create a spraying or split urine stream, recurrent urinary infections, or vaginal voiding. Midurethral and proximal fistulas usually manifest with abnormal urine stream, vaginal pooling of urine, perineal skin irritation, vaginal fungal infections, intermittent positional wetness, and possible stress urinary incontinence (SUI). Forty-nine percent of continent menopausal women have an incompetent bladder neck mechanism and therefore rely on an intact proximal urethral mechanism and external sphincter to maintain continence. When the bladder neck mechanism is competent in a patient with a proximal urethral fistula, incontinence may not occur.8,9 The onset of symptoms relates to the mechanism of the fistula formation. Anterior vaginal wall laceration from trauma or obstetrics usually manifests ≤24 hours or immediately after Foley catheter removal. Ninety percent of fistulas associated with pelvic surgery are symptomatic within 7 to 30 days postoperatively (after catheter removal). Radiation-induced urethrovaginal fistulas are associated with slower progressive devascu263

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Section IV  Common Surgical Considerations

Figure 23-1  Three photographs of a proximal urethral fistula.

BOX 23-1 Principles of Fistula Repair Technique Optimal exposure of the fistula Wide mobilization of tissues Tension-free approximation of the tissues Watertight closure Multilayer repair with no overlapping suture lines Use of vascularized interposition grafts

larization necrosis and may manifest 30 days to many years later.9,10

Diagnosis The differential diagnosis of urethrovaginal fistula includes vesicovaginal fistulas (VVFs) and ureterovaginal fistulas, severe SUI, and occasionally simple vaginal discharge.11 Evaluation must begin with a comprehensive history and physical examination, including information of previous surgery, trauma, or radiation. Diagnosis is usually not difficult, and identification by a vaginal speculum examination and cystourethroscopy is often sufficient. Cystoscopy helps identify the size and location of the fistula tract and enables the urolo-

gist to evaluate the bladder for evidence of bladder neck or trigone involvement. Voiding cystourethrogram (VCUG) and intravenous pyelogram (IVP) are not required to make the diagnosis of a urethrovaginal fistula, but these studies are of paramount importance in excluding VVF and ureterovaginal fistula, respectively. The urologist must have a high index of suspicion for associated injuries. Older series reported a 19% incidence of concomitant VVFs.3 In patients with concurrent SUI, videourodynamic study (VUDS) is helpful in identifying patients who may benefit from an incontinence procedure at the time of the fistula repair.9,10 Urodynamic studies have detected a higher incidence of SUI and detrusor instability with fistulas involving the urethra or bladder neck than with fistulas solely into the vaginal vault.12

Prevention Surgical technique during transvaginal procedures is crucial in preventing the formation of a urethrovaginal fistula. Surgical dissection should be performed carefully to preserve the periurethral fascia and to avoid the risk of injuring the urethral spongiosum, which is highly vascular and associated with fibrosis when

Chapter 23  Management of Urinary Fistulas injured. In urethral dissection, Bovie cautery should be avoided and bipolar cautery should be used preferentially because of the risk of penetrating, full-thickness injury. Before closure of urethral and anterior vaginal repairs, a small-diameter Foley catheter (14 or 16  Fr) should be placed to prevent local ischemic damage and pressure.

Management Repairing urethrovaginal fistulas requires careful assessment of the health and integrity of the tissues surrounding the fistula. Often, urethrovaginal fistulas are associated with significant scarring and insufficient surrounding tissues to achieve a tension-free multiple-layer closure. Therefore, the interposition of well-vascularized tissue is often required to ensure adequate healing. In the absence of tissue for interposition, some series report a 100% failure rate.7,9 Additionally, it is important to determine whether patients have concurrent SUI, which can be treated simultaneously with an autologous fascial sling. The fascial sling has the added benefit of providing an extra layer of tissue between the urethral repair and vaginal closure. Synthetic slings are contraindicated at the time of urethrovaginal fistula repair secondary to the risk of erosion. The optimum timing of surgical correction remains a point of discussion. Repair is usually delayed for >2 months after the initial injury to allow the inflammation to resolve. When the fistula is a result of radiation therapy, repair is usually delayed for ≥1 year until the fistula tract has time to mature and the ischemic injury has stabilized.9,7,13 Radiation-related fistulas should undergo biopsy before repair to rule out local tumor recurrence. During this period before repair, postmenopausal atrophic tissue should be treated with estrogen cream to improve the quality of the tissue and to maximize the potential for a successful repair.11 The complexity and choice of repair depend on the location of the fistula: small, medial to distal fistulas versus large, proximal urethral fistulas with bladder neck or trigone involvement. A common approach for fixing smaller, distal fistulas has been described.8 An inverted-U–shaped incision is made proximal to the urethrovaginal fistula to circumscribe but not excise the fistula. Anterior and posterior vaginal wall flaps are mobilized and the fistula is closed in a two-layer, watertight closure with 3-0 absorbable suture material. When concern exists regarding integrity of tissue near the fistula (e.g., radiation, previous repair), a Martius labial fat pad flap is an important adjunctive procedure. The Martius flap is secured over the fistula repair. An important surgical tip is to avoid making the fat pad too thick because it becomes difficult to close the vaginal incision if the fat pad is bulky. When the gold standard, the Martius labial fat pad, fails or when a large proximal fistula involves the

bladder neck or trigone, the method of repair is more complicated. Additional tissue flaps have been described to achieve proper repair: gracilis flap, peritoneal flaps, gluteal skin flaps, omental flaps, and lyophilized dura mater patches.14 The disadvantages of the other flaps are that they frequently require extra operations and they may be deforming. The pedunculated rectus flap has been described as useful in treating both the fistula and the SUI related to intrinsic sphincter deficiency.15 This flap operation requires a combined vaginal and retropubic approach. Although it is helpful to know of alternative methods to provide healthy tissue interposition, we find that most cases of iatrogenic urethrovaginal fistulas are amenable to correction with primary closure, Martius labial fat interposition, and an autologous pubovaginal sling in select cases. Another important caveat is that any foreign body material such as mesh must be completely removed before closure. In some cases, such as in patients with significant loss of urethral tissue necessitating urethral reconstruction or a neourethra fistula involving the bladder neck or trigone, described techniques fall into the following three categories: 1. Anterior bladder flaps16 2. Posterior bladder flaps17,18 3. Vaginal flaps Blaivas and Heritz19,20 simplified a vaginal approach enabling both fistula repair and a concomitant incontinence procedure. An inverted-U–shaped incision is made in the anterior vaginal wall, through the fistula site, thus circumscribing the fistula and closing the site with absorbable suture. The neourethra is created by making two parallel incisions in the anterior vaginal wall on both sides of the Foley catheter; this maneuver creates flaps that are then tubularized around the catheter. In a patient who has undergone radiation, the use of rectus or gracilis flap is advisable. These well-vascularized grafts provide a new blood supply to the neourethra and allow the defect to be closed in a tension-free manner. Sexual function may be preserved because vaginal stenosis is unlikely to occur.21 Following repair of urethrovaginal fistulas, urinary drainage is usually maintained for 1 to 3 weeks, depending on the location and complexity of the repair. Both suprapubic and urethral catheters (8 or 10 Fr) are often inserted. Because the suprapubic tube is placed under the direct vision of the cystoscope, this tube is generally placed at the start of the procedure. If the surgeon has already decided to use an autologous pubovaginal sling, it will be harvested and the sutures passed before fistula closure. The rationale for completing these tasks before urethrovaginal fistula closure is that doing so reduces the need to pass a scope over the delicate urethral repair. Occasionally, a urethral catheter is avoided to prevent ischemia or pressure to the repair, especially in the case

265

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Section IV  Common Surgical Considerations of middle or distal urethrovaginal fistulas. Oral anticholinergics are always given and may be discontinued 24 hours before a postoperative VCUG is obtained. The VCUG is performed by filling through the suprapubic tube and removing the urethral catheter. When extravasation is present, the suprapubic tube is returned to drainage, and VCUG is repeated in 1 week. The urethral catheter is usually not replaced because of the risk of disturbing the delicate suture lines.8

VESICOVAGINAL FISTULA Etiology The underlying cause of VVF formation is tissue ischemia from pelvic floor injury. VVF can be a result of obstetric trauma, surgery (hysterectomy, antiincontinence procedures), congenital anomalies, or malignant disease or its treatment (radiation). With advances in obstetric care, most VVFs in developed countries (90%) occur after surgical procedures for “benign disease,” and total abdominal hysterectomy accounts for 70% of these fistulas.3 VVF in developing countries remains associated with prolonged labor and traumatic delivery. Current estimates are that 1 in 3 of every 1000 deliveries in West Africa will result in a VVF (Fig. 23-2).25 Even though numerous predisposing factors have been identified in the development of postoperative fistulas (infection, ischemia, arteriosclerosis, pelvic inflammatory disease, previous uterine surgery, uterine leiomyomas, radiation, diabetes), most fistulas occur following normal operative circumstances.26 In cases associated with malignant disease (cervical, uterine, ovarian, rectal), the VVF could be a result of a surgical complication, radiation treatment, or the presence of cancer. Surgical procedures performed for cancer are usually more radical and thus are more likely to cause tissue hypovascularization, which predisposes to the formation of a fistula.27 Radiation causes chronic vascular changes with a field effect leading to a loss of microcirculation, mucosal atrophy, ulceration, and fistula formation. The incidence of fistula formation induced by radiation is 1% to 5%.28,29 VVF may also be caused by direct invasion of the tumor through the vagina or bladder.

Sequelae Multiple autologous, other biologic, and synthetic options for sling material have been described for treating SUI. Most proximal fistulas involve the intrinsic continence mechanism, and therefore these patients benefit from concomitant sling surgery at the time of fistula repair if SUI is demonstrated on the preoperative VUDS evaluation. The incidence of incontinence following all urethrovaginal fistula repairs is 20% to 70%.4,22,23 In one study, Pushkar and colleagues9 reported that 37 of 71 (52%) patients developed SUI following urethrovaginal fistula repair. These patients were treated with a combination of fascial slings, other autologous tissue slings, or tension-free vaginal tapes (retropubic or obturator). Only 8% remained incontinent or were dissatisfied with the results. Blaivas and Heritz20 found three cases of refractory SUI following fistula repair and bladder neck suspension that were cured with pubovaginal slings. A synthetic sling should never be used in an incontinence procedure at the time of a urethrovaginal repair. Periurethral tissue is fragile and a fibrotic reaction is associated with initial injury and repair. Therefore, we prefer to use autologous rectus fascia for all slings in urethrovaginal fistula repair. The role of bulking agents is unclear.24

A

B

Figure 23-2  A, Complete prolapse of bladder mucosa through a large vesicovaginal fistula secondary to obstructed labor. B, Demonstration of the foot drop that accompanies these obstetric fistulas in 20% of cases. (Courtesy of Dr. Alyona Lewis and the West Africa Fistula Foundation.)

Chapter 23  Management of Urinary Fistulas

Presentation The clinical presentation and onset of VVF vary depending on the cause. VVFs that form after pelvic surgery rarely manifest with immediate fever, ileus, abdominal discomfort, hematuria, or bladder irritability, because of urine leakage into the peritoneum. Most patients present with the complaint of vaginal leakage of urine 3 to 7 days after Foley catheter removal; 10% to 15% of these patients present later, 10 to 30 days after the procedure. Patients with a small fistula or a fistula located high in the vaginal vault may void normally. They may note being dry at night while supine and voiding large volumes in the day despite frequent leakage. With larger fistulas, the bladder does not store any appreciable urine, and patients complain of minimal voids with large, continuous leakage. The differential diagnosis includes urethrovaginal fistula, ureterovaginal fistula, and vaginal discharge.21,11 When radiation is the cause of the VVF, presentation may be delayed from 5 months up to 30 years after treatment, and 25% of these patients may be asymptomatic for >5 years. Irritative lower urinary tract symptoms have been reported to be relieved by the sudden appearance of the VVF. Occasionally patients present with vaginal flatulence or feces, and these patients should be evaluated for concomitant rectovaginal fistula.30,31

Diagnosis A complete history and physical examination, including a thorough pelvic examination, are necessary in evaluating for a VVF. In acute fistulas, the mucosa around the VVF tract can be inflamed and erythematous, thus concealing the opening. In mature fistulous tracts, a small opening may be visualized in the vaginal wall. If one is in doubt, fluid collecting at the vaginal apex can be sent for urea and creatinine concentrations to confirm the presence of urine but this is usually not necessary. A simultaneous rectal examination in cases of posterior vaginal distortion by inflammation and edema should be performed to rule out rectal involvement.21 If examination results are highly suggestive of rectal involvement, proctoscopy should be performed. A tampon test using a combination of phenazopyridine (Pyridium) and diluted methylene blue provides preliminary evidence of a VVF or a ureterovaginal fistula. Patients are given phenazopyridine, which colors the urine orange. A tampon is inserted into the vagina before the phenazopyridine is administered. The bladder is also distended with diluted methylene blue before placement of the tampon. The patient then ambulates for 15 to 30 minutes. If the tampon is orange, a ureterovaginal fistula and a VVF are likely. If the tampon turns blue, this finding supports a VVF. Although a classic and frequently described test, it is imperfect. A ureterovaginal fistula cannot be confirmed without imaging. In our

experience, proper cystoscopic and radiologic staging is prerequisite for diagnosis. Radiologic examination should include an IVP or retrograde pyelography, to rule out ureterovaginal fistula, which is present 10% of the time in patients with VVF. With an IVP, ureteral involvement often appears as extravasation or hydronephrosis. A persistent column of contrast material in the ureter may be the only sign of ureteral involvement. Bilateral retrograde pyelography is the most accurate method for determining concomitant ureteral involvement and also for localizing it.21 Cystoscopy with vaginal manipulation is essential in elucidating the size, number, and location of fistulas in relation to the ureteral orifices, vaginal cuff, and trigone (Fig. 23-3). Passage of a 0.35-mm sensor wire through the fistula helps in identification when one of the openings is unidentifiable. VVFs that occur after hysterectomy usually are located along the anterior vaginal vault and the interureteric ridge. Fistulas that occur after radiation are often located in the caudal position of the trigone, distal to the interureteric ridge.32 VUDS is a useful adjunct in evaluating these patients preoperatively. VUDS helps identify patients with SUI who would benefit from a concomitant anti-incontinence procedure at time of VVF repair. Moreover, patients who have received radiation should be evaluated for their bladder capacity and compliance to consider augmentation cystoplasty during fistula repair. VVF in patients with a history of gynecologic malignant disease should always be examined by biopsy preoperatively, to rule out recurrence of malignancy.

Prevention A VVF generally results from simultaneous injury to the bladder and vagina, most commonly occurring during abdominal hysterectomy. Bladder injury usually occurs during sharp and blunt dissection of the cervix from the bladder, especially when the procedure is complicated by prior radiation therapy, obesity, or prior surgery. Injuries take a few forms: direct laceration of the bladder during dissection, excessive cautery producing fullthickness necrosis, and placement of sutures at the vaginal cuff that accidentally incorporate the bladder. Prevention of VVF formation depends on surgical technique and postoperative urinary drainage. The surgeon must maintain a high index of suspicion following dissection, and in cases of suspected bladder or ureteral injury the urologist should be consulted intraoperatively. If the surgeon is a urologist, filling of the bladder with dilute methylene blue can reveal a bladder injury, whereas the intravenous injection of indigo carmine can assist in the diagnosis of a ureteral injury. Technical points in closing a bladder injury include watertight bladder anastomosis, tension-free repair, and interposition of healthy tissue (between bladder repair and vaginal cuff closure). Postoperatively, adequate

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Section IV  Common Surgical Considerations

BOX 23-2

Planning Vesicovaginal Fistula Repair

Timing of repair Choosing an approach (vaginal versus abdominal) Ruling out associated injuries (ureteral involvement) Assessing the health of tissues (infection, estrogenization, recurrent cancer, extent of radiation change) Planning concomitant procedures (ureteral surgery, stress incontinence surgery, or augmentation cystoplasty)

A

B Figure 23-3  A and B, Two cystoscopic photographs of vesicovaginal fistula from within the bladder.

urinary drainage should be accompanied by maximal detrusor relaxation induced by anticholinergic medication, and a confirmatory cystogram should be performed before the urethral catheter is removed.11 The repair and management of ureteral injuries are discussed in the later section on ureteral fistulas.

Management VVFs are classified according to their size and origin. Simple fistulas are small (2.5  cm), often the result of chronic disease or radiation. Intermediate-size fistulas (0.5 to 2.5  cm) are often categorized as complex fistulas.27 Treatment options are based on the origin and

complexity of the VVF and on the timing of repair. Options range from conservative management (bladder drainage, fulguration) to surgical therapy (transvaginal versus transabdominal repair). Conservative treatment has been attempted in simple fistulas 2 weeks to 2 months after injury, with success rates ranging from 0% to 100%.33 No prospective study has correlated the duration of drainage with the chance for spontaneous healing, and often this is based on personal experience. At most, one third of small fistulas will close with catheter drainage.11 Another conservative option for closure of VVF is electrofulguration with or without injection of bovine collagen and fibrin glue. The bladder is subsequently drained for ≤4 weeks.34,35 We find that this approach has very limited utility and rarely use it. Most conservative methods are ineffective; therefore, surgery remains the primary method for repair. Surgical planning includes decisions on timing, approach, the need for fistula tract excision, and the use of interpositional flaps (Box 23-2). Surgical repair is best performed when the edema and inflammation have subsided and no infection is present. Traditionally, a 3- to 6-month waiting period has been recommended to allow the fistula tract to mature. Some studies showed that fistulas may be closed within weeks of diagnosis.36,37 Zimmern and associates38 observed that surgical repair performed 2 to 3 weeks after injury had no associated increased morbidity or failure results. Contraindications to early closure include multiple unsuccessful closures, associated enteric fistula with pelvic phlegmon, and previous radiation. These types of fistulas are usually repaired after a 4- to 8-month waiting period.29 Ultimately, the timing of surgery should be based on the preference of the surgeon and the patient. Traditionally, an abdominal approach was used for supratrigonal fistulas, whereas a vaginal approach was used for infratrigonal, bladder neck, and proximal urethral fistulas. Current practice among experienced transvaginal surgeons is a vaginal approach in cases of VVF with a few exceptions. The advantages of a vaginal approach include patient comfort and recovery time.21 Contraindications to a vaginal approach include severely indurated vaginal epithelium around the fistula, small capacity or poorly compliant bladder requiring augmentation, repair requiring ureteral reimplantation,

Chapter 23  Management of Urinary Fistulas involvement of other pelvic structures, vaginal stenosis, or the inability to obtain proper exposure.36 The classic transvaginal repair for uncomplicated small fistulas was perfected by Raz.38,39 An inverted-J– or U–shaped incision is made circumferentially around the fistula and flaps are dissected, thus mobilizing the vaginal epithelium away from the fistula. The margins of the fistula are trimmed and closed using absorbable suture. It is up to the surgeon to decide whether to excise the fistula. The advantage of excision is achieving a mucosa-to-mucosa closure of healthy tissue. The disadvantage is that the fistula size increases, the hyperemic surrounding tissue bleeds, and that the friable bladder may not hold the stitches. Because the fistula tract also provides extra strength to the closure, most surgeons do not excise simple fistula tracts.11 The perivesical fascia is then closed with absorbable sutures in a perpendicular fashion (over the fistula tract), with the edges inverted. The bladder is filled with diluted methylene blue at this point to check for a watertight closure. Finally, the vaginal wall is closed in a third layer, in a nonoverlapping absorbable suture line. Usually, a suprapubic tube and a Foley catheter are left for straight drainage, and anticholinergics are given liberally. We often remove the urethral catheter before hospital discharge on the first postoperative day. A cystogram is performed 2 to 3 weeks postoperatively and if no extravasation is seen, the suprapubic tube is removed. Complex fistulas including those associated with eroded mesh or radiation require the use of tissue interposition between vesical and vaginal suture lines (Fig. 23-4). Generally, a Martius flap is used for distal fistulas and a peritoneal flap is used for proximal fistulas (high in the vaginal vault). The selection of autologous tissue depends on the size of the fistula, its location, the quality of patient tissues, and the surgeon’s preference. The Martius flap is reliable, but it requires a separate incision and may not reach fistulas high in the vaginal vault. The vagina may be shortened during attempts to extend the flap from the labia to the vagina. Peritoneum is a suitable alternative in these high fistulas. The peritoneal flap is well vascularized and readily available, and it can be harvested with only one incision.37 Raz and colleagues37,40 reported success rates with a peritoneal flap of 91% and, more recently, 96%. To prepare a peritoneal flap, the peritoneum is mobilized in the cul de sac sharply and is advanced over the repair, between the second and third layers of the basic repair.37,40 Another option is a deepithelialized vaginal wall flap. The abdominal approach may be extraperitoneal or transperitoneal, with or without opening the bladder. An abdominal approach is easily reproducible and successful, yet it has the associated risks, complications, and longer convalescence associated with laparotomy. An abdominal approach is required when vaginal exposure is difficult, when concomitant bladder augmentation or

Figure 23-4  A rare form of vesicovaginal fistula created by incorrect placement of a polypropylene sling through the detrusor. Note the sling material being excised from the fistula tract.

ureteral reimplantation is necessary, or when it is the surgeon’s preference. The bladder and vagina are sharply dissected apart, and each opening is closed in single layers. A flap of peritoneum or omentum is placed in between to prevent recurrence or creation of a fistula.11 The traditional abdominal approach, the O’Conor technique,41 is a transperitoneal, transvesical operation in which the bladder is bivalved down to the fistula. The fistulous tract is excised and the bladder is mobilized off the vagina. The vaginal and vesical walls are repaired separately, and omentum or peritoneum is interposed between the two. The incidence of bladder spasms is usually more pronounced followed abdominal repairs and the standard use of a suprapubic tube. Urethral catheters and anticholinergics are maintained until a cystogram is performed 3 weeks postoperatively. The success rates in the literature for repair of VVF, independent of the access route and tissue conditions, approach 90%. In addition to showing no appreciable improvement in success rates with delaying surgical repair, Blaivas and colleagues36 found that, in expert hands, VVF repairs were equivalent whether they used an abdominal or a vaginal approach. The most difficult fistulas to repair are those caused by radiation and therefore the success rates for these repairs should not be compared with rates for nonradiated fistulas. The success rate of nonradiated VVF repair varies from 70% to 100%, with a mean success rate of 92%.23,42-45 Most of these

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Section IV  Common Surgical Considerations operations were performed using a transvaginal approach. Conversely, the success rate of radiationinduced VVF repairs is between 40% and 100%. Some surgeons advocate urinary diversion instead of repair of a radiated fistula. The highest success rates have been noted with procedures performed using an abdominal approach or a combined approach with rectus or omental and gastric flaps based on the right gastroepiploic artery.28,44,46-50 At our institution, a tertiary referral center for many complex, recurrent VVFs, we find that use of only one approach is not practical. The surgical approach is based on the surgeon’s appraisal of each individual case: the location and size of the fistula, the quality of the surrounding tissue, the number of prior repairs, the mobility of the vaginal tissues, the necessary concomitant procedures, and the patient’s comorbidities.

Sequelae Even in cases of successful fistula repair, voiding dysfunction with de novo frequency, urgency, and incontinence may result and may be a considerable burden to the patient. The rates of long-term voiding dysfunction after fistula repair are not commonly reported and very few series address them specifically, nor does a clear consensus exist on what causes postoperative irritative symptoms. The fistula itself and not the repair may be responsible.51,52 Another theory is that bladder capacity may be compromised if repair is delayed, thus resulting in voiding dysfunction. We believe that postoperative voiding dysfunction is multifactorial and is related to the inciting operation, surgical complexity, timing of repair, number of repairs, and adjunctive procedures. In our own series of 48 fistula repair patients from April of 1998 through July of 2006, de novo urgency and frequency were seen postoperatively in 21 (48%). Symptoms may be controlled with anticholinergics or sacral neuromodulation in refractory cases.

URETERAL FISTULAS Ureteral fistulas are rare, but the diagnosis has become more common with the development of advanced and extensive options for pelvic and abdominal disease, endourologic procedures, and vascular reconstruction. Ureteral fistulas are associated with high morbidity. In certain ureteral fistulas, misdiagnosis leads to a 100% mortality rate. This section reviews the etiology, presentation, diagnosis, prevention, management, and sequelae of ureterovaginal, ureteroenteric, and ureteroarterial fistulas.

Etiology The formation of ureteral fistulas depends on injury to the ureter that can expose the ureteral lumen or result

Figure 23-5  Retrograde pyelogram demonstrating a ligation injury and obstruction of the ureter at the time of hysterectomy. This type of injury may lead to ureteral ischemia and potentially a ureteral fistula or stricture.

in delayed necrosis of a portion of the ureter, thus leading to subsequent urine extravasation.53 This injury may be acute or insidious in onset. Acute ureteral injury, as in the case of iatrogenic injuries (suture ligation, incision or transection, avulsion, or crushing) or trauma is immediately apparent. A delayed change in ureteral patency is seen in iatrogenic devascularization, heat therapy or cryoablative therapy, radiation, or vascular grafting.54 The course and blood supply of the ureter are fundamental to an understanding of common sites of ureteral injury (Fig. 23-5). The ureter travels caudally through the retroperitoneum, along the anterior psoas muscle, posterior to the colonic mesentery, and lateral to the gonadal vein. The complex blood supply to the ureter arises from the renal artery, gonadal artery, lumbar arteries, and aorta proximally and from the internal iliac artery and branches distally. The small arteries, intimate with the peritoneum, approach the ureter medially in the abdomen and laterally in the pelvis,54,55 and they direct the surgical approach of the ureter. Ureteral fistulas may occur as complications of colorectal surgery, vascular surgery, other urologic procedures, obstetric care, or penetrating trauma, but most arise following gynecologic surgery. The incidence of iatrogenic ureteral injuries during gynecologic surgery is 0.4% to 2.5%, and these numbers probably underestimate the true incidence.56,57 Many injuries are missed at time of operation until they become symptomatic.58 The ureterovaginal fistula is the most common ureteral fistula. Most ureterovaginal fistulas are caused by one procedure—

Chapter 23  Management of Urinary Fistulas hysterectomy. The risk of ureteral injury is greatest during laparoscopic hysterectomy, followed by abdominal hysterectomy and finally by vaginal hysterectomy. With the introduction of laparoscopy and minimally invasive techniques, the incidence of iatrogenic gynecologic ureteral injuries is increasing.59,60 Risk factors for the development of ureterovaginal fistulas include endometriosis, obesity, pelvic inflammatory disease, radiation therapy, and pelvic malignant disease.58 Most ureterovaginal fistulas occur during procedures for benign indications,61 usually hysterectomy, but also cesarean section, pelvic organ prolapse repair, and other pelvic operations during which surgical injury of the distal third or pelvic portion of the ureter occurs (Fig. 23-6). Ureteroenteric fistulas are extremely rare, with fewer than 15 cases reported in the literature since 1918.62 Most cases reported are ureteroduodenal fistulas secondary to chronic renal infection, ureteral calculi, duodenal ulcer disease, roundworm infection of the urinary tract, iatrogenic injury, trauma, or ingestion of foreign body.63-65 As in most fistulous formation, the presence of ureteroenteric fistulas is often associated with radiation or ureteral ischemia. Ureteroaortic fistulas are also uncommon. Approximately 90 cases have been reported in the English-language literature, mostly since 2000.66 The increased incidence is related to the greater numbers of vascular reconstructions, treatments of pelvic malignant disease, and long-term use of ureteral stents. This is the only type of ureteral fistula that has a 100% mortality rate if it is left undiagnosed and untreated. Ureteroaortic fistulas most commonly involve the middle to distal ureter where the ureters cross the pelvic brim, most commonly involving the common iliac artery,67 but they may also involve the external iliac artery, internal iliac artery, and aorta.68,69 Ureteroaortic fistulas are classified into three categories according to causes: primary, secondary (iatrogenic), and pregnancy related.66 Primary fistulas represent 1 hour to complete are associated with a higher incidence of complications, including water intoxication syndrome (TUR syndrome [TURS]), urethral strictures, sepsis, and excessive blood loss. If greater duration is anticipated, open prostatectomy should be considered. Absolute indications for TURP include acute urinary retention, recurrent infections, recurrent hematuria, and renal insufficiency or failure.9 Most commonly, TURP is performed on men with moderate to severe bladder outlet symptoms that are refractory to pharmacologic therapy. The role of preoperative diagnostic tests is controversial. The American Urological Association Symptom Index and uroflowmetry are useful both to detect severity of symptoms and to assist with monitoring patients after resection.1 Unfortunately, these measurements often do not correlate with the degree of mechanical obstruction.10 Furthermore, these determinations do not always accurately differentiate neurologic causes from obstructing lesions. In questionable cases, a complete urodynamic evaluation with pressureflow studies may be necessary. The surgeon must accurately estimate prostatic size preoperatively. This can be done through a combination of approaches, including digital rectal examination, cystoscopy, and transrectal ultrasound. Prostatic size may be misjudged if a digital rectal examination is performed when large amounts of residual urine are present because the base of the bladder may be palpated, thus obscuring the prostate but possibly being mistaken for the prostate. Any question of prostatic malignant disease, as suggested by the presence of suspicious lesions or abnormalities in prostate-specific antigen (PSA) serology, must be resolved in patients who are candidates to receive primary therapy for prostate cancer. We prefer to resect in two stages when the gland is too large to manage in a single 1-hour session. Although this technique is appropriate when the gland is found during resection to be larger than anticipated, it is questionable, in our opinion, whether a planned two-stage resection is ever justified. The necessary second anesthesia and possible septic sequelae in such cases favor onestage open prostatectomy. Conversely, it is possible to resect one lateral lobe or the middle lobe and one lateral

lobe and still obtain an excellent functional result. This approach is preferable to an incomplete resection of all lobes because the incidence of postoperative slough, hemorrhage, and obstruction is increased with incomplete resection of all lobes. Therefore, if it is impossible to complete the full resection in 1 hour, if the surgeon has concerns over water intoxication through open venous sinuses, or if the surgeon has undermined the trigone, stopping TURP after half-complete resection often results in a good outcome. Small, fibrotic glands should almost invariably be removed by the transurethral route. Transurethral incision of the prostate at the 4- and 8-o’clock positions may work well to relieve obstructive symptoms in such patients.11 Resection may not be necessary. Carcinoma of the prostate that causes lower urinary tract symptoms should also be managed transurethrally if a patient has persistent symptoms after androgen ablative therapy. Associated lesions, such as vesicoureteral reflux, vesical calculi, diverticula, vesical neoplasms, and stones, may alter the decision with regard to the route of prostatectomy.

SURGICAL INSTRUMENTATION When the urologic surgeon begins an endoscopic procedure, it is essential that an appropriate array of instruments be immediately available. Many complications encountered in transurethral surgery are attributable to shortcuts employed because the surgeon did not have appropriate instruments on hand. Moreover, a dedicated operating room should contain all the endoscopic and associated equipment necessary for routine, as well as complicated, cases. The nursing staff should be well versed in the unique setup of the endoscopic suite and equipment and should be familiar with the mechanics, proper functioning, and configuration of each instrument. In addition, the operating table should be freely adjustable by the surgeon and should have radiologic capabilities in case emergencies arise in which cysto­ graphy or urethrography becomes necessary. The instrumentation for standard adult endoscopic procedures should include a full set of van Buren sounds up to 30 Fr. All sizes should be available because overly rapid dilation of a stricture is a major cause of false passages. Similarly, a filiform and followers of woven silk or LeFort sounds and a urethrotome should be included. A full selection of insulated resectoscope sheaths in calibers to accommodate all loop sizes is mandatory. Sheaths with short beaks are preferable because they are less likely to cause injury to the urethra or trigone than are long-beaked sheaths. For similar reasons, the beaks should be inspected for smoothness before each use. Appropriate obturators are necessary for each sheath. It is sometimes helpful to have on hand an obturator with

Chapter 24  Complications of Transurethral Resection of the Prostate a screw tip that can accommodate a filiform thread. Copious amounts of water-soluble jelly for proper lubrication of sounds and sheaths are required for any endoscopic procedure. Whereas the 30- and 70-degree lenses are essential for cystoscopic evaluations of the bladder, the 12-degree lens is optimal for TURP. Because fiberoptic light sources are fundamental components of an endoscopic suite, extra bulbs or an alternative light source should be available. Two resectoscopes should be available, the design of which should be the choice of the individual surgeon. The one-handed instrument of the Iglesias design that frees the opposite hand for rectal or suprapubic manipulation has become the standard. When a one-handed instrument is chosen, an O’Connor rectal shield can be used to enable the physician to perform periodic rectal manipulation without causing contamination. The rectal portion of the shield should be well lubricated to prevent irritation and possible rectal injury. Continuous flow resectoscopes are customary in most endoscopic suites. These instruments allow for uninterrupted resection as well as improved visualization. Because the resection is not interrupted every few minutes to empty the bladder, operative time can be decreased. However, the constant pressure of the continuous flow sheath often compresses veins in the prostatic bed, thus obscuring potential sources of water absorption (resulting in TURS) as well as masking the actual amount of potential blood loss. If a continuous flow resectoscope is unavailable, a percutaneous suprapubic cystotomy can be placed immediately before resection. This approach is advantageous if heavy postoperative bleeding is expected because the volume of irrigant entering through a cystotomy and exiting out a single-lumen urethral catheter is greater than that through a three-way urethral catheter. A full selection of appropriate resectoscope loops with regard to both size and wire caliber should also be available. The thinner the wire, the better the cutting capability is and the poorer the coagulating capacity of the loop. Several loops of each size should be available in the event of breakage. A lithotrite, an electrohydraulic lithotriptor, or a laser filament of the surgeon’s choice should be available to handle unsuspected vesical or urethral calculi. These calculi should be removed before resection of the prostatic adenoma. Similarly, flexible and rigid grasping forceps are useful in the event that material cannot be removed from the bladder by manipulation of the resectoscope loop. Often, frequent levering of the resectoscope sheath successfully evacuates fragments of tissue from the bladder. A Toomey syringe or an Ellik evacuator is also helpful for rapid elimination of vesical debris. The connecting hose should be of large caliber, rigid, and short, with an airtight seal between the

syringe or evacuator and the nozzle that adapts to the resectoscope sheath. To facilitate filling of the syringe or evacuator, a deep bowl of sterile irrigating solution should be prepared. The Ellik evacuator should be inspected for bulb strength and integrity. Surgical instruments for performing meatotomy, vasectomy, and perineal urethrotomy should be available. For such procedures, the minimal requirements include two towel clips, four straight hemostats, one Adson thumb forceps, one scalpel, and one needle holder. The type of suture material depends on the preference of the surgeon. Two electrosurgical units should be available in case the primary unit malfunctions. Desirable features include a weighted foot pedal that will remain relatively stationary during the procedure and a sound mechanism with which cutting and coagulating currents can be differentiated by ear to help prevent the wrong pedal from being pressed inadvertently. To avoid thermal burns to the patient, a warning light or buzzer is imperative for detecting short circuits or improper patient grounding. In addition, no contact should occur between the patient and the metallic part of the operating table. The operating table should be freely adjustable by the surgeon, and the tray should be large enough to facilitate collection of irrigating fluid and resected tissue. The ideal table should have radiologic capabilities in case emergencies arise in which cystography or urethrography is necessary. Semiadjustable or completely adjustable chairs should be available to the surgeon. Operating time may be decreased if the surgeon can adjust the patient’s or his or her own relative position.

IRRIGATING SOLUTION Generous stores of suitable irrigating fluid are imperative. Distilled water should not be used, given its tendency to hemolysis and increased risk of TURS. The ideal irrigating solution should be nonelectrolyte (so as not to interfere with electrical current) and iso-osmotic; solutions composed of 3.3% sorbitol, 5% mannitol, and 1.5% glycine readily satisfy these criteria. Glycine should not be used in patients with hepatic dysfunction because ammonia is a metabolic byproduct in the breakdown of glycine, and hyperammonemia may result. Sorbitol is metabolized to glucose, and its use can cause hyperglycemia. This condition may be a threat to diabetic patients, especially when large amounts of fluid are absorbed or extravasated. Mannitol has the advantage of being an osmotic diuretic, and it potentially helps to unload the patient of increased volume expansion. However, mannitol is not evenly distributed throughout the total body space, and hypervolemic changes may be temporarily compounded and may further contribute to manifestations of TURS.

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PATIENT PREPARATION The identification and preoperative correction of potential medical problems are of primary importance in decreasing morbidity and mortality associated with TURP. The surgeon must ensure that each urologic patient has undergone a thorough medical evaluation.

Cardiac Function The patient’s cardiac status is especially important because he may be challenged by massive shifts in fluid volume and serum electrolyte composition. Cardiac disease has always accounted for a significant proportion of mortality associated with TURP and is becoming more prominent, corresponding to the aging of our patient population. In addition to proper preoperative evaluation, adequate intraoperative monitoring is essential. In high-risk patients, central venous pressure and pulmonary wedge pressure measurements may be necessary. Patients who are receiving anticoagulation medications present an additional dilemma to the transurethral surgeon. Discontinuing these medications may increase the likelihood of a thrombotic cardiac event; continuing the medication increases the pro­ bability of significant postoperative hemorrhage. These patients may be candidates for resection using one of the minimally invasive techniques.12 When TURP is compulsory, consultation with the patient’s cardiologist or cardiac surgeon is mandatory before any decision regarding discontinuation of any cardiac medication is made.

Renal Function It is important to know the renal reserve of the patient to determine his capacity to handle the extra fluid volume. Serum creatinine and creatinine clearance tests are adequate for this purpose. If compromised renal reserve is detected, an attempt should be made to identify the cause and to correct it before the surgical procedure (e.g., catheter drainage for long-standing obstructive uropathy). Bladder drainage should be instituted in patients with upper urinary tract obstruction and the creatinine level should be allowed to stabilize before TURP. Patients with compromised renal function have deficient clotting mechanisms because of abnormal platelet function.13 Evidence also indicates that uremic patients have compromised resistance to infection.13 Most large transurethral series indicated a significantly higher mortality rate among patients with compromised renal function. Patients with uremia secondary to upper urinary tract obstruction and prostatism must be watched carefully for postobstructive diuresis after a catheter has been passed. The diuresis is caused by the

inability of the obstructed kidney to concentrate urine, the abnormal handling of sodium by the obstructed kidney, and the hyperosmolar effect of the elevated urea.14 In addition, most of these patients start out with fluid overload.

Postobstructive Diuresis In the case of postobstructive diuresis, daily weights should be monitored and urine output replaced on a milliliter per milliliter basis with 5% dextrose in half normal saline until the load of urea has been stabilized. Potassium is replaced as it is excreted; frequent urine and serum electrolyte measurements are essential to manage these patients properly. Moreover, calcium and magnesium can also be excreted and their levels must be monitored and replaced as needed. When serum urea nitrogen levels have stabilized, one can begin to reduce fluid replacement so as not to perpetuate this diuresis. Rarely should fluid replacement be 3 months postoperatively. We generally define urinary fistula following partial nephrectomy as urine leakage persisting for >4 weeks after the surgical procedure. Nonetheless, any duration of postoperative urine leak must be appropriately managed by the surgeon. Simple principles of drainage, prevention of infection, and avoidance of ureteral obstruction generally allow resolution of the leak. Careful closure of the collecting system generally prevents urine leak. In cases of large resection bed, or in

tumors resected from the anterior or posterior segment with tangential renal incision, small caliceal injuries may not be identified, and these are often the site of persistent leak. In general, meticulous closure of the collecting system is performed with a layer of interrupted absorbable 4-0 braided sutures. This stage is followed by a second layer of imbricated sutures that attempt to pull the parenchyma together around the defect and thereby reduce tension on the primary closure (Fig. 34-10). In the laparoscopic setting, the collecting system is closed with a running absorbable 2-0 suture, and tension is removed from the closure by anchoring the suture to the surrounding renal capsule. Serial sutures are placed more widely to allow an imbricating effect. Two modifications of technique have greatly reduced our leak rate with open partial nephrectomy: (1) retrograde instillation of methylene blue through the renal pelvis and (2) the use of a layer of tissue adhesive over the closure. The use of tissue adhesive is most important in laparoscopic partial nephrectomy because small caliceal injuries are often difficult to identify. We have adopted a standardized technique of infiltrating Gelfoam (Pfizer Inc., New York) with fibrin sealant (Tisseal, Baxter International Inc., Deerfield, Illinois), molding it to the resection defect, and then activating it through infiltration of thrombin. Additional hemostatic materials are packed into the defect, and then the kidney is folded over the materials using horizontal mattress sutures of 3-0 absorbable non-braided suture anchored to the surrounding renal capsule. In the laparoscopic technique, this latter maneuver is not performed. Urine leak presents in one of two ways. Early leaks often become evident in the recovery room and persist, whereas delayed leaks manifest 5 to 14 days postoperatively and may become symptomatic. It is not clear whether most delayed leaks were simply unrecognized early because of inadequate drainage and lack of symp-

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Area of infarct Tumor Surgeon’s incision within hilum

Area of infarct

Surgeon starts incision away from hilum

A

C

B

D

Figure 34-9  The direction of incision can influence the likelihood of injuring arterial branches that feed the residual kidney. As arteries and more proximal branch points are present in the hilar region, we generally prefer to start resection on the side of the tumor opposite the hilum. This is particularly relevant when operating in the anterior or posterior segment. A, If the incision is carried out from the hilum, infarct radial to the defect can often be seen. B to D, When starting the resection away from the hilum, larger central vessels are preserved and the surrounding kidney remains well perfused.

toms. The old tenet that urine leakage frequently occurs in the first 24 to 72 hours but then resolves is not entirely true. In fact, most renal reconstruction for elective partial nephrectomy should be watertight. Early leakage generally indicates poor collecting system closure or unrecognized collecting system injury, and in our experience this leakage rarely stops within the first few days. Early leak is suspected if drainage of >30 to 40  mL per shift is noted >48 hours after the surgical procedure. Large-volume drain outputs within the first 24 hours may lead one to suspect leak, but intervention is not required unless infection is noted, serum creatinine becomes markedly elevated because of reabsorption, or the patient has no urine output (solitary kidney). In these cases, renal obstruction may be suspected and

early imaging is advised. Urine leak beyond 48 hours is confirmed by measurement of drainage creatinine level relative to serum. If the drainage is pure urine, creatinine levels will generally be >30  mg/dL. When the drainage creatinine is even moderately higher that of the serum, then at least part of the draining fluid is urine and a urine leak is likely present. Minimal creatinine elevation may suggest a resolved urine leak with some dilute urine still in the retroperitoneum. After leak confirmation, we generally perform an immediate ultrasound scan or noncontrast CT study for assurance that the drain is properly positioned, that no undrained urinoma is present, and that the kidney is well drained. If all these tenets are met, the patient is discharged home with prophylactic antibiotics and a drain in place.

Chapter 34  Complications of Partial Nephrectomy

Exposed collecting duct

A

B

Figure 34-10  Two-layer collecting system closure involves two interrupted layers of absorbable suture. The first layer (A) incorporates the edges of the collecting system, whereas the second layer (B) attempts to imbricate normal renal parenchyma to remove tension from the first line. The use of interrupted rather than running suture reduces the likelihood of tearing the collecting system with the suture.

Patients are monitored weekly with electrolytes and renal ultrasound studies to rule out worsening urinoma or drain migration. In cases of undrained fluid, the drain is repositioned to sit immediately adjacent to the leak point. This maneuver can be facilitated by contrast CT with delayed cuts. Ideal drain placement is immediately adjacent to the kidney to allow a drain tract to form. In cases of high-output leak, the drain can be converted from suction to gravity, but a follow-up ultrasound scan within a few days is warranted to rule out a secondary fluid collection. Presentation of delayed leak is usually the result of flank pain, fever, or drainage from a port site or incision. In a patient with fever, evaluation should include a complete blood count with manual differential, blood and urine cultures, and a chest radiograph to identify other potential sources of infection. CT with intravenous contrast should include delayed images to identify urinary extravasation, provided renal function is acceptable for receiving iodinated contrast. Ultrasound can alternatively be used to identify a perirenal fluid collection. Before percutaneous drainage, broad-spectrum antibiotics should be administered. The drain is best positioned immediately adjacent to kidney, but in cases of infection, maximal drainage is paramount to allow defervescence, and this may be best achieved with the patient in the most dependent position.

In the absence of infection, similar evaluation of renal function and imaging to identify fluid collections should be performed. On percutaneous drainage, the fistula output may be quite high initially because of the presence of a large potential space outside the kidney. Maximal kidney drainage is necessary to promote antegrade drainage over time. In general, a ureteral stent is not necessary unless evidence indicates ureteral obstruction, blood clots or debris within the collecting system, or a very large collecting system opening. In our experience, stents often worsen the leak initially, possibly as a result of reflux. It is essential to have a concomitant urethral catheter in place while the leak is perpetuated, particularly in a man with high-pressure voiding. We have generally avoided stent placement unless absolutely necessary because most leaks will close with prolonged drainage. Resolution of urine leak generally requires scarring in of the potential space around the kidney. This occurs as scar tissue fills in around the drain forming a drain tract. We generally prefer to leave the drain on gravity drainage to promote antegrade urine flow within the collecting system. On converting to gravity drainage, a follow-up ultrasound scan within 36 to 48 hours will confirm that no urine collection has formed around the kidney or drain tract. If it has, then the drain should be returned to suction. Urine collections prevent the for-

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Section VII  Complications of Retroperitoneal Surgery mation of a drain tract and delay leak closure. Over a period of 2 to 4 weeks, if properly drained, a drain tract should have formed, and on confirmation of the absence of urinoma, the drain can be advanced back 2 to 3 cm to allow the tract to close between the tip of the drain and the kidney. Every 48 to 72 hours, the drain can be pulled back another 2 to 3  cm until it is removed. During this time of drain advancement, one should monitor for urinoma formation and fever, a finding suggesting recurrence of the urinoma within the drain tract. In cases of high drain outputs (>300 mL/24 hours) more prolonged observation (≤12 weeks) may be necessary before attempting drain advancement. Low-output leaks require minimal observation before closure can be achieved. In this regard, closure of a leak is an active process initiated by the surgeon rather than a passive physiologic process. Urine leak can also result from ureteral injury. Excessive dissection of the renal pelvis, the lower pole of the kidney, and the proximal ureter should be avoided because it can cause devascularization, ischemia, and necrosis with subsequent fistula formation in the dissected segment. On completion of the procedure, fat should be interposed between the lower pole of the kidney and the upper ureter to avoid adherence, scarring, and subsequent stricture of the ureter.

Renal Function Measuring renal functional outcomes after elective partial nephrectomy is most difficult given the compensatory ability of the remaining kidney. Conventional beliefs have been that renal dysfunction following partial nephrectomy is related to the length of renal arterial clamping and the amount of parenchyma resected. In truth, many factors may influence the function of the operated kidney including intraoperative blood pressure variations, fluid resuscitation during the case, and aggressive handling of the kidney. Intraoperative blood loss may result in a higher risk of renal dysfunction because of the possibility of hypotension and reduced tissue oxygenation. When operating on an individual with two kidneys, the risk of postoperative azotemia and the necessity for dialysis depend on the functional reserve of the remaining kidney. Patients with diabetes, hypertension, and known vascular disease are more likely to have transient azotemia postoperatively. Individuals with a solitary kidney are also affected by these factors, but clearly, the risk of azotemia is more strongly affected by renal arterial clamping than in patients with two kidneys and normal renal function. In patients with bilateral functioning kidneys, the reported rate of acute kidney injury after open surgery has been 4%,35 whereas chronic kidney disease has been reported to occur in 2% to 8% of patients.32,35 Similar patients in laparoscopic series were shown to have negligible rates of renal dysfunction.38-40 In patients with

solitary kidneys, the rates of acute kidney injury after open procedures are more evident, ranging between 13% and 38%, with chronic kidney disease occurring from 3% to 30% of these patients.31,41,42 In laparoscopy series, these data have not been consistently reported. Analyzing an initial cohort of 430 patients who underwent laparoscopic partial nephrectomy at the Cleveland Clinic, Gill and colleagues43 observed that in 22 cases with solitary kidneys and 2 of which electively converted to an open procedure, a single patient (4.5%) required temporary dialysis and the chronic kidney disease incidence rate was 13%. Several maneuvers to reduce renal ischemia have been proposed. The use of an osmotic diuretic, such as mannitol, immediately before and shortly after clamping of the renal artery is thought to reduce the accumulation of free oxygen radicals in the tissues. Similarly, cooling of the kidney during ischemia is believed to reduce the likelihood of tissue injury. During open partial nephrectomy, we have used both these maneuvers. The kidney is placed within an intestinal bag with the opening loosely cinched around the renal pedicle. On ice slush packing, the bag serves to hold the ice to the renal surface. After clamping, a period of 5 to 10 minutes is necessary to reach the nadir core temperature within the kidney. We generally begin to operate on the kidney during this period to reduce total ischemia time, but other surgeons advocate waiting a full 5 minutes before renal incision. In general, we do not clamp the renal vein because stretch of the pedicle usually sufficiently reduces venous backflow. Investigators have suggested that retrograde circulation of venous blood may allow low level tissue oxygenation in the setting of arterial clamping. This possibility has been suggested for laparoscopic partial nephrectomy as well.44 In the setting of laparoscopic partial nephrectomy, several investigators have attempted to use various methods of intracorporeal kidney cooling.45-47 We have not found these methods to be practical, and it is questionable how effectively the kidney is cooled. Instead, we use a technique of renal arterial clamping, venous clamping during deep resection in which large venous channels are exposed, and early clamp removal, to allow shorter warm ischemia time. Clearly, this technique is related to operator comfort in reconstruction in the presence of bleeding. An alternative to the use of vascular clamping is manual compression of the renal parenchyma. This technique is quite effective in open partial nephrectomy, particularly for polar lesions. In laparoscopic surgery, the technique can be applied through hand assistance, but this approach is more cumbersome because one-hand suturing is required. Even if the renal vessels are not clamped, they should be fully dissected in case of the need for urgent clamping. Surgery can then be performed by squeezing the renal parenchyma

Chapter 34  Complications of Partial Nephrectomy with the hands and using only enough pressure to control the bleeding. Because of the increased risk of azotemia in the setting of a solitary kidney, we generally avoid arterial clamping in these patients whenever possible.25 In most cases, this situation requires open surgery, but in the case of small exophytic tumors, a laparoscopic approach with no arterial clamping can be considered. Postoperatively, attention should be given to avoiding or minimizing nephrotoxic or harmful medications such as angiotensin-converting enzyme inhibitors, nonsteroidal anti-inflammatory drugs, and aminoglycosides. Individuals at high risk, including those with solitary kidney, large (>50%) renal resections, prolonged ischemia times, preexisting renal insufficiency, and severe vascular disease, should be prepared mentally for the possibility of temporary or even permanent hemodialysis.

Reoperation Urine leak rarely requires reoperation, but in cases of persistent ureteral obstruction perpetuating the leak, recurrent abscess, or severe intraperitoneal leak (laparoscopic), a repeat operation may be necessary. Reoperation for bleeding is required when angiographic techniques fail to control postoperative bleeding. In most cases, reoperation for leak or bleeding results in nephrectomy.

CONCLUSION Partial nephrectomy for tumor resection is an increasingly important technique for practicing urologists to

master. The long-term benefits may be greater than initially perceived. Careful preoperative imaging, knowledge of renal anatomy, attention to patient- and tumorrelated risk factors, and meticulous surgical technique are essential for achieving good surgical outcomes. Complication rates should be acceptably low if following fundamental tenets of surgical technique.

KEY POINTS 1. Knowledge of renal arterial anatomy is essential for performing partial nephrectomy. 2. Complication rates with both open and laparoscopic partial nephrectomy vary with operator experience, but both can be acceptable with careful attention to detail. 3. The risk of bleeding and urine leak should be balanced against the risk of renal dysfunction from prolonged arterial clamping. 4. Renal incision should be planned by ultrasound study according to arterial anatomy and should be started away from the hilum to minimize the risk of infarct. 5. Identification and direct suture ligature of retracted blood vessels within the line of incision avoid retracted sutures deep in the incision bed. 6. At the time of urine leak, the drain should be positioned to remove any extrarenal urine collections completely. A stent is rarely required unless ureteral obstruction is present.

REFERENCES Please see www.expertconsult.com

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35

COMPLICATIONS OF RENOVASCULAR SURGERY David Canes

MD Assistant Professor of Urology, Tufts University Medical School, Boston, Massachusetts

John A. Libertino

MD Chairman, Institute of Urology, Lahey Clinic, Burlington; Professor of Urology, Tufts University Medical School, Boston, Massachusetts

Lesions of the renal artery, including stenoses and occlusions, have a final common pathway of renal ischemia with two clinically relevant findings: hypertension and renal insufficiency. The endocrine effects, mediated through the renin-angiotensin-aldosterone axis, result in hypertension. The cumulative effects of decreased blood flow on the end organ lead to progressive renal impairment. Diagnosis during a window of time before massive parenchymal loss ensues affords the opportunity to intervene and change the natural history of renal disease. Of intrinsic renal artery lesions, the most common cause is atherosclerosis, accounting for two thirds of all cases. It is most often part of generalized vascular disease in a given patient and can be expected to progress in 40%. The remaining two thirds of stenotic renovascular disease cases result from mural dysplasia, most commonly in young women as a result of medial fibroplasia. Other renovascular diseases include aneurysms, emboli, and traumatic injuries. Less commonly, Takayasu’s disease with periarteritis and the endothelial nodules of neurofibromatosis may affect the renal arteries. Few fields demonstrate the ebb and flow of surgical trends quite like renovascular surgery. In 1954, Freeman1 reported the first case of renal thromboendarterectomy and noted “prompt and persistent reduction in the patient’s blood pressure that followed this procedure.” Over the next half-century, various anatomic and extraanatomic reconstructive procedures were developed. Renal revascularization was subsequently almost ex­clusively the therapy of choice for renovascular hypertension. With the advent of diagnostic-value angiotensin-converting enzyme inhibitors, as well as the therapeutic value of other medical antihypertensives, fewer patients were surgical candidates. Catheterbased treatment with percutaneous transluminal renal angioplasty (PTRA) was first reported in 1964 by Dotter and Judkins.2 Renal angioplasty was performed for renovascular hypertension in 1978,3 and was carried out

concomitant with stenting in 1987.4 As a result, younger, healthy patients with less advanced disease are now favored for this approach. In an analysis of hospital discharges in the United States between 1988 and 2001, combined aortic and renal revascularizations decreased by 73%, isolated renal revascularizations decreased by 56%, and endoluminal procedures increased 173%.5 Management to this day remains controversial, and although PTRA has come into favor, urologists must understand the complications of all procedures, including historical ones. As is sometimes the case, exuberance for specific procedures continues until the pendulum swings. The complications of renovascular surgery are grouped in a useful paradigm in Table 35-1. This chapter systematically reviews pertinent complications of common surgical and endoluminal treatments for this disease complex.

PATIENT SELECTION As with any surgical procedure, careful patient selection is the first step to avoid complications. Patients with functionally significant renovascular lesion are candidates for surgery if the following is true: poor control of hypertension after appropriate medical therapy, poor patient compliance with medical treatment, total renal artery occlusion or dissection, deterioration of renal function as manifested by elevated blood urea nitrogen or creatinine level, cross-sectional imaging demonstrating parenchymal loss, angiographic evidence of progressive renal arterial disease, anuria from arterial occlusion in a solitary kidney, or a combination of the foregoing.6 Renal artery stenosis can be corrected by numerous surgical techniques, the details of which are described elsewhere (Box 35-1).7 In general, aortorenal bypass with autologous saphenous vein graft is preferred.8 In cases of severe atherosclerosis of the aorta, splenorenal 415

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Section VII  Complications of Retroperitoneal Surgery TABLE 35-1  Complications of Interventions for Renal Artery Stenosis* Blood Pressure Response Hypertensive crisis Rebound hypertension Persistent hypertension Renal Function Response Acute renal failure Infarction of renal unit Worsening renal function Surgical Technical Hemorrhage Renal artery/graft thrombosis Intimal dissection Anastomotic disruption Anastomotic stenosis Conduit related Saphenous vein aneurysm Synthetic graft delayed bleeding Synthetic graft–enteric fistula

A

C

Cardiovascular Myocardial infarction Cerebrovascular accident Emboli (atheromatous, cholesterol)

Procedure or Site Specific Saphenous vein donor site Skin flap necrosis Bleeding, hematoma Splenorenal Pancreatitis Postsplenectomy immunocompromise Hepatorenal Gangrenous cholecystitis Bile duct injury PTRA ± stent Hematoma, AV fistula, hemorrhage, dissection, perforation, emboli, stent restenosis, stent thrombosis

B

D

*Complications are grouped in categories: (A) related to physiologic perturbances, overall success; (B) related to cardiovascular comorbidity, diffuse atheromatous plaque; (C) related to technical factors, and (D) site-specific surgical complications. AV, arteriovenous; PTRA, percutaneous transluminal renal angioplasty.

BOX 35-1

Spectrum of Nonmedical Interventions for Renal Artery Stenosis

Endoluminal Repair PTRA PTRA with stent Reconstructive Surgery Aortorenal bypass Renal artery reimplantation Thromboendarterectomy Excision and primary reanastomosis Extra-anatomic bypass •  Splenorenal •  Hepatorenal •  Gastroduodenal-renal •  Iliorenal •  Mesentorenal •  Thoracic aortorenal Ex vivo reconstruction and autotransplantation Ablative Surgery Partial nephrectomy Nephrectomy PTRA, percutaneous transluminal renal angioplasty.

(left-sided renal artery stenosis) or hepatorenal (rightsided renal artery stenosis) bypass is preferred, to reduce the troublesome complications associated with atheroemboli from clamping a diseased aorta.9-13 Alternative inflow may be employed in appropriate circumstances from the iliac artery, superior mesenteric artery, gastroduodenal artery, and thoracic aorta. Patients with mural dysplasia extending into segmental vessels or associated

with aneurysms are better served by ex vivo repair with autotransplantation.14-16 Indications for autotransplantation should not be overzealously extended when acceptable forms of in situ repair could be accomplished.6 Thromboendarterectomy has been largely abandoned but is occasionally performed for ostial stenosis of accessory arteries or bilateral renal artery stenosis. Nephrectomy is of course reserved for patients who are poor surgical risks and in whom medical therapy has failed and for patients with extensive unreconstructable branch vessel disease, extensive unsalvageable unilateral parenchymal damage, or complete occlusion and infarction following arterial reconstruction. Nephrectomy is also indicated for total renal artery occlusion unless the following are true: 1. Angiography, isotope renography, or intravenous pyelography demonstrates a nephrogram. 2. Angiography detects retrograde filling of distal circulation by perihilar collateral vessels. 3. Intraoperative backbleeding from a renal arteriotomy occurs. 4. An intraoperative or preoperative biopsy demonstrates intact glomerular architecture.17,18 PTRA is most successful in young women with fibromuscular dysplasia, in whom little controversy exists over its use for this indication. In patients with atherosclerosis, nonostial lesions respond best to PTRA.19,20 Outcomes for ostial lesions secondary to atherosclerosis are improved with PTRA and stenting.21

Chapter 35  Complications of Renovascular Surgery

CARDIOVASCULAR COMPLICATIONS AND OVERALL MORTALITY Renal artery stenosis in patients with atherosclerosis is often a manifestation of global vascular atheromatous disease. Technical advances in surgical procedures, anesthetic care, and perioperative monitoring have made this high-risk patient population appropriate surgical candidates. It is paramount that the urologist understand that medical comorbidity is the rule rather than the exception in this group. Cherr and colleagues22 reviewed their series of 500 hypertensive patients undergoing surgical intervention for atherosclerotic renovascular disease. Cardiac comorbidity was present in 70% of patients, including angina, prior myocardial infarction, left ventricular hypertrophy, congestive heart failure, or prior revascularization (coronary artery bypass grafting, percutaneous transluminal coronary angioplasty). Cerebrovascular comorbidity was present in 32%, including prior transient ischemic attack, stroke, or endarterectomy. During early experience with surgical revascularization of the renal artery, excluding the fibrodysplastic group, coronary artery disease was the leading cause of operative mortality.23 Thus, after documenting the need for PTRA or open surgical reconstruction of renovascular disease, the patient must be extensively evaluated for extrarenal atherosclerosis with particular attention to coronary and carotid circulations. In addition to a carefully obtained history and physical examination, all patients should undergo electrocardiography, cardiac stress testing, noninvasive carotid studies, and directed angiography where indicated.24 Obviously, correctable coronary or carotid artery disease should be addressed before operative intervention for renovascular disease, to reduce associated perioperative morbidity and mortality.13 Perioperative mortality rates from contemporary surgical series are acceptably low. More useful data predictive of early mortality arise from subgroup and multivariate analysis. Cherr and colleagues22 reported a 4.6% 30-day overall mortality rate. However, mortality was 0.8% for isolated renal artery repair and 6.9% for combined aortic or bilateral repair.22 On multivariate analysis, only advanced age and clinical congestive heart failure were significant predictors of mortality. The extent of the surgical procedure was not significant, probably because increased morbidity may be more a reflection of diffuse vascular disease in patients requiring more extensive surgical intervention. Darling and colleagues,25 in a report of 568 patients, had a 5.5% mortality rate, 4% for unilateral and 10.5% for bilateral repair, and 22.3% for emergency repair. In this series, bilaterality was a significant predictor of mortality (P < .05). Over the period from 1988 to 2001, the Nationwide Inpatient Sample database was used to analyze treatment trends, and mortality figures were comparable to

these reports. The in-hospital mortality rate was 5.2% for combined aortic and renal revascularization, 2.2% for isolated renal revascularization, and 0.8% for angioplasty and stenting.5 Significant predictors included advanced age (>75 years), emergency admission, and nonwhite race. The finding on multivariate analysis that emergency repair predicts increased perioperative mortality is important because approximately 3% of our patients require an emergency operation for repair of renal artery rupture or dissection with complete occlusion after PTRA.20 In the case of young, otherwise healthy women with fibrous dysplasia, as expected, the opposite is true, with 0% operative mortality reported in one series for this subgroup.26 To summarize, preoperative cardiovascular screening, risk stratification, and preoperative targeted extrarenal revascularization are paramount. The overall early mortality rate for surgical repair of renovascular stenosis is in the 5% range, and it is even lower in patients with unilateral or fibrodysplastic disease. Bilateral or concomitant aortic repair should be approached with caution. Emergency procedures are associated with significantly increased mortality. The mortality rate for PTRA is approximately 1%.

PHYSIOLOGIC COMPLICATIONS Hypertensive Crisis Even with patent inflow after successful revasculari­ zation, hypertensive crisis may occur in the early postoperative period. The following may potentiate hypertension in this setting: 1. Intraoperative fluid overload 2. Vasoconstriction from hypothermia 3. Sympathetic overdrive from poor analgesia

incisional

Once these correctable factors have been addressed, calcium channel blockade or sodium nitroprusside is appropriate. Dramatic hypertension should also initiate radiographic imaging to exclude graft thrombosis. In any of the foregoing situations, continuous hemodynamic monitoring in an intensive care setting may be appropriate. Rebound hypertension intraoperatively or immediately postoperatively may also result from abrupt withdrawal of antihypertensive medications.22 Patients receiving high doses of single-agent therapy with β-blockers and angiotensin-converting enzyme inhibitors should instead receive low doses by initiating combination therapy with vasodilators or calcium channel blockers. Furthermore, constitutive activation of the renin-angiotensin-aldosterone axis with or without concomitant diuretic therapy results in volume contraction. This poses a delicate situation to our anesthesia

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Section VII  Complications of Retroperitoneal Surgery colleagues, who must replete volume at the very least with central venous monitoring and preferably with a pulmonary artery catheter. Too little volume correction results in hypovolemia and graft thrombosis, whereas hypervolemia potentiates hypertension, as discussed.

Persistent Hypertension The end point of blood pressure response is important. Failure of blood pressure to respond can be considered a late complication of treatment, even when a technical error may not be apparent. The ultimate response depends on the clinical subgroup. In the atherosclerotic group, approximately 5% to 20% of patients have a failed hypertension response to revascularization.22,24,26,27 In the fibromuscular dysplasia group, whereas the overall cure rate is higher, failures are comparable, in the range of 10%. The natural history of hypertension in patients whose condition is eventually improved or cured after revascularization is frequently that of a slow, gradual decline over several weeks.

Renal Failure: Acute and Chronic Acute renal failure is reviewed in Chapter 34. The same considerations apply here with regard to warm ischemia time and its influence on postoperative acute renal failure. Proper preclamping renal protection with intravenous hydration, mannitol, and heparinization is applicable. Warm ischemia time is best kept to 7 to 10 days postoperatively and a ureteral stent was not inserted intraoperatively, then a stent should be placed. Frequently, when a stent cannot be passed in retrograde fashion, anterograde placement is more successful. If a stent cannot be placed in either fashion, percutaneous drainage through a nephrostomy tube alone will allow ureteral edema to resolve and may permit resorption of previously extravasated urine that is distorting the ureter and preventing stent passage. With both percutaneous nephrostomy tube drainage and a stent in place, the fistula will heal without stricture development, and normal renal function can be expected in 63% to 95% of cases.42-45 In my experience, in the presence of properly placed drains and a functioning ureteral stent, urine leakage usually resolves without requiring percutaneous nephrostomy drainage. In some cases, placement of a stent may increase urinary extravasation through reflux of urine. This is particularly true in cases of bladder outlet obstruction or significant bladder instability. In these patients, a urethral catheter may be required until the leak seals. The use of drains at the site of ureteral repair is imperative. The choice of suction drain or flat Penrose drain is based on the preference of the surgeon. When prolonged urinary drainage is anticipated, use of a nonsuction drain may be preferable to avoid perpetuation of the leak. In cases of prolonged anastomotic drainage, if a suction drain was used, removing suction from the drain may allow the leak to seal. In rare instances, persistent urine leakage from abdominal drains may resolve

by advancing the drain away from the operative site. Before advancing the drain, or removing suction, it may be advisable to image the retroperitoneum to rule out an undrained urine collection. If leakage persists, distal ureteral obstruction must be ruled out and treated accordingly. This obstruction may result from either a distal stone fragment after ureterolithotomy or a previously unrecognized distal ureteral abnormality. The timing of ureteral leakage can influence management. Persistent urinary extravasation from the time of reconstruction is likely caused by technical error and usually heals with prolonged drainage. Significant extravasation in these cases can increase the risk of extraureteral scarring or anastomotic stricture. In cases of delayed leakage, beginning >10 to 14 days postoperatively, ischemic necrosis should be suspected. In such patients, drainage remains the mainstay of management. Healing may require proximal urinary diversion through nephrostomy, and a high likelihood of stricture formation at the ischemic site exists. When healing does not occur through drainage or when leakage results in significant infection or azotemia, early repair may be warranted. Urine leakage that fails to resolve with conservative management can be managed by either open repair or nephrectomy. In such cases, reconstruction can be extremely difficult and temporizing ureteral ligation with delayed repair may be necessary. With a normally functioning contralateral kidney, nephrectomy should be strongly considered in chronically ill or elderly, debilitated patients, especially in the presence of vascular grafts or known infection.

Ureteral Stricture Another important complication of ureteral surgery is ureteral stricture. Before recommending therapy, one must prove, by IVU, furosemide (diethylene triamine penta-acetic acid or mercaptotriglycylglycine) renal scan, or Whitaker testing, that the stricture is causing significant renal obstruction. When a wire can be advanced beyond the stricture, endourologic management remains a viable therapeutic option. It offers the advantage of decreased postoperative pain, shorter hospitalization, and less time for convalescence compared with open surgical repair.46 Techniques now used in endourologic management include balloon dilation, hot- or cold-knife incision, laser incision, or hot-knife incision using an Acucise catheter. These procedures can be performed either in an anterograde or a retrograde fashion. Balloon dilation of ureteral strictures (excluding strictures of the ureteropelvic junction or ureterointestinal anastomosis) has had a varying success rate ranging from 50% to 76%, although in my experience the success rate is substantially lower.47 Hot- or cold-knife incision of strictures appears to be more effective than

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Section VII  Complications of Retroperitoneal Surgery balloon dilation, with success rates ranging from 43% to 100%.48-50 Success rates with balloon dilation and incision can be expected to be much lower with strictures longer than 1.5 to 2  cm and when the stricture tissue is devascularized secondary to surgical intervention or radiation therapy.43,46

ACKNOWLEDGMENT I greatly appreciate the input and contribution of Dr. Robert B. Smith.

KEY POINTS 1. In female patients, the distal ureters enter the base of the broad ligament 1 to 2 cm lateral to the uterocervical junction and are crossed anteriorly by the uterine vessels, thus making this portion a common site of injury during radical hysterectomy. 2. Surgical exploration may reveal less viable ureter for reconstruction than was expected preoperatively. This potential discrepancy must be anticipated and planned for accordingly. If interposition with bowel is under consideration, preoperative bowel preparation is mandatory. 3. When attempting to identify the strictured segment of a ureter intraoperatively, it is often necessary first to identify the ureter at an uninvolved, anatomically reliable site (e.g., anterior to the iliac bifurcation) and trace it back toward the diseased segment. 4. When ureteral injury and débridement result in lengthy ureteral gaps that prevent a tension-free anastomosis, other mobilization techniques must be considered. These include the vesicopsoas hitch, the Boari bladder flap, and downward renal mobilization.

REFERENCES Please see www.expertconsult.com

5. TUU is absolutely contraindicated in the presence of transitional cell carcinoma of the ureter or renal pelvis and in the presence of recurrent urolithiasis. The donor ureter should course above the level of the inferior mesenteric artery to avoid impingement between the cleft of the aorta and the inferior mesenteric artery. 6. When one performs ureterolysis, stent placement should always be attempted before the procedure to aid with identification and mobilization of the ureter. 7. When one performs a psoas hitch or Boari bladder flap, prerequisites include a normal bladder capacity, no evidence of a neurogenic bladder, and no prior pelvic irradiation. Bladder outlet obstruction should be treated preoperatively. 8. In considering ileal ureter placement, patients should have a preoperative serum creatinine concentration 5 cm and resection is recommended for all lesions >6 cm.20,21 Adrenal cancers have a high propensity to invade adjacent organs.20 Invasion can be missed on preoperative imaging so the operating surgeon must have a high index of suspicion for adrenal carcinoma before surgical removal. Metastatic evaluation is also important preoperatively. Because the preferred management of this disease is surgical removal, preparation for en bloc resection and knowledge of surrounding anatomic features are crucial. Patients must also be aware that that adjacent organ removal may be necessary because the best hope for cure is total resection. Intraoperatively, the anesthesia team should be prepared for the possibility of a long surgical procedure with significant blood loss.

Adrenal Incidentaloma The critical determination in the evaluation of an incidentally discovered adrenal lesion is whether the lesion is hyperfunctioning. Careful history and physical examination may reveal undiagnosed signs of adrenal disease. Laboratory evaluation to rule out a hyperfunctioning adenoma and especially a pheochromocytoma should be performed in all cases.7 Because some adrenal adenomas turn out to be pheochromocytomas, this diagnosis must be excluded before the surgical procedure (Table 39-2). Accurate diagnosis preoperatively can avoid intraoperative and postoperative complications. Imaging can be helpful as well because certain diseases have specific characteristics on CT and MRI.19 Table 39-3 summarizes the different radiographic appearances and characteristics of adrenal tumors. Box 39-3 highlights common errors that can be made during the diagnostic evaluation of adrenal masses.

SURGICAL APPROACHES AND INTRAOPERATIVE COMPLICATIONS Both laparoscopic and open approaches can be used for adrenalectomy. In a comparative evaluation of 50 laparoscopic adrenalectomy studies and 48 open adrenalectomy studies with >3700 patients total, Brunt1 revealed that laparoscopic adrenal surgery was associated with a decrease in complications and a shorter duration of hospitalization. In the last few years, most adrenal surgery publications have promoted laparoscopic adrenalectomy as the treatment of choice for most

Chapter 39  Complications of Adrenal Surgery TABLE 39-2  Evaluation of Adrenal Tumors Hypersecretory State

Prevalence (%)

Screening Test

Hypercortisolism

5-14

Urinary free cortisol, adrenocorticotropic hormone, cortisol rhythm, 1-mg dexamethasone suppression test

Hyperaldosteronism

1.5-3.3

Potassium, aldosterone-to-plasma renin activity ratio

Congenital adrenal hyperplasia

Rare

Adrenocorticotropic hormone test

Virilization

0-11

Dehydroepiandrosterone, testosterone

Feminization

Rare

Estradiol

Pheochromocytoma

1.5-25

Urinary catecholamines/metanephrines

From Barzon L, Boscaro M. Diagnosis and management of adrenal incidentalomas. J Urol. 2000;163(2):398-407.

TABLE 39-3  Radiographic Appearances and Characteristics of Adrenal Tumors Adrenocortical Adenoma

Adrenocortical Carcinoma

Pheochromocytoma

Metastasis

Size

Small, usually ≤3 cm in diameter

Large, usually >4 cm in diameter

Large, usually >3 cm in diameter

Variable, frequently 10 Hounsfield units (usually >25)

>10 Hounsfield units (usually >25)

>10 Hounsfield units (usually >25)

Vascularity on contrastenhanced CT

Not highly vascular

Usually vascular

Usually vascular

Usually vascular

Rapidity of washout of contrast medium

≥50% at 10 min

6  cm should be removed through an open approach.21 Before incision, patients should have sequential compression devices placed and should receive perioperative antibiotics. Because most laparoscopic and open procedures involve a flank approach or a modified flank approach, appropriate padding of the patient’s arms,

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Section VII  Complications of Retroperitoneal Surgery Common Errors That Can Be Made During the Diagnostic Evaluation of BOX 39-3 Adrenal Masses: Pitfalls in the Diagnosis of Surgical Adrenal Disorders Primary Aldosteronism Challenge with sodium loading (10 g/day) before measuring plasma potassium (K+) Repletion of K+ to normalize plasma K+ before measuring plasma or urinary aldosterone Complete reliance on a postural aldosterone stimulation test (70% accuracy) Failure to measure cortisol during adrenal vein sampling of aldosterone to validate correct positioning Failure to recognize bilateral adrenal hyperplasia Adrenal hemorrhage during adrenal vein sampling Cushing’s Syndrome Resulting From Adrenal Adenoma or Carcinoma Failure to identify the use of exogenous steroids causing Cushing’s syndrome Inadequate physical examination essential for the diagnosis Knowledge that alcoholism and depression can mildly elevate plasma cortisol (pseudo-Cushing’s syndrome) Inability to diagnose pituitary Cushing’s syndrome by finding elevated plasma adrenocorticotropic hormone Adrenal Carcinoma Evaluation for metastatic disease Incidentaloma Metabolic evaluation to identify functional lesions MRI to determine tissue composition Pheochromocytoma Careful evaluation to reveal multiple lesions Measurement of urinary catecholes and metabolites even if plasma catecholes are normal Evaluation for other components when multiple endocrine abnormality syndromes are suspected From Vaughan ED. Diseases of the adrenal gland. Med Clin North Am. 2004;88(2):443-466.

legs, and torso is important. When patients are obese, a flank position in both the open and laparoscopic approach will allow the pannus to fall away and thus will make placement of instruments easier.25 Patients with pheochromocytoma and some with aldosteroneproducing adenomas should be well hydrated before induction of anesthesia. In patients with pheochromocytoma and adrenal cortical carcinoma, thought should also be given to pulmonary artery catheterization and arterial line placement because significant hemodynamic changes should be expected.26 Correction of hypokalemia, control of blood pressure, and tight glycemic control should all be assessed before induction of anesthesia. Patients with Cushing’s syndrome should receive glucocorticoids in the perioperative period.

The most common complications encountered during open adrenal surgery are hemorrhage, wound problems, adjacent organ injury, infections, and pulmonary problems. In the laparoscopic approach the incidence of all these problems with the exception of bleeding is significantly reduced.1 Regardless of the approach, attention to surgical technique and knowledge of adrenal anatomy are crucial to performing successful adrenalectomy. Port placement should be selected based on the type of laparoscopic approach used by the surgeon. Retroperitoneoscopy offers the advantages of less intraabdominal organ manipulation. It may have some benefit for recovery but comes at the cost of a smaller working space and for some surgeons a less familiar view of the retroperitoneum compared with the transabdominal approach.27 Retroperitoneoscopic adrenalectomy may also be favorable in the setting of previous abdominal surgery in which adhesions may complicate or limit a transabdominal open or laparoscopic approach.28 A transabdominal laparoscopic approach to the adrenal gland is still the most common approach. It affords a larger work space with a more familiar approach to the abdomen and may permit easier removal of large masses when compared with a retroperitoneoscopic approach.29 In addition, during difficult dissections, a hand port can be easily placed during transperitoneal surgery to combine the benefits of tactile feedback with minimally invasive techniques.30 Closure of the fascia at the port sites and any incision will limit the occurrence of hernias and is particularly important in patients with Cushing’s syndrome, who are prone to poor wound healing, and after transperitoneal laparoscopic adrenalectomy to limit the incidence of bowel entrapment.31 After placing all ports it is imperative to assess for injuries from port site placement including bleeding and solid organ injury because these complications may occur during port placement. The induction of pneumoperitoneum can cause a significant increase in circulating catecholamines in patients with pheochromocytoma. Insufflation pressures of ≤10 mm Hg have been shown to limit this catecholamine rise. This technique may help prevent cardiovascular complications before any manipulation of the adrenal gland.26,32 Conversely, high insufflation pressures during adrenal surgery may increase the working space and tamponade bleeding vessels. Caseby-case evaluation is crucial, and high insufflation pressures should be used with caution in patients with pheochromocytoma. As always, it is important to lower the pressure at the completion of the surgical procedure to inspect for sites of bleeding.33 The approach for adrenalectomy should reflect the underlying pathologic process. For large tumors suggestive of adrenal cortical carcinoma, it is best to approach these cases with the possibility that multiple surround-

Chapter 39  Complications of Adrenal Surgery ing organs may need to be resected along with the vena cava.34 Preparation for this is important. Accessing and obtaining vascular control are important considerations in the choice for the location of the incision. Because of high local disease recurrence rates, a laparoscopic approach is not favored for lesions that are clearly malignant.34 Some surgeons advocate exploring large lesions laparoscopically when preoperative imaging shows no evidence of malignancy and no evidence of surrounding organ invasion (Fig. 39-2). Most surgeons recommend that once an adrenal carcinoma is encoun-

Adrenal Cortex Tumor 60 mm

Evidence of local invasion

No evidence of local invasion

Laparoscopic approach Signs of invasion No signs of local invasion

Open surgery—radical compartmental resection

Complete LA—minimal touch technique, include surrounding periadrenal fat

Figure 39-2  Algorithm for the surgical management of adrenal tumors ≥60 mm in diameter. LA, laparoscopic adrenalectomy. (From Palazzo, FF, Sebag, F, Sierra, M, et al. Long-term outcome following laparoscopic adrenalectomy for large solid adrenal cortex tumors. World J Surg. 2006;30[5]:893-898.)

tered, the procedure should be converted to an open approach.22,35 When using a lateral flank approach, care should be taken to avoid the neurovascular bundle that runs in the bed of the 11th rib (Fig. 39-3). Damage can cause muscle prolapse or a flank hernia, both of which are difficult to treat. If a thoracoabdominal approach or flank approach is chosen, attention must be turned to the possibility of pleural violation and pneumothorax. A large violation is best treated with a chest tube connected to a −20-cm contained vacuum device. Smaller rents in the pleura can be easily treated and resolved intraoperatively by using a red rubber catheter to evacuate any air that is present. A pursestring suture is used to close the pleura and closure of the fascial layers occurs around the catheter, the open end of which is subsequently placed in a small container of saline solution or water. Under positive pressure, the pneumothorax is then “bubbled out” through the catheter. The catheter is removed after wound closure. Postoperative chest radiographs should be checked in these patients. If a significant residual or expanding pneumothorax is still evident, chest tube placement may be needed.36 Knowledge of the relationship of the adrenal gland with other abdominal and retroperitoneal organs and the neighboring vasculature is crucial (Fig. 39-4). This knowledge is particularly important during mobilization of surrounding organs for exposure and when the diagnosis of adrenal cortical carcinoma is considered because en bloc organ resection may be necessary (Fig. 39-5).34 During a transabdominal approach, the spleen and tail of the pancreas need to be clearly visualized and

Neurovascular bundle

Figure 39-3  Dissection of the intercostal nerve during flank surgery. (From George, K, Chow, MLB. Surgery of the adrenal glands. In: Wein AJ, Novick A, Partin A, Peters C, eds. Campbell-Walsh Urology, 9th ed. Philadelphia: WB Saunders; 2007:1868-1889.)

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Section VII  Complications of Retroperitoneal Surgery Right inferior phrenic artery Right adrenal artery

Left superior adrenal artery Right inferior pole adrenal artery Left inferior adrenal artery

Left adrenal vein

Figure 39-4  Vascular relationships. (From Duh Q-Y, Yeh MW. The adrenal glands. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery, 18th ed. Philadelphia: WB Saunders; 2007.)

Spleen L. Adrenal R. Adrenal

R. Kidney Pancreas

Sto

Tr a

nsverse Co

lo

m

ac

h

n

Figure 39-5  Visceral relationships. (From George, K, Chow, MLB. Surgery of the adrenal glands. In: Wein AJ, Novick A, Partin A, Peters C, eds. Campbell-Walsh Urology, 9th ed. Philadelphia: WB Saunders; 2007:1868-1889.)

Chapter 39  Complications of Adrenal Surgery dissected free from the adrenal gland. If a pancreatic injury is suspected drains should be left in place and care should be undertaken with dietary advancement until the type of drainage fluid is determined. If the splenic capsule has a small violation, splenorrhaphy can be performed. For large injuries, splenectomy may be necessary. If a colon injury occurs during mobilization, repair can be attempted for serosal tears and in cases with no contamination. Spillage of enteric contents and significant bowel injury are exceedingly rare and should warrant definitive expert repair in accordance with general surgical principles.37 Meticulous planning and the implementation of every possible precaution will decrease the risk of complications during adrenalectomy. Preoperative bowel preparation may reduce colonic volume and make mobilization easier, especially in laparoscopic procedures, which should include placement of an orogastric or nasogastric tube. During laparoscopic adrenalectomies, once the spleen and colon are mobilized, positioning the table to elevate the left side allows these organs to fall medially and thus aid adrenal exposure.38 When dissecting around the upper pole of the kidney it is important to limit the amount of posterior mobilization to prevent the kidney from falling medially and impairing adrenal visualization. For right-sided lesions, liver and ascending colon are the most prominent organs requiring mobilization for visualization of the adrenal gland. These structures, as well as the inferior vena cava, duodenum, and head of the pancreas, must be clearly identified during dissection. A Kocher maneuver may be helpful to expose the inferior vena cava and any short right adrenal veins. In the laparoscopic approach an extra port may be needed to elevate the liver for adequate exposure.39 In patients with significant retroperitoneal fat or in patients whose adrenal gland is difficult to identify, laparoscopic ultrasound examination has been successfully used not only to identify the adrenal gland but also to establish its relationship with the inferior vena cava and surrounding structures.40-43 Early control of the adrenal vein facilitates the surgical procedure and decreases blood loss. In the case of pheochromocytoma, early ligation of the adrenal vein is paramount because it limits catecholamine surge and helps to protect the patient from vascular compromise.44,45 Although minimizing manipulation of the adrenal gland is important for all tumors to prevent capsular violation, it is particularly important in pheochromocytoma because this is the time of peak catecholamine levels during the operation. As mentioned earlier, preoperative management of patients with pheochromocytoma is essential, and α-adrenergic blockade with phenoxybenzamine or doxazosin is highly recommended. β-Adrenergic blockade and calcium channel blockade may also be useful, as may

the addition of α-methyl-para-tyrosine.18 Adequate fluid intake and resuscitation are important. Minimizing adrenal gland manipulation is essential in patients with potentially malignant lesions to prevent tumor spillage and peritoneal contamination.22,26,35,46,47 Vascular injuries are common in adrenal surgery. The most frequently injured vascular structures are the inferior vena cava and the adrenal vein. Avulsion of the adrenal vein can cause significant bleeding, and special attention to the short length of the right adrenal vein is important. When a vascular injury is identified, use of compression, application of Allis clamps, intracorporeal suturing, clipping, or stapling, volume resuscitation, and communication with the anesthesiologist may all be necessary to control hemorrhage.48,49 If the procedure is performed laparoscopically, the surgeon should not hesitate to convert it to an open operation if laparoscopic control is not possible. Having the equipment in the room to convert to an open operation is vital because bleeding may be brisk and may allow little time to wait for instruments.49 It is also important not to staple over metal clips because this maneuver may hinder proper stapler application and lead to bleeding.48 When using clips to ligate the adrenal vein, it is recommended to use two clips on the vena cava side to ensure vessel ligation before specimen removal.50 Renal artery injuries can occur and cause severe bleeding as well as revascularization and ischemia to the kidney. Identification of the end organ supplied by each artery and vein before ligation is crucial to prevent such injuries. The surgeon must also recognize the potential for vascular anomalies and multiple adrenal vessels. Accessory adrenal veins can occur ≤10% of the time.51 Castilho and colleagues52 reported on converting a laparoscopic adrenalectomy in a child to an open operation when hemorrhage occurred from an unrecognized secondary adrenal vein draining to the liver. Identification and ligation of the branches off the inferior phrenic arteries should be performed when the superomedial portion of the gland is dissected.47,53 Vascular injury can also happen during port site placement. The inferior epigastric artery as well as major mesenteric and pelvic vessels can be injured during trocar insertion.39,49 The role of partial adrenalectomy is debated in the literature; some investigators have reported long-term adrenal salvage rates with partial adrenalectomy particularly in patients with inherited disorders such as multiple endocrine neoplasia and von Hippel–Lindau disease.54 Some of these patients had recurrent lesions. Many of these patients still required corticosteroid therapy postoperatively and a few had acute addisonian crisis.54 Another series demonstrated that on pathologic examination of isolated aldosterone-producing adenomas removed by partial or total adrenalectomy, 27% of specimens had multiple adenomas in the specimen. In one series, 2 of 29 patients who underwent partial

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Section VII  Complications of Retroperitoneal Surgery adrenalectomy had persistent hyperaldosteronism and hypertension, whereas all 63 patients who underwent total adrenalectomy had resolution of the hypertension and improvement in aldosterone levels.55 At this time, we recommend against partial adrenalectomy in patients with no inherited syndrome and a unilateral adrenal mass. Adrenal-sparing surgery may be considered in patients with inherited syndromes, but these patients must be watched extremely closely for both recurrences and any signs of adrenal insufficiency.

POSTOPERATIVE COMPLICATIONS AND PATIENT MANAGEMENT The postoperative management of patients undergoing adrenal surgery is dictated largely by the type of adrenal lesion removed (Box 39-4). In the postoperative period, all patients should use incentive spirometry liberally. Early ambulation is strongly encouraged. Sequential compression devices should be placed on both lower extremities. Hospital-specific guidelines on the use of routine postoperative anticoagulation are available in most medical centers. Blood counts and electrolytes should be checked in patients after the surgical procedure and again the following morning.50 Close blood pressure monitoring is important in all patients. Any concern for bleeding should lead to appropriate and immediate imaging or intervention based on the situation.

Pheochromocytoma Patients with pheochromocytoma should be monitored closely in either the intensive care unit or an intermediate care unit after the surgical procedure. These patients are at an increased risk for postoperative hypoglycemia, hypertension, and hypotension.56 Hypoglycemia can occur as a result of rebound hyperinsulinemia after tumor removal.56 Hypotension results from abrupt withdraw of catecholamines. Volume resuscitation is important in the postoperative period as is the judicious use of catecholamines.17

Hyperaldosteronism After adrenalectomy for an aldosterone-producing adenoma, blood pressure should be monitored very closely and for a prolonged period. These patients are at risk for long-term hypertension, and blood pressure typically falls progressively for a few weeks after adrenalectomy.5 During hospitalization (and perhaps after discharge), these patients should have daily potassium levels drawn because early potassium replacement may be required. Although rare, some patients may experience salt wasting and hyperkalemia from suppression of the contralateral adrenal gland, and patients must also be monitored for this complication in the postoperative

BOX 39-4

Postoperative Complications of Adrenal Surgery

Primary Aldosteronism Hypokalemia: secondary to continued potassium loss immediately postoperatively Hyperkalemia: secondary to failure of contralateral adrenal gland to secrete aldosterone Cushing’s Syndrome Inadequate steroid replacement leading to hypocortisolism Fracture secondary to osteoporosis Hyperglycemia Poor wound healing Increased risk of infection Pheochromocytoma Hypotension secondary to α-adrenergic blockade after tumor removal Generic Complications Hemorrhage Inferior vena cava Adrenal arteries Pneumothorax Pancreatitis Pneumonia Hiccups From Vaughan ED Jr. Complications of adrenal surgery In: Taneja SS, RM Ehrlich RM, Smith RB, eds. Complications of Urologic Surgery, 3rd ed. Philadelphia; WB Saunders; 2000:362-369.

period.5 The use of potassium-sparing diuretics such as spironolactone should be stopped.

Cushing’s Syndrome Patients undergoing bilateral adrenalectomy for Cushing’s disease require long-term corticosteroid replacement and are at risk of developing Nelson’s syndrome.9 These patients are also at risk of recurrent episodes of addisonian crisis. Addisonian crisis has been reported after unilateral and partial adrenalectomy; therefore, most patients require at least short-term corticosteroid and mineralocorticoid replacement in the postoperative period and some require long-term treatment.33,37,50,54 Acute adrenal insufficiency may manifest with fever, nausea, vomiting, lethargy, and hypotension. Any patients presenting with these symptoms after adrenal surgery should be treated with dexamethasone and electrolyte correction until the diagnosis is made (Table 39-4).50 Patients with severe manifestations of Cushing’s syndrome are a higher risk for infectious and wound complications and should be watched closely. Patients with Cushing’s disease have a persistent risk of fracture from osteoporosis and should be clinically monitored.10 Other postoperative complications can include infections such as pneumonia, urinary tract colonization,

Chapter 39  Complications of Adrenal Surgery TABLE 39-4  Symptoms and Signs in Acute Adrenocortical Insufficiency (“Adrenal Crisis”) Symptoms and Signs (Clinical Deterioration Without Obvious Cause)

Prevalence (%)

Fever

70

Nausea and vomiting

64

Abdominal pain

46

Hypotension

36

Abdominal distention

32

Obtundation and lethargy

26

Hyponatremia

45

Hyperkalemia

25

Modified from May ME, Vaughan ED Jr, Carey RM. Adrenocortical insufficiency: clinical aspects. In: Vaughan ED Jr, Carey RM, eds. Adrenal Disorders. New York: Thieme; 1989:176; and Duh Q-Y, Yeh MW. The adrenal glands. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery, 18th ed. Philadelphia: WB Saunders; 2007.

abscess formation, and sepsis. Pancreatitis can occur from manipulation of the pancreas in addition to an overt injury. Port site complications can include hernias and hematomas. Patients may have delayed bleeding, delayed recognition of bowel injuries, and unrecognized or increasing pneumothorax. Patients should be evaluated and treated for these conditions based on their individual clinical situations. For delayed bleeding, reoperation may be necessary.38 Local recurrences

after adrenalectomy for adrenal cortical carcinoma can be seen after open and laparoscopic adrenalectomy. Patients undergoing laparoscopic adrenalectomy for malignant disease are also at risk for port site recurrences. Any patient with adrenal cortical carcinoma should be followed closely with imaging for recurrence.34 With a proficient knowledge of underlying adrenal disease, solid open and laparoscopic surgical technique, and a thorough awareness of the spatial relationships between the adrenal and surrounding vascular and visceral structures, surgeons can avoid or at least minimize many of the complications of adrenal surgery.

KEY POINTS 1. With the widespread use of laparoscopy, the landscape of adrenal surgery has changed dramatically over the past decade. 2. Complications associated with adrenal surgery are most often uniquely related to the underlying pathology of the disease under treatment. 3. Many adrenal surgical complications can be avoided with a rigorous diagnostic evaluation and a meticulous preoperative preparation.

REFERENCES Please see www.expertconsult.com

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40

COMPLICATIONS OF LYMPHADENECTOMY Ofer Yossepowitch

MD Attending Surgeon, Department of Urology, Rabin Medical Center, Petah-Tikva, Israel

Bernard H. Bochner

MD Attending Surgeon, Department of Surgery, Urology Service, Memorial Sloan-Kettering Cancer Center, New York, New York

Lymphadenectomy, the excision of the regional lymph nodes draining a tumor, is a mainstay in the surgical management of solid cancers. The procedure is essential to accurate nodal staging, which allows for uniform assessment of treatment outcomes across institutions as well as appropriate selection of candidates for additional therapies. For some cancers, lymphadenectomy has been shown to provide a therapeutic benefit. As with all surgical interventions, lymph node dissection has the potential for adverse side effects. Nevertheless, until advances in imaging and molecular markers allow for accurate assessment of nodal involvement preoperatively, lymph node dissections will continue to be of paramount importance to patients and physicians. This chapter describes the complications associated with lymph node dissection for genitourinary malignant diseases. The intent is not only to help urologists manage these complications but also, more importantly, to help avoid these complications. Fundamental techniques and anatomic considerations that should be employed in the perioperative and operative settings are highlighted.

PELVIC LYMPH NODE DISSECTION Removal of the pelvic lymph nodes provides diagnostic or therapeutic benefit for several major urologic malignant diseases, including bladder, prostate, and penile cancers. Although the indications and anatomic boundaries of pelvic lymph node dissection (PLND) in prostate cancer remain an area of contention, extended lymphadenectomy is now becoming a standard of care for patients undergoing radical cystectomy for muscleinvasive bladder cancer.

Radical Prostatectomy PLND at the time of radical prostatectomy improves the accuracy of prostate cancer staging. In an era of down-

ward stage migration in which many cancers harbor favorable characteristics,1 however, a pertinent question remains whether all men newly diagnosed with low-risk, localized prostate cancer truly benefit from PLND. Opponents quote the low incidence of lymph node involvement in prostate cancer and recommend employing risk stratification models to omit PLND in men with a low risk of lymph node metastasis.2,3 Proponents argue that currently available predictive tools are unreliable because of sampling error (i.e., models are based on limited data from inadequate dissections) and the evolution of Gleason score interpretations over time.4 Furthermore, an increasing body of evidence suggests that PLND improves not only staging but also recurrence-free survival.5,6 Investigators generally agree that imaging studies, including computed tomography (CT) and magnetic resonance imaging (MRI) of the pelvis, lack the sensitivity required to supplant the reference standard of PLND. Two techniques that show promise for detection of occult lymph node metastases are positron emission tomography7 and MRI combined with intravenous lymphotrophic superparamagnetic nanoparticles.8 These techniques, however, require further validation before they can be incorporated into routine clinical practice. For PLND in prostate cancer, the anatomic boundaries (i.e., extent) of dissection remain controversial. Prostate lymphatic vessels may drain by way of three major routes: ascending ducts into the external iliac lymph nodes, lateral ducts into the hypogastric and obturator lymph nodes, and posterior ducts into the sacral lymph nodes.9 The limited PLND or node sampling for prostate cancer, as performed by many urologists, typically includes only a portion of the lymphatic tissue between the external iliac vein and obturator nerve. Proper lymph node dissection as originally described by McCullough and associates10 and later reiterated by Bader and colleagues11 should include all the tissue between the external iliac vein and hypogastric vein, 463

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Section VII  Complications of Retroperitoneal Surgery above and below the obturator nerve, including the obturator and hypogastric nodes. Additionally, some investigators recommend including the common iliac and presacral nodes.5 Compared with limited PLND, appropriate dissections result in a greater node yield and a higher incidence of positive lymph node results.12 In one large series of PLNDs for prostate cancer, the reported incidence of lymph node metastases reached 24% in patients with a prostate-specific antigen (PSA) value of ≥10 and a Gleason score of ≥7.11 Moreover, approximately 70% of positive lymph nodes were located along the internal iliac vessels. In approximately 20% of node-positive patients, this was the sole location of lymph node involvement and, in fact, nodal metastases were more likely to be found in the hypogastric and obturator nodes than in the external iliac nodes. Taken together, these data provide strong support for extended PLND in patients undergoing radical prostatectomy, particularly for those with moderate- to highrisk cancers. The major concern deterring many urologists from adopting this approach is the higher incidence of morbidity.13,14

Radical Cystectomy The extent of lymph node dissection required to stage and treat bladder cancer optimally at the time of radical cystectomy is equally controversial. Investigators generally agree that lymph node dissection is an important part of the surgical management of bladder cancer. In patients with invasive bladder cancer, the regional lymphatics are frequently involved and not uncommonly represent the only site of metastatic disease. Lymph node involvement, one of the strongest adverse prognostic features, is often used to determine the subsequent treatment strategy and the need for adjuvant therapy.15 PLND not only provides valuable staging information but also enhances the rate of local disease control and survival.16 Despite the growing body of evidence to support the use of more extended dissection at cystectomy, no guidelines regarding the optimal boundaries of PLND have been established.17 Mapping series indicate that the common iliac and presacral nodal regions are more frequently involved with tumor metastases than was previously recognized.18-20 In fact, 35% of the 599 positive lymph nodes identified in the series by Leissner and colleagues18 were located above the bifurcation of the common iliac vessels, outside the limits of a standard lymphadenectomy template. More than half the node-positive patients had nodal metastases in the common iliac lymph nodes, and nearly one third had nodal metastases in the region of the distal aorta. These investigators concluded that had they restricted the nodal resection to the obturator fossa, >74% of all lymph node metastases would have been left behind, and 7% of patients

would have been incorrectly categorized as having lymph nodes negative for cancer. Similarly, Vazina and associates20 demonstrated that among node-positive patients in their series, 20% with pT2 disease and 30% with pT3 disease had nodal metastases located cephalad to the bifurcation of the common iliac vessels. Some studies support extending lymph node dissection to include all areas below the aortic bifurcation.21,22 Several investigators reported that removal of an increased number of lymph nodes at cystectomy improved survival. This association was maintained when controlling for age and other comorbidities, features that could affect the decision to perform extensive node dissection or could influence overall and diseasespecific survival.23 Thus, based on available evidence and despite the lack of randomized trials investigating the impact of dissection boundaries on outcome, many investigators believe that the most reliable diagnostic and therapeutic approach to bladder cancer includes routine extended PLND in all patients undergoing cystectomy with curative intent. Exceptions to this recommendation include salvage radical cystectomy following definitive radiation treatment (>5000 rads). In these patients, care should be taken because extended lymphadenectomy may be associated with additional morbidity.24

Complications Perioperative complications associated with PLND can be classified as local or systemic. Local complications may include deep vein thrombosis, pelvic hemorrhage, abscess formation, wound infection, and wound dehiscence. Systemic problems may include pulmonary embolism, pulmonary atelectasis, pneumonia, myocardial infarction, congestive heart failure, arrhythmias, and prolonged ileus. Additional specific complications of lymphadenectomy include pelvic neuropathies, lymphocele formation, vascular injuries, and lymphedema of the lower extremities. Nerve injures and lymphoceles are discussed in the sections that follow. Lymphedema is discussed in detail in the later section on inguinal lymphadenectomy for carcinoma of the penis.

Nerve Injuries The spatial relationship between the pelvic lymph node chains and pelvic nerves puts pelvic nerves at risk for injury during PLND. Nerve injuries fall into three general categories,25 as follows: 1. Neurapraxia is a functional injury caused by nerve compression or traction and resulting in a conduction block without overt axonal degeneration. Recovery from neurapraxia is expected to occur within a matter of weeks. 2. Axonotmesis, a more severe injury caused by prolonged compression or excessive traction, is charac-

Chapter 40  Complications of Lymphadenectomy terized by wallerian degeneration in which the neural elements distal to the injury site degenerate, whereas the supporting neuronal structures and envelopes (epineurium, perineurium, and endoneurium) remain intact. The supporting neuronal structures allow for nerve regeneration, and function recovers slowly over 6 months to 1 year. 3. Neurotmesis, the third and most severe form of injury, denotes complete division of the nerve. Recovery from neurotmesis is not expected. Nerves that may suffer injury during major pelvic surgery for urologic malignant diseases include the obturator, femoral, and genitofemoral nerves. Injury to the sciatic nerve is extremely rare and is not addressed in this chapter. Obturator Nerve Injury 

Anatomic and Functional Considerations  The obturator nerve innervates the medial adductor muscles of the thigh, namely, the gracilis, pectineus, adductor longus, adductor brevis, and adductor magnus (the most powerful adductor), as well as the obturator externus. These thigh adductors also act to a varying extent as flexors, extensors, and rotators of the leg. After arising from the L2-L4 segments of the lumbar plexus, the obturator nerve pierces the medial border of the psoas muscle and enters the pelvic cavity along the lateral pelvic wall within the obturator fossa. The nerve travels parallel to the pelvic sidewall usually above the obturator artery and vein and leaves the pelvis through the obturator foramen accompanied by the obturator vessels. Although the obturator nerve receives sensory input from the medial aspect of the thigh, it is the only motor nerve that arises from the lumbar plexus and passes through the pelvis without innervating any of the pelvic organs. As such, this nerve can be completely dissected and mobilized within the obturator fossa without risk of denervating any of the pelvic organs. Injury to the obturator nerve itself during PLND is possible by excessive traction, crush, use of electrocautery in close proximity to the nerve, or inadvertent nerve transection.26 Prolonged surgery associated with acute hip flexion has also been implicated in this type of injury.27 Clinical sequelae of obturator nerve injury can include motor deficits, sensory symptoms, or both.26 The sensory component typically manifests as pain and diminished sensation, which extends down the medial thigh into the knee and occasionally into the hip. The pain is commonly exacerbated by extension and abduction or inward thigh rotation. When clinically apparent, weakness of the ipsilateral hip adductors may vary in severity and can be quite debilitating, particularly when the patient tries to drive an automobile. Occasionally, electromyography is required to diagnose and isolate the motor component, particularly if symptoms are equivocal. In patients who have under-

Figure 40-1  Division of the node packet, proximally and distally, should be performed only after clear visualization of the nerve throughout its entire course within the obturator fossa.

gone complete nerve resection, spontaneous recovery, when it occurs, is likely to result from a compensatory response by other thigh muscles or from the presence of an accessory obturator nerve.28

Technical Highlights and Intraoperative Techniques to Avoid Injury  The key to avoiding damage to the obturator nerve is sound knowledge of its anatomic course and relationship to pelvic structures. Damage to the nerve typically occurs during the proximal or distal aspect of the lymph node dissection. Identifying the lymph node of Cloquet (marking the distal limit of the dissection above Cooper’s ligament) is a mandatory step. Dissection above Cooper’s ligament is generally safe, but any dissection below this landmark should be carried out with great attention because it may lead to inadvertent nerve damage. Proximally, the nerve can be identified lateral to the bifurcation of the common iliac vessels as it exits the psoas muscle. Complete exposure of the nerve is facilitated by its careful dissection laterally away from the accompanying obturator vessels and nodes (Fig. 40-1). Node packet division, proximal and distal, should be performed only after the nerve can be visualized throughout its entire course within the obturator fossa. Traction injury or partial or complete transection of the nerve may occur while the nerve is freed from the lymph node packet within the obturator fossa. The nerve may be predisposed to injury in patients with tumor involvement of the obturator nodes, prior chemotherapy with subsequent tumor scarring, or prior pelvic irradiation because the perineural tissues may be particularly adherent to surrounding tissues. Additionally, abrupt bleeding during dissection may necessitate electrocautery in proximity to the nerve or application

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Figure 40-2  Potential sources of cumbersome bleeding during lymph node dissection in the obturator fossa: anomalous vascular tributaries emanating from the obturator vessels, vascular branches arising off the external iliac vein, and small vessels traveling between the lymph node packet and the pelvic sidewall. Prospective identification and control of these vessels permit meticulous dissection in a bloodless field.

of hemoclips in a poorly visualized field, either of which could result in inadvertent thermal injury or crush injury. Therefore, surgeons should recognize and avoid three potential sources of cumbersome bleeding during dissection in this area: 1. Anomalous vascular tributaries emanating from the obturator vessels 2. Vascular branches arising off the external iliac vein 3. Small vessels traveling between the lymph node packet and the pelvic sidewall (Fig. 40-2) To avoid inadvertent damage to the nerve, the surgeon should obtain adequate visualization before sutures or hemoclips are placed deep within the obturator fossa. Any bleeding can be initially managed by packing the obturator fossa with a small sponge. Gentle pressure applied for several minutes may effectively minimize venous bleeding and allow for careful application of hemoclips to any remaining conspicuous bleeding vessels. In general, management of obturator neuropathy should include immediate repair of intraoperative transection by epineural suture approximation using microsurgical techniques.26,29 After repair or postoperative recognition of injury, physical therapy should be instituted promptly. Femoral Nerve Injury 

Anatomic and Functional Considerations  Arising from segments L2-L4 of the lumbar plexus, the femoral nerve emerges from the lateral border of the psoas muscle and courses along the groove between the psoas and iliacus muscles. It then enters the thigh beneath the inguinal ligament and divides into motor and sensory branches.

Figure 40-3  Femoral nerve injury caused by indirect compression from retracting the psoas muscle laterally while pressing on the nerve against the pelvic sidewall.

The motor divisions innervate the leg flexors, namely, the iliac, quadriceps, pectineal, and sartorius muscles, whereas the sensory branches innervate the anteromedial aspect of the thigh and leg. Damage to the femoral nerve typically results from intraoperative nerve compression, which leads to direct nerve injury or ischemic injury secondary to reduced blood flow in the iliolumbar, lateral circumflex, or deep circumflex arteries. Causes of nerve compression include direct compression by the tips of the retractor blades and indirect compression from retracting the psoas muscle laterally while pressing on the nerve against the pelvic sidewall (Fig. 40-3). The severity of the injury is usually related to the duration of retraction and positioning of the patient. Pelvic surgeons tend to place more lateral retraction on the left iliopsoas muscle to obtain better exposure near the rectosigmoid colon, a maneuver that increases the risk of injury to the left femoral nerve.30 In addition, the paucity of vascular anastomotic branches supplying the left deep circumflex artery renders the left femoral nerve more vulnerable to ischemic injury than the right femoral nerve. Because the extrapelvic portion of the femoral nerve is angulated sharply around the inguinal ligament, excessive flexion of the thigh with abduction and external rotation of the hip in the lithotomy position carries increased risk of femoral nerve compression, particularly when “candy cane” stirrups are used.31

Intraoperative Techniques to Avoid Injury and Postoperative Treatment  Self-retaining retractors cause most femoral nerve injuries.32 Therefore, urologic surgeons should become familiar with the proper placement of surgical retractors. The lateral blades should cradle the rectus muscles without compressing the psoas muscles. A folded laparotomy sponge should be used beneath each blade to cushion and protect the lateral pelvic sidewall. Proper placement of the blades should be con-

Chapter 40  Complications of Lymphadenectomy firmed by visualizing or palpating a clear space between the tips of the blades and the psoas muscle. Therefore, it is imperative to use the shortest available blade that can effectively retract the rectus muscle, particularly in patients with a thin abdominal wall, poorly developed rectus muscles, or a narrow pelvis. In obese patients, surgeons tend to use a longer blade to allow retraction of the thick abdominal wall. Because the tip of a long blade may impinge excessively against the psoas muscle, obese patients are also at risk for femoral nerve injury. During lithotomy positioning, the surgeon should limit hip flexion, abduction, and external rotation to prevent postural nerve entrapment injury beneath the inguinal ligament. Postoperatively, femoral neuropathy should prompt immediate physical therapy to prevent muscle wasting. This therapy should include early ambulation with knee stabilizers to compensate for thigh weakness and to prevent falling, as well as passive range-of-motion exercises and stretching to prevent muscle contractures. To minimize risk of thromboembolic complications, routine application of an intermittent calf compression device (e.g., Venodyne, Microtek Medical, Columbus, Mississippi) is warranted, and low-molecular-weight heparin may be used judiciously. Chronic neurogenic pain during the recovery period should be treated with non-narcotic analgesics. Drugs such as carbamazepine, which stabilizes the neuronal membrane, and amitriptyline, which blocks catecholamine reuptake at the nerve terminal, are useful adjuncts to analgesics.31 Femoral nerve compression almost invariably resolves spontaneously; however, the time to resolution remains quite variable. Certain neurologic deficits, particularly motor impairment, may require a prolonged recovery. As nerve function returns, motor activity will increase, not infrequently accompanied by intensified neuropathic pain. This pain, however, generally responds to the aforementioned medications. In a large series of 282 patients with femoral neuropathy following pelvic surgery, 265 patients (94%) recovered spontaneously.32 The remainder experienced mild residual symptoms that lasted ≤4 months postoperatively. Genitofemoral Nerve Injury 

Anatomic and Functional Considerations  The genitofemoral nerve is a mixed motor and sensory nerve with a preponderance of sensory fibers. After originating from L1-L2 nerve roots, the genitofemoral nerve travels obliquely between the two bellies of the psoas muscle, perforates the psoas major, and descends along its anterior belly. It then takes a caudal course lateral to the external iliac vessels and, at a variable distance above the inguinal ligaments, divides into its terminal branches, which are the genital and the femoral branches. The genital branch receives sensory input from the skin of the scrotum in men and the mons pubis in women and innervates the cremasteric muscle.

Figure 40-4  The genitofemoral nerve commonly lies in the groove between the iliac vessels and the psoas muscle, typically engulfed within nodal tissues. Complete mobilization of the artery and vein medially may facilitate identification and preservation of the nerve. Care should be taken to secure and divide all vascular tributaries from both vessels to the psoas muscle during this maneuver.

The femoral branch supplies the skin overlying the femoral triangle. Great variation of the genitofemoral sensory nerves to the inguinal region (with free communication among branches of the genitofemoral, ilioinguinal, or iliohypogastric nerves) renders the clinical sequelae of genitofemoral nerve injury inconsistent.

Intraoperative Techniques to Avoid Injury  Genitofemoral nerve injury may occur in patients undergoing standard lymphadenectomy or extended lymphadenectomy including the common and external iliac lymph nodes. The keys to avoiding inadvertent avulsion of the genitofemoral nerve are knowing its location and identifying it early. The nerve commonly lies adjacent to the common iliac vessels, in the groove between the vessels and the medial aspect of the psoas muscle (Fig. 40-4). Dissection of the nodal tissue should start proximally at the para-aortic or paracaval nodes in an extended template. Because the nerve is frequently engulfed within the common and external iliac lymph nodes, freeing it may require a split-and-roll technique. Complete mobilization of the artery and vein medially may facilitate identification and preservation of the nerve. Care should be taken to secure and divide all vascular tributaries from both vessels to the psoas muscle during this maneuver. Once the nerve is identified clearly, dissecting it laterally with gentle traction away from the nodal tissue is generally straightforward and ensures that the nerve remains intact. Lymphocele Lymphocele is defined as a lymph collection within a thick fibrotic wall lacking an epithelial lining. The most common cause of pelvic lymphoceles is lymphadenectomy performed for staging of urologic malignant

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Section VII  Complications of Retroperitoneal Surgery diseases. The mechanism underlying formation of pelvic lymphoceles is drainage of lymphatic fluid from transected afferent lymphatic channels into a closed space. Lack of smooth muscle cells in the wall of lymphatic vessels precludes vasoconstriction and allows lymphatic channels to remain patent >48 hours after injury. Because the peritoneum has high capacity to absorb lymph, lymphoceles typically develop after extraperitoneal surgical procedures. However, with the liberal use of abdominal imaging following radical cystectomy and laparoscopic radical prostatectomy, it became evident that lymphocele can form after intraperitoneal surgical procedures as well. A variety of factors may contribute to the formation of lymphoceles, most commonly inadequate lymphostasis, the presence of metastatic lymph nodes, the long-term use of steroids or diuretics, prior pelvic irradiation, the extent of lymphadenectomy, and low-dose heparin administration. Of these factors, low-dose heparin has been studied most extensively. Catalona and associates33 and Tomic and coleagues34 were first to suggest that subcutaneous heparin administration carries a major risk for lymphocele formation following extraperitoneal lymphadenectomy. Their observation was confirmed by Kropfl and associates,35 who further noted that risk of lymphocele formation was considerably reduced when the heparin was injected into an upper limb as opposed to the lower abdomen or thigh. Drainage fluid from all patients who had heparin injected into the thigh was found to contain high levels of heparin, but fluid from patients who had heparin injected into the arm lacked heparin. Paucity of clotting factors and lack of platelets are believed to render the lymphatic fluid more vulnerable to the effect of anticoagulants than is blood. Another significant risk factor for pelvic lymphoceles is extended lymphadenectomy. In one report, the rate of lymphocele formation was twofold higher in patients with prostate cancer who were undergoing extended compared with limited PLND (10.3% versus 4.6%, respectively; P = .01).13 The increased risk for lymphocele formation following extended PLND in bladder cancer is less well documented. Most lymphoceles are asymptomatic and often remain undetected. Hence, the reported incidence of pelvic lymphoceles following PLND in modern series is fairly low, ranging from 2% to 27%.36 When symptoms do occur, they usually manifest early in the postoperative course as a sensation of pelvic fullness. As the lymphocele enlarges, symptoms related to compression of adjacent anatomic structures may become evident. Urinary frequency from bladder compression, constipation from rectosigmoid compression, pain from pressure on pelvic nerves, and edema (scrotal, labial gland, and rarely lower extremity edema) may occur as pelvic venous return is hindered. Compression of major pelvic veins may occasionally lead to thrombotic complica-

B

Figure 40-5  A 57-year-old man 16 days after radical prostatectomy and bilateral pelvic lymph node dissection presenting with vague abdominal pain and urinary frequency. Axial CT shows compression of the bladder (B) by a large pelvic lymphocele.

tions. Ureteral compression with subsequent hydronephrosis is rare. Associated fever is infrequent, and its presence indicates a possible superinfection, which generally requires prompt lymphocele drainage. Physical examination is typically unremarkable. Only occasionally, in patients with very large fluid collections, is a pelvic mass just above the inguinal ligament visible or palpable. Imaging studies are required to make the diagnosis, and at the majority of centers ultrasound examination is used most commonly, particularly after prostatectomy. On ultrasound imaging, lymphoceles appear as anechoic cystic structures that may contain thin septations and debris. Occasionally, a lymphocele may be mistaken for a large postvoid residual noted on routine office evaluation. CT is more expensive but provides excellent visualization of most pelvic and retroperitoneal fluid collections. It is generally the preferred imaging modality following radical cystectomy. On CT images, lymphoceles are seen as thin-walled hypodense lesions with negative Hounsfield unit values (Fig. 40-5). A finding of a thickened wall with regional enhancement suggests the presence of infection. Management  Currently, no consensus exists on the optimal management of pelvic lymphoceles. In fact, only half of all pelvic lymphoceles ultimately require intervention.36 Small, uncomplicated lymphoceles can be managed expectantly and, except for monitoring, usually require no further treatment. One should consider the relationship of the lymphocele with the iliac or femoral vein. Venous compression resulting in lower extremity venous stasis or deep vein thrombosis may be one indication for intervention in the absence of pain or infection. Large or symptomatic lymphoceles, which

Chapter 40  Complications of Lymphadenectomy generally require treatment, can be managed by percutaneous techniques or surgically. In the past, percutaneous drainage was performed by simple aspiration, but this approach was abandoned because of high (80%-90%) recurrence rates and a substantial (25%-50%) risk of infection.37,38 This method is currently reserved for diagnostic purposes only and has been supplanted by placement of a percutaneous drainage tube. Reported success rates with the drainage tube are approaching 80%, with a mean drainage duration ranging anywhere from a few days to several months.39 A major disadvantage of this technique, particularly when prolonged treatment is required, is the need for frequent tube exchanges as a result of clogging of the small-caliber side holes. Sclerotherapy through a percutaneous catheter has become popular in cases of recurrent lymphoceles. Sclerosing agents offer the potential for faster resolution because these agents obliterate the lymphatic channels by a chemical effect. Instillation of sclerosing agents can be tried as an alternative when lymphoceles do not resolve after catheter drainage alone.40 Multiple sclerosing agents have been explored over the years, including povidone-iodine, ethanol, ampicillin, tetracycline, doxycycline, bleomycin, sodium aztreonam, sodium tetradecyl sulfate, fibrin glue, and talc.36,40 Ethanol and povidone-iodine are the two most commonly used sclerosing agents, with success rates varying between 88% to 97% and 62% to 89%, respectively.36 Bleomycin is generally reserved for sclerotherapy of resistant lymphoceles. The major impediment to successful resolution of pelvic lymphoceles after percutaneous drainage, either alone or in combination with sclerotherapy, is the presence of a multiloculated cavity. McDougall and Clayman41 proposed an alternative, minimally invasive intervention for managing persistent lymphoceles: dilating the percutaneous track followed by careful endoscopic fulguration of the cavity lining. The most durable solution to refractory lymphoceles is probably internal marsupialization, which consists of creation of a peritoneal window to allow the lymphocele to drain into the peritoneal cavity. Peritoneal drainage can be performed laparoscopically or using an open technique but is contraindicated in the setting of infection because of the increased risk of peritonitis.42 Unfortunately, complete resolution with this technique is not guaranteed, and relapse rates approach 20%.36 To improve outcomes, some investigators have suggested packing the cavity with omentum to prevent window closure and to facilitate transperitoneal absorption of lymphatic fluid. Other investigators have instilled diluted methylene blue solution into the drained cavity to enable precise identification of the lymphocele location and extent.43 Open external drainage is reserved primarily for loculated, infected lymphoceles that fail to respond to percutaneous drainage and antibiotic therapy.44

Intraoperative Techniques to Avoid Lymphocele Formation  The key surgical tenet for avoiding or minimizing formation of pelvic lymphoceles is meticulous control of the divided lymphatic channels. Although small and innocuous lymphatic channels can be readily sealed with electrocautery, it is imperative to apply clips or suture ligatures to any major lymphatic trunks. Particular attention should be given to controlling the distal and proximal limits of the lymph node packet dissected (see Fig. 40-1). Because lymphatic vessels are frail and prone to disruption, care should be taken to avoid excessive traction on the packet before it is clipped. Whether pelvic drains actually reduce the incidence of lymphocele formation remains an area of contention. In an earlier study,10 pelvic drains were reported to reduce the incidence of lymphocele formation, although a subsequent study of patients after radical hysterectomy failed to show any advantage.45

RETROPERITONEAL LYMPH NODE DISSECTION Retroperitoneal lymph node dissection (RPLND) plays a critical role in the management of testicular cancer. Although no consensus exists on the extent and clinical benefits of lymph node dissection for renal cell carcinoma and upper urinary tract urothelial tumors, many urologists consider RPLND in these patients to be part of extirpative surgical treatment. Germ cell tumors of the testis are both rare (accounting for only 1%-2% of all neoplasms in men) and unique because they affect almost exclusively young men 5 years.53 In contrast, patients who have underlying IVC occlusion (complete or nearly complete) experience minimal, if any, venous congestion or third-space extravasation of lymphatic drainage. In a study of patients with chronic IVC occlusion, 40% had no sequelae and 30% developed minimal disability following ligation of the IVC.54 Gradual IVC occlusion, often associated with long-standing external compression from encasing tumor, allows for development of collateral veins that mitigate acute and chronic venous morbidity. Therefore, it is important for surgeons contemplating IVC resection not to sacrifice any competitive venous collaterals that have developed. When performing the lymph node dissection, one should attempt to preserve the contralateral testicular, lower lumbar, and pelvic veins to avoid compromising the venous return through the hemiazygos or azygos systems.55 If these venous tributaries must be sacrificed to attain complete tumor resection, the intervertebral veins of Batson may provide additional means of circumventing the obstructed caval segment. The resected IVC is best replaced by an interposition polytetrafluoroethylene graft or an autologous pericardium tube graft. Grafts in the venous system are far more likely to occlude than are arterial grafts. Slow venous flow against a hydrostatic pressure gradient, low intraluminal pressure, and the presence of competitive flow from venous collaterals all put the IVC graft at risk for occlusion.52 Because the long-term patency of IVC reconstruction is questionable, this procedure should be reserved for patients with poor collateral circulation. MRI and MRA can be useful in assessing the patency of the infrarenal vena cava as well as for identifying enlarged collateral vessels.48 Normal venous pressure in the lower limbs of a patient with suspected IVC obstruction may indicate adequate collateral circulation superficially through the epigastric and axillary veins and, at a deeper level, from the hypogastric vein through the rectal plexus and portal venous system. In one reported

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Section VII  Complications of Retroperitoneal Surgery series of patients undergoing RPLND with IVC resection, the absence or presence of preoperative venous signs and symptoms was a poor predictor of chronic venous sequelae.52 Other early complications of IVC resection include renal insufficiency, deep vein thrombosis, and increased incidence of chylous ascites and autonomic dysfunction.

Retroperitoneal Lymphoceles and Chylous Ascites Anatomic and Physiologic Considerations The main lymphatic channels in the retroperitoneum are the ascending lumbar lymphatic trunks. These chains travel posterior and parallel to the aorta and IVC and are formed by the coalescence of the common iliac lymph vessels. Typically, both lymphatic trunks merge posterior and medial to the aorta to form the cisterna chyli (Fig. 40-6). The cisterna chyli, which is a saccular dilatation of the main lymphatic trunk, is commonly situated behind the left crus of the diaphragm. It marks the termination of the retroperitoneal lymphatic pathway and the beginning of the thoracic duct. The thoracic duct traverses the aortic hiatus into the right posterior mediastinum, courses to the left at the level of the fourth thoracic vertebra, and commonly drains into the venous system at the junction of the left jugular

Figure 40-6  Merging of the right and left lymphatic trunks posterior and medial to the aorta to form the cisterna chyli. Inadvertent injury to this delicate structure results in marked lymph secretion into the peritoneal cavity.

and subclavian veins. A distinct cisterna chyli is present in approximately half the cases; in the rest, it is replaced by a variable lymphatic plexus.56 The cisterna chyli and thoracic duct transport lymph from the lower hemitrunk back to the circulatory system. Anywhere from 50% to 90% of lymphatic fluid is derived from the intestine and liver. This fluid contains mostly dietary fat in the form of chylomicrons. Because intestinal lymphatic fluid is returned by the lacteals (generally into the left trunk), ingestion of a fatty meal can increase the lymph flow in the lacteals and retroperitoneal lymphatic trunks ≥200-fold compared with a fasting state. Unrecognized disruption of the cisterna chyli, the thoracic duct, or their major tributaries can lead to major lymphatic leak and development of retroperitoneal lymphoceles and, less frequently, the accumulation of chylous ascites.

Management and Intraoperative Techniques to Avoid Retroperitoneal Lymphoceles and Chylous Ascites Small lymphoceles are fairly common after extensive RPLND and most are clinically innocuous. Symptomatic retroperitoneal lymphocele is rare. Presenting symptoms may include a sense of abdominal fullness, flank pain related to ureteral compression, and fever and chills related to lymphocele infection. CT may reveal a thin-walled cystic lesion. Any radiographic evidence of a lobulated collection containing fluid and air with wall enhancement should prompt concern of a retroperitoneal abscess (Fig. 40-7). Retroperitoneal abscesses are treated by CT-guided percutaneous drainage and appropriate antibiotics. Abdominal distention, enlarging girth, and disproportionate weight gain are among the most common

Figure 40-7  A 21-year-old man 4 weeks after postchemotherapy retroperitoneal lymph node dissection presenting with increasing left flank pain, night sweats, and elevated fever. CT shows a lobulated collection containing fluid and air with wall enhancement (arrow) indicating a retroperitoneal abscess.

Chapter 40  Complications of Lymphadenectomy

Figure 40-8  A 35-year-old man presenting with uncomfortable sensation of abdominal fullness 3 weeks following postchemotherapy retroperitoneal lymph node dissection. CT demonstrates a large amount of ascitic fluid. Paracentesis confirmed the diagnosis of chylous ascites.

signs of chylous ascites. Patients may complain of an uncomfortable sensation of abdominal fullness and dyspnea related to restriction of the diaphragm or leakage of ascitic fluid into the chest and formation of chylothorax.56,57 The diagnosis of chylous ascites is generally made by CT scan (Fig. 40-8) and is confirmed by analyzing the fluid obtained by paracentesis. Typically, the fluid appears milky and odorless (provided it is sterile) and has a high content of protein (>3 g/dL) and triglycerides (twofold to eightfold higher than that of plasma). Management of postoperative chylous ascites is primarily conservative. Treatment goals include decreasing the mesenteric lymph flow and lymph leakage into the peritoneum, alleviating mechanical symptoms related to the distended abdomen, and providing adequate replacement of nutritional losses. Common conservative measures consist of repeat therapeutic paracentesis, dietary modifications, hyperalimentation, and the administration of a somatostatin analogue. Surgical intervention is reserved as a last resort for patients for whom nonoperative management is ineffective. Diagnostic paracentesis is often required early in the evaluation of chylous ascites. Repeated attempts at therapeutic paracentesis and placement of an externalized peritoneal drain are rarely effective and may prolong the leakage of ascitic fluid, exacerbate nutritional and immunologic losses, and increase the risk of peritonitis.58 Dietary intervention is the mainstay of nonoperative therapy for chylous ascites. A high-protein, low-fat diet containing medium-chain triglycerides (which are transported directly into the portal circulation, thus bypassing intestinal lymphatics) yields minimal lymph flow within the major lymphatic trunks and facilitates

the spontaneous closure of lymphatic fistulas. Nutritional manipulations alone or in combination with diuretics may be effective in as many as 50% of patients.56-58 Total parenteral nutrition is generally recommended as second-line therapy when dietary manipulations fail. Hyperalimentation has the advantage of resting the bowel while restoring crucial nutritional deficits and effectively further decreases the production and leakage of lymph. Finally, the adjunctive use of the somatostatin analogue octreotide offers additional benefit by drastically reducing the lymphatic output through the fistula within 24 to 72 hours after initiating therapy.59 Octreotide therapy should be attempted early in the course of treatment with low-dose, subcutaneous injections of 100  µg three times daily. Close monitoring of blood glucose levels and gradual tapering of octreotide on complete resolution of the condition are prudent. Persistent active lymphatic leakage after several weeks to months of maximal conservative management warrants a more aggressive approach. Surgical repair by direct suture ligation of a leaking lymphatic channel and peritoneovenous shunting with a LeVeen or Denver shunt have been described, although the role and timing of surgical repair remain controversial.57 The singular difficulty with surgical ligation lies in identifying the exact locations of lymphatic leakage. Several techniques facilitate localization of large, open lymphatic channels: prescribing a heavy, fatty meal preoperatively; using lipophilic dyes; and performing lymphoscintigraphy. If a definitive fistula cannot be identified, nonselective suturing of retroaortic tissues may successfully resolve the leak.56 The primary means of minimizing postoperative lymphatic leakage is to secure (ligate or clip) the cut ends of lymphatic vessels throughout the procedure. Particularly vulnerable locations include the region of the right renal artery, where large tributaries to the cisternae chyli are located, and the numerous lymphatic channels overlying the left renal vein. Large lymphatic channels at the base of the pancreas and superior mesenteric artery also require meticulous control. At the completion of dissection, the surgical field must be thoroughly irrigated with warm water, and lymphostasis must be ensured.

Ejaculatory Dysfunction Anatomy and Neurophysiology of Antegrade Ejaculation Normal antegrade ejaculation is a coordinated, sequential process of seminal emission and ejaculation proper. During emission, the two vasa deferentia contract to propel sperm from the epididymis, mix it with fluids from the seminal vesicles, prostate, and bulbourethral glands, and deliver the ejaculate into the posterior urethra. For normal ejaculation to ensue, the bladder

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Section VII  Complications of Retroperitoneal Surgery neck must be closed (or partially closed) at this phase. During ejaculation proper, the semen is ejected through the penile urethra. Ejaculation is prompted by the rhythmic contractions of the bulbocavernosus and ischiocavernosus muscles coupled with complete bladder neck closure and relaxation of the external urethral sphincter and urogenital diaphragm. From a neurophysiologic standpoint, ejaculation initiates with transmission of afferent stimuli from the genital end organs through the pudendal nerve onto the cerebral cortex. Efferent impulses are transmitted through the anterolateral spinal cord columns to the thoracolumbar sympathetic outflow tract. These preganglionic fibers synapse in the ganglia of the paravertebral sympathetic trunk and exit through L1-L4 postganglionic fibers. Although individual anatomic features vary greatly, ejaculatory information is transmitted predominantly through the L3-L4 fibers and to a lesser degree through L1-L2. The efferent signals then travel through the postsympathetic fibers to the hypogastric plexus and on to the vas, ampulla, seminal vesicles, prostate, and bladder neck. Thus, whereas the ejaculatory phase is under control of a somatic spinal reflex at the S2-S4 level, seminal emission and bladder neck closure are governed by the sympathetic nervous system and are most vulnerable to damage during RPLND.

Figure 40-9  Anterior split-and-roll maneuver over the aorta may result in disruption and damage to the left postganglionic sympathetic fibers. The nodal tissue can be safely split over the inferior vena cava.

Intraoperative Techniques to Avoid Autonomic Nerve Injury Nerve-sparing RPLND requires a sound understanding of the anatomy of the retroperitoneum. The keys to avoiding sympathetic nerve damage and ensuring preservation of normal ejaculation are prospective identification and meticulous dissection of the sympathetic trunks, the postganglionic sympathetic fibers (particularly L3 and L4), and the hypogastric plexus. The sympathetic chains run parallel to the great vessels and are located in the retroperitoneum between the medial border of the psoas muscle and the vertebral column. The right chain is typically located posterior to the IVC, whereas the left chain is located posterolateral to the aorta. The sympathetic chains and ganglia are intimately involved with lumbar vessels. Therefore, great care should be taken to avoid injury to these delicate structures during isolation and division of these vessels. The left postganglionic sympathetic fibers emerge lateral to the aorta and then traverse anteriorly to join the hypogastric plexus near the takeoff of the inferior mesenteric artery. On the right side, postganglionic fibers emerge underneath the IVC, course medially at an oblique angle anterior to the aorta, and then converge into the hypogastric plexus. Thus, an anterior split-and-roll maneuver over the IVC can be carried out safely, whereas dissecting over the aorta may result in disruption and damage to the left postganglionic fibers

(Fig. 40-9).60 The interaortocaval and para-aortic lymphatic tissue should be dissected only after the nerve fibers have been isolated and properly encircled with soft vessel loops. Isolating the subtle fibers of the hypogastric plexus, which is generally situated between the two common iliac arteries, should be done carefully. To reduce the incidence of postoperative ejaculatory failure, two surgical approaches—nerve-sparing techniques and modified templates—have become popular. Nerve-sparing techniques rely on precise dissection and preservation of vital neuroanatomic structures. In patients with limited residual retroperitoneal disease, selective or unilateral nerve sparing may be contemplated if the margin of resection and oncologic safety will not be compromised. Successful nerve sparing is more difficult after chemotherapy because of nerve entrapment and fibrosis between the tumor mass and the adventitia of the great vessels. Modified dissection templates are intended to limit the extent of dissection to anatomic regions likely to be at increased risk of metastatic disease. Prompted by the high incidence of permanent ejaculatory dysfunction in patients undergoing extensive, bilateral RPLND and driven by surgical mapping studies in testicular cancer,61,62 modified dissection templates have been developed for low-volume disease. All minimize or

Chapter 40  Complications of Lymphadenectomy avoid contralateral dissection, particularly below the level of the inferior mesenteric artery. Combining nerve-sparing techniques with modified templates has resulted in postoperative ejaculation rates of 84% to 98%.60,63 However, the concept of modifiedtemplate RPLND has been challenged.64 Lack of adequate postoperative follow-up to account for surgical or pathologic sampling errors, as well as overreliance on postoperative chemotherapy, may undermine some of the conclusions drawn from these mapping studies. An analysis of >500 patients with clinical stage I to IIA nonseminomatous tumors who underwent primary RPLND, for example, found that 23% of men with retroperitoneal metastases had disease present outside the limits of the modified templates, and 20% to 30% of these tumors had chemoresistant teratomatous elements.65 Intraoperative use of Brindley’s electrostimulation device to facilitate identification and isolation of postganglionic sympathetic fibers has been reported by several investigators. Although bladder neck closure and seminal emission can be documented endoscopically, it is unclear whether these factors affect or predict future fertility in these patients.66 For men with retrograde ejaculation in whom emission is preserved, treatment with an α-adrenergic sympathomimetic agent may restore an intact bladder neck status and antegrade ejaculation. For patients with failure of seminal emission, transrectal electroejaculation is required to recover motile sperm for assisted reproductive techniques, with a resulting pregnancy rate of 43%.67

Gastrointestinal Complications Mobilization and retraction of the duodenum may result in transient pancreatitis (manifesting as nausea and vomiting) in conjunction with elevated serum levels of amylase and lipase. Attention to proper positioning and to tension placed on the retractor blades is key to avoiding pancreatic irritation. Conservative treatment with dietary restriction is often sufficient to resolve this temporary pancreatic inflammation. Postoperative paralytic ileus is reported in approximately 0.2% of patients undergoing primary transabdominal RPLND and in 2% of those undergoing the procedure after chemotherapy.68 The more extensive the retroperitoneal dissection, the higher is the likelihood of protracted ileus, which usually resolves with conservative measures after an extended hospital stay. The incidence of this complication is minimized by careful mobilization of the duodenum and root of the small bowel mesentery and cautious avoidance of inadvertent pressure or serosal abrasions from retractor blades. Direct injury to the bowel is rare and most likely occurs after chemotherapy when a large, adherent inter-

aortocaval mass is dissected. This injury usually involves the third or fourth segments of the duodenum. Fullthickness injury requires primary, two-layer closure with interposition of omentum between the great vessels and the bowel to decrease the incidence of abscess formation and potentially fatal disruption of an aortoduodenal fistula. Tension-free reapproximation of the visceral peritoneum (overlying the small bowel mesentery) to the serosa (covering the duodenum) and the edge of the mesocolon minimizes the likelihood of an internal hernia. This technique also facilitates future access to the retroperitoneum (in case a salvage procedure is required) by preventing fibrous adhesions to an extensively dissected, raw retroperitoneal surface.

INGUINAL LYMPH NODE DISSECTION Penile cancer spreads along predictable routes, following the lymphatic drainage of the penis. Initial spread to the superficial inguinal nodes is followed by extension to the deep inguinal nodes of the femoral triangle and ultimately to the ipsilateral pelvic lymph nodes. Because inguinal lymph node involvement invariably precedes the spread of distant disease, the most important prognostic indicator for patients with carcinoma of the penis remains the presence or absence of regional lymph node metastases. Metastatic penile carcinoma in the regional lymph nodes generally confers a poor prognosis; however, aggressive lymphadenectomy has been associated with improved survival and cure in 30% to 60% of patients.69,70 Even though the diagnostic value of groin dissection in these patients is evident and the concept of surgical curability has been confirmed in numerous studies, management of regional lymph nodes in penile cancer remains controversial. Given the inaccuracy of clinical staging (by physical examination and imaging studies) and the significant morbidity incurred with groin dissection,71-73 many urologists are reluctant to recommend inguinal lymphadenectomy unless the lymph nodes have become overtly palpable. Because the extent of morbidity is directly related to the extent of dissection, some surgeons are now trying to limit the boundaries of dissection while relying on frozen section analysis intraoperatively for margin assessment.

Anatomic Considerations Inguinal lymph node dissection in penile cancer can be prophylactic, therapeutic, or palliative. Prophylactic groin dissection is indicated for patients with an invasive primary tumor (TNM stage T1 at minimum) and no palpable adenopathy. In this setting, patients undergo modified superficial inguinal lymph node dissection (including the lymphatic tissue above the fascia lata)

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Section VII  Complications of Retroperitoneal Surgery between the sartorius muscle laterally and the adductor longus muscle medially. The saphenous vein is invariably dissected from the nodal packet and is preserved. In the absence of lymph node metastases on frozen section analysis, the procedure is concluded. If metastases are detected, complete inguinal and ipsilateral pelvic dissection is performed. Therapeutic groin dissection is indicated for men with overtly palpable adenopathy after a course of antibiotics to rule out a possible inflammatory component. In this setting, the saphenous vein has traditionally been divided at the saphenofemoral junction, the femoral vessels are skeletonized to allow for removal of deep inguinal nodes, and a sartorius muscle flap is generally rotated medially to cover the exposed femoral vessels. If a mobile nodal mass is fixed to the skin, an ellipse of involved skin should be excised en bloc with the specimen. Palliative groin dissection is performed to remove all gross residual disease after chemotherapy. To achieve negative surgical margins, the resection often includes the inguinal ligament, the spermatic cord, and the ipsilateral testis. More rarely, the dissection also includes segments of the femoral artery and vein (with adequate reconstruction by a patch or bypass grafting) and inferior portions of the rectus abdominis and external and internal oblique muscles. Myocutaneous flaps to cover a large defect may occasionally be required and remain a necessary step to ensure adequate reconstruction.

Complications Complications consistently reported in groin dissection series are related to disruption of the lymphatics draining the lower extremities and damage to the overlying skin flaps from devascularization. These complications include skin edge necrosis (45%-62% of dissections), wound infection (14%-17%), seroma formation (6%16%), and lymphedema (23%-50%).71-73 Skin flap necrosis remains a frequent complication of groin dissections. The blood supply to the skin of the inguinal region is derived from branches of the common femoral artery. Complete groin dissection necessitates skeletonization of the femoral vessels and ligation of these branches, with potential compromise in blood supply to the raised skin flaps. Viability of the skin edges in this setting depends primarily on anastomotic vessels running along the superficial fatty layer of Camper’s fascia. Because lymphatic drainage of the penis to the groin is beneath Camper’s fascia, this layer can be preserved and left attached to the overlying skin when the skin flaps are fashioned. Several surgical modifications have been developed to minimize skin flap necrosis, including avoidance of the inguinal skin crease during the initial skin incision, meticulous skin edge handling with fine hooks, creation

of thicker skin flaps in which Camper’s and Scarpa’s fascial layers are preserved, and limitation of the extent of flap mobilization (superiorly to the inguinal ligament and inferiorly to the tip of the femoral triangle). Careful hemostasis and excision of ischemic flap margins at the end of the procedure are mandatory. Additionally, placing horizontal sutures to anchor the underlying muscle aponeurosis may reduce the tension at the flap edges. Taken together, these surgical tenets have substantially reduced the incidence of skin edge necrosis from the 50% to 60% reported historically to 8% in a study reported in 2002.71 If skin necrosis does occur, débridement and split-skin grafting may be necessary.

Lymphedema Lymphedema following groin dissection can be bothersome and debilitating with respect to ambulation, difficulty in standing for prolonged periods, and recurrent bouts of cellulitis induced by lymphostasis. The overall incidence of postoperative lymphedema has been reported to be ≤50%, with severe lymphedema occurring in 35% of patients. Limiting the template of dissection, specifically by sparing the saphenous vein in these circumstances, has resulted in reduced rates of postoperative lymphedema. This concept was validated in the gynecologic literature in a study evaluating the advantages of saphenous vein preservation in lymphadenectomy for carcinoma of the vulva.74 The study demonstrated a decrease in the incidence of chronic lower extremity edema from 32% to 3% without affecting local cancer control. Persistent lymphedema is rare but if left untreated may become progressive, chronic, and incurable. A stepwise approach to the management of chronic lymphedema was developed and advocated by the International Society of Lymphology.75 It consists of initial skin care, light manual massage, elevation of the affected limb, range-of-motion exercises, and intermittent compression with low-stretch elastic stockings or multilayered bandage wrapping. Failure to achieve significant improvement should prompt maintenance therapy with a 24-hour compression garment and intermittent pneumatic compression devices. Diuretics, benzopyrenes (which hydrolyze tissue proteins), and surgical intervention (e.g., resection, liposuction, and microsurgical procedures) are all of questionable efficacy. Comprehensive lymphedema therapy can produce rapid reduction in all stages of lymphedema but has the disadvantages of being labor intensive, compliance dependent, and costly.76 Wound infection and seroma formation are fairly uniform among contemporary reports, with incidences ranging between 10% and 15%. Impaired lymphatic drainage and the frequent occurrence of seromas render these wounds particularly susceptible to infection. Parenteral antibiotics with staphylococcal coverage and

Chapter 40  Complications of Lymphadenectomy meticulous skin preparation of the genital folds by both patients (preoperatively) and the surgical team serve to reduce infective complications. Vacuum-assisted closure therapy in complex inguinal wound failures appears to be superior to conventional wound care without conferring an increased risk of local recurrence.77

KEY POINTS 1. Lymphadenectomy remains crucial in the surgical management of urologic malignancies, yielding both diagnostic and therapeutic benefits. 2. The split-and-roll technique should be used invariably to dissect lymphatic tissue overlying the large arteries and veins. 3. Sound knowledge of the pelvic and retroperitoneal anatomy are key to avoiding complications associated with lymph node dissections.

REFERENCES Please see www.expertconsult.com

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41

COMPLICATIONS OF RADICAL CYSTECTOMY Erik Pasin

MD Resident, Department of Urology, University of Southern California, Norris Comprehensive Cancer Center, Los Angeles, California

Maurizio Buscarini

MD Resident, Department of Urology, University of Southern California, Norris Comprehensive Cancer Center, Los Angeles, California

John P. Stein

MD Professor, Department of Urology, University of Southern California, Norris Comprehensive Cancer Center, Los Angeles, California

In the United States, bladder cancer is the fourth most common cancer in men and the eighth most common in women, with transitional cell carcinoma compromising nearly 90% of all primary bladder tumors.1 Although most patients present with superficial bladder tumors, 20% to 40% of patients present with or ultimately develop muscle-invasive disease. Invasive bladder cancer is a lethal malignant disease. If it is untreated, >85% of patients will die of their disease within 2 years of the diagnosis.2 Furthermore, a certain percentage of patients with high-grade bladder tumors without involvement of the lamina propria will have recurrent or progressive disease or unsuccessful intravesical management, and they may best be treated with earlier cystectomy, when survival outcomes are optimal.3 The rationale for an aggressive treatment approach employing radical cystectomy for high-grade, invasive bladder cancer is based on several clinical observations: 1. The best long-term survival rates, coupled with the lowest local recurrence rates, are seen following definitive surgical treatment including removal of the primary bladder tumor and regional lymph nodes.4,5 2. The morbidity and mortality of radical cystectomy have significantly improved over the past several decades. 3. Transitional cell carcinoma tends to be resistant to radiation therapy, even at high doses. 4. Chemotherapy alone or in combination with bladdersparing protocols has not demonstrated long-term

local control and survival rates equivalent to rates reported with cystectomy.6 5. Radical cystectomy provides accurate pathologic staging of the primary bladder tumor (p stage) and regional lymph nodes and thus permits selective determination of the need for adjuvant therapy based on precise pathologic evaluation. For the aforementioned reasons, radical cystectomy has become standard treatment and arguably the ideal form of therapy for high-grade, invasive bladder cancer today. The evolution and improvements in lower urinary tract reconstruction, particularly orthotopic diversion, have been major components in enhancing the quality of life of patients requiring cystectomy. Currently, most men and women can safely undergo orthotopic lower urinary tract reconstruction to the urethra following cystectomy.7 Orthotopic reconstruction most closely resembles the original bladder in both location and function, provides a continent means to store urine, and allows volitional voiding through the urethra. The orthotopic neobladder eliminates the need for a cutaneous stoma and a urostomy appliance, as well as the need for intermittent catheterization in most cases. These efforts have been directed to improve the quality of life of patients who must undergo bladder removal and have stimulated patients and physicians to consider radical cystectomy at an earlier, more curable stage of disease.8 At the University of Southern California (USC) in Los Angeles, a dedicated effort has been made to improve 481

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Section VIII  Complications of Pelvic Surgery on the surgical technique of radical cystectomy and to provide an acceptable form of urinary diversion without compromising a sound cancer operation.9-11 Radical cystectomy is a technically challenging operation, often performed in elderly patients with associated comorbidities that requires diligent attention to preoperative, intraoperative, and postoperative details. Despite this attention, complications do occur. Therefore, it is prudent for all surgeons to be familiar with the presentation, prevention, and treatment of the major causes of morbidity and mortality associated with this surgical procedure. The complications of radical cystectomy can be categorized as (1) those specific to the removal of the anterior pelvic organs and associated lymphadenectomy and (2) those specific to the form of urinary diversion. This chapter focuses on the early and delayed complications associated with radical cystectomy and intestinal urinary diversion.

COMPLICATIONS OF CYSTECTOMY Mortality With improvements in surgical technique and perioperative anesthetic care, the early mortality rate associated with radical cystectomy has decreased from nearly 20% before 197012 to 1% to 5% in most contemporary series.4,5,13-16 In a retrospective analysis of 1359 patients following radical cystectomy at USC, the most common cause of death in the perioperative period was cardiovascular, and septic complications from resulting urine and bowel leaks were the second most common (Table 41-1).12 The USC surveillance regimen after radical cystectomy is shown in Table 41-2.

Hemorrhage Hemorrhage is a common complication of radical cystectomy that can occur acutely intraoperatively and in

TABLE 41-1  Perioperative Mortality Rates From Radical Cystectomies, 1971 to 2001 (N = 1359 Patients)

Category

No. Perioperative Mortalities

Total No. Patients With Type of Complication

Complications Resulting in Perioperative Mortality (%)

Median Age (yr) at Surgery (Range)

Median Time (Days) to Death (Range)

65 (47-72)

13 (0-28)

34

24

71 (58-78)

33 (23-47)

212

4

72 24

4 13

Cardiovascular

8

Acute myocardial infarction

4

Arrhythmia

2

Cerebrovascular accident

1

Arterial thrombosis (superior mesenteric artery)

1

Infectious/Sepsis

8

Primary contributing factor Urine leak Bowel leak/fistula Small bowel obstruction Hematoma

3 3 1 1

Pulmonary Embolus

4

69 (66-77)

20 (0-28)

25

16

Hepatic Failure

3

73 (62-78)

38 (5-48)

34*

15*

Upper Gastrointestinal Bleeding

2

Hemorrhage, surgical site

1

Hemorrhage

2

72 (66-77)

23 (1-44)

34*

15*

Hemophilia B

1

Conduit-arterial fistula

1

Unknown

2

62 (57-67)

64 (47-80)

27

67 (47-78)

28 (0-80)

Total

*All hemorrhagic complications regardless of primary cause are considered collectively.

Chapter 41  Complications of Radical Cystectomy the delayed setting. The bladder, prostate, uterus, and vagina are vascular organs that are drained by a rich venous supply, which necessitates careful and secure vascular control. Although several patient-related characteristics may affect intraoperative blood loss and the need for transfusion, a sound understanding of pelvic anatomy and adherence to proper surgical technique remain the cornerstones of prevention of significant bleeding in the intraoperative and delayed settings. The blood supply to the anterior pelvic organs is derived primarily from the anterior branches of the internal iliac vessels. The anterior division of the hypogastric artery gives off seven branches supplying the pelvic viscera (superior vesical, middle rectal, inferior vesical, uterine, internal pudendal, obturator, and inferior gluteal arteries) that collectively form the lateral pedicle. At our institution, the lateral vascular pedicle is isolated, and each individual branch is clipped and divided after dissecting the obturator fossa and ligating the obturator vessels. Isolation and development of this pedicle are crucial for proper vascular control and to help minimize bleeding during radical cystectomy. With the lateral pedicle entrapped between the surgeon’s left index and middle fingers, firm traction is applied vertically and caudally (Fig. 41-1). This maneuver facilitates identification and allows individual branches of the anterior portion of the hypogastric artery to be isolated. The posterior trunk of the hypogastric artery, including the superior gluteal, iliolumbar, and lateral sacral arteries, is preserved to avoid gluteal claudication. All anterior branches of the hypogastric artery are isolated and divided between hemoclips down to the endopelvic fascia. The proximal aspect of each vessel is doubly clipped. We prefer right-angle hemo-

clips, with care ensuring that 0.5 to 1 cm of tissue projects between each clip when the pedicle is divided. This technique prevents the clips from becoming dislodged during the operation, with resulting unnecessary bleeding. After control of the lateral pedicle, attention is directed toward the posterior pedicle. The posterior pedicle is developed after entry into Denonvilliers’ space. The pouch of Douglas is incised slightly on the rectal side, and the plane between the posterior sheath of Denonvilliers’ fascia and the rectum (Denonvilliers’ space) is developed. A combination of sharp and blunt dissection allows the rectum to be carefully swept off the seminal vesicles, prostate, and bladder in men and the posterior vaginal wall in women. This sweeping motion, when extended laterally, helps to thin and develop the posterior pedicle, which resembles a collar emanating from the lateral aspect of the rectum (Fig. 41-2). Once the posterior pedicles have been defined, they are clipped and divided down to the endopelvic fascia in the male patient. In women, the posterior pedicles, including the cardinal ligaments are divided 4 to 5 cm beyond the cervix. Again, proper hemoclip placement and technique are essential to minimize blood loss. Although it is standard practice at USC to dissect and ligate the individual vessels of the lateral and posterior pedicles between carefully placed hemoclips, investigators have proposed that staple ligation of these pedicles contributes to significantly lower estimated blood loss and transfusion requirements compared with suture ligation alone.17 We have not found this technique useful and in fact strongly encourage individual vessel ligation to ensure optimal vascular control.

TABLE 41-2  University of Southern California Surveillance Regimen After Radical Cystectomy

Orthotopic neobladder, continent cutaneous diversion*, ileal conduit†,‡

4 Months

1 Year

2-5 Years (Annually)

After 5 Years (Annually)

IV pyelogram (ultrasound if creatinine >1.8 mg/dL)

IV pyelogram (ultrasound if creatinine >1.8 mg/dL)

IV pyelogram (ultrasound if creatinine >1.8 mg/dL)

IV pyelogram (ultrasound if creatinine >1.8 mg/dL)

Gravity cystogram

Gravity cystogram

Gravity cystogram

Gravity cystogram

Comprehensive metabolic panel

Comprehensive metabolic panel

Comprehensive metabolic panel

Comprehensive metabolic panel

Liver function tests

Liver function tests

Liver function tests

Liver function tests

Chest radiograph

Chest radiograph

Chest radiograph

Chest radiograph

Urine cytology

Urine cytology

Urine cytology Vitamin B12 every other year

*Same as orthotopic neobladder with annual urethral washings in male patients. † Same as orthotopic neobladder, may use loopogram to assess upper tracts. ‡ Consider computed tomography of the abdomen or pelvis at 6, 12, and 24 months in pT3 or pT4 disease. IV, intravenous.

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Section VIII  Complications of Pelvic Surgery The third major vascular structure that must be controlled before removal of the cystectomy specimen is the dorsal venous complex (DVC). Although several methods have been described, we use one of two methods of securing the DVC, both of which offer excellent vascular control. An angled clamp can be passed carefully beneath the DVC, anterior to the urethra. The venous complex can then be ligated with a 2-0 absorbable suture and divided close to the apex of the prostate. Any additional bleeding after transection of the venous complex, should it occur, can be oversewn with the previously placed absorbable 2-0 suture. Alternatively, the DVC may be gathered at the apex of the prostate with a long Allis clamp. This technique may help to define the plane between the DVC and the anterior urethra more clearly. A figure-of-eight 2-0 absorbable suture can then be placed under direct vision anterior to the urethra and distal to the apex of the prostate around the gathered DVC. This maneuver not only affords secure vascular control but also avoids passage of instruments between the DVC and the rhabdosphincter that could potentially injure these structures and compromise the continence mechanism. Several patient-related characteristics reported in the literature predispose to greater estimated blood loss and a higher transfusion rate. Increased body mass index was

shown to correlate with a larger estimated blood loss in several retrospective analyses.18,19 In one analysis, body mass index was the only preoperative variable on a multivariate analysis to predict increased blood loss during radical cystectomy independently.18 Gender differences have been thought to affect transfusion requirements in patients undergoing radical cystectomy. One study found that the transfusion rate and the median number of units transfused were greater in women compared with men as a result of the rich lateral vascular pedicles unique to the female pelvis (cardinal and uterosacral ligaments).20 Controlled hypotensive anesthesia as a means to reduce blood loss in radical cystectomy has been studied and remains standard surgical practice in selected patients at our institution.21 At USC, the anesthesiologist titrates intravenous (IV) nitroglycerin to lower mean arterial pressure until the cystectomy specimen is removed, at which time the blood pressure is returned to normal range. Return to normotension facilitates identification of any bleeding vessels that may not have been identified or properly secured during the hypotensive period and thus allows further pelvic hemostasis. Despite obtaining secure vascular control during the intraoperative period, postoperative bleeding may occur that requires immediate return to the operating room.

Figure 41-1  Technique for isolation and ligation of the lateral pedicle. All anterior branches of the hypogastric vessels are isolated and divided between hemoclips down to the endopelvic fascia.

Figure 41-2  Technique for isolation and ligation of the posterior pedicle. The posterior pedicle is developed after entry into Denonvilliers’ space and, with a combination of blunt and sharp dissection, resembles a collar emanating from the lateral aspect of the rectum.

Chapter 41  Complications of Radical Cystectomy In our series of 1359 patients who underwent cystectomy, 11 patients (0.8%) experienced surgically related postoperative hemorrhage, 8 of whom (72%) required return to the operating room. We routinely place a large Hemovac drain in the pelvis to drain any blood for the first 24 hours postoperatively. An undrained pelvic hematoma may predispose to abscess formation, delayed return of bowel function, or disruption of urethralintestinal anastomoses in orthotopic neobladders.

Rectal Injury Rectal injury as a complication of radical cystectomy has potentially grave consequences if it is not recognized intraoperatively. Contemporary cystectomy series report an incidence of rectal injury ranging from 0.3% to 9.7%.4,5,14,15,16,22 Factors predisposing to intraoperative rectal injury include prior pelvic surgery, colonic inflammatory disease, extensive prior transurethral resection of a posterior bladder mass, direct extension of a posterior bladder mass into Denonvilliers’ space, and, most importantly, prior pelvic radiation therapy.22 Morbidity can be minimized by prospectively identifying those patients at increased risk and employing primarily sharp dissection of the posterior bladder off the anterior rectal wall in patients with an obliterated posterior plane. Furthermore, intraoperative recognition of a rectal injury, appropriate repair, adequate decompression of the injured rectum, establishment of sufficient pelvic drainage, and aggressive nutritional and antimicrobial support are all critical to prevent significant potential sequelae. The advent of preoperative bowel preparation in the 1970s led to numerous clinical trials that clearly demonstrated the decreased incidence of infectious postoperative complications in modern elective colorectal surgery.23 Proper bowel preparation is also important to minimize the infectious sequelae of rectal injury. A three-tier regimen is standard practice when performing surgical procedures in which breach of the distal intestinal tract is anticipated.23 This regimen includes the following steps:

120 mL of castor oil orally at 09.00 hours; 1 g of neomycin orally at 10.00, 11.00, 12.00, 13.00, 16.00, 20.00, and 24.00 hours; and 1 g of erythromycin base orally at 12.00, 16.00, 20.00, and 24.00 hours. We find that this regimen is generally well tolerated, it obviates the need for enemas, and it maintains nutritional and hydration support. Key to minimizing the risk of rectal injury is a sound understanding of the fascia layers between the bladder and the rectum. The anterior and posterior peritoneal reflections converge in the cul-de-sac to form Denonvilliers’ fascia, which further extends caudally to the urogenital diaphragm (Fig. 41-3). This important anatomic boundary in the male patient separates the prostate and seminal vesicles from the rectum posteriorly. The plane between the prostate and seminal vesicles and the anterior sheath of Denonvilliers’ fascia does not develop easily. However, the plane between the rectum and the posterior sheath of Denonvilliers’ fascia (Denonvilliers’ space) should develop easily with sharp and blunt dissection. Therefore, the peritoneal incision in the culde-sac should be made slightly on the rectal side, rather than on the bladder side. This technique facilitates proper and safe entry and development of Denonvilliers’ space. Occasionally, patients with an invasive posterior bladder tumor or those who have undergone

1. Preoperative mechanical cleansing to decrease the fecal load and facilitate the efficacy of the orally administered antibiotics 2. Preoperative oral antimicrobial bactericidal therapy targeting both aerobic and anaerobic organisms 3. Perioperative parenteral antimicrobial therapy All patients at our institution who are undergoing radical cystectomy are admitted the day before the procedure for antibacterial bowel preparation and IV hydration. A clear liquid diet may be consumed until midnight, at which time the patient is to consume nothing orally thereafter before the operation. A standard Nichols bowel preparation23 is given, as follows:

Figure 41-3  The peritoneal incision in the cul-de-sac (arrow) should be made slightly on the rectal side for safe entry into Denonvilliers’ space and should develop easily with sharp and blunt dissection. Knowledge of the fascial layers between the bladder and rectum facilitates the posterior dissection and minimizes the risk of rectal injury.

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Section VIII  Complications of Pelvic Surgery previous pelvic radiation therapy may have this plane obliterated, thus increasing the risk of rectal injury. Because most rectal injuries are created as a result of the shearing forces produced during blunt dissection of Denonvilliers’ space, patients with obliterated posterior planes necessitate entry into this space sharply. If rectal injury does occur, it is crucial that it be identified intraoperatively. Often a small rectal laceration can be missed, and in patients at high risk for rectal injury, diligent intraoperative inspection of the anterior and lateral rectal walls is essential. When visualization is inconclusive and rectal injury is suspected, delineation of the site of injury can be accomplished by insufflating the rectum with air while the pelvis is filled with fluid. Once rectal injury is identified, it should be closed in layers. In previous reviews, investigators had advocated that proctotomies be closed at the time of initial injury in three layers,24 although most literature currently considers a two-layer closure sufficient.25 A running absorbable suture is used to close the mucosa after the wound edges are débrided. Care should be taken to invert the mucosal edges into the bowel lumen when this layer is closed. The second layer of interrupted silk sutures in a Lembert fashion is used to complete the closure. If possible, the interposition of a greater omental apron is advised to discourage fistula formation,26 particularly if rectal injury occurred in the setting of orthotopic neobladder construction, in which fresh suture lines of the neobladder and urethral anastomosis are vulnerable. Diversion of the fecal stream by means of a sigmoid loop colostomy should be performed when the rectal defect is considerable, the contamination is great, or impaired healing from previous pelvic radiation or colonic inflammatory disease is expected.22

Venous Thromboembolism It lingers in the mind of every surgeon that after a dedicated intraoperative effort, acute pulmonary events developing from insidious venous clots may complicate the patient’s perioperative outcome. A wealth of information has been published regarding the cause, risk factors, treatment, and prevention of venous thromboembolism since Virchow first reported on the factors that predispose to thrombosis in 1856. Thromboembolism accounts for 1% to 4% of all perioperative complications reported in contemporary cystectomy series.4,5,14-16 Several risk factors have been identified that predispose patients to a higher incidence of venous thromboembolism than in the general population (Box 41-1). Indisputable evidence has accumulated in the form of randomized clinical trials to demonstrate the effect of primary thromboprophylaxis in the reduction of deep vein thrombosis (DVT), nonfatal pulmonary embolism, and fatal pulmonary embolism.27 To prevent such complications, it is common

BOX 41-1

Risk Factors for Venous Thromboembolism

Obesity Smoking Advanced age Previous venous thromboembolism Prolonged immobility/paresis Trauma (major or lower extremity) Central venous catheterization Estrogen-containing oral contraceptives Heart or respiratory failure Myeloproliferative disorders Acute medical illness Inherited or acquired thrombophilia

practice for surgical patients to be prescribed some form of thromboprophylaxis during their hospital stay. The evidence-based guidelines of the Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy reported that the absolute risk of DVT in hospitalized patients who undergo major urologic surgery (defined as open urologic procedures) and who receive no form of thromboprophylaxis is 15% to 40%.27 Additionally, the conference reported that the ratio between asymptomatic DVT and symptomatic thromboembolism is approximately 5 : 1 to 10 : 1. The conference thus recommended, based on strong evidence,28 that in patients undergoing major, open urologic procedures, routine prophylaxis with low-dose unfractionated heparin twice or three times daily is the preferred thromboprophylaxis regimen. Low-molecular-weight heparin or prophylaxis with intermittent pneumatic compressions or graduated compression stockings is an acceptable alternative. For patients with multiple risk factors, the conference recommended combining graduated compression stockings or intermittent pneumatic compressions with either low-dose unfractionated heparin or low-molecular-weight heparin. For those patients actively bleeding or at high risk of bleeding, the conference recommended the use of mechanical thromboprophylaxis with intermittent pneumatic compressions or graduated compression stockings at least until the bleeding decreases.27 Because most venous thromboembolic events are diagnosed several weeks after hospital discharge, the duration of thromboprophylactic therapy necessary to prevent thromboembolism while negligibly affecting the rate of hemorrhage in postoperative patients with cancer remains unclear. One study found that enoxaparin prophylaxis for 4 weeks after surgical treatment of abdominal or pelvic cancer was safe and significantly reduced the incidence of venographically demonstrated thrombosis, as compared with enoxaparin prophylaxis for 1 week.29 These limited data suggest that some form

Chapter 41  Complications of Radical Cystectomy of thromboprophylaxis for 1 month postoperatively may be important. At our institution, warfarin (Coumadin) and intermittent pneumatic compression devices are used as thromboprophylaxis in the postoperative hospitalization period for patients undergoing cystectomy. It has been our large experience that excellent prophylaxis of thromboembolic events with minimal effect on postoperative hemorrhage rates can be achieved with an initial warfarin load of 10  mg given through a gastrostomy tube immediately in the postanesthesia recovery unit, followed by daily administration of warfarin while monitoring the patients prothrombin time to keep within a range of 18 to 22 seconds. For patients who are particularly sensitive to warfarin, smaller doses are commonly used, and any dangerous elevation of the prothrombin time can be effectively and immediately reversed with the administration of IV vitamin K. As seen in Table 41-1, 25 of 1359 patients (1.8%) receiving radical cystectomy in our series developed pulmonary embolism at a mean of 20 days postoperatively. Sixteen percent of these embolisms proved fatal, a finding emphasizing the potential significance of this complication after major pelvic exenterative surgical treatment of malignant disease. In our experience, the rate of hemorrhage and the need for transfusion in patients receiving low-dose unfractionated heparin or low-molecular-weight heparin are greater compared with the use of warfarin, and as such, warfarin administration in the postoperative period as a means of thromboprophylaxis for the patient after radical cystectomy has been standard practice at USC.

Ileus Postoperative ileus is the prolonged delay in the coordinated movements of the gastrointestinal (GI) tract. This common complication of intra-abdominal surgery is often responsible for a lengthy hospital stay and significant perioperative morbidity. The following factors responsible for the pathogenesis of postoperative ileus have been elucidated: imbalances among the sympathetic, parasympathetic, and intrinsic nervous systems of the small intestine and colon; and the role of inflammatory mediators. Although a complete discussion of this extensive topic is beyond the scope of this chapter, the reader is referred to an excellent review for more detail regarding the origin and pathogenesis of postoperative ileus.30 Prolonged ileus after radical cystectomy is a common complication with an incidence ranging from 7% to 23% in several series.4,5,14-16,31 In one report, ileus was the most common complication resulting in a prolonged hospital stay following radical cystectomy.31 Chang and colleagues31 defined ileus as a delayed return of bowel function beyond postoperative day 4. As such, larger numbers of patients from their retrospective series were

regarded as having ileus compared with other series.31 The definition of ileus is debatable; however, the delay in recovery of coordinated intestinal movements from surgical trauma typically resolves after 3 to 4 postoperative days, with the colon the last of the intestinal segments to regain function.30 Because postoperative ileus prolongs hospital stay, and longer time spent in the hospital places patients at increased risk for nosocomially acquired infections and other complications, it seems prudent for physicians to tailor the standard perioperative care toward evidencebased strategies shown to help resolve postoperative ileus in the safest and most expeditious manner. Although ascertaining the best method of reducing the duration of postoperative ileus is difficult because much of the published literature is skewed by differences in study protocols, several general conclusions can be made. Some investigators recommend placement of a thoracic epidural catheter and the use of local anesthetic to reduce the possibility of a postoperative ileus.30 Epidural anesthesia with bupivacaine has been shown to be superior to systemic and epidural opioid with respect to reduction in postoperative ileus and without significantly affecting pain relief in patients undergoing abdominal surgical procedures.30 Limiting the use of IV opioids and supplementing narcotics with nonsteroidal anti-inflammatory drugs may also be helpful. In addition to reducing the total amount of narcotic use, the use of nonsteroidal anti-inflammatory drugs decreases the amount of local inflammatory mediators in the intestinal wall and may minimize the duration of postoperative ileus through this alternative mechanism as well.30 No prospective, randomized trials have validated the use of prokinetic agents, including erythromycin or metoclopramide, in the resolution of postoperative ileus. Cisapride did show promise in previous years, although the discovery of its arrhythmogenic effect as a consequence of its prolongation of the Q-T interval led to its current unavailability in the United States.30 Contrary to popular belief, early ambulation has no demonstrable effect in expediting the resolution of postoperative ileus. Early ambulation is to be encouraged, however, because it is beneficial primarily in the prevention of atelectasis, pneumonia, and deep vein thrombosis.30 Ileus that fails to resolve by the 10th to 14th postoperative day may warrant investigation into the cause. Correction of electrolyte imbalances, particularly hyponatremia, hypokalemia, and hypomagnesemia, which may occur in the perioperative period, is important to restore bowel function. A search for additional causes such as abscess from intestinal anastomotic or urine leak should also be considered. Bowel decompression is advised to prevent the sequelae of ileus including nausea, vomiting, abdomi-

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Section VIII  Complications of Pelvic Surgery nal distention, and pain. Poorly decompressed bowel in the setting of unresolved ileus may also cause significant fluid shifts and may potentially stress enteric anastomoses and predispose the patient to anastomotic leaks. Traditionally, nasogastric decompression was the method of choice in conservative management of postoperative ileus. In addition to the general discomfort associated with nasogastric tubes, more recent literature suggested that postoperative nasogastric intubation was the single most important variable associated with the development of postoperative pulmonary complications.32 It is therefore standard practice at USC to place an operative gastrostomy tube at the time of cystectomy in a modified Stamm fashion, in which greater omentum is interposed between the stomach and the abdominal wall, to facilitate resolution of postoperative ileus,33 without the need for a nasogastric tube.

Bowel Leak and Enterocutaneous Fistula The development of a bowel leak following radical cystectomy is a devastating complication associated with a significant morbidity and mortality. Up until the 1960s, the mortality rate of patients with GI fistulas was 43%.34 Although the advent of improved methods of critical care and artificial nutrition steadily decreased the mortality rate of postoperative bowel leaks, these complications continue to pose significant anxiety, discomfort, and negative self-image for patients during the course of disease and remain a considerable source of elevated hospital cost.34 The finding of fever, wound infection, and elevation of white blood cell count on the fifth to seventh postoperative day or a delayed return of bowel function persisting and temporally associated with these events should raise suspicion of an intra-abdominal abscess from a potential bowel leak or an unrecognized enterotomy. Patients are often extremely ill and may display signs of sepsis, including hypotension, tachycardia, and organ system failure requiring an intensive care setting. The finding of enteric contents from a surgically placed drain confirms the diagnosis. A computed tomography (CT) scan with water-soluble oral contrast material in those patients with no external evidence of fistula is prudent and typically reveals extravasation of contrast from the bowel lumen into an intra-abdominal or pelvic fluid collection. A CT scan is also necessary to rule out any distal intestinal obstruction that may have contributed to the formation of, and will invariably prevent the closure of, the enteric fistula. Once the complication is diagnosed, management of a bowel leak from an unrecognized enterotomy or breakdown of intestinal anastomosis is a clinical dilemma. Two schools of thought exist: emergency laparotomy and conservative management. The decision to choose one or the other is not always obvious given the lack of clear evidence-based guidelines in dealing

with this complication. The decision to begin a trial of conservative management largely depends on the presence or absence of peritonitis or sepsis.35 If drainage is adequate, or if the patient has a controlled fistula and in the absence of clinical peritonitis or multiple intraabdominal abscesses refractory to percutaneous drainage, a trial of conservative management is warranted.35 Maximal drainage of any intra-abdominal or pelvic fluid collections from radiographically placed drains is mandatory to treat the septic patient. Every attempt to control intra-abdominal infection aggressively is essential because the major cause of death in this group of patients is sepsis, which is the result of a neglected or undrained intra-abdominal or pelvic abscess.36 The abdominal incision, if displaying signs of infection, should be opened and left to heal by second intention. Cultures should be obtained and broad-spectrum antibiotic therapy should be employed and tailored to microbial sensitivity. The patient should be made to take nothing by mouth. Proximal decompression and drainage by means of a nasogastric or gastrostomy tube should be begun, and hyperalimentation should be instituted. Total parenteral nutrition is classically indicated in patients with enterocutaneous fistulas. Total parenteral nutrition has been shown to increase the spontaneous closure rate by inducing bowel hypoactivity and to provide better nutritional preparation of the patient for reoperation after a defined period of nutritional support if the fistula fails to close spontaneously.37 Data regarding the use of somatostatin analogues in the conservative management of enterocutaneous fistula are debatable. Although somatostatin and its analogues have been shown to decrease fistula output thus make it easier to manage fluid, electrolytes, and protein imbalances, the therapeutic advantage with regard to reducing the time to fistula closure has not been consistently shown in clinical trials.38-41 Despite attention to detail and patience, with conservative treatment, only 50% of postoperative bowel fistulas close spontaneously in ≤4 to 6 weeks in the absence of distal obstruction or the loss of bowel continuity. If nutritionally anabolic and free of sepsis, the remainder of patients usually respond favorably to elective reoperation to repair the fistula and restore intestinal continuity.35 Reoperation is best delayed for at least 3 to 4 months postoperatively. The decision to perform acute emergency laparotomy is warranted in patients displaying peritonitis or signs of sepsis with proven or suspected intraperitoneal abscesses that are not amenable to percutaneous drainage or in which percutaneous drainage has failed.35 The goal of laparotomy is to cleanse the abdominal cavity and pelvis of any loculated abscesses by using copious irrigation, to provide adequate drainage of the pelvis and peritoneum by means of surgically placed drains, and to control the source of contaminating infection,

Chapter 41  Complications of Radical Cystectomy typically through the creation of a proximal enterostomy, irrespective of the level of injury.35 It may be possible to resect the affected bowel segment and primarily reanastomose it in a patient who presents with a fistula within the first 2 postoperative days. These occurrences are usually the result of technical error and may afford a cure in a minimally compromised patient with insignificant peritonitis and a normal serum albumin concentration.35 However, intestinal diversion should be performed if the quality of bowel is suspect or if the patient has a history of radiation therapy, because primary repair often fails in these patients. Strict attention to surgical detail during intestinal anastomosis is crucial to avoid the development of an enterocutaneous fistula. At our institution, a traditional two-layered, hand-sewn, interrupted, end-to-end anastomosis using a series of 3-0 silk sutures is performed to reestablish intestinal continuity after the appropriate segment of bowel is gathered to form the urinary reservoir. Adequate exposure to the anastomosing segments, maintenance of excellent blood supply to the severed ends, avoidance of local spillage of enteric contents that may facilitate a focal septic environment, accurate serosa-to-serosa apposition, and avoidance of tissue strangulation by sutures tied too tightly are all important details that, when methodically followed, allow for successful intestinal anastomosis.42

Lymphocele Numerous studies emphasized the importance of pelvic lymph node dissection during cystectomy for invasive bladder cancer. Most of these investigators advocated lymph node dissection not only as a staging procedure but also as an integral part of the curative intent of radical surgery for invasive bladder cancer.43-45 Although most patients undergoing radical cystectomy are elderly and have significant comorbidities, proper lymphadenectomy may still be beneficial. Studies have shown that removing more lymph nodes increased survival in patients with node-negative as well as nodepositive bladder cancer.46-48 However, opinion continues to be divided on the extent of the lymphadenectomy and the minimum number of nodes that should be removed. The incidence of lymphocele with limited or extended lymph node dissection is 1% to 4%, according to major published series.44,49 Most of these cases can be managed expectantly. In the USC series with extended lymphadenectomy, only two patients required percutaneous CT-guided drainage of the lymph collection, and this maneuver promptly resolved the problem in both cases. In another study, Brossner and colleagues45 reported the events during and after radical cystectomy in a series of 92 consecutive patients, in terms of major and minor complications, and compared minimal and extended lymphadenectomy procedures. These investi-

gators found that extended lymphadenectomy in patients undergoing radical cystectomy did not increase morbidity within 30 days of the surgical procedure. We believe that extended lymphadenectomy causes no significant increase in complications during and after the procedure.

Wound Infection and Fascial Dehiscence Surgical site infections and wound and tissue dehiscence are well-known postoperative complications in GI and urologic surgery. The severity of these complications ranges from mild cases needing local wound care and antibiotics to serious cases with multiple reoperations and a high mortality rate. Usually, infectious complications prolong hospitalization, with a substantial increase in cost of care.50,51 The incidence of wound infection and fascial dehiscence after radical cystectomy in reported series is 3% to 6% and 1% to 3%, respectively.4,5,14-16 Several patientrelated characteristics increase the risk of wound infection and fascial dehiscence in major abdominal operations. Extensive prior smoking history, diabetes mellitus, and cardiopulmonary disease are associated with increased risk of surgical site infections and abdominal wall dehiscence52-57 by a variety of proposed mechanisms. Smoking, microvascular disease as a result of long-standing diabetes mellitus, and severe lung disease are known causes of peripheral tissue hypoxia,58,59 which increases the risk of wound infection and dehiscence.60 In addition, some studies suggest that hypoxia, smoking, and diabetes reduce collagen synthesis and oxidative killing mechanisms of neutrophils,61-65 with resulting impairment of wound healing. The association between elevated perioperative blood loss and postoperative tissue and wound complications in elective operations suggests that hypovolemia and reduction of tissue oxygenation by loss of red blood cells are also detrimental to healing and increase the risk of infection and tissue dehiscence.66-71 Disruption of the local vascular supply, thrombosis of vessels, and tissue hypoxia are common to all tissues subject to surgical intervention.72 Once the blood supply is restored, several factors may further complicate healing. The most important seems to be proliferation of bacteria in the wound and tissue that affects the processes involved in wound healing and increases the risk of wound infection and dehiscence. Fascial dehiscence is invariably associated with previous wound infection,73 and it represents a serious postoperative problem that often necessitates immediate operative exploration and repair. Occasionally, in the case of minor fascial separation, it may be possible to delay immediate repair for several months in the absence of frank evisceration or incarceration of bowel. However, immediate return to the operating room is usually mandatory in patients with evisceration or obstruction.

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Section VIII  Complications of Pelvic Surgery

URETHRAL AND VAGINAL PRESERVATION IN CYSTECTOMY As patients are living longer and with higher expectations, quality of life issues are becoming more important factors in patients undergoing radical cystectomy. These issues should not, however, override the need for providing sound oncologic surgical extirpation. Orthotopic diversion most closely resembles the original bladder in its location and functional characteristics. Advances in surgical technique have obviated the need for external appliances and cutaneous stomas in appropriately selected patients and have made volitional voiding possible. The ideal reservoir should fulfill five criteria: 1. Maintenance of a large capacity 2. Low filling pressures 3. Protection of the upper urinary tracts 4. Relatively nonabsorptive surface area 5. Allowance for continent volitional voiding Orthotopic diversion currently represents the procedure of choice in the properly selected patient undergoing cystectomy. Currently, >90% of male and female patients at USC undergo orthotopic lower urinary tract reconstruction.74-76 With the advent of orthotopic urinary diversion, preservation of the rhabdosphincteric continence mechanism has become the most important functional goal in the surgical management of the patient undergoing cystectomy; second only to the complete extirpation of the malignant disease. Based on the neuroanatomic studies of Walsh and Donker80 and others during the early 1980s, and through steady refinement in the surgical techniques applied to radical retropubic prostatectomy,77-80 the importance of the external striated urethral sphincteric complex in maintaining continence has become evident in those patients undergoing enterourethral anastomosis following radical cystectomy. Preservation of the rhabdosphincter and its pudendal innervation is critical in allowing the return of continence.81 Precise neuroanatomic and histologic studies of the pelvis and urethra have provided a better understanding of the rhabdoid sphincter and a rational basis for continence preservation in radical pelvic surgery.81-83 Proper knowledge and preservation of the anatomic configuration of the rhabdosphincter muscle and its pudendal nerve supply81,82 following cystectomy should provide continence and volitional voiding. Attention to anatomic details and meticulous surgical technique are of the utmost importance to optimize functional and clinical outcomes. Overall, daytime continence rates of ≥80% have been reported in most large series with orthotopic reconstruction.9,74-76,84

Minimal manipulation of the external striated urethral sphincteric complex (the muscle fibers of the rhabdosphincter and its fascial attachments) and of its innervation is essential in providing optimal urinary continence.76,79,81,83 The pudendal nerve provides somatic innervation to the rhabdosphincter and enters this muscle in the perineum through the perineal nerve and from the pelvis by way of the intrapelvic branch of the pudendal nerve.79,81 Branches of the pudendal nerve that run along the pelvic floor below the endopelvic fascia ultimately innervate the rhabdosphincter. Therefore, minimal dissection should be performed along the pelvic floor levator musculature to avoid injury to the rhabdosphincter innervation. Our experience with the orthotopic ileal neobladder has demonstrated excellent long-term continence rates.74-76,84 More than 85% of male patients rated their continence as good or satisfactory during the day and night. However, as with other orthotopic diversions, more patients (≈20%) achieved better continence during the day than during the night. The ultimate level of daytime and nighttime continence was achieved by 1 year postoperatively in 89% and 85% of the male patients, respectively. In general, younger patients tended to fare better than did older patients. Over an 8-year study period, only 2.7% of patients required an artificial urinary sphincter secondary to unsatis­ factory continence following orthotopic bladder replacement.75,84 Since 1990, the USC group has also been committed to providing orthotopic lower urinary tract reconstruction in appropriately selected female patients.9,76,85,86 In fact, many of the early neuroanatomic studies demonstrating the pudendal innervation to the rhabdosphincter complex were generated from female cadaveric dissections.82,83 In our series of women undergoing orthotopic diversion, complete daytime continence was reported by 85% of patients, with nighttime continence rates reported by 82%. Eighty-five percent voided to completion, whereas the initial results suggested that 15% required some form of intermittent catheterization.76 With longer follow-up, it appears that 30% to 40% of women will require some form of intermittent catheterization to empty their neobladder.

Continence-preserving Technique Several technical issues should be considered intraoperatively to help achieve maximum continence in both men and women who require radical cystectomy and orthotopic urinary diversion. Attention to surgical detail is most important and deserves special mention.

Anterior Apical Dissection in the Male Patient The technique of bilateral pelvic lymphadenectomy with radical cystoprostatectomy has been previously

Chapter 41  Complications of Radical Cystectomy

Figure 41-4  One technique for ligation of the dorsal venous complex. An angled clamp is passed beneath the dorsal venous complex, anterior to the urethra. The venous complex can then be ligated with a 2-0 absorbable suture and divided close to the apex of the prostate. If any bleeding occurs from the transected venous complex, it can be oversewn with an absorbable (2-0 polyglycolic acid) suture.

reported.87 Urethral preparation with preservation of the continence mechanism is of critical importance when orthotopic diversion is anticipated in men. Only after the cystectomy specimen is completely freed and mobile posteriorly is attention directed anteriorly to the urethra. All fibroareolar connections among the anterior bladder wall, the prostate, and the undersurface of the pubic symphysis are divided. The endopelvic fascia is incised adjacent to the prostate, and the levator muscles are carefully swept off the lateral and apical portions of the prostate. The superficial dorsal vein is identified, ligated, and divided. With tension placed posteriorly on the prostate, the puboprostatic ligaments are identified and are slightly divided just beneath the pubis and lateral to the DVC that courses in between these ligaments. Care should be taken to avoid any extensive dissection in this region. The puboprostatic ligaments should be incised only enough to allow for proper apical dissection of the prostate. The apex of the prostate and membranous urethra now become palpable. Several methods can be performed to control the DVC properly, as previously described (see the earlier section on hemorrhage). A more illustrative description

Figure 41-5  Technique of gathering the dorsal venous complex at the apex of the prostate with a long Allis clamp. A figure-of-eight 2-0 absorbable suture can then be placed under direct vision anterior to the urethra (distal to the apex of the prostate) around the gathered venous complex. This suture is best placed while the surgeon faces the head of the table and holds the needle driver perpendicular to the patient. This maneuver avoids the unnecessary passage of instruments between the dorsal venous complex and the rhabdosphincter that could potentially injure these structures and compromise the continence mechanism.

follows. One may carefully pass an angled clamp beneath the DVC, anterior to the urethra (Fig. 41-4). The venous complex can then be ligated with a 2-0 absorbable suture and divided close to the apex of the prostate. If any bleeding occurs from the transected venous complex, it can be oversewn with an absorbable (2-0 polyglycolic acid) suture. In a slightly different fashion, the DVC may be gathered at the apex of the prostate with a long Allis clamp. A figure-of-eight 2-0 absorbable suture can then be placed under direct vision anterior to the urethra (distal to the apex of the prostate) around the gathered venous complex (Fig. 41-5). This suture is best placed while the surgeon faces the head of the table and holds the needle driver perpendicular to the patient. The suture is then tagged with a hemostat. This maneuver avoids the unnecessary passage of any instruments between the DVC and the rhabdosphincter that could potentially injure these structures and compromise the continence mechanism. After the complex has been ligated, it can be sharply divided with excellent exposure to the anterior surface

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Section VIII  Complications of Pelvic Surgery

Figure 41-6  Suspending the venous complex anteriorly to the periosteum helps reestablish anterior fixation of the dorsal venous complex and puboprostatic ligaments and may enhance continence recovery.

Figure 41-7  When the posterior pedicles are developed in women, the posterior vagina is incised at the apex, just distal to the cervix.

of the urethra. Once the venous complex has been severed, the suture can be used to secure the complex further. The suture is then used to suspend the DVC anteriorly to the periosteum to help reestablish anterior fixation of the DVC and puboprostatic ligaments (Fig. 41-6). This technique may enhance continence recovery. The anterior urethra is now exposed. Regardless of the technique, the urethra is then incised 270 degrees just beyond the apex of the prostate. A series of 2-0 polyglycolic acid sutures is placed in the urethra circumferentially, with careful incorporation of only the mucosa and submucosa of the striated urethral sphincter muscle anteriorly. The urethral catheter is clamped and divided distally. Two sutures are placed that should incorporate the rectourethralis muscle posteriorly or the caudal extent of Denonvilliers’ fascia. Next, the posterior urethra is divided and the specimen is removed. Frozen section analysis of the distal urethral margin of the cystectomy specimen is then performed to exclude tumor involvement.

the cervix (Fig. 41-7). This incision is carried anteriorly along the lateral and anterior vaginal wall to form a circumferential division. The anterolateral vaginal wall is then grasped with a curved Kocher clamp. This maneuver provides countertraction and facilitates dissection between the anterior vaginal wall and the bladder specimen. Careful dissection of the proper plane prevents entry into the posterior bladder and reduces the amount of bleeding in this vascular area. Development of this posterior plane and vascular pedicle is best performed sharply with the use of hemoclips and is carried just distal to the vesicourethral junction. Palpation of the Foley catheter balloon assists in identifying this region. This dissection should effectively maintain a functional anterior vaginal wall (Fig. 41-8). Furthermore, an intact anterior vaginal wall helps support the proximal urethra through a complex musculofascial support system that extends from the pelvic floor, which may be an important component to the continence mechanism in these women. Alternatively, in the case of a deeply invasive posterior bladder tumor with concern of an adequate surgical margin, the anterior vaginal wall should be removed en bloc with the cystectomy specimen. After dividing the posterior vaginal apex, the lateral vaginal wall subsequently serves as the posterior pedicle and is divided

Anterior Dissection in the Female Patient When considering orthotopic diversion in female patients, several technical issues are critical to maintain the continence mechanism. When the posterior pedicles are developed in women, the posterior vagina is incised at the apex, just distal to

Chapter 41  Complications of Radical Cystectomy

Figure 41-8  A Kocher clamp provides countertraction and facilitates dissection and preservation of a functional anterior vaginal wall.

Figure 41-9  Vaginal reconstruction by a clam-shell technique and placement of urethral sutures after the cystectomy specimen is removed.

distally. This maneuver leaves the anterior vaginal wall attached to the posterior bladder specimen. Again, the Foley catheter balloon facilitates identification of the vesicourethral junction. The surgical plane between the vesicourethral junction and the anterior vaginal wall is then developed distally at this location. A 1-cm length of proximal urethra is mobilized while the remaining distal urethra is left intact with the anterior vaginal wall. Vaginal reconstruction by a clam-shell (horizontal) or side-to-side (vertical) technique is required. Other means of vaginal reconstruction may include a rectus myocutaneous flap, detubularized cylinder of ileum, a peritoneal flap, or an omental flap. When the posterior dissection is completed (ensuring dissection just distal to the vesicourethral junction), a Satinsky vascular clamp is placed across the bladder neck to prevent any tumor spill from the bladder. With gentle traction, the proximal urethra is completely divided anteriorly, distal to the bladder neck and clamp, and the specimen is removed. The female urethra is positioned in a more anterior position than in men, and this position facilitates placement of 8 to 10 urethral sutures after the specimen is removed (Fig. 41-9). Frozen section analysis is performed on the distal margin of the cystectomy specimen to exclude tumor. If the anterior vaginal wall has been preserved, the vagina is then closed at the apex in two layers. In the past, the vagina was suspended to Cooper’s ligament

to prevent vaginal prolapse or the development of an enterocele postoperatively. Currently, we perform a colposacropexy incorporating Marlex mesh, which fixates the vagina to the sacrum without angulation or undue tension. Regardless of the form of vaginal reconstruction, a well-vascularized omental pedicle graft is placed between the reconstructed vagina and the neobladder and is secured to the levator ani muscles to separate the suture lines and prevent fistulization (Fig. 41-10). As in men, no dissection should be performed anterior to the urethra along the pelvic floor in women considering orthotopic diversion. This technique prevents injury to the rhabdosphincter region and corresponding innervation. Some reports suggest that a sympathetic nerve-sparing cystectomy is important in maintaining continence in these women. We routinely sacrifice the autonomic nerves coursing along the lateral aspect of the uterus and vagina and rely successfully on the pudendal innervation of the rhabdosphincter region for maintenance of continence. Fluorodynamic studies in women undergoing orthotopic diversion have also identified the rhabdosphincter region as the area that provides the continence mechanism in these women. It is possible that preservation of the sympathetic nerves may contribute to the high incidence of hypercontinence and urinary retention requiring continuous intermittent catheterization reported by Hautmann and associates.88

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Section VIII  Complications of Pelvic Surgery

Figure 41-10  Greater omental apron interposed as a bed on which the neobladder will reside. This vascular tissue acts as a barrier to discourage fistula formation between vulnerable suture lines of the neobladder and the reconstructed vagina.

COMPLICATIONS OF CYSTECTOMY AFTER RADIATION THERAPY AND TOTAL PELVIC EXENTERATION Total pelvic exenteration has historically been associated with a high incidence of perioperative complications, with rates ranging from 32% to 84%.89-96 This patient population has the additional disadvantage of often having undergone high doses of preoperative radiation to the pelvic area, thus creating unique physiologic and pathologic changes to the pelvic organs and increasing the perioperative complication rate. The complications seen with total pelvic exenteration were reviewed by Pearlman,97 who found that complication rates varied between 30% and 70%, whereas Soper and associates91 reported a reoperation rate of 26%. In a more recent series, overall morbidity was 28% with a reoperation rate of 18%. In this report, the incidence of bowel obstruction and fistula formation was 3% for both, significantly lower than 8% and 19%, respectively, reported by others.99 These differences may be related to the use of omentum or pedicled muscle transposed into the pelvis required to repair the pelvic floor, to fill the dead space, and to separate suture lines. The incidence of complications appears to be lessened by the transposition of nonirradiated tissue into the pelvis.100 In one study,95 45% of patients required at least one readmission to the hospital, and 32% required addi-

tional operative procedures. The most common complications associated with exenteration in this study included wound or pelvic complications, GI or genitourinary fistulas, and small bowel obstruction. Although many complications after this surgical procedure may be considered minor, major complications are not infrequent. Specifically, serious infections of the wound or pelvis and problems with the urinary conduit are the most common major perioperative complications.101-105 Considerable variations have been reported in the rates for both short-term and long-term complications of the urinary conduit.106-110 Early complications can occur in ≤10% of patients and usually involve problems with the urinary enteric anastomosis, such as leaks and obstruction. Most leaks can be managed conservatively with prolonged conduit drainage and, if needed, proximal diversion of the urine stream with percu­ taneous nephrostomy tubes. Late urinary complications include stenoses and fistulas, which have been reported to develop in ≤16% of patients.111 Major complications involving the urinary and GI tracts do correlate with prior exposure to radiation therapy.101-104 In one series,100 67% of patients who had undergone radiation therapy developed postoperative complications, compared with 26% of those who had not had prior irradiation. The perioperative mortality rate for patients having undergone total pelvic exenteration ranges from 0% to 18%.112-114 The markedly different early mortality rates may reflect surgical expertise concentrated into experienced consultant-led operative teams, careful patient selection, improved postoperative care, and antibiotic and thromboembolic prophylaxis. These reasons have been suggested to be predominantly responsible for the reduced perioperative mortality rate (from 18% to 8% over a 50-year period) and an overall complication rate in one series.112 Simultaneous pelvic reconstruction following surgical extirpation is increasingly popular among highvolume surgical oncology centers.115-118 In this manner, the patient is afforded the opportunity to have these procedures done concurrent with the extirpative portion of the procedure. The creation of a neovagina, urinary diversion, and functional low colon can be performed with acceptable morbidity and gives the patient the opportunity for better organ function following this extensive extirpative surgery.119-125 Since the late 1980s, many surgeons have transitioned to continent urinary diversion as a means of lower urinary tract reconstruction following total pelvic exenteration without an appreciable increase in morbidity.126-127 The rectus abdominis flap is increasingly used for vaginal reconstruction following pelvic exenteration. It is technically easy to harvest and results in an excellent neovagina with a more suitable vaginal

Chapter 41  Complications of Radical Cystectomy caliber.125 Low colon reanastomosis is routinely performed and more recently our institution has used the J-pouch to increase the likelihood of anorectal continence.118 Considerable morbidity may be associated with the resultant large, empty pelvic dead space left after pelvic exenteration. The pelvic dead space predisposes patients to abscesses, fistula formation, perineal wound problems, and intestinal obstruction. Thus it is prudent to fill this space with omentum or other autologous tissue. Many groups use myocutaneous flaps to fill the pelvic dead space after pelvic exenteration, especially in patients who have previously undergone irradiation. The advantages of myocutaneous flap reconstruction in the irradiated pelvis and perineal wound include reduction of dead space, interposition of well-vascularized, nonirradiated tissue, and replacement of resected skin.125 The use of myocutaneous flaps, such as those based on the rectus abdominis, gracilis, and gluteus maximus muscles, have provided excellent results.120,121 In the setting of prior pelvic radiation, continent urinary reservoirs may also be predisposed to complications. Previously, sigmoid, ileum, and transverse colon were widely used for urinary diversion in the setting of prior pelvic radiation.105,126-128 Each technique had advantages in terms of capacity and ability to avoid using radiated bowel segments; however, reported disadvantages included sustained incontinence and the incidence of ureterointestinal complications. Wammack and associates128 prospectively compared operative outcomes in a series of 36 irradiated patients and 385 nonradiated patients who underwent continent urinary reservoir formation with either a Mainz I pouch, using the appendix to form the continence mechanism, or an ileal intussuscepted nipple valve (Indiana pouch). Of the 36 radiated patients, 31 (86%) developed a pouch-related complication, whereas 88 (23%) of the 385 nonradiated patients developed complications. In this series, pouch-related complications were defined as failure of the continence mechanism, ureterointestinal stricture, leakage, or fistula and stomal stenosis. Overall, a fourfold increase in complications was observed in the radiated patients. Wilson and associates105 observed a similar increased risk of complications in radiated patients and reported a fivefold increase in

complications related to the ureterointestinal anastomosis in radiated compared with nonirradiated patients undergoing Indiana pouch reconstruction. It is apparent that complications after total pelvic exenteration are significant, particularly in patients who received prior pelvic radiation therapy. Given that urinary and bowel complications after such surgical procedures can often become demoralizing to patients with newly diagnosed malignant, if not fatal, disease, concentration is imperative on surgical detail in this patient population.

CONCLUSION Radical cystectomy has become standard treatment and arguably the best definitive form of therapy for highgrade, invasive bladder cancer. Lower urinary tract reconstruction, particularly orthotopic diversion, has been a major component in enhancing the quality of life of patients requiring cystectomy. As with any major surgical procedure, however, complications do occur. It is important for all surgeons to be familiar with the presentation, prevention, and treatment of the major causes of morbidity and mortality associated with radical cystectomy and lower urinary tract reconstruction. The complications discussed are among the most common associated with cystectomy. In fact, many other complications may be encountered, as the published literature testifies, and a thorough understanding of their presentation, prevention, and treatment is equally essential for a successful patient outcome. A sound understanding of surgical anatomy and adherence to proper surgical technique, familiarization with recent data regarding the most successful treatment methods, and attention to detail in the perioperative period are crucial for minimizing complications in any surgical undertaking.

ACKNOWLEDGMENT Dr. Stein, You will always be in my mind, my heart, and my hands. Thank you, John. EAP

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KEY POINTS 1. Cardiovascular events are the leading causes of mortality in patients immediately after cystectomy. 2. A sound understanding of pelvic anatomy and adherence to proper surgical technique remain the cornerstones in preventing significant bleeding in intraoperative and delayed settings. 3. Key to minimizing the risk of rectal injury is a sound understanding of the fascia layers between the bladder and rectum and the use of sharp dissection in the posterior plane in those patients at high risk for rectal injury. Furthermore, adequate bowel preparation, intraoperative recognition, appropriate repair, adequate decompression of the injured rectum, establishment of sufficient pelvic drainage, and aggressive nutritional and antimicrobial support are all critical to prevent possible significant sequelae from rectal injuries. 4. Routine thromboprophylaxis is imperative to prevent development of deep vein thrombosis after major open urologic surgical procedures. 5. Ileus is the most common complication resulting in a prolonged hospital stay in patients undergoing radical cystectomy. Ileus that fails to resolve by postoperative day 10 to 14 warrants investigation into its cause. 6. The decision to perform acute emergency laparotomy is warranted in the patient with a documented bowel leak who has peritonitis or signs of sepsis with proven or suspected intraperitoneal abscesses that are not amenable to percutaneous drainage or in which percutaneous drainage has failed. Conservative management

REFERENCES Please see www.expertconsult.com

with hyperalimentation may be attempted in controlled fistulous settings. Fistulas that fail to close after approximately 4 months of conservative therapy require surgical correction. 7. Lymphocele is a rare complication of radical cystectomy that usually can be managed conservatively. 8. Fascial dehiscence is invariably associated with previous wound infection and, when associated with evisceration, represents a serious postoperative problem that often necessitates immediate operative exploration and repair. 9. Preservation of the rhabdosphincter and its pudendal innervation is critical in allowing the return of continence after radical cystectomy and neobladder reconstruction. 10. Careful radiographic surveillance of the upper urinary tracts of patients with ureteroenteric anastomoses is essential to identify ureterointestinal anastomotic strictures early and to preserve kidney function. 11. Endoscopic methods of reservoir stone removal are highly effective and minimally invasive. 12. All surgeons need to be familiar with the presentation, prevention, and treatment of the major causes of morbidity and mortality associated with radical cystectomy and lower urinary tract reconstruction. A sound understanding of the surgical anatomy, adherence to proper surgical technique, familiarization with recent data regarding the most successful treatment methods, and attention to detail in the perioperative period are crucial for minimizing complications in any surgical undertaking.

Chapter 

42

COMPLICATIONS OF SIMPLE PROSTATECTOMY William J. Ellis

MD Professor, Department of Urology, University of Washington, Seattle, Washington

Jonathan L. Wright

MD, MS Assistant Professor, Department of Urology, University of Washington, Seattle, Washington

Open prostatectomy was once the primary treatment for symptomatic benign prostatic hyperplasia (BPH). However, with the advent of minimally invasive procedures and the development of medical therapies, the use of open prostatectomy significantly declined. Currently, interest is growing in the role of transurethral holmium laser enucleation of the prostate as a treatment alternative to open prostatectomy for large glands.1 Although infrequently performed in the United States, open prostatectomy continues to be extensively performed in other countries where resources limit the medical and endoscopic options available to patients and providers.2-4 A retrospective review in of surgical therapy for BPH performed in 1992 compared with 2002 in Spain found that although the overall rate of surgical intervention declined by 18%, the proportion of open prostatectomies performed increased.5 Clear indications for open prostatectomy still remain, but with surgeons’ decreasing familiarity with the procedure, the need to understand and recognize the complications of this procedure becomes even more important.

INDICATIONS Open prostatectomy may be performed in prostate glands >80 to 100 g6 when the presence of other disease requires an open surgical procedure and when the patient’s anatomic features preclude appropriate positioning for endoscopic resection. Prostate glands >200 g may be efficiently enucleated with the open approach, and complication rates are low. Open prostatectomy should be considered in patients with bladder calculi or bladder diverticula that may be dealt with through an open approach. Certain anatomic factors favor open prostatectomy: severe hip or knee contractures, penile prostheses, and ureteral orifices in close proximity to the bladder neck where endoscopic visualization is limited. Patients with a penile prosthesis, particularly a

semirigid prosthesis, may require perineal urethrostomy for endoscopic resection.

SURGICAL APPROACH The suprapubic and retropubic approaches are both employed for open prostatectomy. The perineal approach is rarely used today. Surgeons are gaining increasing experience with the laparoscopic approach.7,8 The surgical techniques are well described elsewhere, and this chapter highlights procedural details as they relate to specific complications. Briefly, the suprapubic approach involves adenoma enucleation from within the bladder by using an anterior cystotomy. This approach is often preferred when large bladder calculi or bladder diverticula must be repaired. The retropubic technique achieves enucleation through an anterior prostatic capsulotomy. The laparoscopic approach is performed extraperitoneally, and both open suprapubic and retropubic techniques described earlier can be performed.8

EARLY COMPLICATIONS Hemorrhage Widely ranging significant perioperative bleeding events have been recorded, with an incidence of 0% to 35%.9 Much of the variability may result from transfusion thresholds, autologous blood banking, reporting, and experience of the surgeon. Large European series reported transfusion rates of 6% to 8%.10-12 In another series of 56 patients, 36% received blood transfusions, but 80% of those patients received autologous blood for which the transfusion threshold was likely lower.13 The second half of a Nigerian study of 240 patients showed marked decreases in clot retention and transfusion rates related to experience of the surgeon.4 497

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Section VIII  Complications of Pelvic Surgery Several surgical techniques to control intraoperative bleeding have been described. In the 1940s, Rolnick14 advocated packing the prostatic fossa with gauze for ≥5 minutes after enucleation. Even today, this technique remains the standard for initial efforts at hemostasis.15 After removing the packing, hemostatic sutures at the 5- and 7-o’clock positions incorporating the bladder mucosa, bladder neck, and prostatic capsule in a figureof-eight fashion usually provide adequate hemostasis. If persistent hemorrhage is present, several additional maneuvers are available. Hemostatic agents (e.g., oxidized cellulose [Surgicel]) may be placed in the fossa along with temporary packing to assist in achieving hemostasis. To facilitate capsular contraction and tamponade, Shaikh and Malament16 described placing an absorbable pursestring stitch at the bladder neck. The O’Conor stitch is an absorbable placating stitch placed in the posterior capsule that similarly provides capsular tamponade17 (Fig. 42-1). Other investigators have described placing a nonabsorbable pursestring stitch that is brought out through the abdominal wall and is removed in 24 to 48 hours.18,19 Some investigators emphasize the importance of obtaining hemostasis before capsulotomy during the retropubic approach with ligation of the dorsal venous complex with 0-chromic ligature.20 Exposure of the dorsal vein is accomplished by releasing the puboprostatic ligaments, incising the endopelvic fascia, and passing a right-angle clamp between the dorsal vein and the urethra. Alternatively, the dorsal vein may be ligated with figure-of-eight 2-0 chromic sutures without incision of the endopelvic fascia. Next, the lateral vascular pedicles are ligated with sutures placed at the posterolateral edges of the prostate. Studies have highlighted the importance of these lateral sutures in limiting intra-

operative hemorrhage.21 This concept of early vascular control has been extended by some investigators to include clamping of the internal iliac arteries.22 Once these maneuvers are complete, capsulotomy is performed in what should be a relatively bloodless field. Retropubic enucleation of small glands may result in tearing of the lateral edges of the capsulotomy with a finger and subsequent hemorrhage, which can be avoided by performing adequately sized capsulotomy. Clot retention is prevented with continuous bladder irrigation through a 22- or 24-Fr three-way catheter or by a suprapubic tube catheter through the dome of the bladder and a two-way catheter draining the bladder through the urethra. A large-diameter outflow port is crucial to allow for clot evacuation. A 30-mL balloon is used on the Foley catheter with a general rule of 1 mL of fluid for each gram of adenoma removed. Venous bleeding can be further controlled postoperatively by placing traction on the urethral catheter to provide tamponade. Only light traction is required for adequate tamponade; tight traction increases bladder spasms. Arterial bleeding cannot be controlled well with traction and may require reoperation. Some large series reported reoperative rates for bleeding of 1% to 3.7%.2,4,10,11 Most arterial bleeding can be endoscopically fulgurated. Selective angioembolization or hypogastric artery embolization is rarely required. Delayed bleeding (>2 weeks postoperatively) is rare and should be managed initially with bladder irrigation, Foley catheter traction, and reoperation if needed.

Infection Infections after open prostatectomy include urinary tract infection, epididymitis, and wound infections. The rate of urinary tract infection or epididymitis following open prostatectomy is comparable to the rate after minimally invasive procedures (median, 8%; range, 3% to 17%).6 Patients at risk include those with long-term indwelling Foley catheters, chronic urinary tract infections, or a history of epidiymitis.23 Graham and Grayhack23 recommended that prophylactic vasectomy be performed before open prostatectomy in high-risk patients, but this recommendation has not been critically studied and is not routinely followed. Wound infections are specific to open surgical techniques and have been reported to occur in 2.5% to 4.3%.2,4,9,12 Preoperative urine cultures and perioperative antibiotics should be given to all patients undergoing open prostatectomy.

Incontinence Figure 42-1  Capsule placating sutures as described by O’Conor. Two sutures are placed in the posterior fossa to aid in prostatic contraction. (From O’Conor VJ Jr. An aid for hemostasis in open prostatectomy: capsular placation. J Urol. 1982;127[3]:448.)

Urinary incontinence after open prostatectomy may be urge, stress, or mixed. In a survey analysis of 1804 open prostatectomies in Italy, reported rates of early and late urinary incontinence were 3.7% and 1.2%, respec-

Chapter 42  Complications of Simple Prostatectomy tively.11 No distinction was made based on severity or type of incontinence. Urge incontinence, usually resulting from bladder instability, has been reported in ≤8% of cases. This complication is generally transient and resolves within 8 weeks of the surgical procedure. Stress incontinence may result from sphincteric deficiency, sphincteric injury, or neurapraxia. During apical enucleation, the urethra can often be pinched off at the apex of the adenoma. Extensive traction or tearing can disrupt the external urethral sphincter complex. Using curved Satinsky scissors for sharp dissection of the urethra at the prostatic apex can help minimize trauma to the external sphincter. Urodynamic studies in patients before open prostatectomy and 6 months postoperatively demonstrate reversible bladder changes that can occur.9 Whereas 22% of patients in this series had detrusor instability preoperatively, only 9% had instability postoperatively. In addition, significant changes in the maximum bladder contraction force were observed at 6 months postoperatively. In this series, 9% of patients had postoperative stress incontinence that resolved by 12 weeks. These investigators further demonstrated a reduction in bladder wall thickness present as early a 1 week postoperatively (mean, 3.3  mm versus 5.2  mm) that reached its nadir at 6 weeks (2.9  mm) and remained constant for ≤1 year. Resolution of urge incontinence may be the result of these reversible changes of bladder hypertrophy. Neuropathy of the external sphincter after open prostatectomy has not been well described. In theory, if the capsule is not disrupted, the nerve supply should remain intact. A study of 47 men after open prostatectomy examined the electromyographic responses of the external urethral sphincter and the bulbocavernosus muscles after electrical stimulation of the bulbocavernosus reflex.24 All men in the study had an intact reflex arc and eternal urethral sphincter with latencies within the normal range. The investigators concluded that the somatosensory components of the pudendal nerve are not compromised after open prostatectomy, but this area requires further study.

Persistent Urinary Leak The incidence of persistent urinary leakage from the cystotomy or capsulotomy after all drains are removed is 1% to 2%.19 In a series of 200 patients undergoing suprapubic prostatectomy, 2 patients had persistent urinary leakage.2 Both patients were managed with Foley catheter drainage and had spontaneous resolution within 4 weeks. It is normal to have same drainage for ≤48 hours after drain removal, but failure to seal is considered persistent urinary leakage. The cause is most commonly high postvoid residuals from anatomic obstruction (e.g., urethral stricture) or poor detrusor function. Treatment is with bladder drainage until the

leakage site has healed. Inadequate cystotomy or capsulotomy closure is rarely the cause of persistent leakage. A three-layer closure for cystotomies after suprapubic prostatectomies was described using perivesical fat as the third layer, with a reduction in the leakage rate from 13% to 2% (P = .06) in one prospective, randomized series.25 Leakage from the capsulotomy site after retropubic prostatectomy is rarer and is usually adequately treated with bladder drainage. Surgical drainage of the retropubic space should be performed in all open prostatectomies, either with a Penrose drain or a suction drain. Some investigators prefer Penrose drains because of the belief that a suction drain encourages leakage when the drain is placed adjacent to the suture line of the capsulotomy or cystotomy. If persistent drainage is present, the drain should be withdrawn slightly to increase the separation between the suture line and the drain. Suction drains should be taken off suction to allow a persistent tract between the suture line and the drain to collapse. Drains should remain in place until catheter removal and until drainage is 10 years, have localized disease (organ confined), and have had no radiation therapy to the prostate.

PERIOPERATIVE COMPLICATIONS Hemorrhage Hemorrhage during radical perineal prostatectomy usually originates from either the dorsal venous complex or the arterial branches to the prostate or seminal vesicles. In performing radical perineal prostatectomy, the

surgeon is usually able to divide the endopelvic fascia at the apex and dissect along the anterior prostate and thereby avoid the large venous tributaries that make up the dorsal venous complex (Fig. 43-1). On occasion, however, perforating vessels are present or the surgeon is unable to avoid the venous complex, and substantial venous bleeding results. Sometimes this bleeding can be controlled by packing the wound and waiting, although active hemostasis is often required. Electrocautery is generally useless in this situation, and the surgeon is best served by suture ligating the vessels with 3-0 polyglactin 910 (Vicryl). A figure-of-eight suture placed anteriorly to the urethra is usually sufficient. Arterial tributaries are usually easier to control. The arterial supply to the prostate originates from a branch of the pudendal artery and is located posterolaterally to the prostate and seminal vesicles. Generally, minor tributaries from the inferior vesical artery in the anterior bladder neck can be controlled with electrocautery. The posterior pedicles to the prostate consist of a superior pedicle that enters the prostate at its posterior base and is a constant anatomic finding and the more variable inferior pedicle that is found near the apex of the prostate. These pedicles can be isolated, divided, and ligated; if a nerve-sparing operation is not contemplated, they can be cauterized. The artery to the seminal vesicle enters the seminal vesicle at its tip and should be cauterized during the dissection. If arterial bleeding persists after the prostate is removed, the surgeon can generally isolate the sites by packing 4 × 8-inch sponges in each side of the wound and removing one and then the other. To visualize the deeper aspects of the wound adequately, it is frequently very important to have optimal lighting, which can be obtained only with a halogen head lamp and adequate retraction. Delayed bleeding is an uncommon complication and may result from either inadequate control of vessels before closing or clotting abnormalities. The vessels 503

504

Section VIII  Complications of Pelvic Surgery TABLE 43-1  Nerve-Sparing Radical Perineal Prostatectomy: Morbidity Complication

Percentage (%)

Strictures

6.7

Incontinence   Significant   Minor

3.1 7.1

Rectal injury

1.3

Wound infection   Deep vein thrombosis   Cerebrovascular accident

1.3 0.4 0.4

Perioperative myocardial infarction

1.3

Cardiovascular Complications Cardiovascular complications include pulmonary embolus and myocardial infarction. The cardiovascular complications are a reflection of the patient population, who are generally older and have some degree of underlying cardiovascular disease. The patients are placed in a position that allows maximum drainage of the veins of the lower extremities and their legs are wrapped to the groin before positioning, measures that should prevent pulmonary embolism. I do not routinely use any preoperative anticoagulation and have seen only 4 cases of pulmonary emboli in >500 patients after radical perineal prostatectomy in the past few years.

Rectal Injury Puboprostatic ligament Venous plexus

Anterolateral fascia

Figure 43-1  The solid arrow indicates the proper plane of dissection beneath the anterolateral fascia and beneath the venous plexus. Dissection above this fascia (dotted arrow) carries the hazard of disruption of the venous sinus and troublesome bleeding.

most easily missed during closure are on the anterior rectal surface or are retracted within the bladder neck. Vessels retracted within the bladder neck can be detected by irrigating the Foley catheter after the anastomosis is completed. Another potential site of hemorrhage is the bulb of the penis. This bleeding usually occurs when the dissection proceeds too far anteriorly during an attempt to divide the rectourethralis. This hemorrhage will not respond to any intervention other than suture ligation. Since 1991, average blood loss among patients in my practice has been 2 L and is likely influenced by operative technique, the presence or absence of nerve sparing, time, and the experience of the surgeon.5,10 Several surgeons have suggested various means of perioperative blood management to minimize the need for transfusion. Rates of allogeneic transfusion in contemporary series have varied from 2.4% to 21% independent of autologous blood donation.5,11-15 Reoperation for bleeding is extremely rare, with a reported incidence as low as 0.3% in one large series.15 The use of autologous blood donation was previously shown to reduce the risk for allogeneic transfusion. Several investigators challenged the need for blood donation.13,16,17 Koch and Smith13 reported an overall transfusion rate resulting from intraoperative bleeding of 2.4% in 124 patients undergoing radical prostatectomy without preoperative autologous blood donation. Because it is unlikely that most surgeons will be fortunate enough to experience such a minimal likelihood of intraoperative and postoperative bleeding, and for this reason, it is advisable that some form of preventive management be instituted in patients undergoing radical prostatectomy. Chun and associates18 proposed the use of preoperative erythropoietin injections instead of autologous donation. Patients were given one to two injections of erythropoietin, provided their preoperative hematocrit was 50%. For this reason, careful selection with regard to the possibility of cancer cure should be a fundamental tenet of salvage prostatectomy. We have not been strong advocates of the idea of palliative resection for locoregional control in this setting and believe that patient selection based on oncologic tenets is essential.

KEY POINTS 1. When performing open radical prostatectomy, the rate of bleeding varies with operator experience and technique. The use of preoperative erythropoietin or autologous blood donation can lower the likelihood of allogeneic transfusion greatly. 2. Control of the dorsal venous complex prior to division can greatly reduce blood loss during radical prostatectomy. Accurate and complete bunching of the dorsal vein hood over the base of the prostate is helped by wide incision of the endopelvic fascia back to the bladder neck. 3. Early release of the lateral prostatic fascia on the anterolateral surface of the gland facilitates release of the neurovascular bundles prior to urethral division, thereby reducing traction on the neurovascular structures.

REFERENCES Please see www.expertconsult.com

4. In performing the urethral anastomosis, tensionfree mucosal apposition is essential in avoiding bladder neck contracture. 5. Pelvic hematoma due to postoperative bleeding causes distraction of the urethral anastomosis, potentially causing urinary extravasation and eventual bladder neck contracture. In such cases prolonged catheterization is warranted. 6. Rectal injury at the time of radical prostatectomy does not require diverting colostomy in the majority of cases. Bowel preparation, antibiotics, methodical closure of the rectum, and interposition of either omental or peritoneal closure of the rectum, and interposition of either omental or peritoneal flap can all help in avoiding the need for colostomy.

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45

LONG-TERM OUTCOMES OF RADICAL PROSTATECTOMY George J. Huang

MD Clinical Instructor, Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, Los Angeles, California

David F. Penson

MD, MPH Professor of Urology, Vanderbilt University, Nashville, Tennessee

Radical prostatectomy (RP) is a standard treatment for clinically localized prostate cancer. Furthermore, the literature indicates that RP alone may be curative in many cases of locally advanced disease.1-4 With an estimated >100,000 cases of RP performed annually in the United States, RP is one of the most commonly performed operations in the field of urology.5 RP provides excellent long-term cancer control and disease-specific survival, but untoward effects of surgery can negatively affect a patient’s health-related quality of life (HRQOL).6 Specifically, RP can result in urinary dysfunction in the form of stress incontinence or bladder neck contracture and sexual dysfunction in the form of anejaculation and erectile dysfunction (ED). We have a relatively good understanding of outcomes in these domains during short-term follow-up (≤2 years postoperatively), but our understanding of longer-term outcomes (after year 2) in these areas is far less complete and is still evolving. To counsel patients properly, it is imperative that practicing urologists fully appreciate and acknowledge the side effects of RP, as well as the effects of other treatments. To date, no adequately sized randomized clinical trial has compared the long-term oncologic outcomes of surgery with other treatments for localized prostate cancer. In the absence of this information, patients often base treatment decisions on the side effect profiles of available therapies7 and rely on their physicians to provide them with accurate information. Presenting only 1- or 2-year outcomes, however, is inadequate and may even be somewhat misleading. Immediate side effects of treatment may continue to evolve or improve, whereas new symptoms may also arise beyond the first 2 years. The normal aging process may also play a confounding role that affects HRQOL over the long term. Knowledge of long-term outcomes thus allows patients to consider treatment side effects in the appropriate context.

The importance of long-term quality of life research is heightened by the changing demographics of prostate cancer in the era of prostate-specific antigen (PSA) testing. Men are now diagnosed with earlier-stage disease and at a younger age. Most patients diagnosed with prostate cancer today can expect to live 10 to 20 years after diagnosis. To limit discussion of the survivorship experience to the first 2 years ignores 80% to 90% of the patient’s remaining lifetime. Clearly, we need to appreciate and understand the long-term complications of prostate cancer treatments. The goal of this chapter is to provide an overview of long-term outcomes following RP. Long-term oncologic outcomes are discussed first, but the focus of the chapter is on long-term HRQOL outcomes, particularly those in the urinary and sexual domains. Comparison of RP with other active treatment modalities, such as external beam radiation therapy, brachytherapy, and androgendeprivation therapy (ADT), is beyond the scope of this chapter and is not addressed.

LONG-TERM ONCOLOGIC OUTCOMES Prostate cancer is a heterogeneous disease. Significant percentages of cases have a prolonged natural history. Many men diagnosed with the disease die with rather than of the cancer. As a result, an ongoing debate exists about whether surgery, and in fact any form of active treatment, actually improves overall survival when compared with expectant management (i.e., active surveillance or watchful waiting) among men with early-stage disease. Proponents of surgical treatment cited excellent cancer-free survival rates in several wellknown large single-center series as proof that surgical intervention benefits the majority of patients who elect to undergo RP.8-10 In contrast, opponents quoted large observational studies and meta-analyses that also dem521

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Section VIII  Complications of Pelvic Surgery onstrated excellent 10-year disease-specific survival rates in men who elected conservative management initially.11,12 Unfortunately, these supporting data cited by both sides of the argument were flawed by selection bias that limited their generalizability. A randomized clinical trial from Sweden overcame many of the design flaws of the aforementioned studies and provided the first level I evidence that RP resulted in better overall, disease-specific, and metastasis-free survival rates than did conservative management. This study, initiated before widespread adaptation of PSA screening, randomized 695 men with clinically localized prostate cancer diagnosed between 1989 and 1999 to either surgery or watchful waiting. In 2002, Holmberg and colleagues13 initially reported that at a median follow-up of 6.2 years, the group randomized to surgical treatment experienced improved metastasis-free and disease-specific survival compared with the group randomized to watchful waiting. However, no difference in overall survival was observed between the two groups. In 2005, the same group reported updated data at a median follow-up of 8.2 years. These investigators noted that with longer follow-up, improved overall survival rates were observed for men who received surgical treatment, in addition to superior disease-specific and metastasis-free survival rates.14 Furthermore, the investigators also noted that the magnitude of difference in survival between the two groups appeared to increase over time. It is likely that the relative survival advantage provided by surgical treatment will continue to increase with even longer-term follow-up. The natural history of early, localized disease as demonstrated by men who have undergone conservative management shows that the largest drop-off in cumulative progression-free, metastasis-free, and disease-specific survival rates occurs 15 to 20 years after diagnosis.15 Clearly, in selected patients, surgical treatment results in improved survival compared with observation. The real challenge, however, is proper patient selection. To realize a survival advantage, a patient has to have a natural life expectancy of ≥5 to 10 years at the time of surgery. Furthermore, for men with well-differentiated disease, aggressive treatments may not be indicated. Prior large observational studies of men who underwent conservative management indicated that men with well and moderately well differentiated disease have only a small to modest risk of dying of prostate cancer, even with 20-year follow-up.16 In contrast, men with highergrade disease have a much higher risk of dying of their disease, and this risk appears to increase or accumulate over time.15,16 RP provides excellent control of localized prostate cancer, but active surveillance may be appropriate in selected patients (i.e., older patients with less aggressive disease). Although overall survival and disease-specific survival are the primary clinical end points of interest, recurrence-free survival should also be considered.

Reported 10-year recurrence-free survival rates following RP range from 52% to 75%.8-10,17 Among patients with recurrent disease, many have isolated biochemical recurrence. Currently, no uniformly accepted definition of a biochemical recurrence following RP exists,18 and the most conservative definition is a rising PSA >0.4 ng/mL. Data from Johns Hopkins University in Baltimore showed that at 10 years, 15% of men had an isolated detectable PSA as the only evidence of disease recurrence.10 A unique characteristic of the Johns Hopkins cohort was the conservative approach used in treating patients with biochemical recurrence. Patients were discouraged from receiving secondary therapy until they become symptomatic, an approach that allowed for the natural history of untreated biochemical recurrence to be observed. The median time from biochemical recurrence to development of metastatic disease was approximately 8 years, and the time from metastatic disease to death was 5 years.19 A subsequent follow-up study of the same cohort with expanded and updated data demonstrated that most patients who developed PSA recurrence could expect excellent long-term survival. In this cohort, the median time from biochemical recurrence to cancer-specific mortality was not reached even after 16 years of follow-up.20 PSA doubling time following biochemical recurrence, time to recurrence from surgical treatment, and Gleason score were all found to be significant predictors of prostate cancer–specific mortality following PSA recurrence.20 Although many patients who develop biochemical disease recurrence experience an indolent course, even an isolated biochemical recurrence may negatively affect a patient from a quality of life perspective.21 The reason underpinning the effect of PSA-documented disease recurrence on emotional and psychological wellbeing is intuitive, but the reason for the effects on other aspects of HRQOL (e.g., in sexual and urinary domains) is less obvious. The likely answer lies in the natural tendency of patients and providers to use secondary therapy on discovery of biochemical disease recurrence. In fact, investigators showed that men who underwent secondary therapy after RP experienced significant, progressive declines in the role-emotional and sexual function HRQOL domains, whereas patients not requiring secondary therapy did not.22 Secondary therapy after initial localized treatment is not uncommon. Three important studies examined this issue. The first used the population-based Surveillance, Epidemiology and End Results (SEER)–Medicare data set to assess secondary therapy use after RP.23 Subjects in this cohort were diagnosed relatively early in the PSA era (1985-1991), and therefore the observed 5-year cumulative secondary therapy incidence of 34.5% did not likely reflect current trends. Grossfeld and colleagues24 examined secondary therapy use in the Cancer of the Prostate Strategic Uro-

Chapter 45  Long-term Outcomes of Radical Prostatectomy logic Research Endeavor (CaPSURE) dataset, a large, national, community-based observational registry of men with prostate cancer. In this study, 17% of all patients received secondary therapy within 3 years of treatment. Fifteen percent of patients who received surgical treatment and 24% of those who underwent radiation therapy had received secondary therapy within 3 years of diagnosis. Finally, researchers from the Urologic Diseases of America Project recapitulated the SEER-Medicare analysis using a more contemporary cohort (1991-1997) with median follow-up of approximately 6 years.25 These investigators found that 19% of surgical patients and 13% of patients who underwent external beam radiation therapy received secondary treatments. All these studies were published with relatively short follow-up. Therefore, we can expect rates of postoperative secondary therapy to be higher with longer follow-up. In all these studies, the most common secondary therapy received was ADT.23-25 Numerous reports have documented the relationship between ADT and certain deleterious clinical side effects, such as hot flashes,26 gynecomastia,27 and decreased bone density28 resulting in increased risk of bone fractures.29 The concurrent administration of bisphosphonates has been shown reverse the deleterious bony effects of ADT,30,31 and bisphosphonate use may actually improve functional status and general HRQOL.32,33 Yet, little is known regarding how widely these agents are used in general practice. In addition to bony complications, ADT may also result in endocrinologic abnormalities,34 hyper­ lidemia,34 and increased risk of fatal myocardial infarctions.35 Given that long-term ADT can cause significant additional morbidity, it is not surprising that this therapy negatively affects the HRQOL of patients. Although studies on this topic have often focused on men with metastatic disease, we can extrapolate the results to men who have undergone RP and have experienced an asymptomatic biochemical recurrence for which they are receiving secondary ADT. Herr and associates36 compared patients with metastatic disease who were receiving early hormonal therapy with patients who elected to defer treatment until they were symptomatic. These investigators found that the patients who received immediate ADT experienced more fatigue, loss of energy, emotional distress, and a lower overall quality of life. Basaria and associates37 compared HRQOL outcomes in 20 men receiving ADT with 20 aged-matched controls. In addition to changes in body mass index and bone density, the ADT-treated group had worse sexual function and significant limitations in physical function and perception of physical health. In a randomized trial of 65 men with nonlocalized prostate cancer who were randomized to receive either immediate or delayed hormonal therapy, Green and

colleagues38 demonstrated that men receiving early therapy reported worse sexual function and decreased role and social functioning. Potosky and colleagues39 in the Prostate Cancer Outcomes Study (PCOS), studied HRQOL in men who received ADT for localized disease. Compared with men with localized disease who did not receive ADT, men in the ADT group reported worse sexual function and more physical discomfort, a finding once again illustrating the adverse effects of hormone ablation therapy on HRQOL. In summary, long-term disease-specific survival following RP is excellent. Roughly one third of patients will experience biochemical disease recurrence in the first 10 to 15 postoperative years.10 The clinical implications of biochemical recurrence vary among patients, but most patients who experience biochemical recurrence can expect prolonged survival. Additional research is sorely needed to refine risk stratification in these patients. When confronted with biochemical recurrence, providers need to consider carefully the purported advantages conferred by early initiation ADT together with its significant side effect profile. The risk of biochemical recurrence and the possibility of secondary therapy should be included in the discussion with patients when initial therapy is chosen. We recommend limiting the use of ADT to patients at greatest risk for prostate cancer–specific mortality.

MEASUREMENT OF HEALTH-RELATED QUALITY OF LIFE OUTCOMES FOLLOWING PROSTATECTOMY RP is a well-tolerated procedure associated with very low perioperative mortality (13,000 men with biopsy-proven prostate cancer followed at 31 community-based and academic sites across the United States.41 These two cohorts provide a comprehensive portrait of long-term clinical and quality of life outcomes in the United States. In Europe, the Rotterdam Study, performed within the context of the European Randomized Study of Screening for Prostate Cancer (ERSPC), provides an important non-American perspective on this topic.42

Generic Health-related Quality of Life Available evidence from large cross-sectional studies and a well-known randomized trial indicate that longterm physical well-being and mental or psychological well-being are no different among men with prostate cancer who undergo active treatment or expectant management and age-matched men without prostate cancer. In a study comparing HRQOL among different treatment groups and age-matched controls, Litwin and colleagues43 noted comparable scores in seven of the eight generic domains of the Short Form-36 (SF-36), a validated and commonly used questionnaire. Patients who underwent watchful waiting reported greater role limitations from emotional problems than did those who underwent active treatment, including RP.43 Investigators from the University of Michigan noted similar SF-36 scores on the mental composite summary and the physical composite summary at single time point among patients who underwent surgery, external beam radiation therapy, or brachytherapy a median of 2.6 years after treatment and age-matched controls who did not have prostate cancer.44 The Scandinavian Pro­ state Cancer Group Study noted similar physical and psychological functioning between men randomized to RP and watchful waiting at a median of 4 years after diagnosis and randomization.6 Does generic HRQOL change over time for patients undergoing active treatment? Longitudinal studies documented the stability of long-term generic HRQOL outcomes. In the University of Michigan cohort, no changes in general HRQOL were noted for any of the active treatment groups after an additional 4-year follow-up.45 Another study that used the CaPSURE database demonstrated that mental and physical component HRQOL summary scores for those patients who underwent various primary active treatments and watchful waiting changed little from baseline to 4 years after diagnosis.46

Investigators from the Rotterdam Study also noted similar stability in generic HRQOL from diagnosis to 5 years after treatment in patients who underwent RP and external radiation.42 Thus, published data have consistently indicated that men treated with RP can generally expect excellent general HRQOL outcomes over the long term. However, not all men experience the same outcomes after RP. Patients 55 years old, 56% of men age 55 to 59 years, and 46% of men age 60 to 64 years who underwent bilateral nerve-sparing surgical treatment reported erections firm enough for intercourse. In contrast, only 18% of the

527

Section VIII  Complications of Pelvic Surgery Sexual Function on Long Term Follow-up 100 UCLA PCI Sexual Function Summary Score

528

90 80 70 60 CaPSURE PCOS

50 40 30 20 10 0

0

1

2

3 4 Time from Surgery (yrs)

5

6

Figure 45-2  Long-term sexual function following radical prostatectomy. Results are from two large datasets.46,68 (Health-related quality of life scores range from 0-100, with higher scores representing better quality of life.) CaPSURE, Cancer of the Prostate Strategic Urologic Research Endeavor; PCOS, Prostate Cancer Outcomes Study; UCLA PCI; University of California Los Angeles Prostate Cancer Index.

men >65 years old reported erections firm enough for sexual intercourse 5 years after diagnosis. These findings underscore the close relationship between age and sexual outcomes in prostate cancer. A similar age effect on the effectiveness of sildenafil after bilateral nerve-sparing surgical therapy was seen in the PCOS cohort.68 Age clearly affects the likelihood of response to treatments for impotence after RP.

Sexual Bother ED is an important (and arguably the dominant) longterm sexual outcome to consider after RP. It is not the only outcome of interest in the sexual domain, however. All patients have dry ejaculation after RP. In addition to this ejaculatory dysfunction, many patients with prostate cancer experience a decrease in libido, often resulting from the use of adjuvant or secondary hormonal therapy. All these sexual dysfunctions can cause bother for patients, although the degree to which men are bothered by their sexual dysfunction is not as closely related to the degree of their dysfunction as in the urinary domain.75 Data from PCOS revealed that at all time points throughout postoperative follow-up, the percentage of patients who reported being moderately or severely bothered by sexual dysfunction was consistently lower than was the percentage of patients who reported impotence. Furthermore, the gap between the two parameters widened over time, a finding suggesting that patients learn to cope with ED. At 1-year follow-up, 61% of men in this cohort reported being moderately or

significantly bothered by their sexual dysfunction, whereas by 5-year follow-up, this percentage had decreased to 46%.68

CONCLUSION RP provides excellent long-term control of clinically localized prostate cancer. Although it negatively affects sexual and urinary function, most men learn to cope with the side effects of surgery, report excellent general HRQOL postoperatively, and are satisfied with their choice. Data from PCOS indicated that 2 years following treatment, 83.1% of men who underwent RP were either mostly satisfied, pleased, or delighted with their treatment,77 and 90.7% indicated that they would make the same treatment choice again.77 The degree of satisfaction appears to be maintained with long-term followup. In another study examining confidence men had in the treatment they had received 4 to 8 years previously, 77% of men in this cohort who underwent RP were confident that RP provided good cancer control.78 In men with localized prostate cancer, the underlying tumor biology may be a primary determinant of cancer outcome, and baseline patient-related characteristics may contribute significantly to post-treatment functional recovery. However, surgical technique also clearly matters for patients who undergo RP. Future investigations should continue to consider measures, both surgical and nonsurgical, to decrease the likelihood of biochemical recurrence, bladder neck contracture, stress incontinence, and sexual dysfunction.

Chapter 45  Long-term Outcomes of Radical Prostatectomy

KEY POINTS 1. Although long-term survival following radical prostatectomy is excellent, a considerable number of patients receive secondary therapies. Because secondary therapies, particularly hormonal therapy, have significant negative effects on health-related quality of life, careful consideration must be given as to which patients who experience biochemical recurrence after surgery should be receiving secondary therapy and which should be observed. 2. Although the primary impact of prostatectomy on urinary-specific quality of life domains is stress incontinence, the impact of anastomotic stricture should not be underestimated and surgeons should use techniques to minimize anastomotic strictures.

REFERENCES Please see www.expertconsult.com

3. Although urinary incontinence most commonly occurs immediately in the first 3 to 6 months after surgery, studies show that there is often improvement after the initial nadir. However, most patients experience a plateau in return of urinary function by 1 year and do not have additional improvement after this. 4. Erectile dysfunction also occurs most commonly in the first 6 months after surgery, but patients can expect to experience improvement up to 2 years after surgery. After this point, however, it is unlikely there will be any additional natural return of function. 5. Both urinary and sexual dysfunction can cause bother for patients.

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46

COMPLICATIONS OF CONDUIT URINARY DIVERSION Jamie A. Kanofsky

MD Resident in Urology, Department of Urology, New York University Langone Medical Center, New York, New York

Guilherme Godoy

MD Fellow in Urologic Oncology, Bruce and Cynthia Sherman Fellowship in Urologic Oncology, Division of Urologic Oncology, Department of Urology, New York University Langone Medical Center, New York, New York

Samir S. Taneja

MD The James M. Neissa and Janet Riha Neissa Associate Professor of Urologic Oncology; Director, Division of Urologic Oncology, Department of Urology and New York University Cancer Institute, New York University Langone Medical Center, New York, New York

In 1851 Sir John Simon of London attempted open ureterosigmoidostomy in dogs. He reported that the operation was “almost always fatal, and it was plain that the peritoneum would be exposed to much hazard.”1 Although urinary diversion can be dated back to 1851, it was not until 1950 that Bricker2 reported on the use of ileum for “bladder substitution after pelvic evisceration.” Although ileal conduit is the simplest and most popular of diversions, complications are frequent.3 The surgeon should discuss the options as well as the advantages and disadvantages of conduit and continent diversion with the patient well before the operative day. Critical factors to consider include the patient’s age and performance status, manual dexterity, body habitus, motivation and desires, expected long-term functional status, bowel condition, bowel length, prior surgery or radiation, and renal reserve. Construction of the urinary conduit carries the potential for a great number of unforeseen events. Complications can be divided into two categories, early (≤30 days of the surgical procedure) and late. The rate of early complications has been reported to range from 20% to 56%,4 and such complications include intestinal obstruction, fistula formation, leakage from the ileal-ileal or ureteroileal anastomosis, wound infection, wound dehiscence, loop necrosis, and pyelonephritis. The incidence of late complications reportedly ranges from 28% to 81%,4 and these complications include intestinal obstruction, pyelonephritis, renal deterioration, ureteroileal strictures and obstruction, stomal stenosis, parastomal herniation, calculi, metabolic abnormalities, and the development of carcinomas.

In evaluating quality of life issues, Turner and colleagues5 found that 88% to 95% of patients were satisfied overall, whereas 17% to 19% of patients were bothered by impaired body image. With regard to sexuality, 30% of patients reported decreased libido, whereas 20% felt less sexually attractive.6 Hart and associates7 reported frequent difficulty in caring for the collection device in 57% of their patients who had undergone ileal conduit procedures. More recently, Dutta and colleagues8 found that 85% of patients undergoing ileal conduit would make the same choice of urinary diversion again.

PREOPERATIVE CONSIDERATIONS Complications related to major intra-abdominal surgery include those secondary to anesthetic, cardiac, pulmonary, and thromboembolic events. Prevention of such complications is discussed elsewhere in the text. Preoperative patient selection and proper evaluation by a cardiologist or pulmonologist may be necessary. In today’s age of managed care, most patients undergo bowel preparation at home. Wolff and colleagues9 found little difference between aggressive antibiotic preparation and a minimal preparation of enemas, dietary restrictions, and mechanical lavage. This finding suggests that aggressive preparation can be safely avoided, thus reducing the risk of perioperative colitis. We routinely use a 2-day bowel preparation in which patients are started on a clear liquid diet 2 days before the surgical procedure. Magnesium citrate is prescribed for 2 days preoperatively along with two saline laxative 533

534

Section IX  Complications of Reconstructive Surgery (Fleet) enemas the night before the operation. Alter­ natively, 1 day postoperatively, patients are asked to drink ≤1 gallon of polyethylene glycol and electrolyte solution (GoLYTELY) until the stool is clear. The classic use of antibiotic preparation is discouraged.

Selection of Bowel Segment Based on early experience, the use of jejunum in urinary reconstruction has fallen out of favor. Although functional results are not significantly different from those seen with ileum, tremendous metabolic complications arise secondary to water and salt loss. Golimbu and Morales10,11 used both canine and clinical models to evaluate jejunal conduits. These investigators reported on a series of 30 jejunal conduits used in patients with a history of prior radiation, multiple pelvic surgical procedures, or poor condition of the distal ureters, ileum, or colon. They found that the major complications with use of jejunum were electrolyte abnormality and water loss. However, the resulting hypochloremic, hyponatremic, and hyperkalemic metabolic acidosis, generally accompanied by dehydration, usually responded to increased salt and fluid intake. Despite these findings, jejunum is rarely used today because of the great consequences of fluid shifts, and this method should be considered only when no other option is viable. The use of ileum and colon has similar functional and metabolic outcomes. In general, those patients with metabolic abnormalities are found to have hyperchloremic metabolic acidosis secondary to luminal bicarbonate loss and active hydrogen ion or ammonium reabsorption.12 Factors influencing the severity of the metabolic abnormality include the contact time of urine and bowel (conduit length), the drainage of the conduit (adequate stoma), and the underlying renal function of the patient. Other metabolic conditions include encephalopathy from elevated ammonia, weakness from hypocalcemia, neuromuscular dysfunction from hypomagnesemia, and osteomalacia or growth delay in children. Patients with osteomalacia specifically develop bony pain, muscle weakness, decreased phosphate, increased alkaline phosphatase, and excess osteoid in the bone. The physiologic features and management of the metabolic abnormalities accompanying ileal or colon diversion are discussed in detail in Chapter 5. In general, the acidosis is easily treated by one of a variety of medications.13 Although functional and metabolic results of colon and ileal conduits are generally similar, Mogg14 initially described the technique of the colon conduit to be superior to that of ileal conduit because of the thicker musculature, infrequent peristalsis, and the need for less intraperitoneal manipulation. In his review of 48 cases, Mogg found complications in 16 patients: 4 patients developed stones, 2 developed ureteral stenosis, 8 had stomal ulceration, and 2 developed urinary peritonitis.

Morales and Golimbu15 evaluated 46 colon conduits, of which 39 were constructed using transverse colon. In their study, these investigators observed a 15% mortality rate. Early complications included intestinal obstruction in 3 (6.5%), intestinal anastomotic leak in 2 (4%), and bilateral ureteral obstruction in 1 (2%). Late complications included acute pyelonephritis in 8 (17%) and stomal prolapse in 6 (13%), with 4 (8.5%) of these patients requiring surgical repair. In addition, 6 patients (13%) had ureterointestinal anastomotic obstruction. In evaluating the patients’ upper urinary tracts, 32% of normal kidneys showed deterioration postoperatively, 37% of preoperatively abnormal renal units improved, and 25% of preoperatively abnormal renal units deteriorated. The investigators used an intraluminal nipple to achieve an antirefluxing mechanism, and no patient with antirefluxing ureters developed renal damage. Complication rates with ileal conduit diversion have been similar to those observed with colon conduit. Jahnson and Pedersen16 reported on 124 patients with ileal conduits followed for ≤20 years. Of the 124 patients, 48% had early complications including urine or intestinal anastomotic leaks, urinary or intestinal obstruction, wound dehiscence, infection, or cardiovascular misadventure. These investigators noted a 6% mortality rate in the perioperative period (4 deaths from septicemia, 2 from myocardial infarction, and 1 from uremia). Jahnson and Pedersen also found an association between preoperative radiation therapy and the rate of wound infection. In addition, the investigators reported a late complication rate of 52%, including 22% of patients with ureteroileal obstruction or stricture. More recently, Singh and associates17 evaluated 93 patients undergoing ileal conduit for benign disease and looked at the complication rate after an average of 5 years. These investigators reported a mortality rate of 2.1%. Complications again were related to the stoma (31%); 10% of patients developed a parastomal hernia and 4.3% developed stomal retraction and stenosis. These investigators reported complications of the ureteroileal anastomosis in 7% of the patients. In addition, 34% of patients had upper urinary tract dilatation, 10% with bilateral changes. In general, it appears that ileal and colon conduit diversions have similar outcomes. Because of the technical ease of ileal diversion, this remains the segment of choice. The decision to use colon is usually based on the condition of the ileum or distal ureters as a result of pelvic irradiation or prior surgical intervention, the length of ureter resected at the time of operation, or the presence of inflammatory bowel disease in the terminal ileum. When the surgeon performs en bloc resection of the colon or rectum, a sigmoid colon conduit may eliminate the need for two bowel anastomoses, or any anastomosis if a colostomy is to be constructed. Finally, if an upper abdominal stoma is required, the transverse

Chapter 46  Complications of Conduit Urinary Diversion colon can be used to reduce technical difficulty associated with bowel mobility. In patients undergoing colon conduit, barium enema should be adequate to rule out the possibility of colonic malignant disease or other abnormalities. In patients undergoing ileal diversion, barium enema is not necessary, but it may be helpful in ruling out potentially obstructive distal abnormalities.

Selecting the Length of Bowel As mentioned previously, the length of bowel used can be a critical determinant of the severity of metabolic abnormality associated with the pouch. A length of 10 to 12 cm serves as a general guideline. In obese patients with a large amount of abdominal wall to traverse, a longer segment should be isolated. Lengthening and mobilizing the distal conduit can be achieved either through aggressive division of the mesentery (with care taken to preserve the proximal ileocolic branch) or, as a preferred method, resection of a segment of bowel immediately distal to the conduit (Fig. 46-1). Another option in the management of a short distal mesentery is the use of a Turnbull loop stoma. In this technique, a “knuckle” of the distal conduit is brought through the fascial opening. The antimesenteric border is incised,

Distal segment to be discarded

thus allowing circumferential maturation without any tethering from the distal mesentery. The surgeon should pay careful attention to the anatomic lie of the conduit after maturation of the stoma. The intra-abdominal portion of the conduit should be relatively straight, with no kinking or twisting to impair luminal drainage. A red rubber catheter left in the length of the conduit can allow the conduit to heal in a straight fashion. In individuals with a thin abdominal wall or small body habitus, as short a segment as possible should be used. Preserving good length of the ureters can allow the ureterointestinal anastomoses to “rise” along the lateral abdominal wall and can thereby minimize the intra-abdominal length of the conduit. Tension on the ureteroileal anastomoses can be avoided by fixation of the proximal segment of the conduit to the sacral promontory or by a lateral retroperitoneal incision. In patients with impaired renal reserve, as noted by elevated serum creatinine concentration or creatinine clearance 7 to 10 days postoperatively are often the result of ischemic ureteral necrosis. Early attempts at conservative therapy are still worthwhile, and percutaneous nephrostomy is an important adjunct to such therapy. If the leak continues as a high-output fistula despite proximal drainage, it may require early exploration because this finding suggests major ureteral necrosis. If proximal drainage reduces or abrogates fistula output, surgical repair is still likely necessary.

However, waiting for 6 to 10 weeks to allow inflammation to subside is wise. If the patient does not respond to conservative therapy, early surgical exploration and repair must be attempted. Hensle and colleagues53 suggested repair after 72 hours if no improvement is noted, whereas Coleman and Libertino54 suggested waiting ≤3 weeks. In the study by Coleman and Libertino, leaks in 7 of 10 patients resolved after 3 weeks, whereas 3 of 10 patients required open revision. The decision to wait must be based on the patient’s condition, the size of the leakage, the output volume, the presence of persistent infection, and the presence of signs of improvement. In repairing an early leak, surgical exploration usually includes creating a new anastomosis. Simple placement of additional sutures in a preexisting anastomosis is rarely successful and is ill advised. Stent placement in the new anastomosis is strongly advised. The previous opening in the ileum should be identified and closed. To facilitate intraoperative dissection and mobilization, a Foley catheter with 3 to 5 mL in the balloon can be placed in the conduit. Antegrade stenting of the ureters is also helpful in localizing, mobilizing, and repairing the anastomosis.54 The surgeon should anticipate very friable tissues, and the repair should focus on identification of a viable, minimally inflamed ureteral edge, mucosal apposition, and tension-free anastomosis. Watertight closure is often not possible because of the condition of the tissues. Eyre and associates52 recommended sending the distal ureter for frozen section during repair, to assess tissue necrosis or small vessel occlusion. However, this condition may be difficult to assess in the presence of acute inflammation. Patients with a delayed urine leak (10-14 days) usually have ischemic necrosis. This complication can involve a variable length of ureter and, in severe cases, can extend all the way to the renal pelvis. The technique of repair should be based on the length of the defect. Complete resection of the devitalized ureter must be performed with creation of an ileal interposition, transureteroureterostomy, or renal autotransplantation. Minimal to moderate gaps can be closed by mobilization of the proximal conduit itself. In patients with significant ureteral necrosis, critical illness or sepsis, or multiple comorbidities, the surgeon should give strong consideration to nephrectomy if the contralateral kidney is adequately functioning. Before surgical exploration, a renal scan may be performed to assess bilateral function, if necessary. Bowel preparation should be performed, if possible, based on the patient’s overall condition.

Anastomotic Strictures The incidence of ureteroileal strictures ranges from 1.5% to 18.4%.20 For example, Bricker35 found a 3.75% incidence of reoperation for ureteroileal obstruction in his initial 54 cases. In addition, Cass and colleagues,37

Chapter 46  Complications of Conduit Urinary Diversion and Frazier and associates46 reported stricture rates of 6.5% and 7%, respectively. More recently, Madersbacher and colleagues55 noted upper urinary tract obstruction in 13 of 131 (10%) patients as a result of stenosis at the ureteroileal anastomosis, and Gburek and associates56 reported a 5% rate of stricture in 66 patients, their most common late complication of ileal conduit creation. The possible causes of stricture formation include tension at the anastomosis, devascularization and ischemia of the ureter, prior radiation therapy, prior leakage, and infection. In the setting of prior leakage, dense reaction surrounding the ureteroileal reimplantation results in extrinsic scarring of the anastomosis. Stricture at the anastomosis should be considered in any patient with decreased renal function (increased serum BUN and creatinine levels), hydronephrosis, flank pain, decreased urine output, fever, or sepsis. The diagnosis of ureteroileal anastomotic stricture can be made with ultrasound, CT scan, IVP, and loopogram. IVP and loopogram can localize and define the length of the stricture. Newer techniques, including three-dimensional reconstructed spiral CT scan, CT urogram, and magnetic resonance imaging urogram, may also be used if available. In patients with poorly functioning or nonfunctioning kidneys, antegrade pyelography is often necessary to define the stricture. Hudson and colleagues57 reported a rate of correlation between loopogram and IVP of 81%. Although reflux on a loopogram can rule out stenosis, the absence of reflux does not confirm obstruction. In a study by Hudson and colleagues,57 84% of obstructed kidneys were on the left, likely the result of extensive left ureteral mobilization and angulation or tension of the left ureter as it crosses behind the sigmoid mesentery. One must also be concerned with recurrent cancer as a cause of stenosis because carcinomas tend to develop at the ureterointestinal anastomosis.58 Initially, the conduit should be examined endoscopically to rule out recurrent malignant disease. In patients with established percutaneous access, antegrade endoscopy can further aid in defining the nature and extent of the stricture. The surgeon is then faced with choosing between endoscopic and open treatment. Endoscopic management by antegrade or retrograde methods is discussed in detail elsewhere in the text. Although endoscopic management is increasingly popular, high failure rates are noted unless the stricture is short and uncomplicated. In the setting of an uncomplicated, short (1 cm long, it may be wise to consider open repair initially. During open reimplantation of a strictured ureteroileal anastomosis, it is best to place an antegrade stent to the level of stricture. The distal ureter is often encased in fibrotic reaction, particularly in the setting of previous leak or infection, and placement of antegrade stents can allow the surgeon to identify the ureters in an otherwise nondiscernible surgical plane. A catheter is placed in the conduit for similar reasons. The distal ureter must be mobilized, but extreme caution should be taken to avoid devascularization of the healthier proximal ureter. In cases of severe periureteral scarring, it is often preferable to excise the stricture, limit mobilization of the proximal ureter, maximally mobilize the conduit, and bring the conduit to the more fixed segment of viable ureter. We also recommend sending the distal ureteral margin for frozen section pathologic evaluation. If malignant disease is identified, a larger segment of ureter should be resected to achieve a cancer-free ureteral margin. For long stricture defects, numerous surgical options exist, including ileal interposition, transureteroureterostomy, renal autotransplantation, and, on rare occasion, nephrectomy. When the ureteroileal stricture is identified late and the residual renal unit is nonfunctioning, nephroureterectomy is the treatment of choice. This is particularly true in the setting of underlying urothelial malignant disease because a nonfunctioning obstructed upper tract moiety is difficult to follow up for recurrent malignant disease.

Fate of the Kidney During the preoperative evaluation, the status of the patient’s renal function should be evaluated by sending blood for BUN and creatinine. One of the primary goals of conduit surgery is the preservation of renal function. In patients with a serum creatinine level >2.5 ng/mL or significant renal disease on radiographic studies, a short conduit should be created to help decrease stasis and to minimize electrolyte abnormality.

Pyelonephritis and Renal Damage The rate of early pyelonephritis ranges from 1.8% to 3.1%, whereas the rate of late pyelonephritis ranges from 3.1% to 13%.20,46 A reduction in the incidence of pyelonephritis has been reported in contemporary series, perhaps owing to improved technique and better perioperative antibiotics. In early series, Bricker35,36 observed that ≤33% of his patients suffered from early pyelonephritis. More recently, Madersbacher and colleagues55 noted that 23% of their patients who had ileal conduits had symptomatic urinary tract infections severe enough to lead to hospital admission. These

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Section IX  Complications of Reconstructive Surgery investigators observed acute or recurrent pyelonephritis in 15 of 131 (11%) patients; this complication was associated with postrenal obstruction caused by anastomotic strictures, stomal stenosis, or urolithiasis in 13 of these patients. Recurrent urinary tract infections without clinically overt pyelonephritis were seen in 10 of 131 (7%) patients, and urosepsis occurred in 5 (4%) patients, associated with upper tract dilatation in 4 of these patients. Gburek and associates56 observed pyelonephritis as an early complication in 6% of their patients and as a late complication in 2% of their patients.

Refluxing Versus Nonrefluxing Anastomoses The question whether a nonrefluxing ureterointestinal anastomosis has any added benefit in conduit surgery has been the topic of much debate. Although early experiments suggested renal compromise in the setting of a refluxing moiety,59 little clinical evidence exists to support this view. Kristjansson and associates60,61 found no difference in glomerular filtration rate or stricture between refluxing and nonrefluxing anastomoses. A 15% rate of ureterointestinal stricture was noted in each group. Both bacteriuria and renal scarring were more common among refluxing anastomoses. Several investigators demonstrated improvement in hydronephrosis in the majority of patients when nonrefluxing anastomoses were used.62,63 Stein and associates64 reported on 105 children who were followed up for 16.3 years after construction of a nonrefluxing colon conduit. These investigators noted a 65.3% incidence of pyelonephritic changes, a rate comparable to that found in other studies, which reported a rate of change in children of ≤68%. In adults, a conduit with freely refluxing ureters is preferable, mainly for ease of follow-up. Studies show no significant difference in renal damage and, most importantly, no difference in long-term glomerular filtration rates when comparing nonrefluxing and refluxing conduits. In patients with refluxing conduits who have persistent pyelonephritis with renal damage, the physician may consider revision to a nonrefluxing colon conduit.

Bacteriology of the Ileal Conduit Guinan and colleagues65 reported on the bacterial milieu of the ileal conduit. The native ileum before creation of a conduit was sterile in 9 of 10 patients, and 1 of 10 grew fungus. Postoperatively, 74% of conduits had urine cultures demonstrating bacterial growth. The most common infectious organism was Proteus followed by Pseudomonas and Escherichia coli. These investigators found IVP changes in 67% of infected conduits but no significant correlation between urinalysis and culture results. The changes seen were most pronounced in the presence of Proteus or Pseudomonas infection. We recommend treating patients with significant asymptomatic bacteriuria (>105 organisms) in the setting

of Proteus and Pseudomonas infections. Obviously, aggressive treatment is indicated in individuals with pyelonephritis or systemic signs of illness such as fever or leukocytosis. The surgeon must ensure that the conduit is adequately draining, to minimize reflux and the potential for pyelonephritis in the patient with asymptomatic bacteriuria.

Other Potential Complications The incidence of duplex ureters found on autopsy is 0.3% to 2.5%.66,67 The presence of this condition, if unknown preoperatively, can greatly compromise the outcome of conduit surgery. Careful examination of preoperative imaging studies is essential for the recognition and management of the duplicated ureter. When this condition is recognized, the ureters can be implanted separately or together with a Wallace-type anastomosis. Another unfortunate but uncommon complication is conduit-enteric fistula. The finding of decreased output, severe watery diarrhea, and fecaluria can lead to the diagnosis of a fistula.68 Stomal varices are another rare and problematic complication. Varices are usually seen in patients with cirrhotic or metastatic liver disease. These patients usually present with gross hematuria coming from the mucocutaneous junction and can usually be treated by correcting the underlying coagulopathy. Occasionally, the use of coagulation or techniques to oversew the varices may be necessary. Transjugular intrahepatic portosystemic shunts have been used to correct the underlying portal hypertension and to stop the bleeding in these patients.69

KEY POINTS 1. In performing radical cystectomy, the urinary diversion is the most common source of morbidity. 2. Careful selection of the bowel segment based upon mesenteric arcades is essential in avoiding bowel ischemia or bowel anastomotic leak. 3. In preparing the bowel, the distal mesenteric incision will provide greatest length to the stoma in reaching the skin. 4. Stomal preparation prior to abdominal wall transposition may avoid stomal retraction. 5. Care of the stoma, stomal hygiene, and periodic inspection by an enterostomal therapist may help the patient avoid eventual stomal stenosis. 6. Both Bricker and Wallace style uretero-intestinal anastomotic techniques can be associated with low morbidity, but a tension-free anastomosis with careful attention to ureteral vascularity is essential for success.

REFERENCES Please see www.expertconsult.com

Chapter 

47

COMPLICATIONS OF CONTINENT CUTANEOUS DIVERSION Eila C. Skinner

MD Professor of Clinical Urology, Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California

Matthew D. Dunn

MD Assistant Professor of Urology, Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California

Complications related to radical cystectomy and urinary diversion are very common, occurring in ≤35% to 40% of all patients.1,2 Many of these complications such as bleeding, infection, ileus, bowel obstruction, thromboembolic events, nonurologic infections, and cardiovascular complications are related to the surgical procedure overall, and prevention and management of these complications are covered in Chapter 41. Approximately half of the early complications and three fourths of late complications are related to the diversion itself.3 This chapter focuses on the management of both early and late complications related to continent cutaneous urinary diversion. Continent diversion should be considered as a possible alternative to ileal conduit unless the patient has significant renal insufficiency, lack of a suitable bowel segment, or inability to take responsibility for adequate self-care.4 Many different techniques are available for constructing a continent form of urinary diversion, including orthotopic neobladders as well as continent cutaneous diversions. Continent cutaneous diversion is specifically indicated for male and female patients undergoing cystectomy who are candidates for continent diversion but in whom an orthotopic neobladder is either contraindicated or not desirable. These indications include the following: 1. The patient prefers continent cutaneous diversion. 2. The external urethral sphincter is incompetent. 3. Severe urethral stricture disease is present. 4. The patient is unwilling or unable to catheterize through the urethra. 5. The patient has chronic bladder or urethral pain or severe interstitial cystitis. 6. The patient has known prostatic stroma invasion with urothelial cancer (relative contraindication to orthotopic diversion).

7. Patients who have had previous radical prostatectomy or high-dose radiation therapy to the area of the bladder neck are at higher risk of both incontinence and neobladder-urethral strictures (relative contraindication for orthotopic diversion depending on the severity of the scarring encountered during the surgical procedure). 8. Results of frozen section biopsy of the female urethra or prostatic apex are positive for urothelial cancer. Many complications are common to all types of diversion (e.g., early urinary leak and ureteral obstruction), but others are unique to continent cutaneous diversion. These diversions are constructed from isolated colon or ileum with a large variety of continence mechanisms. A discussion of the pros and cons of the various techniques is beyond the scope of this chapter. The following discussion focuses on the most common forms of continent cutaneous diversion, including the Indiana pouch and its variations, the right colon pouch with appendix or tubularized ileal stoma, and the cutaneous T-pouch. We also discuss the complications associated with the cutaneous Kock pouch, although that type of diversion is now rarely performed in the United States. Metabolic complications associated with the use of bowel in the urinary tract are covered elsewhere (see Chapter 5).

PREVENTION OF COMPLICATIONS Careful surgical technique is the key to minimizing complications related to the continent diversion. The choice of bowel segment must allow for adequate pouch volume. In general this requires approximately 44 linear cm of small bowel or 26 to 30 cm of colon for the reservoir portion. If the available colon length is 135,000 patients undergoing surgical intervention. These studies are likely somewhat dated given the shift in types of SUI procedures now performed as compared with the procedures that were popular when these data were compiled. The actual incidence of any single given complication in the general population cannot be calculated because the total number of procedures performed for UI, especially SUI is, at best, an estimate. These data can be partially captured using government databases as noted earlier or manufacturer’s sales figures for proprietary products, but this type of analysis excludes large numbers of patients such as privately insured and uninsured patients who cannot be counted using this methodology. In addition, patients undergoing surgical treatment without the use of a commercially available proprietary product (i.e., until recently, most surgical procedures performed in the United States) cannot be accounted for using this analysis. Nevertheless, the overall complication rate of all procedures is likely underreported. Deng and colleagues28 reported on complications in patients referred for repair

to a single tertiary care institution over a 4-year period and noted that despite the devastating nature of some of these complications, the reported rate in the literature was much lower than expected based on their experience. Mandatory reporting of operative complications in the United States is not required, nor does a mandatory central database or repository exist for any given procedure. In the United States, for example, surgical complications related to device malfunction can be reported to the FDA Manufacturer and User Facility Device Experience (MAUDE) database.29 This reporting is completely voluntary, and it possible that the time and effort required in reporting on this site are disincentives to reporting complications. The threat of malpractice litigation also likely contributes to underreporting of surgical complications. Furthermore, it is difficult to extrapolate the risk of a given complication occurring in the community setting, where most surgical procedures are done. Almost all the literature is published from tertiary care academic centers that may be biased toward reoperative surgery and may be influenced by ongoing resident training. In one prospective Dutch study of TVT, there was an increased risk of complications in teaching hospitals as compared with non-teaching hospitals.30 Finally, and perhaps most importantly, the definition of a complication is unclear. This lack of standardization permits considerable variability in the reporting of complications. For example, some bleeding is commonly encountered in the performance of transvaginal anti-UI procedures. However, how much bleeding must occur for it to be considered a complication? A surgeon may choose not to report bleeding at all as a complication if it happens quite commonly in his or her experience. Other surgeons may report bleeding as a complication only if it results in the development of postoperative hypotension, the requirement for transfusion, or even hemorrhagic shock and death.

Complications Related to Stress Urinary Incontinence Surgery Intraoperative Complications Bleeding  The risk of bleeding during surgical treatment of SUI can be minimized but not entirely eliminated by good operative technique. Multiple blood vessels traverse the deep pelvis including large venous channels in the retropubic space. Named vessels in the obturator fossa, along the pelvic sidewall including the iliac vessels, and within the vascular pedicle of the bladder are at risk for injury especially during vaginal surgical treatment of UI because of the lack of direct visualization of these structures during passage of trocars or needles. Major vascular injury can quickly lead to life-threatening hemorrhage if it is not recognized intraoperatively and may result in large retropubic hematomas postoperatively.31,32

Chapter 50  Complications of Female Incontinence Surgery In a series of >5000 midurethral slings reported by the Austrian Working Group for Urogynecology, bleeding problems were reported in 2.7% of cases.33 Only 0.8% of patients required intervention for bleeding, and most cases were managed conservatively without operative intervention; 200 mL in >1400 patients who underwent TVT treatment. Bleeding during retropubic bladder neck suspension is usually easily visualized and controlled with a combination of cautery, suture ligature, and if necessary direct compression. Occasionally, sponge sticks and readjustment of the retractors may be needed to visualize the bleeding vessels optimally. The retropubic anatomy is very familiar to most urologic surgeons, and bleeding during these procedures is rarely problematic. In contrast to bleeding during retropubic surgical procedures, bleeding during transvaginal operations can be more problematic at times and more difficult to control. The initial dissection of the vaginal wall from the underlying fascia should be associated with minimal bleeding. Bleeding encountered during this early dissection may indicate an excessively deep and incorrect surgical plane within the wall of the bladder or urethra. In this circumstance, immediate recognition and reevaluation are necessary to avoid inadvertent entry into the urinary tract and to minimize bleeding. Following identification of this situation, dissection should then proceed in the proper surgical plane, which, in reoperative surgical procedures, may be difficult to identify. Another common site of bleeding during transvaginal anti-UI surgical procedures occurs when the endopelvic fascia is traversed. Entry into the retropubic space from the transvaginal side or placement of the suprapubic needles or trocars from the abdominal side may be associated with copious bleeding as the endopelvic fascia is perforated. Again, knowledge of the anatomic features, careful attention to technique, maintenance of countertraction, and proper positioning of the perforating scissors (with the tips curved away from the bladder) or trocar in three planes minimize most bleeding (Fig. 50-2). An initial gush of venous bleeding is not unusual during this maneuver, and although it may be unsettling to the operating surgeon, the bleeding dissipates quickly without further manipulation. If the bleeding continues and is brisk, the vagina can be packed. It can be very helpful to elevate the anterior vaginal wall manually and compress it anteriorly directly against the posterior symphysis pubis for several minutes using the surgeon’s hand, a sponge stick, or a retractor. These maneuvers effectively tamponade bleeding in the retropubic space. It is not advisable to “chase” this bleeding using a transvaginal approach. Only very rarely

Figure 50-2  The proper plane of dissection. The scissors are directed toward the patient’s ipsilateral shoulder. Countertraction is applied to the vaginal wall.

is the exact bleeding point identified and controlled in this manner. Transvaginal exploration for bleeding results in ongoing blood loss as the surgeon struggles with relatively poor exposure and visualization. Packing and compression lead to adequate control in most cases, and if not, the surgeon should expeditiously complete the procedure, close the incisions, and pack the vagina.34 Occasionally, in addition to vaginal packing, a Foley catheter inserted through the urethra with the balloon overinflated and then placed on traction adds additional security. Brisk bleeding that does not respond to manual compression for an extended period may suggest a major vessel injury and mandates retropubic exploration. Urinary Tract Injury  During surgical procedures for SUI, the urethra, bladder, or much more rarely the ureters may be injured. Key to the management of each of these injuries are immediate recognition and repair. Long-term sequelae resulting from unrecognized urinary tract injury can be devastating to the patient and can have potentially substantial medicolegal implications for the physician. Urethral Injury  From the transvaginal side, injury to the urethra may occur during initial dissection of the vaginal wall off the underlying fascia. As noted earlier,

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Section IX  Complications of Reconstructive Surgery excessively deep dissection, especially in reoperative surgical procedures, risks urethral injury. This injury is usually although not invariably heralded by an unexpected amount of bleeding. Placement of a urethral catheter before incision will help to identify the urethra intraoperatively and in the case of urethral injury will allow immediate recognition as the catheter becomes visible in the operative field. If a urethral injury is suspected, urethroscopy may be performed. The urethra should be repaired immediately and primarily in two layers by using absorbable sutures in a watertight fashion. The urethra can be repaired over a ≥14-Fr catheter. It is not necessary to leave a drain other than the urethral catheter. The integrity of the repair can be tested by injecting saline through a syringe attached to an angiocatheter (intravenous [IV]) sheath into the urethral meatus adjacent to the catheter with the balloon snugged up against the bladder neck. Failure to recognize the injury or failure to repair it properly risks urethrovaginal fistula, erosion of sling material into the urethral lumen postoperatively (especially synthetic sling material), infection, and a multitude of other potential problems. The urethra may also be injured during trocar placement in midurethral sling procedures, needle placement for transvaginal suspensions, or cystocele repair. Countertraction during the initial dissection, maintenance of adequate exposure and a working knowledge of the anatomy are helpful in avoiding urethral injury. In the event of a planned synthetic sling in the setting of a concomitant urethral injury, it is probably advisable to repair the urethra and abort the sling procedure until the urethra is completely healed. An autologous sling may be considered a safer alternative than a synthetic sling as an anti-UI procedure at the time of a urethral injury, but few data support this notion. The urethra is rarely injured during retropubic surgical procedures because the middle and distal thirds are protected by the symphysis pubis. Bladder Injury  Intraoperative bladder injury may occur during transabdominal and transvaginal anti-UI surgical procedures. The potential for urinary tract injury varies considerably with the experience of the surgeon,35 as well as with the operative approach. Investigators generally believe that the risk of bladder injury is higher with a retropubic approach as compared with a transobturator approach during midurethral sling operations. However, multiple reports of bladder injury during transobturator midurethral sling procedures have been published.29,36 The relative risk of urinary tract perforation with a transvaginal versus suprapubic approach to midurethral slings is unclear. Although one study noted an extremely high bladder perforation rate with a suprapubic approach (29% versus 4%, suprapubic versus transvaginal, respectively),37 others did not.38 In one small ran-

domized prospective trial comparing transobturator with retropubic midurethral slings, bladder perforation was noted only in the patients who underwent retropubic procedures (4 of 42, 9.5%) whereas vaginal injury was noted only in the patients who underwent transobturator procedures (5 of 46, 10.9%).39 It is possible that the difference in complication rates results from surgical factors other than approach. Kuuva and colleagues16 reported that the risk of bladder perforation during a transvaginal midurethral sling varied with the experience of the operating surgeon. Surgeons performing >80 procedures had almost 50% fewer perforations than did surgeons who had performed 4 weeks occurred in 3% to 7% of patients undergoing Burch procedures, in 4% to 8% of those undergoing transvaginal needle suspensions, and in 3% to 11% of patients undergoing sling procedures.10 The incidence of voiding dysfunction, including urinary retention and de novo urgency and urge UI, following midurethral sling procedures ranges from approximately 2% to 25%.16,19,20,22,40,46-53 Surgical intervention for voiding dysfunction and urinary retention has been reported in 0% to 5% of patients undergoing midurethral slings.22,40,46-48,52 As noted previously, short-term voiding difficulties follow-

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Section IX  Complications of Reconstructive Surgery ing Burch procedures appear more likely than following TVT.17 This situation may also be true for pubovaginal slings as compared with TVT.54 In one multicenter but limited retrospective study, transobturator slings had fewer “obstructive” complications than did retropubic midurethral slings.55 The minimally invasive midurethral sling procedures are mechanistically tension free, and as such it is not surprising that they likely result in an overall lower incidence of postoperative voiding dysfunction than seen with other types of open SUI procedures. The finding of absolute prolonged urinary retention makes the diagnosis of obstruction fairly straightforward if the patient had relatively normal voiding dynamics preoperatively. One potential exception is the patient who voids primarily by pelvic floor relaxation. Female patients may void without a perceptible increase in intravesical pressure and in these individuals, even a modest increase in outlet closure forces, such as that caused by a sling, may result in urinary retention. In many other patients, the diagnosis of BOO is extremely difficult. Urodynamic studies, especially videourodynamic studies, are often pursued diagnostically but may not be helpful in many cases because the classic “high pressure–low flow” pattern may not be present. No pressure-flow urodynamic criteria accurately predict successful voiding following urethrolysis. Various nomograms have been developed for the diagnosis of female BOO but none are absolutely accepted as the gold standard. For patients not in frank urinary retention, the diagnosis of BOO is strongly suggested by the postoperative onset of irritative voiding symptoms, recurrent UTIs, and a poor urine stream. Physical examination may be completely normal or suggest an oversuspended midvaginal segment or the lack of mobility of the urethra following insertion of a metal sound. De novo prolapse should be excluded as a cause of postoperative BOO. An unrecognized and thus unrepaired cystocele may result in BOO following SUI surgical procedures. Before surgical intervention for postoperative urinary retention is considered, many transient causes should be considered. These are potentially unrelated to iatrogenic BOO and the mechanical effects of the procedure. In the immediate postoperative period, pain is a common reason for delayed micturition. Postoperative pain at the surgical site or catheterization trauma may suppress the micturition reflex.56 Similarly, postoperative pain relief from narcotic analgesics may suppress micturition as well. These effects are temporary and a period of catheterization for several days postoperatively allows resumption of normal voiding in most cases. Other potential causes of temporary postoperative urinary retention include patient immobility, edema at the operative site, and retropubic hematomas.

Management options for prolonged voiding difficulties include repeated voiding trials, initiation of intermittent urethral catheterization, and incision of the sling or urethrolysis. Some investigators recommended conservative therapy for postoperative voiding dysfunction for ≤3 months before surgical revision is attempted.57 Most patients resume normal voiding following midurethral slings within 1 to 2 days of the procedure. However, some patients may be delayed for 1 to 2 weeks and those with a history of prior SUI surgical procedures or those undergoing concomitant prolapse repair may be further delayed.58 However, a prolonged time to intervention for BOO may be associated with long-term, potentially irreversible bladder dysfunction even following successful urethrolysis.59 As compared with obstructive symptoms such as hesitancy, straining, and poor force of urine stream, overactive bladder symptoms resulting from iatrogenically induced BOO following an anti-UI surgical procedure are less likely to improve despite a technically successful operation. In one series, voiding symptoms resolved in 82% of obstructed patients following urethrolysis, whereas overactive bladder (storage) symptoms resolved in only 35%.60 In this series, increased time to intervention was not correlated with persistent detrusor dysfunction. Once the diagnosis of BOO is considered or established, options include long-term intermittent urethral catheterization, transvaginal or retropubic urethrolysis, or, if applicable, transvaginal incision of the sling. Transvaginal incision of autologous pubovaginal slings is often highly successful in improving voiding dynamics.61,62 With the advent of midurethral slings, transvaginal incision of the sling is also often attempted as an initial step in these cases.63 This procedure can be performed as soon as 1 week from the surgical procedure, although investigators vary with respect to the optimal timing of intervention. The incision can be made using local anesthesia in some cases. Care must be taken to avoid urethral injury while performing a sling incision because the urethral wall may be draped over the taut sling and may be inadvertently pinched and perforated during dissection and isolation of the sling for incision. Generally, the longer the time from sling surgery to sling incision, the more difficult it can be to find the sling during repeat exploration. Following isolation and division of the sling, the edges of the cut sling often separate by 1 to 2 cm, a finding indicating a satisfactory result. Iatrogenic obstruction resulting from autologous fascial slings is often treated in this manner as well.62 However, historically, some investigators waited ≤3 months before consideration of sling incision for obstructing fascial slings (Fig. 50-3). For patients in whom transvaginal incision fails, or in patients who underwent a nonsling procedure as the

Chapter 50  Complications of Female Incontinence Surgery

Figure 50-4  A small area of beefy granulation tissue (black arrow) is seen along the anterior vaginal wall in this patient, a finding suggesting vaginal extrusion.

Figure 50-3  Transvaginal incision of a fascial sling. The sling in this case is seen between the tip of the sucker and the white arrow as a shiny band of tissue.

cause of their BOO, urethrolysis may be performed.64,65 Through a transvaginal or retropubic approach,64,66,67 the retropubic space is entered and the urethra is sharply dissected off the posterior surface of the symphysis pubis and is freed from the surrounding scar. The limbs of the sling or other retropubic attachments are isolated and divided in the retropubic space. Lateral attachments to the pelvic sidewall are incised as needed for patients who previously underwent a Burch or paravaginal repair. A transvaginal, suprameatal approach to urethrolysis has also been described and may be particularly applicable to those patients who previously underwent an MMK procedure.67 Recurrence of SUI symptoms following urethrolysis or sling incision may occur in 15% to 20% of patients.62,68 Patients should be counseled regarding this possibility preoperatively because some may wish to continue performing intermittent catheterization rather than risk recurrent SUI. Vaginal Extrusion and Urinary Tract Erosion  Vaginal extrusion refers to the finding of exposed sling material in the vaginal canal postoperatively, whereas erosion implies the finding of material within the lumen of the urinary tract at some time interval postoperatively that was clearly documented as not being within the urinary tract intraoperatively.

Extrusion of material may be related to surgical technique, infection, or the physical properties of the implanted material. The extruded material may be located in the midline at the incision line or at the anterolateral vaginal wall. Midline extrusions imply wound dehiscence. Lateral extrusions may result from an unrecognized vaginal wall perforation or injury at the time of sling placement. Patients are usually symptomatic and have complaints suggesting an extrusion, including a malodorous vaginal discharge, vaginal spotting, vaginal pain, and dyspareunia. Patients may present several days to months postoperatively. On physical examination, the extruded material is often visible, but physical findings may also be quite subtle (Fig. 50-4).69 Granulation tissue suggests the presence of an extrusion. Extruded synthetic mesh is often palpable within the vagina, although the patient’s discomfort may preclude a complete examination. Factors responsible for extrusion include the physical nature of the implanted material, the quality of the vaginal tissues of the host, sling tension, wound healing, and infection.70 It appears that multifilament materials are at greater risk for extrusion than monofilaments.71 In addition, a pore size that is large enough to permit fibroblast and macrophage infiltration and subsequent tissue ingrowth is an important factor in preventing extrusion.72 Some risk factors are not well defined and are specific to the material; as a result, some products were removed from the market.73,74 Synthetic material placed years earlier may eventually become infected and create a draining sinus or may become a nidus of pelvic infection or recurrent UTIs.75 These materials will require exploration and explantation. Small extrusions may heal with conservative management including the application of topical estrogen

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Section IX  Complications of Reconstructive Surgery changes to the anterior thigh or in more severe cases weakness of hip flexion. Severe abduction and external rotation of the thigh should be minimized during positioning to avoid this complication. The peroneal nerve can be injured by direct compression while the patient is in the lithotomy position. Lateral direct pressure on the peroneal nerve between the stirrup at the lateral aspect of the knee joint and the fibular head for a prolonged period may result in peroneal nerve palsy and foot drop.77 This injury may also occur with compression of the fibular head against the stirrup holder, especially when candy cane stirrups are used because the leg rotates externally after placement in the holders. The ilioinguinal and iliohypogastric nerves may be injured by suprapubic trocar placement or dissection resulting in pain in the suprapubic region.78 Figure 50-5  Intravesical erosion of a polypropylene sling.

creams. Larger extrusions can be managed with copious irrigation and secondary closure in the operating room. Some patients with large extrusions may benefit from excision and removal of the extruded segment of the sling. In the immediate postoperative period, avoiding vaginal intercourse or vaginal tampon use should be strongly encouraged for the first 4 to 6 weeks following vaginal surgery to avoid disruption of the vaginal incision and subsequent extrusion of the sling material. Urinary tract erosion may occur with synthetic, biologic, or autologous materials.76 This is a devastating complication that unlike extrusion is almost always managed operatively. Whether urinary tract erosion results from a missed intraoperative urinary viscus perforation or from migration of the material into the urinary tract sometime following the surgical procedure is unclear. Patients may complain of irritative lower urinary tract symptoms, recurrent UTIs, hematuria, dysuria, and pelvic pain. The definitive diagnosis is usually made endoscopically (Fig. 50-5). For intravesical erosions, endoscopic scissor or laser transection of the intravesical portion of the eroded sling may permit the remaining sling material to retract outside the urinary tract. If this procedure fails or is technically not feasible, then open operative exploration, removal of the eroded material, closure of the urinary tract, and postoperative drainage will be necessary. Nerve Injury  Several nerves traverse the deep pelvis as well as superficially within the lower abdominal soft tissues. These nerves are at risk for injury during UI surgical procedures in female patients. Stretch or compression injury to the femoral nerve can result from positioning. Femoral nerve compression may occur at the level of the inguinal ligament in response to flexion of the hip joint.77 This complication results in sensory

Bone Anchor–related Complications  Although the use of bone anchors (BAs) was originally suggested as an alternative and perhaps even superior method of suture fixation during surgical procedures for SUI such as pubovaginal slings and needle bladder neck suspensions, the evidence to date supporting the use of BAs is weak. BAs have been at times touted as effective and minimally invasive; however, since their introduction, a convincing argument for the use of BAs has not evolved clinically or in the literature.13 With the advent of minimally invasive midurethral slings, the use of BAs has declined. The complications associated with BAs can be devastating, including osteitis pubis and osteomyelitis of the symphysis pubis. Numerous reports exist of BA-related complications associated with female UI surgical procedures in the urologic, gynecologic, and orthopedic scientific literature.79-83 Graham and Dmochowski83 reported on nine patients with pubic osteomyelitis following BA placement elsewhere who were referred for definitive therapy. The BAs were removed successfully from all patients, although residual problems included UI (five of nine patients), and chronic pain (three of nine patients). In a thorough review of the literature, Rackley and colleagues81 estimated the prevalence of BA-related infections in female pelvic reconstructive procedures to be approximately 0.6%. Once diagnosed, osteomyelitis related to BAs requires operative exploration and removal of the BA. The BAs are often seated below the cortical bone, a site that mandates partial resection of the overlying bone, usually with fluoroscopic guidance, to locate and remove the BA. Sexual Dysfunction  Historically, female sexual dysfunction following surgery for UI has only infrequently been reported. Whether this finding is the result of a generalized lack of understanding of the condition, a lack of interest in reporting or investigating its occurrence, or an actual low incidence is unclear. Only more

Chapter 50  Complications of Female Incontinence Surgery recently has the trend been to query female patients regarding sexual dysfunction, and to date few instruments exist.84 Female sexual dysfunction is a complex and poorly understood phenomenon,85-87 and a full discussion is beyond the scope of this chapter. Coital incontinence can be improved following successful sling operations,88,89 and sexual function scores are similarly improved.90 However, new-onset sexual dysfunction following sling procedures that is unrelated to vaginal sling erosion has been reported in ≤20% of patients in some series.91,92 Shah and colleagues93 reported no difference in female sexual function following distal urethral sling procedures. Dyspareunia is only one form of sexual dysfunction, but it may occur following anti-UI surgical procedures. Vaginal anatomy is altered by the surgical treatment of SUI. The vaginal axis can be shifted, thus changing the angulation of the vaginal canal. Circumferential narrowing of the vagina may result from excessive trimming of vaginal wall during prolapse repair or simply as a result of aberrant scarring. Dissection along the anterior vaginal wall may cause nerve injury and neuroma formation. Other ill-defined and poorly understood factors contributing to postoperative sexual dysfunction may exist. For example, in some series, 4% to 5% of patients following TVT or intravaginal slingplasty experienced decreased libido.89,91 The reason for this decreased libido is unclear. Postoperative dyspareunia should be assessed by a thorough physical examination. When vaginal scarring or narrowing and especially sling extrusion have been excluded, other causes of new-onset sexual dysfunction should be explored and treated.94

function95 including urinary retention, and hematuria are seen with all the periurethral injectable agents. Minor complications have been reported in ≤20% of patients receiving GAX collagen, although most of these complications are self-limited. Stothers and colleagues96 reviewed complications related to intraurethral collagen injection in a large series of patients. Of 337 patients injected with intraurethral collagen, approximately 20% had ≥1 minor complication. The most common reported complication was de novo urge UI in 12.6%, followed by hematuria in 5% and urinary retention in 1.9%. Three patients developed a delayed hypersensitivity reaction at the skin test site, 2 of whom patients had significant arthralgias. Although the nature of the complications attributed to intraurethral collagen in this study was somewhat benign and self-limited, even this relatively conservative therapy for the treatment of SUI is not without adverse effects. Transient dysuria is not uncommon following intraurethral injections. This symptom is generally self-limited. For those individuals with persistent symptoms, UTI should be excluded. Tegress (ethylene vinyl alcohol), which was removed from the commercial marketplace, was associated with persistent dysuria, sometimes on exposure of the material in the urethral lumen following injection. In a series of 17 male patients injected with Tegress for the treatment of SUI, symptomatic urethral erosion of the material was noted in 41%.97 Distal and systemic migration of periurethral injectable agents including Teflon and carbon-coated beads has been reported. The long-term ramifications of these synthetic materials in the lymph nodes, lungs, and other organs are unknown.98

Other Postoperative Complications  Urinary fistula following anti-UI surgical procedures is quite rare. Nevertheless, an unrecognized and unrepaired intraoperative injury to the ureter, bladder, or urethra may result in ureterovaginal, vesicovaginal, or urethrovaginal fistula. Intraoperative recognition of the injury is critical to prevent fistula formation, and thus the importance of a careful intraoperative endoscopic examination and confirmation of urinary tract patency cannot be overemphasized. De novo vaginal prolapse including cystocele and enterocele may also occur following anti-UI surgical procedures. Alteration of the vaginal axis especially with open retropubic procedures such as the Burch or MMK may result in anatomic changes that predispose patients to postoperative vaginal prolapse. Predicting which patients will develop postoperative vaginal prolapse is exceedingly difficult.

Complications Related to Urge Incontinence Surgery

Periurethral Bulking Agents In general, the morbidity associated with periurethral injectable agents is low. UTI, short-term voiding dys-

Botulinum Toxin A Although BT is potentially quite toxic, few complications have been reported with its use. Local and selflimited complications such as hematuria, dysuria, pain, and infection are infrequently reported. The most worrisome potential complication, respiratory suppression, has not been reported with urinary tract injection of BT. Urinary retention following intradetrusor injection in non-neurogenic detrusor overactivity is uncommon but has been reported in 5% to 16% of patients.99 Because the pharmacologic effects of BT are not manifest for 7 to 10 days following injection, immediate urinary retention following BT injection is likely related not to the agent itself but rather to other factors including instrumentation. Urinary retention or voiding dysfunction resulting from BT usually occurs 1 to 2 weeks following injection. Scattered reports of systemic adverse effects have been noted with the use of the Dysport formulation of BT available in Europe. The FDA approved Dysport for

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Section IX  Complications of Reconstructive Surgery TABLE 50-3  Adverse Events Related to Sacral Neuromodulation (InterStim Implantation) in 219 Patients Adverse Event

Percentage (%)

Pain at the stimulator site

15.3

New pain

9.0

Lead migration

8.4

Infection

6.1

Transient electric shock

5.5

Pain at the lead site

5.4

Changes in bowel function

3.0

Adapted from Seigel SW, Catanzano F, Dijkema H, et al. Long-term results of a multicenter study on sacral nerve stimulation for treatment of urinary urge incontinence, urgency-frequency and retention. Urology. 2000;56(suppl 6):87-91.

use in the United States in April 2009. These reactions have included generalized muscle weakness and hyposthenia in ≤6% of individuals and appear to be dose related because they have not been reported with the use of lower doses of the material.99 One case of mild arm weakness has been reported with the use of the BOTOX formulation of BT that is available for certain nonurologic applications in the United States.

Sacral Neuromodulation Several complications related to sacral neuromodulation have been well documented. Overall, the reported surgical revision or removal rate has been reported to be ≤16% to 32%.100,101 Seigel and colleagues102 reported adverse events in 219 patients (Table 50-3); in these

patients, pain at the stimulator site was the most common event. Pain at the stimulator site is the most frequently reported complication in many series.101,103 Generally relocation of the device into another buttock or lower abdominal site improves the pain.

KEY POINTS 1. The popularity of midurethral polypropylene slings has changed the types of complications seen in surgical treatment of SUI. 2. New voiding symptoms including overactive bladder symptoms or recurrent UTIs following anti-UI surgical procedures may indicate iatrogenic BOO, which is a very difficult and subtle diagnosis in many patients. 3. Intraoperative trocar injury to the bladder during midurethral sling placement is common, and completion of procedure can be accomplished with minimal morbidity. 4. Currently, few or no data on complications support one approach to midurethral slings over another (i.e., retropubic versus transvaginal versus transobturator) as causing less morbidity. 5.  Attention to technique, experience of the surgeon, and careful endoscopic examination of the urinary tract following anti-UI surgical procedures are important factors in reducing operative and postoperative complications.

REFERENCES Please see www.expertconsult.com

Chapter 

51

COMPLICATIONS OF SURGERY FOR MALE INCONTINENCE Katie N. Ballert

MD Fellow, Department of Urology, New York University School of Medicine, New York, New York

Victor W. Nitti

MD Professor and Vice Chairman, Department of Urology, New York University School of Medicine, New York, New York

Urinary incontinence is a potential complication following surgical treatment of benign prostatic hyperplasia or prostate cancer and has a significant impact on quality of life.1,2 Most cases of incontinence following radical prostatectomy and some cases of incontinence caused by treatments for benign prostatic hyperplasia result from sphincteric insufficiency.3,4 The artificial urinary sphincter (AUS) is the current gold standard for the treatment of male stress urinary incontinence. Other treatment options such as male sling (MS) procedures and inflatable balloon compression devices have been described for patients with less severe incontinence and those not desiring a mechanical device. Three distinct types of sling procedures have been described: 1. The so-called bulbourethral slings compress the urethra and extend from suprapubically to suburethrally.5,6 2. The bone-anchored perineal slings compress the urethra from a perineal approach only and are the most commonly used MSs.7,8 Intermediate-term success rates comparable to those seen with the AUS in appropriately selected patients have been reported with the bone-anchored sling.9 3. More recently, the transobturator sling was developed as an additional treatment option for male stress incontinence. The theory is that this sling restores continence not by urethral compression but rather by repositioning the proximal urethra. Tensioning causes proximal movement of the dorsal portion of the proximal bulb that, in turn, affects closure of the urethral lumen and advances the membranous urethra cranial and posteriorly.10 Outcome data available on transobturator slings are limited. Each of these procedures has its own set of complications of which physicians and patients should be aware.

In this chapter, we first discuss preoperative evaluation, which can influence potential complications. We then briefly describe the surgical procedures most commonly performed for male urinary incontinence (in order for the reader to appreciate when and why certain complications occur), and finally we discuss the potential complications encountered during the procedures with respect to their temporal occurrence (Table 51-1).

PREOPERATIVE CONSIDERATIONS Traditionally most urologists agreed that patients should be followed for approximately 12 months before surgical management of postprostatectomy incontinence is pursued. More recently, earlier intervention (e.g., at 6 months) has been recommended in severe cases of incontinence with no temporal improvement. The evaluation of a patient with postprostatectomy incontinence should include a thorough history and physical examination. Important aspects of the history include precipitating factors, associated symptoms (frequency, urgency, nocturia, weak urine stream), severity of incontinence, and impact on quality of life. The history should also address the patient’s voiding symptoms before prostate surgery as well as a history of neurologic disease or symptoms, radiation therapy, additional procedures, and earlier attempts at treating the incontinence. During the physical examination, the patient should be instructed to cough or perform a Valsalva maneuver to demonstrate the presence of stress incontinence. In addition, a focused neurologic examination should be performed. We perform a 24-hour pad test to assess the severity of incontinence objectively as well as to help guide our discussion with the patient regarding surgical options and outcome expectations. In a study by Fisher and colleagues,11 the only preoperative factor predictive of success following a perineal MS procedure was 24-hour 593

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Section IX  Complications of Reconstructive Surgery TABLE 51-1  Complications of Male Incontinence Surgery Intraoperative

Early

Late

Artificial urinary sphincter

Corporeal injury Urethral injury Device injury Bleeding

Hematoma Retention Infection Erosion

Infection Erosion Urethral atrophy Mechanical Retention

Male sling

Bleeding Urethral injury Obturator nerve injury

Hematoma Retention Infection Pain Paresthesia

Infection Erosion De novo urgency Obstruction Prolonged pain Prolonged paresthesia

pad weight. Patients with high-grade incontinence and those with very low-grade incontinence do not do as well with an MS.11 The reason for the lower rate of satisfaction among patients with very low-grade incontinence was thought to be related to extremely high expectations in that group. We also perform urodynamic studies in all patients before surgical treatment of postprostatectomy incontinence. Urodynamic testing allows for determination of the cause and guides the treatment of male urinary incontinence.12 The main goals of the urodynamic evaluation are to determine the presence of sphincteric insufficiency or bladder dysfunction, to evaluate for obstruction, and to assess detrusor contractility. It is crucial that the study reproduce the patient’s symptoms, which in this case would be incontinence. We follow the urodynamic protocol described by Huckabay and colleagues13 that includes evaluation both with and without a urethral catheter. This urodynamic protocol addresses the subset of men with postprostatectomy stress urinary incontinence who have no leakage with the catheter in place4,14 and allows for documentation of sphincteric insufficiency in these men. In addition, a flow rate without the catheter allows corroboration of free maximal flow (free Qmax) and Qmax in those patients who have suspected obstruction based on pressure-flow analysis.

PROCEDURES FOR MALE INCONTINENCE Artificial Urinary Sphincter Various techniques exist for implantation of the AUS (AMS 800, American Medical Systems, Minnetonka, Minnesota). The classic approach consists of a perineal incision and a lower abdominal incision (either transverse or midline). Other investigators have described placement through a single penoscrotal incision.15 Traditionally, after placement of a Foley catheter, a midline perineal incision is made and the bulbospongiosus muscle is exposed. The bulbospongiosus muscle can be split or preserved, although we and most other surgeons

choose to split it. The urethra is then dissected circumferentially with special attention given to mobilization of the urethra from the intracrural septum. An approximately 2-cm window is made between the corpora cavernosa and the urethra. The urethra is inspected for injury by withdrawing the Foley catheter into the distal urethra and instilling saline solution. The urethra is then measured, and the appropriately sized cuff is placed. We typically use a transverse lower abdominal incision for placement of the reservoir; however, a midline incision is also an option. The reservoir can be placed preperitoneally, intraperitoneally, or in the retropubic space. We retract the rectus muscle medially, open the transversalis fascia, and place the reservoir in the retropubic space. Typically, a reservoir with 61 to 70 cm H2O pressure is used and is filled with 23 mL of saline solution. The tubing from the cuff is passed over the pubic bone into the suprapubic incision. Finally, a plane is developed between the suprapubic incision and the ipsilateral hemiscrotum, and a pocket is created in a dependent position for the pump. The components are then connected, and the device is cycled and deactivated.

Male Slings Bone-Anchored Sling The most commonly used bone-anchored sling is the InVance sling (American Medical Systems, Minnetonka, Minnesota). We prefer regional anesthesia so that a cough test can be performed during the procedure. A Foley catheter is placed, and a midline perineal incision is made. The bulbospongiosus muscle is identified and the bilateral pubic rami are exposed. Three bone anchors with attached polypropylene suture are placed bilaterally with the use of a drill. The first anchor is placed at the junction of the pubic symphysis and the pubic ramus, the second is placed approximately 3 cm below the first, and the last splits the distance between the two. A 4 × 7 cm silicone-coated polyester mesh sling is secured unilaterally with the polypropylene sutures. Initial tension is determined by performing a cough test

Chapter 51  Complications of Surgery for Male Incontinence

Transobturator Male Sling

Figure 51-1  Bone-anchored male sling secured into position.

with 250  mL in the bladder. The contralateral side of the sling is secured with a single throw in the sutures, and a retrograde leak point pressure (RLPP) is determined. Tension is readjusted if the RLPP is not ≥60 cm H2O. The sling is completely secured into position (Fig. 51-1), and both the cough test and the RLPP are repeated to ensure appropriate tension. The excess mesh is then excised.

Bulbourethral Slings A percutaneous suprapubic tube and a Foley catheter are placed. A transverse suprapubic incision is made and is taken down to the rectus fascia. A midline perineal incision is made and Colles’ fascia is incised laterally to the bulbocavernosus muscle. Finger dissection medial to the ischial arch and lateral to the bulbocavernosus muscle is performed. A modified Stamey needle is passed from the suprapubic incision, lateral to the vesical neck and urethra, and out through the perineal membrane anteriorly between the bulbocavernous muscle and the ischial bone. The sutures on one end of three previously prepared bolsters are passed through the needle, and the needle is withdrawn into the suprapubic incision. The procedure is then repeated on the contralateral side. The bolsters are placed in parallel formation over the urethra to form a sling, and the most posterior bolster is sutured to the bulbocavernous muscle to prevent migration. Tension is placed on the sutures and, using pressure measurements as a guide, they are tied across midline. Cystoscopy can either be performed during or following needle passage to exclude urethral injury.5 Romano and colleagues6 described modifications to the procedure that allow placement of an adjustable bulbourethral sling (Argus, Promedon SA, Cordoba, Argentina). The modifications include omitting the suprapubic tube and passing the needle from the perineum to the abdomen in an attempt to decrease urethral injuries.6

The most commonly used transobturator MS is the Advance (American Medical Systems, Minnetonka, Minnesota). A Foley catheter is placed, and a midline perineal incision is made. The bulbospongiosus muscle is identified, split in the midline, and dissected off the urethra. The urethra is dissected to the level of the perineal body and genitourinary diaphragm. A mark is made on the skin approximately 2 cm below and 1.5 cm lateral to the insertion of the adductor longus. A spinal needle may be used to ensure that the obturator fossa lies at the level of the mark, and a small skin incision is made. A helical passer is then passed through the skin incision, the obturator fossa, the obturator externus muscle, and the obturator membrane. The triangle formed by the urethra, the bulbospongiosus muscle, and the bulbocavernosus muscle is palpated and the trocar is guided onto the surgeon’s index finger. A similar procedure is performed on the contralateral side. Cystoscopy is performed to ensure that no injury to the bladder or urethra has occurred. The sling is then attached and is brought out through the skin. The sling is secured proximally and distally in the midline with suture, and tension is placed to provide elevation of the urethra. Cystoscopy is repeated to evaluate urethral coaptation.10

Inflatable Balloon Compression Prostate adjustable continence therapy (ProACT, Uromedica, Plymouth, Minnesota) has been introduced as a minimally invasive treatment for postprostatectomy incontinence. At the time of this writing, ProACT is not available in the United States, although it is used commonly in other countries around the world. The patient is placed in the lithotomy position and cystoscopy is performed. Instillation into the bladder of 50 to 100 mL of contrast material is performed and the cystoscope sheath with its obturator is left in place. A perineal incision is made, and previously a Kelly clamp was used to perforate the pelvic floor.16,17 More recently, a tissue expansion device has been used to facilitate development of the periurethral space.18 Following creation of the tract using a special trocar in a U-shaped cannula, the tissue expansion device is inserted. The balloon is then placed in an area beneath the bladder neck and dorsolateral to the urethra. The balloon is filled with 1 to 5  mL of contrast medium and sterile water. A balloon is placed on the contralateral side in a similar fashion. Cystoscopy is performed to confirm balloon position and to exclude urethral injury. Blunt dissection is then performed toward the scrotum, and the balloon ports are placed bilaterally just beneath dartos fascia in the scrotum. This technique allows for percutaneous needle access for future inflation or deflation of the balloons.16,17

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Section IX  Complications of Reconstructive Surgery

INTRAOPERATIVE COMPLICATIONS Artificial Urinary Sphincter Most intraoperative complications are inconsequ­ ential if they are recognized and treated at the time of the surgical procedure. The exception is urethral injury, which requires aborting the procedure in most cases.

Corporeal Injury In AUS placement procedures, urethral or corporeal injury can occur during mobilization of the urethra from the intracrural septum. Corporeal injury may result in significant bleeding that can impair visualization. Adequate exposure is the key to identifying the injury. Once the injury is identified it can be repaired with absorbable suture.

Urethral Injury Urethral injury is another potential intraoperative complication and one that should not go unrecognized. Urethral injury typically occurs dorsally, where the spongiosum is thinnest. To detect an unrecognized urethral injury, saline or dilute indigo carmine can be instilled along side the Foley catheter or through the Foley catheter while moving it in a retrograde fashion. If a urethral injury is identified, it should be repaired in multiple layers with absorbable suture, if possible. Most surgeons would abort AUS placement and a leave a Foley catheter for an appropriate period of time. In rare cases if the injury is small and away from the intended site of implantation, the cuff can be placed, although this must be done with extreme caution. If any question exists regarding the repair or if the cuff cannot be placed away from the site of injury, then the procedure should be aborted. Injury to the corpus spongiosum but not involving the urethra is usually inconsequential especially when it occurs ventrally where the spongy tissue is thick. Such injuries can simply be oversewn to control bleeding. Dorsally, where the sponge this thin, concomitant urethral injury is common.

Device Injury Care must also be taken to avoid any injury to the device. Damage to the device can result in leakage of fluid from the device and mechanical failure. The tubing should be handled with rubber-shod clamps and care should be taken not to injure the device with sharp instruments or needles. If a device injury is noted, the “injured” component should be replaced. Unrecognized injury results in malfunction of the device as fluid leaks out of the system.

Bleeding Most significant bleeding with AUS placement results from corpora cavernosa or spongiosum injury (see

earlier). Bleeding can also occur with placement of the reservoir from epigastric or retroperitoneal vessels.

Male Sling Intraoperative complications with sling placement are unusual, and the most common with a boneanchored sling is bleeding. Minimal literature is available on the newer transobturator placement of an MS. Based on the technique, obturator nerve injury would certainly seem to be a possibility, but it has not yet been reported.

Bleeding We are unaware of any reported cases of significant intraoperative bleeding following MS procedures, and none of the major series have reported transfusions.9,11,19-21 However, corporeal injury and bleeding can occur during dissection or during placement of the bone anchors. This bleeding usually occurs when the corporeal bodies are dissected off the pubic ramus to facilitate placement of bone anchors. Bleeding can also occur when a bone anchor is placed through the corpora. Bleeding from a main or accessory obturator vessel would certainly be possible with transobturator sling placement. When a transobturator sling is placed, it is not unusual to encounter bleeding as the urethra is dissected to the perineal body. This bleeding usually results from small injuries to the spongiosum that can be oversewn with fine absorbable suture (e.g., 4-0 polyglycolic acid). During the same procedure, bleeding can be caused by injury to small vessels along the route of needle passage through the obturator fossa. When this occurs, bleeding can usually can be controlled by tensioning the sling. Certainly, injury to a major obturator vessel is possible, but we are unaware of any reported cases of major vascular injury.

Urethral Injury Urethral injury with the bone-anchored sling is not reported in the literature but is certainly possible and should be treated as described earlier for the AUS. Romano and colleagues6 reported a potential urethral perforation rate of 6% with the Argus adjustable bulbourethral sling. This situation was addressed intraoperatively by repositioning the needle and resulted in no further complications.6 With transobturator sling placement, urethral injury is possible from needle perforation, usually near the bladder neck. Thus cystoscopy after sling placement is essential. If such an injury is seen, the needle or sling should be removed. The injury is usually not in a position that can easily be repaired, so treatment is with catheter drainage for ≤7 days depending on the size of the injury. The sling may be replaced in the same setting at the surgeon’s discretion depending on the site and size of the injury.

Chapter 51  Complications of Surgery for Male Incontinence

Inflatable Balloon Compression No major bleeding complications have been reported during placement of ProACT. Hübner and Schlarp18 reported an 8% rate of urethral perforation, a 4% rate of immediate balloon rupture, and a 4% rate of intraoperative balloon migration in their initial 50 patients. In the most recent 50 cases, no urethral perforations, balloon ruptures, or migrations have occurred intraoperatively.18

Bladder Perforation Bladder perforation rates of 8% to 18% have been reported. In the majority of cases, this complication resulted in delayed implantation on the affected side with an indwelling Foley catheter for 3 days.16,17 However, more recently, Hübner and Schlarp18 reported placing the balloon more distally in cases of “minor” perforation.

EARLY POSTOPERATIVE COMPLICATIONS Artificial Urinary Sphincter Hematoma Scrotal hematoma is a common minor postoperative complication associated with AUS implantation. Hematomas typically resolve spontaneously without intervention; evacuation is rarely indicated.

The most common organism in early infection is Staphylococcus epidermidis.24 Another potential cause of early infection is unrecognized urethral injury. Urethroscopy should be performed when the device is removed. Infection requires removal of the entire device and reimplantation after ≥3 months. In selected cases, one may consider device replacement at the time of removal after aggressive wound irrigation with antibiotics, as described by Bryan and colleagues25 (see later).

Early Erosion Early erosion can also occur with or without infection. It is likely the result of unrecognized iatrogenic urethral injury, urethral thinning, or early postoperative replacement of a Foley catheter. Erosion may manifest with pain or swelling in the scrotum or perineum, pain referred to the tip of the penis, recurrent incontinence, dysuria, hematuria, or bloody discharge. If erosion occurs without infection, the tubing can be capped at the time of cuff removal. If it is associated with infection, the entire device should be removed. The urethra is repaired with absorbable suture, if possible, and a Foley catheter is left indwelling. A voiding cystourethrogram is performed to ensure that the urethra has healed before the catheter is removed, and at the time of reimplantation a different site is selected for the cuff.

Male Perineal Sling

Urinary Retention

Hematoma

Another early complication is urinary retention as a result of postoperative edema. We typically leave a 14-Fr Foley catheter in place overnight in an attempt to avoid this problem. Bladder neck dilation (for anastomotic stricture) is a risk factor for urinary retention beyond 24 hours. If retention occurs following removal of the Foley catheter, the first step should be examination of the device to ensure deactivation with the cuff in an open position. If catheterization is required, it should be performed carefully with a small 10- to 14-Fr Foley catheter and catheterization time should be kept to a minimum (preferably 100 mL) that resolved within 48 hours. We currently leave a Foley catheter indwelling for 48 to 72 hours after placement of bone-anchored perineal slings to avoid acute postoperative urinary retention. We found a relatively high rate of failure to void when the catheter was removed after 24 hours. Postoperative pain may contribute to early urinary retention. After 48 hours, the risk of urinary retention is 4 months after implantation) are thought to be the result of hematogenous seeding secondary to bacteremia from another source.23,24 Late infections most commonly present with scrotal pain, but they may also manifest with erythema, edema or induration around the pump, or fever. Infection is most commonly managed by removing all components of the device; however, Bryan, Mulcahy, and Simmons25 reported management of patients with a salvage technique similar to that used for salvage of penile prostheses. Cystoscopy is performed to rule out urethral erosion. All prosthetic parts are removed, wounds are copiously irrigated according to a seven solution protocol, and a new device is implanted.25 In several large series, erosion rates ranging from 2.2% to 6.6% were reported.26-31,34 Common causes of erosion included prolonged catheterization, catheterization without cuff deactivation, and repeated endoscopic manipulation of the urethra. In a study by Raj and colleagues,35 patients with hypertension, coronary artery disease, prior radiation, and prior AUS revision (especially for erosion) were found to have a higher likelihood of erosion. These investigators also found that patients undergoing revision for erosion had worse postoperative continence rates than did those undergoing revision for other reasons.35 Other investigators also found a higher rate of erosion in irradiated patients. In a series of men with post­ prostatectomy incontinence, Walsh and colleagues32 reported that erosions were more common in patients that had received radiation therapy (23%) than those that had not (1%). On the contrary, Lai and colleagues26 found no statistical difference in erosion rates among nonirradiated patients, irradiated patients, patients with neurogenic disease, or patients who underwent secondary implantation. In patients who experienced erosion, these investigators found a median time to erosion of 19.8 months.26 Potential manifestations of urethral erosion include pain or swelling in the perineum or scrotum, pain referred to the tip of the penis, recurrent incontinence, dysuria, hematuria, or bloody discharge. Erosion is typically into the urethra, but erosion of tubing to the skin can also occur. Urethral erosion typically occurs on the dorsal side of the urethra where the sponge is thinnest, but it can occur anywhere, especially if is associated

Chapter 51  Complications of Surgery for Male Incontinence period of catheterization. In either case, a Foley catheter is left indwelling until closure is evidenced by voiding cystourethrogram, usually in 1 to 2 weeks. Reimplantation is performed 3 to 6 months later. Before reim­ plantation, cystourethroscopy is performed to ensure adequate healing and to rule out formation of a stricture at the site of previous erosion. The new cuff is positioned away from the erosion site. Guralnick and colleagues36 described a transcorporeal technique to address patients who require a distal cuff location secondary to previous erosion or urethral atrophy. This technique involves vertical corporotomies with creation of a tunnel leaving a cuff of tunica albuginea on the dorsal surface of the urethra.36

Recurrent Incontinence

Figure 51-2  Urethral erosion of an artificial urinary sphincter, cystoscopic view. The color indicates that this is likely a longstanding erosion.

Recurrent incontinence can result from bladder or sphincteric dysfunction. When it is caused by sphincteric insufficiency, it is likely related to urethral atrophy or mechanical malfunction of the device, as discussed later. Recurrent incontinence can also be a manifestation of infection or erosion, as previously discussed. If it is not clear whether the incontinence is the result of bladder or sphincteric dysfunction, urodynamic evaluation can be helpful. When performing urodynamic studies in a patient who has an AUS, the device should be deactivated with the cuff deflated before the catheter is inserted. Once the catheter is in place, the AUS should be reactivated for filling and stress testing.

Urethral Atrophy

Figure 51-3  Urethral erosion of an artificial urinary sphincter, gross view.

with trauma (Figs. 51-2 and Fig 51-3). When urethral erosion occurs, at a minimum the cuff must be removed. If one suspects an associated infection, the entire device should be removed. The site of erosion may be repaired with absorbable suture if it can be easily accessed. However, dorsal erosions are the most common and are often left unrepaired and simply allowed to heal with a

The introduction of the narrow-backed cuff has improved urethral pressure transmission; however, urethral atrophy still accounts for a significant portion of nonmechanical AUS revisions.28,37 Rates of urethral atrophy have been reported to range from 0% to 14%.26-31 Obviously, these rates vary depending on length of follow-up. Urethral atrophy manifests as new-onset incontinence. Examination demonstrates a normally functioning pump. Cystourethroscopy may reveal incomplete coaptation of the urethra, and the urethra may appear thin and pale. Multiple management options have been proposed for urethral atrophy including downsizing the cuff,38 placing the cuff in a more proximal location,39 placing tandem cuffs,40 increasing reservoir pressure, or placing the cuff transcorporeally.36 In addition, one report demonstrated that in patients who deactivated their cuff at night, recurrent incontinence secondary to urethral atrophy was decreased from 21% to 10%.37 We prefer to downsize the cuff if possible as the first-line treatment for urethral atrophy. Our second choice is to move the cuff to another position, usually proximally. Placing a transcorporeal cuff is also a viable option when adequate urethral circumference cannot be obtained. Rahman and colleagues41 also described

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Section IX  Complications of Reconstructive Surgery wrapping the urethra with a biologic material to increase bulk.

Mechanical Malfunction Mechanical malfunctions can include leakage from one of the components, kinking of the tubing, pump malfunction, and connector separation. Reported rates of mechanical malfunction in several large series ranged from 6% to 25.3%.26-31 A >50% decrease in mechanical failure rates has been attributed to improvements in the material used to make the AUS and the introduction of the narrow-back cuff.28,42 Mechanical malfunction typically manifests with recurrent incontinence, but it can also manifest with urinary retention. Physical examination often reveals a pump that is difficult to compress, one that is partially decompressed, or one that takes too long to refill. Intraoperative methods of evaluating component leakage including Ohm testing and volumetric pressure measurements are available. If a component-specific malfunction is identified, the component can be replaced. If the problematic site (e.g., point of leakage) cannot be found or the device is >3 years old, all components should be removed and replaced.

Figure 51-4  Eroded male sling, cystoscopic view.

Urinary Retention Urinary retention that manifests as a late postoperative complication requires endoscopic examination to evaluate the AUS and the bladder neck for contracture or urethral stricture. Contracture and urethral stricture usually result from prostate surgery and not from the AUS per se but nevertheless must be checked. Difficultly with voiding or urinary retention can also be a sign of AUS erosion or late infection. Urinary retention may also be the result of mechanical malfunction.

Male Sling

Figure 51-5  Eroded male sling, gross view.

Infection and Erosion Reported rates of infection and erosion following a bone-anchored MS are 2.1% to 7.9% and 0% to 2.6%, respectively (Figs. 51-4 and 51-5).9,19-21 All cases of reported erosion occurred with associated infection. There is very little information available regarding the time to infection or erosion. In our experience, patients more commonly present at 6 to 9 months postoperatively. However, Fassi-Fehri and colleagues reported that two of the infections they observed occurred within the first postoperative month and one occurred at 3 months postoperatively.20 Little information exists regarding the clinical manifestations of infection or erosion. We have noted that patients with infection often present with chronic, low-grade symptoms including mild perineal pain or swelling, or a sinus tract that intermittently drains small amounts of fluid (Fig. 51-6) as opposed to acute or systemic symptoms. Removal of the sling is the typical treatment of infection or erosion. However, we

Figure 51-6  Infected male sling with granulation tissue and sinus tract.

Chapter 51  Complications of Surgery for Male Incontinence have found that despite infection some patients are very reluctant to undergo sling removal secondary to improvement in their continence. We attempted salvage of the sling in two of these patients using the irrigation protocol previously described for salvage of the AUS.25 This was unsuccessful and both slings subsequently required removal. In addition, we have one patient who has been managed with intermittent antibiotics and fulguration of a chronic sinus tract for >1 year because of his reluctance to have the sling removed. At 4-year follow-up after bulbourethral sling placement, Stern and colleagues43 reported an 8% (5 of 62) bolster removal rate in patients who had not received prior radiation therapy and a 22% (2 of 9) bolster removal rate in those who had received radiation therapy. Among patients who had not received radiation therapy, four had bolsters removed secondary to infection or erosion and one had bolsters removed secondary to nonfunction. In patients who had received prior radiation therapy, one required bolster removal secondary to infection and the other underwent removal because of nonfunction.43 Romano and colleagues6 reported a 6% (3 of 48) rate of infection and a 4% (2 of 48) rate of erosion following placement of the Argus adjustable sling. All five slings were removed.6 To date, no known reports exist of infection or erosion with the Advance transobturator sling, but certainly both complications are possible.

De Novo Urgency To our knowledge, de novo urgency is a previously unreported complication. However, in our series, one patient (1.6%) developed de novo urge incontinence 6½ months postoperatively that was confirmed with urodynamic studies.11 De novo urgency requires urodynamic evaluation to rule out possible obstruction. If no evidence of obstruction is present, a trial of anticholinergic agents is recommended.

Obstruction Iatrogenic obstruction following placement of an MS is rare but not impossible. In addition, it was previously reported that the fixed urethral resistance provided by the MS would not result in bladder outlet obstruction.44 In our experience, however, three patients (4.8%) developed prolonged obstructive symptoms postoperatively.11 The sling caused the obstruction in two of the patients who experienced urinary retention requiring intermittent catheterization. The other patient had impaired detrusor contractility and the sling did not result in urodynamic obstruction, but it may have increased voiding symptoms. All three patients underwent sling revision. To address obstruction and maintain some improvement in continence, the sling can be loosened. The sling can be isolated in the midline and partially cut (Fig. 51-7). Alternatively, or if this does not help, the sling can be completely transected.

Figure 51-7  A right angle was placed between the intact sling and the urethra and the sling was cut until tension was relieved.

Other options for sling revision include removal and replacement of the sling or release of one side of the sling and replacement of sutures more laterally on the sling. In our experience, the second option has not been possible because the excess sling has typically been excised at the time of sling placement. With regard to the bulbourethral sling, Schaeffer and colleagues5 reported that one patient (1.6%) had persistent urinary retention requiring clean intermittent catheterization.

Prolonged Pain and Paresthesia Most patients have perineal pain after placement of a bone-anchored sling; however, most published series have reported resolution of the pain 3 to 4 months postoperatively.9,19 We found that 8.1% of patients experienced prolonged (>3 months) paresthesia or perineal pain.11 In addition, Fassi-Fehri and colleagues20 reported a 12% incidence of prolonged pain requiring analgesic management. In our experience, patients with prolonged paresthesia following bone-anchored sling procedures typically located the symptoms to the scrotum, and those who had prolonged pain experienced it in the perineum. Most of our patients were managed effectively with watchful waiting and antiinflammatory medications. In patients with severe, persistent pain, however, we obtain a bone scan and a CT scan to evaluate for osseus or infectious complications. Pain can be a manifestation of sling infection. One patient in our series had persistent pain severe enough to require removal of the sling. Despite unremarkable imaging, the sling was infected at the time of removal. Clemens and colleagues45 found that, 9 months after a bulbourethral sling procedure, only 47.5% of patients reported no perineal numbness or pain and 26% reported moderate or severe pain. At 4-year follow-up, however, these investigators found that 82% of patients

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Section IX  Complications of Reconstructive Surgery reported no perineal numbness or pain and only 12% reported moderate or severe pain.43

Osseus Complications A potential risk for osseus complications exist because screws are placed into the bone. To our knowledge, however, no osseus complication, osteomyelitis, or osteitis pubis has been reported following placement of an MS.

Recurrent Incontinence Following a bone-anchored sling procedure, recurrent incontinence should be evaluated with urodynamic studies. In patients with recurrent stress incontinence, a pelvic radiograph should be obtained to evaluate for bone anchor dislodgment. Comiter9 reported bone anchor dislodgment in 4.2% (2 of 48) of patients. In this series, patients presented with recurrent incontinence, screw dislodgment was confirmed with pelvic radiograph, and successful sling revision was performed.9 When bone anchor dislodgement is not the cause of recurrent stress incontinence, other treatment options include bulking agents, repeat MS (if it is thought that compression is not adequate), and placement of an AUS. Recurrent incontinence following a bulbourethral sling operation is managed with a retightening procedure. Stern and colleagues43 reported that 14.5% (9 of 62) of patients who did not have prior radiation required a retightening procedure, and three of these patients required a second retightening procedure. Of the patients who had prior radiation therapy, 66.7% (6 of 9) required a retightening procedure, and two of these required a second procedure.43

Inflatable Balloon Compression Balloon Rupture or Deflation In their first 50 patients, Hübner and Schlarp18 reported 15 balloon ruptures in 13 patients. Conversely, only 2 ruptures occurred in 2 patients in their most recent 50 patients.18 The balloons were reengineered to strengthen their attachment to the tubing after several leakages were discovered in the first 50 patients.16 Trigo-Rocha and colleagues17 reported a 4% (1 of 25) rate of balloon deflation. These patients were managed with revision to replace the deflated balloons.

Balloon Dislocation Hübner and Schlarp18 found a balloon dislocation rate of 18% in their initial 50 patients and a rate of 6% in

their most recent 50 patients. These patients were managed with operative repositioning of the balloons.18

Erosion Hübner and Schlarp18 reported 5 erosions in their first 50 cases and 4 in their most recent 50 cases. However, these investigators did not specify how many patients experienced erosions, and two balloons were placed in each patient. In addition, they did not differentiate between urethral and bladder erosions. Erosions were managed with removal of the devices and reimplantation 6 weeks later.18 Trigo-Rocha and colleagues17 reported a single patient (4%) with erosion of one injection port through the scrotal skin. This erosion was managed by removal of both devices. These investigators did not report any urethral or bladder erosions.17

Infection Hübner and Schlarp18 reported a wound infection rate of 4% in their first 50 patients and no infections in their most recent 50 patients. Infections were managed by removing the balloon on the infected side. These investigators did not mention when or whether the balloons were reimplanted.18

CONCLUSION The AUS, MS, and ProACT balloon compression (not currently available in the United States) are the current surgical treatment options for sphincteric insufficiency following prostate surgery. Each has acceptable complication rates that can be minimized with attention to detail and meticulous surgical and aseptic technique. Patients obviously should be informed of the potential complications associated with the procedures. Along with more minor complications, the AUS, the MS, and the ProACT balloon compression device are associated with a risk of infection and erosion that can result in the need for explantation. In addition, the AUS is a mechanical device that inherently carries a risk of mechanical malfunction and the need for device revision or replacement. Although pain or paresthesia is typically not severe, patients undergoing MS should also be made aware of the possibility of this complication. Patients who understand their treatment options and who are well informed regarding potential risks and complications are more likely to be satisfied postoperatively.

Chapter 51  Complications of Surgery for Male Incontinence

KEY POINTS 1. Most intraoperative complications are inconsequential if they are recognized and treated at the time of the surgical procedure. Conversely, urethral injury typically requires aborting the procedure. 2. To facilitate detection of an unrecognized urethral injury, saline solution or dilute indigo carmine can be instilled next to the Foley catheter or through the Foley catheter while moving it in a retrograde fashion. 3. AUS tubing should be handled with rubber-shod clamps and care should be taken not to injure the device with sharp instruments or needles. Damage to the device can result in leakage of fluid from the device and mechanical failure. 4. Early infection of the AUS, and most likely the MS, is typically the result of bacterial contamination at the time of implantation. 5. Erosion of an AUS is commonly caused by prolonged catheterization, catheterization without

REFERENCES Please see www.expertconsult.com

cuff deactivation, or repeated endoscopic manipulation of the urethra. 6. Urinary retention that manifests as a late complication following AUS or MS requires endoscopic evaluation for infection or erosion and evaluation of the urethra and bladder neck for stricture or contracture. 7. De novo urgency following MS procedures requires urodynamic evaluation to rule out obstruction or recurrent stress incontinence. 8. Iatrogenic obstruction following placement of an MS rare but not impossible. 9. Patients with an infected MS may present with chronic low-grade symptoms such as mild perineal pain or swelling or an intermittently draining sinus tract. 10. The AUS is a mechanical device that inherently carries a risk of mechanical malfunction as well as the need for device revision or replacement.

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COMPLICATIONS OF URETHRAL RECONSTRUCTION Joel Gelman

MD Associate Clinical Professor, Department of Urology, University of California, Irvine School of Medicine, Irvine, California

Patients diagnosed with urethral strictures can be managed with observation, endoscopic treatment with dilation or incision, urethral stent placement, or formal open reconstruction with excisional or tissue transfer repair. This chapter reviews the complications that can be associated with the disease itself, the diagnostic testing, and the endoscopic and open surgical treatment of urethral strictures.

COMPLICATIONS OF URETHRAL STRICTURE DISEASE Observation is always a treatment option, and the potential complications of observation must be discussed when patients are counseled and giving informed consent. Patients often present with obstructive voiding symptoms, and it would be a mistake for a patient to conclude that having to live with obstructive voiding symptoms would be the only potential drawback of observation. Distal obstruction is associated with high-pressure voiding. The bladder compensates by thickening with the development of trabeculation, and the urethra proximal to the obstruction can become distended (Fig. 52-1). High-pressure voiding through the prostatic urethra can be associated with extravasation of urine in retrograde fashion into the prostatic ducts. In a physiologically normal patient, extravasation of contrast material into the prostatic ducts is not seen during retrograde urethrography, but this finding is not uncommon in patients with strictures. Eventually, diverticular formation or bladder decompensation can develop with an increased capacity and residual or urinary retention. Secondary reflux with or without associated recurrent pyelonephritis can also occur. Ultimately, although not common, acute or chronic renal failure can develop as a complication of untreated stricture disease. In patients with balanitis xerotica obliterans (BXO), a disease of the penile skin, glans penis, and urethra (Fig.

52-2), stricture progression is common. The obstruction is generally initially within the distal urethra. Often, extravasation into the periurethral glands of Littre is seen during urethral imaging studies in patients with BXO (Fig. 52-3), and it is thought that the extravasation of urine into the periurethral glands may be associated with proximal stricture progression. It is not at all unusual for patients with BXO who are conservatively managed to undergo their first retrograde urethrogram and be diagnosed with a >20-cm panurethral stricture (Fig. 52-4). Patients who are clinically diagnosed with BXO on physical examination and who have stricture disease limited to the distal urethral stricture disease are best managed with open staged urethral reconstruction or extended meatotomy.1,2 In summary, the complications of treatment with observation include but are not limited to prostatitis, bladder decompensation, urinary retention, secondary vesicoureteral reflux, pyelonephritis, renal deterioration, and stricture progression in addition to obstructive symptoms.

COMPLICATIONS OF DIAGNOSTIC PROCEDURES Diagnostic testing procedures for known or suspected urethral strictures include urethral calibration with bougie à boule, urethroscopy, retrograde urethrography (RUG), and voiding cystourethrography (VCUG). Bougie calibration, properly performed to assess the caliber of the urethral meatus and fossa navicularis, does not dilate the urethra and therefore is generally not associated with complications. When urethroscopy is performed, the most common complication is urethral trauma. This trauma can be intentional when scope dilation is performed in an effort to visualize the stricture in its entirety and enter the bladder. This situation represents treatment with dilation before the extent of the stricture is first assessed and the patient is informed of all treatment options. Should the patient be a candidate for open repair, the operation must be delayed for 605

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Figure 52-3  Retrograde urethrography with extravasation into the periurethral glands of Littre. Figure 52-1  Markedly dilated posterior urethra proximal to a narrow-caliber bulbar stricture seen on voiding cystourethrography.

A A

B B Figure 52-2  Balanitis xerotica obliterans can manifest with whitish skin color changes and meatal stenosis (A) or with a more severe deformity including a total loss of the coronal sulcus and loss of penile length and girth (B).

several months following scope or other dilation because open reconstruction is best performed when the stricture is mature and stable. Urethral contrast imaging is necessary to assess the length and exact location of the stricture because urethroscopy usually identifies only the distal extent of the disease.

Figure 52-4  Appearance of the penis (A) and retrograde urethrography of the same patient (B) with balanitis xerotica obliterans.

Complications of urethral imaging include urinary tract infection with or without sepsis and extravasation. Improperly performed studies can be associated with a higher complication rate. At our institution, diagnostic testing is performed with flat plate imaging, and this includes both RUG and VCUG. The patient is placed in the oblique position. After a scout film is obtained, gauze is wrapped around the coronal sulcus and the penis is placed on stretch. A 60-mL syringe connected

Chapter 52  Complications of Urethral Reconstruction

Figure 52-5  Extravasation into the corpus spongiosum and venous system during retrograde urethrography injection.

Figure 52-7  Outside retrograde urethrography obtained during a forceful attempt to advance the catheter for the injection procedure.

Figure 52-6  Foley catheter after balloon inflation with 2 mL of water. The caliber is >50 Fr (1.7 cm diameter).

to a cone-shaped adaptor is placed into the urethral meatus to form a seal, and RUG is performed during the injection of contrast material. The bladder is then slowly filled in retrograde fashion similarly until the patient has the urge to void. VCUG is performed while the patient is voiding. Extravasation into the corpus spongiosum or venous system is rare when contrast material is instilled gently. However, this complication can occur (Fig. 52-5). Sepsis is a concern with extravasation, and when extravasation occurs, prophylactic antibiotics are given. When imaging is performed with alternative techniques at radiology imaging centers, we have observed a high complication rate related to poor technique. The injections are usually performed with catheter insertion into the urethra and inflation of a balloon within the urethra and subsequent contrast injection through the catheter. We measured the caliber of the balloons of 12- to 16-Fr catheters after inflation with 1 to 3 mL of water. With only 2 mL of inflation, the caliber of the balloon was >50 Fr (Fig. 52-6). The caliber of the

penile urethra is approximately 30 Fr, except for the glans and fossa navicularis, which are generally 6 months in 9% of the patients, initial difficulty with mouth opening, and changes in salivation. One patient developed a mucus retention cyst that

Figure 52-11  Buccal mucosa is marked for harvest, and Stensen’s duct is identified.

required excision. Some surgeons close the donor site and others leave the harvest site open. Both options are considered acceptable. However, in this study, the mean pain score for patients with donor site closure was significantly higher than for patients without donor site closure. In addition to buccal grafts, other autologous graft materials used in urethral reconstruction are splitthickness skin grafts (STSG) often harvested from the thigh, temporalis fascia, and recently, the under surface of the tongue.31 The harvest of any graft can be associated with bleeding, scarring, contracture (generally not with split-thickness grafts), and infection. However, these grafts can generally be harvested with low morbidity.

Tissue Transfer Reconstruction All tissue transfer reconstructions, and stricture repairs in general, can be complicated by stricture recurrence, bleeding, urinary tract infection with or without sepsis, wound infection, and breakdown of the repair. However, specific complications are generally associated with flap and graft reconstructions. Skin flaps by definition retain their blood supply because they are mobilized on a vascular pedicle and are relocated to augment the caliber of the urethra. The most commonly used flap is a penile skin flap. The penile skin is supplied by branches of the superficial external pudendal arteries. These vessels course along the tissue deep to the skin and superficial to Buck’s fascia. The supply is axial as opposed to random and is defined. During the elevation of a penile skin flap, under optical magnification, a tissue plane is developed between the superficial and deep plexus of the fascia. Careful attention to technical detail is required so blood supply is maintained both to the skin flap and to the remaining penile skin. Potential complications of flap elevation include ischemic changes to the penile skin, especially along the

Chapter 52  Complications of Urethral Reconstruction distal aspect, and flap ischemia.32 Distal penile skin ischemia and necrosis are generally managed with débridement of devitalized tissue and wound care. In general, the skin is adequately redundant so that the loss of a small amount of penile skin is not disabling. In patients who previously underwent flap repair and who develop a recurrent stricture, a penile flap may be elevated again by some surgeons. However, once a flap is used, the blood supply of the penile skin is not axial and well defined, but rather random in distribution. Therefore, repeated use of skin flaps can be associated with a higher rate of ischemic flap failure and recurrent stricture formation. Although currently not commonly used as a urethral replacement, scrotal skin can be used for urethral reconstruction. When scrotal skin is rotated as a flap, it must be nonhirsute. In addition, the skin must be marked on stretch to avoid redundancy that can be associated with diverticula formation (Fig. 52-12). Penile skin flaps must also be nonhirsute. In general, the foreskin and distal penile shaft skin are not hair bearing. However, before shaving and draping, when skin flaps are to be used, the

skin should be evaluated under optical magnification to ensure that only nonhirsute skin is selected. When hairbearing skin is used to repair the urethra, hair will then grow within the lumen of the reconstructed urethra (Fig. 52-13) and may be a source of infection, stone formation, or recurrent obstruction. Grafts are detached from their blood supply at the donor site and are transferred to a recipient bed. Grafts obtain blood supply through a process of graft take. Initially, the graft receives nutrients by passive diffusion, a process called imbibition. Then, neovascularization occurs. This is called inosculation. One possible complication is failure of the graft to take. Proper surgical technique significantly reduces the likelihood of graft take failure. The graft must be firmly approximated to the recipient bed. This is facilitated by creating small slits within the graft to allow blood to escape that may elevate the graft from the recipient bed and prevent neovascularization. In addition, grafts are now often quilted to the recipient bed by using multiple fine absorbable sutures to provide further fixation because graft movement during the process of imbibition and inosculation is deleterious to graft take. Buccal grafts can be used for one-stage reconstructions as a dorsal, ventral, or lateral onlay or for staged repairs. STSGs are generally used for staged repairs. Buccal mucosa is a better graft material than is STSG because success rates are higher with buccal grafts than with skin grafts, and chordee is less, given that skin is

A

B Figure 52-12  A, Retrograde urethrography demonstrates a markedly dilated proximal penile and distal bulbar urethral diverticulum that contains filling defects in a patient who previously underwent a one-stage tubed tissue transfer repair with scrotal skin. B, At the time of surgery, the massive diverticulum contained multiple stones.

Figure 52-13  Hair developed within the lumen of the urethra after reconstruction using hair-bearing genital skin.

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Section IX  Complications of Reconstructive Surgery much less elastic than is buccal mucosa.33 However, the supply of buccal mucosa is limited. Stricture recurrence is the main complication of urethral reconstruction. In addition to attention to surgical detail, procedure selection is a factor that influences the success rate. In general, the success rate is higher when transferred tissues are used for onlay repair than for tubed reconstruction.34 In comparison with STSGs and penile skin flaps, buccal grafts appear to have a higher success rate, and the results with onlay buccal mucosa grafts are excellent regardless of whether the graft is placed dorsally and is quilted to the corporal bodies, as originally described by Barbagli and associates,35 or is placed ventrally or laterally.36 Urethral stricture disease associated with BXO was previously commonly managed with penile skin flap repair. However, investigators showed that although short-term success rates with flap procedures were high, the long-term failure rate 10 years postoperatively was extremely high.37 As a result, the shift in management has been toward staged repairs using extragenital tissues.38 BXO is a frustrating disease that can recur and lead to stricture recurrence even after technically successful staged repairs. Extended meatotomy or proximal urethrostomy has been proposed for complex cases as the most appropriate surgical treatment.2 Diverticula formation and the development of urethrocutaneous fistulas are rarely seen when buccal mucosa is used for urethral reconstruction in patients without hypospadias because the urethra is circumferentially well supported and the penile skin is separated from the urethral lumen by the corpus spongiosum. However, when staged repairs and skin flaps are performed, particularly in patients with hypospadias, which is a condition associated with a poorly developed distal corpus spongiosum, urethrocutaneous fistula is a more common complication.39 These fistulas, when persistent, can be closed primarily but may then recur. Recurrent fistulas may require more complex closure with the interposition of a tunica vaginalis flap. Incontinence of urine in the bladder is generally not a complication of anterior urethral reconstruction because the surgical procedure is performed distal to both the bladder neck and the external urethral sphincter. However, after tissue transfer reconstruction in particular, the urethra does not coapt normally, and pooled urine present within the reconstructed segment of the urethra after voiding can dribble out after urination.40 Patients who report this complication should be instructed to “milk” their urethra with their hand from behind the scrotum toward the urethral meatus after urination. Sexual dysfunction can occur after anterior urethral reconstruction, but one study revealed that the incidence of erectile dysfunction was no higher after urethroplasty than after circumcision.41 However, another study reported that patient satisfaction with the

A

B Figure 52-14  A and B, These two patients previously underwent multiple failed hypospadias repair procedures. The stretched penile length, as shown, is 11.5%), spinal cord injuries, or a history of urinary tract infection.4-9 Skin-dwelling bacteria are usually responsible for operative wound contamination. The most common bacterium associated with penile implant infection is Staphylococcus epidermidis. Highly virulent organisms such as methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, Enterococcus species, Prevotella species (Bacteroides subspecies), and fungi have been associated with penile implant infections. Patients with infected penile implants usually present between 1 and 8 weeks postoperatively with fever, pain, and swelling overlying the prosthesis often (but not always) accompanied by purulent wound drainage. Other signs and symptoms of a developing infection are persistent pain over parts of the implant on palpation, elevated white blood cell count, elevated erythrocyte sedimentation rate, cellulitis, fever, chills, erosion (Fig. 53-4), or fixation of parts of the prosthesis (tubing or pump) to the scrotal wall. Although it is uncommon, infection may manifest after 8 weeks within the first year after the surgical procedure. Such an infection is usually caused by S. epidermidis and manifests in an indolent fashion. Anecdotally, reports have noted implant infection occurring years after implantation. This phenomenon is believed to result from hematogenously disseminated bacteria leaked into the bloodstream after a surgical or dental procedure. Carson and Robertson1 described a series of delayed prosthetic infections presumably caused by hematogenous bacterial spread from a remote focus. All six patients underwent uncomplicated prosthesis implantations and had an extended problem-free period of use before the inset of infection.1 All the devices in this series were explanted. If the penile prosthesis is infected, it must be removed. Systemic administration of antimicrobial agents alone

is ineffective in destroying all offending bacteria. On an ultrastructural level, biofilm produced by bacteria surrounds the implanted device and thereby radically reduces the ability of antimicrobial agents to penetrate the area where the bacteria are located.10 Additionally, the human body produces a fibrotic capsule that surrounds the prosthesis. This fibrotic capsule has minimal blood supply, a feature that also reduces the efficiency of antibiotic penetration. Once the prosthesis is removed, the surgeon must decide whether to reimplant another prosthesis several months later or to perform a salvage procedure. Traditionally, following removal of the prosthesis, the area is copiously irrigated with antibiotic solution. Some experts leave drains in place, and the incision is closed, whereas others do not leave drains. This appears to be a matter of choice because no evidence-based medicine has addressed this issue. Based on intraoperative wound and blood cultures, the patient is treated with appropriate systemic antimicrobial agents. If placed, drains may be irrigated two to three times per day with antibiotic solution for several days. Two to 6 months later, a new penile prosthesis may be reinserted. An alternative approach is to reimplant a new prosthesis immediately, during the same operative session as the explantation. Procedurally, all parts of the infected prosthesis are removed, the wound is copiously irrigated with a series of antibiotic or antimicrobial solutions, the patient is prepared and draped again, and the new prosthesis is inserted.11 The benefit is that this approach allows for easier cylinder insertion and abrogates the penile shortening that occurs secondary to corporal fibrosis if the cylinders are removed and are not immediately replaced.11,12 Mulcahy reported long-term success in 45 of 55 (82%) men who underwent salvage of their penile prostheses in the setting of infection.12 Occasionally, the surgeon may determine that only the prosthesis cylinder or pump is infected, not the reservoir. In this instance, although it is controversial, we have on occasion attempted and succeeded in salvaging only the cylinders (acting as stents to prevent penile shortening) and returned later for pump and reservoir placement. Exclusion criteria proposed for salvage include any degree of immunocompromise, sepsis, tissue necrosis, and copious amounts of pus within the corporal bodies.11 Other relative indications are erosion of the cylinders and the presence of uncontrolled diabetes. In 2001, Montague and colleagues13 conducted a retrospective reviewed of 491 patients who received a three-piece inflatable penile prosthesis. These investigators reported infection rates and risk factors in these recipients. Of the 491 total patients, 10 infections (2.0%) occurred. Seven of the infections were in first-time prosthesis recipients and 3 were in recipients of secondary inflatable penile prostheses. The presence of diabetes played a minor role in the development of inflatable

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Section IX  Complications of Reconstructive Surgery penile prosthesis infection because 3 of the total 10 infections were in the 137 men with diabetes mellitus. The remainder of infections occurred in patients who did not have diabetes. Surprisingly, this study13 did not find statistically significant differences in infection rates between first-time and secondary prosthesis recipients or between diabetic and nondiabetic recipients, findings dissimilar to the conclusions published in studies by Jarow2 and by Lynch and colleagues.14 Jarow2 reported a higher infection rate in patients undergoing a secondary procedure for corporal reconstruction versus prosthesis revision versus first-time insertion of an inflatable penile prosthesis (21.7% versus 13.3% versus 1.8%). This finding is in contrast to the results of the study by Montague and associates.13 Jarow2 found convincing evidence not only that reoperation is associated with higher rates of device-related infections but also that complex corporal reconstruction further increases the chance of postoperative infection of inflatable penile prostheses. Diabetes mellitus, a reported risk factor for the development of implant infections, has been the subject of articles by luminaries in the field of sexual medicine. One of the first reports in the modern era noted a 22% incidence of infection in patients with diabetes but a 6.7% infection rate in patients who did not have diabetes.14 Subsequent reports by Wilson and colleagues15,16 failed to link diabetes (regardless of mean glycosylated hemoglobin levels) to a higher risk of prosthesis infection.

Antibiotic-impregnated Prostheses In an effort to decrease the rate of prosthetic-associated infection, specially modified implants have been developed. AMS introduced InhibiZone prostheses (which are coated with rifampin and minocycline) and MentorColoplast marketed a device with a low-friction, antibiotic-absorbing coating on their Titan prostheses. In nonrandomized studies, both these coatings were shown to decrease the incidence of implant-related infections. Carson17 in 2004 retrospectively reviewed the difference in infection rates between patients who received AMS penile implants impregnated with a combination of rifampin and minocycline and those who received untreated prostheses. He reported that the infection rate was initially 1.59% in the noncoated implant and it decreased to 0.2% at 12 months in the coated implant.17 These data are based on the use of patient information forms completed at the time of the surgical procedure by the surgeon. Thus, these data are not generated from a randomized study, nor is the surgeon blinded to the device type. In 2006, Abouassaly and colleagues18 assessed the impact of prosthesis replacement for mechanical failure in infection rates with an AMS antibiotic-coated pros-

thesis (coated with rifampin and minocycline). Although the investigators excluded salvage procedures for clinically infected prostheses, 1 of 55 patients experienced postoperative device infection in the 32-month followup period. The investigators concluded that insertion of an antibiotic-coated inflatable penile prosthesis may result in lower infection rates in this cohort of men.18 In 2007, Wilson and associates19 reported that “InhibiZone-coated inflatable penile prostheses showed a statistically significant reduction in infection in virgin nondiabetic, virgin diabetic, and revision with washout implants. No reduction in the infection rate occurred among revision patients without washout.” Specifically, in 467 patients receiving InhibiZone-coated implants, no infections developed among the 223 first-time implants in nondiabetic patients, 1 of 83 diabetic patients developed an infection, 4 infections were found in 39 patients who underwent implant revisions, and infections developed in 4 of 123 men when a salvage operation was combined with antibiotic washout.19 Rajpurkar and colleagues20 demonstrated the ability of the antiadherence coating on the surface of polyurethane strips cultured with and without antibiotics to decrease bacterial colony counts in rats. After the strips were dipped in a vancomycin-gentamicin solution or saline, they were implanted subcutaneously along with a bacterial solution containing S. epidermidis. After 7 days, the strips were explanted, sonicated, and incubated. The antibiotic treatment of coated Bioflex caused a significant reduction in the bacterial colony-forming units compared with uncoated Bioflex, thus representing a 55% reduction in the bacterial count.20 Hellstrom and associates21 found similar results when they used antibiotic, hydrophilic-coated, Bioflex disks in rabbits.21

MECHANICAL MALFUNCTION Although infection may be the most serious penile prosthetic complication, mechanical malfunction remains the most frequent reason for reoperation (Table 53-1).22 Common reasons for malfunction are cylinder aneurysm, tubing leakage, reservoir leakage, cylinder leakage, and connector fracture. Failure rates have been reported to be 15% at 5 years and 30% at 10 years.23 In the event of malfunction, we believe that replacement of the entire device is prudent if initial insertion occurred >2 years previously because this approach will increase the likelihood of longevity of the device. Frequent updates and revisions of the penile implant devices make it difficult to ascertain their true mechanical longevity scientifically. Levine and colleagues24 retrospectively reviewed reliability, complication, and patient satisfaction rates in 131 men with the two-piece AMS Ambicor penile prosthesis. Ten patients had complications, 6 of which resulted from mechanical failure. The Ambicor penile

Chapter 53  Complications of Surgery for Erectile Dysfunction and Peyronie’s Disease TABLE 53-1  Mechanical Reliability of Penile Prostheses Author

Year

No. Patients

Type of Prosthesis

Young

2001

273

AMS CXM700

7.3

Levine

2001

131

Ambicor

4.6

Montorsi

2000

200

AMS CXM700

4

Wilson

1999

410 971

Original Mentor Alpha I Enhanced Mentor Alpha I

5.6 1.3

Lewis

1995

56

Mentor Alpha I

1.8

Wilson

1993

64

Mentor 3 piece

18.8

Lewis

1993

275

AMS-700CX

4.7

Quesada

1993

214

AMS-700CX

1.9

Goldstein

1993

112

Mentor Alpha I

3.6

Fein

1992

80

Mentor Mark II

0

Sternkohl

1991 1991

46 43

Mentor 3 piece AMS-700CX

28 5

Knoll

1990

94

AMS-700CX

Wilson

1988

29

AMS-700

Furlow

1988

120

AMS-700

8.3

Merill

1988

301

Mentor 3 piece

6

Hackler

1986

46

Mentor 3 piece

0

Fishman

1984

113

AMS-700

1.8

prosthesis historically has had high satisfaction rates coupled with reliable function. A review by Carson and associates23 of the reliability of and satisfaction with the AMS 700CX three-piece penile prosthesis encompassed a median follow-up of 47.7 months and had two phases.23 Phase 1 reviewed the medical record of 372 patients and phase 2 was a telephone interview of 207 patients. Medical record review found that the devices were functionally reliable 92.1% of the time after 3 years and 86.2% after 5 years. Seventy-nine percent of the patients with a device used it at least twice monthly and 88.2% would recommend an implant to a relative or friend. The investigators concluded that the AMS 700CX penile implant was reliable, provided excellent patient and partner satisfaction, and had a low postoperative morbidity profile.23 Ferguson and Cespedes25 prospectively evaluated the long-term reliability of and patient satisfaction with the AMS Dura-II malleable penile prosthesis. In this study, the 94 patients who underwent implantation with the Dura-II device were prospectively examined and asked to complete standardized questionnaires regarding sexual activity, prosthesis function, intercourse satisfaction, and overall quality of life. During the follow-up period of nearly 6 years, 76% and 87% of patients reported satisfactory rigidity and ease of concealing the device, respectively. Quality of life was enhanced by the

Mechanical Failure (%)

6.4 14

implant in 87% of men and 88% would recommend this prosthesis to a friend. Malleable penile prostheses appear to be as effective and satisfactory as are fluidfilled models. Patient selection and recipient expectations undoubtedly play large roles in determining the likelihood of a satisfactory outcome. Wilson and associates26 published a large, long-term, historical prospective study of 2384 patients to estimate mechanical and overall revision-free survival of 4 different inflatable penile prostheses (Mentor Alpha 1, Mentor Alpha NB, AMS 700 CX, and AMS 700 Ultrex). At 10 and 15 years, mechanical reliability was 79.4% and 71.2%, respectively. More recent Mentor Alpha models improved 10-year survival to ≤88.6%. The newer iterations of the ASM CX devices had a reported 97.9% freedom from mechanical breakdown at 3 years. This large study conducted in 2007 further lends credence to the excellent mechanical durability of modern inflatable penile prostheses. In an effort to elucidate the chronology of patient satisfaction after implantation of a penile prosthesis, we prospectively evaluated men with the International Index of Erectile Function (IIEF) questionnaire preoperatively as well as 3, 6, and 12 months postoperatively. The investigators also administered the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire postoperatively at 3, 6, and 12 months.

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Section IX  Complications of Reconstructive Surgery The study of 96 men found that 6- and 12-month scores were higher than baseline, but satisfaction was statistically higher at 12 months as measured by the IIEF satisfaction domain. This first of its kind study elucidated that satisfaction with penile implant further increases after 6 months, but more importantly it provided physicians with additional information to impart to patients.

EROSION Erosion of a component of the prosthesis is not rare. The device can erode through skin (cylinder or reservoir) or erode through tunica (cylinder), such that it lies subcutaneously. When erosion through skin occurs, the device is inherently infected and probably eroded in the first place because of a low-grade infection. Our approach to this complication depends on the nature of the erosion. Erosion of the corporal cylinders extracorporally through the distal portions of the corporal bodies may occur iatrogenically from overenthusiastic corporal dilation or oversizing of the cylinders.27 Patients with decreased distal sensation such as those with spinal cord injury or diabetes mellitus may have an increased incidence of distal erosion.28 In addition, we have seen this complication in patients who have received previous pelvic irradiation. Techniques of distal corporal erosion repair include creation of a new pocket for the tip of the cylinder through a hemicircumferential incision for established or impending distal erosion. In cases of lateral extrusion of corporal cylinders, Mulcahy29 described the creation of a new corporal cavity to reseat the prosthetic device. In this situation, a hemicircumcising incision is made and the cylinder tip is exposed. Next, a 3-inch lateral longitudinal corporotomy is made proximally over the cylinder. The back wall of the fibrotic sheath is then incised transversely and a new plane of dissection is developed. Finally, the cylinder is inserted into this new cavity.

CRURAL PERFORATION Proximal (crural) perforation is not uncommon, although no data exist in the literature. This complication usually results from overly vigorous or misdirected proximal dilation such that the dilating instrument perforates the tunica and lies in the perineum. If perforation is noted intraoperatively, no long-term concern exists, but failure to identify this complication at the time of implantation may result in proximal migration of the cylinders out of the glans and into the perineum. Certain surgical approaches are aimed at preventing proximal slippage of the cylinder without direct repair of the crural tunica. Historically, this goal has been accomplished by wrapping the proximal end of the

Figure 53-5  Fashioning a windsock around the rear end of the cylinder to prevent proximal migration in the setting of crural perforation. The windsock if used, contemporarily uses an off-the-shelf material such as cadaveric pericardium or intestinal submucosa.

cylinder in a “windsock” made of either synthetic or available natural material such as cadaveric pericardium or intestinal submucosa (Fig. 53-5). This windsock is then sutured to the tunica to prevent proximal migration of the cylinder. A second method is to suture the rear-tip extender (if used) to the corporal tunica with nonabsorbable monofilament suture. The cylinder of the prosthesis is then securely seated into the rear-tip extender. A newer approach to this problem is the simple use of a suture hammock around the exit tubing at the proximal end of the cylinder. A simple U-type suture in this setting prevents proximal cylinder migration.

SST DEFORMITY The SST deformity is the name given to the glans of the penis when it appears to bend or hang most commonly downward (but also occasionally upward) limply from the erect penile shaft. This condition may lead to difficulty with penetration or irritation of tissue overlying the ends of the corporal body. The deformity may be the result of inappropriately sized implant cylinders, inadequate distal corporal dilation, or a constitutionally hypermobile glans. This issue may be remedied through a subcoronal incision and dissociation of the glans penis from the distal ends of the corporal bodies. With care taken to avoid neurovascular bundle injury, the glans is then repositioned more proximally on the corporal bodies and is fixed using two nonabsorbable sutures (No. 1 polyester, Ticron, Tyco Healthcare, Waltham, Massachusetts) placed on either side of the midline in a horizontal mattress fashion. These sutures are ideally placed through the tunica albuginea on the corporal body and through the fascial layer on the undersurface of the glans penis.30,31

Chapter 53  Complications of Surgery for Erectile Dysfunction and Peyronie’s Disease

PENILE NECROSIS The most devastating complication following penile prosthesis insertion is penile necrosis. This rare complication is most often precipitated by local infection; however, pressure dressing or the prolonged presence of a urethral catheter may contribute to the development of necrosis.32 Adherence to the following basic principles may help avoid this issue: 1. Rigorous sterility of the operative field 2. Limited use of an indwelling catheter 3. Avoidance of circumferential penile compression bandages 4. Proper sizing of penile corporal cylinders 5. Avoidance of prolonged cylinder inflation Although we have no way to predict who will develop this problem, aggressive treatment may be lifesaving. The prosthesis should be removed, the corporal bodies irrigated, and necrotic tissue débrided. Care must be taken to preserve as much viable tissue (and to avoid amputation) as possible for future penile reconstruction. In the setting of superficial penile gangrene, avoidance of prosthesis removal may be possible but not recommended.33 Perfusion and healing may be enhanced with hyperbaric oxygen, warm compresses, or vasodilators, although no data exist in the medical literature on these strategies and thus they are purely empirical.

COMPLICATIONS OF PENILE VASCULAR SURGERY Vascular surgery encompasses penile revascularization and crural ligation surgery for venous leak. Vascular surgery is the only treatment modality that has the potential to allow the permanent return of spontaneous erections without the need for pharmacologic or device support. Specifically, the goal of the surgical procedure is to increase the cavernosal arterial perfusion pressure and inflow in patients with erectile dysfunction resulting from pure arterial insufficiency. The ideal patient is a young man with pure arteriogenic erectile dysfunction who has no other vascular risk factors. Penile revascularization has undergone many refinements since its first description by Vaclav Michal and associates in 1973.34 Many variations have been described by Michal and associates,35 Virag,36 Hauri, Crespo and colleagues,37 and Hatzichristou and Goldstein.38 No further revolutionary changes have occurred in the realm of penile revascularization surgery, nor does consensus exist among experts with regard to the definitive technique. Complications of penile revascularization occur in approximately 25% of patients.39-41 Postoperative arterial hemorrhage with hematoma formation may result from disruption of the microvascular anastomosis. This is the culmination of the repetitive stretching and

tearing of the vascular anastomosis during coitus or masturbation. In our practice, we recommend abstention from sexual activities involving an erect penis for at least 6 weeks postoperatively. Another rare complication is glans hyperemia, which occurs when the dorsal vein has been arterialized (inferior epigastric artery or dorsal artery to deep dorsal vein anastomosis).39,41 The treatment is to ligate the deep dorsal vein distally. Diminished penile sensation may result from dorsal nerve injury but is uncommon because an operating microscope is used for dorsal vessel dissection.42 Crural ligation for venous leak has seen a resurgence in use at major referral centers. In an effort to correct isolated venous leak from crural veins, this procedure entails ligation (or exclusion) of the proximal corpora with umbilical tape.43,44 Two of the more influential studies of this procedure are by John Mulhall and Tom Lue and their associates. Mulhall and colleagues43 described success using a transscrotal approach, whereas Lue and colleagues44 favored a 3-inch inguinoscrotal approach. The most common complications in these studies were scrotal hematoma, infection, and continued erectile dysfunction. We had a single case of infection of the umbilical tape, which was removed. We now treat all patients with preoperative, perioperative, and postoperative oral antibiotics.

PEYRONIE’S DISEASE SURGERY COMPLICATIONS Peyronie’s disease is a fibrotic disorder of the tunica albuginea that results in penile deformity, penile pain, and in some patients erectile dysfunction.45 The etiology and pathophysiology of this disorder have not been completely elucidated.46-48 Prevalence estimates range from 1% to 8.9%.49,50 The natural history of Peyronie’s disease was initially described by Williams and Thomas in 1970.51 In this small study, the investigators reported a spontaneous resolution rate of 50%.51 As a result of this study, many patients with Peyronie’s disease are prescribed conservative treatment. In a later report, Gelbard and colleagues52 described resolution of penile curvature in 13% of patients with nonsurgical treatment. In 2006, we53 reported an analysis of the natural history of Peyronie’s disease in 246 untreated patients. Mean follow-up was 18 months, at which time 12% of men had an improved curvature, 40% remained stable, and 48% worsened. The most important information from this report is that the average improvement in curvature was 15 degrees, but in patients who experienced worsening of curvature, the mean change was 22 degrees.53 These and other articles suggest that spontaneous resolution of penile curvature from Peyronie’s disease is uncommon. Peyronie’s disease has two phases: acute (inflammatory) and chronic. It is best to correct the penile defor-

623

624

Section IX  Complications of Reconstructive Surgery mity surgically after the acute phase has passed. Typically, this is 12 to 18 months after the onset of the condition. In the chronic phase, the penile curvature has stabilized and although penile plaque may be prominent and calcified, it is not associated with penile pain. This is the optimal time for surgical intervention.

Indications and Procedures Tornehl and Carson54,55 published criteria for the surgical intervention of Peyronie’s disease. In our practice, we communicate to patients that no absolute indications exist for curvature correction. However, if the patient can answer any the following questions in the affirmative, if he is ≥12 months from the initial onset of symptoms, and if he has had a stable deformity for ≥3 months, he is then considered to be a candidate for surgical correction of the penile deformity: 1. Does the patient hate the appearance of his penis? 2. Is the patient unable to have penetrative sexual relations? 3. If the patient is able to have penetrative sexual relations, is the experience cumbersome or unsatisfactory? Once the decision to proceed with operative intervention has been made, the surgeon must choose the most appropriate method of curvature correction based on physical examination (nature and magnitude of deformity) during maximal rigidity erection, baseline erectile function, and penile dimensions. Surgical procedures for correcting curvature resulting from Peyronie’s disease fall into three major categories. For a full review of these categories, the reader is referred to the article by Tornehl and Carson55 in Urologic Clinics of North America: 1. Plication: Nesbit, 16-dot, corporoplication, Kelami’s corporoplasty, or incisional corporoplasty, Yacchia procedure 2. Plaque manipulation: removal or incision of the plaque with subsequent coverage of the corporal defect with synthetic or nonsynthetic graft material 3. Penile prosthesis insertion Selecting the correct surgical approach for the individual patient is critical to optimizing results. Patients with complex deformities or those who have at baseline a foreshortened penis are not good candidates for penile plication surgery. Patients with preexisting erectile dysfunction or low-degree simple curvatures are not excellent candidates for plaque incision and grafting surgery. Patients with normal erectile function should probably not undergo penile implant surgery unless they have a complex deformity or a significant hour-glass deformity.

Plication-type procedures are best used in the patient with congenital penile curvature. This approach has a short surgical time, is relatively simple, and has little impact on existing erectile capacity. Plaque manipulation techniques are used in patients with complex deformities, hourglass deformities, normal erectile function, or preexisting penile shortening. Unfortunately, the disadvantages of this method are degeneration of erectile function or dysfunction and dorsal nerve entrapment or damage leading to penile neurosensory alterations. The use of a penile prosthesis in Peyronie’s disease is reserved for men with preexisting moderate to severe erectile dysfunction who have unsuccessfully tried oral and injectable agents.

Penile Plication Complications Complications of plication procedures include hematoma formation, decreased penile sensation (anesthesia, dysesthesia), erectile dysfunction, and bother from suture material palpable after the operation. We perform all dorsal plication procedures after neurovascular bundle elevation.56,57 This approach minimizes the risk of decreased penile sensation in the postoperative setting. We recommend incising Buck’s fascia and using loupe magnification to visualize the dorsal penile nerve bundles. We also use braided nonabsorbable suture (No. 1 polyester [Ticron]) when performing plications because this material is less palpable and may reduce the incidence of patient bother from suture knots. In 1998, Pryor58 reported data from 359 patients dating from 1977 to 1992 who had penile plication performed using the Nesbit technique. The investigators convincingly argued that this technique translates into a high patient satisfaction rate (≤90%) while minimizing postoperative complications. These investigators found that Nesbit-related penile shortening was not a significant problem in this patient population; only 6 men were unable to have penetrative sexual relations because of this issue.58 A more contemporary series of 68 patients from Spain confirmed the findings of other reports.59 At 36 months of mean follow-up, 20% of patients had penile shortening of >1.5 cm, but 85% of the men were satisfied with the cosmetic result of Nesbit technique. Complications of the surgical procedure were minimal; 2 men developed phimosis and 2 needed a second procedure for recurrent curvature.59 Pertinent results of these and other studies are contained in Table 53-2.

Plaque Manipulation Surgery The risk of complications from plaque-based surgery is low. Initial complications include hematoma (supragraft and subgraft) formation and rarely infection. Hematoma formation may be limited by the use of watertight suture lines, small-diameter suture needles,

Chapter 53  Complications of Surgery for Erectile Dysfunction and Peyronie’s Disease TABLE 53-2  Outcomes of Penile Plication Surgery Author

Year

No. Patients

Mean Follow-up (mo)

Sulaiman

1994

78

50

?

4

18

Ralph

1995

185

180

?

3

90

Savoca

2000

157

72

14

?

88

Syed

2003

42

84

76

10

50

Savoca

2004

218

89

17

?

83.5

Bokarica

2005

40

81

100

?

?

Moyano

2006

68

36

20

and narrow-gauge needles when erectogenic drugs are administered to generate an artificial erection. Intermediate and late complications are penile skin necrosis, penile length loss, and recurvature. Loss of penile skin, although rare, is caused by the circumferential skin incision. Because the skin of the penile shaft and the skin of the glans have a separate but anastomotic blood supply, we advocate the use of a single circumcising incision. If needed, a transverse scrotal incision can be made in addition to provide access to the proximal corpora. The recurrence of curvature within a short period postoperatively is the result of either suture failure (we use 4-0 polydioxanone [PDS]) or an inadequately sized graft. Nonabsorbable or delayed-absorption suture must be used in grafting because the tunical forces developed during an erection far exceed the tensile strength of partially absorbed polyglactin (Vicryl, Ethicon, Somerville, NJ) or synthetic polyester (Biosyn, Syneture/US Surgical, Norwalk, Connecticut). The choice of the best grafting material has been the subject of quiet debate. Synthetic materials (e.g., GoreTex) are of historical significance because autologous and cadaveric (processed, prepackaged) grafts are readily available and provide fewer complications. Autologous material (e.g., buccal, dermal, tunical, vein), although available, incites minimal host reaction and infection risk and requires an auxiliary procedure to harvest. An Italian group led by Montorsi60 assessed the longterm outcome of vein grafting in 50 patients with Peyronie’s disease. After a mean follow-up of 32 months, complete resolution of penile curvature in 40 men (80%), minor residual curvature of ≤30 degrees in 7 men (14%), and recurrence of curvature in 3 men (6%) were reported. The procedure was complicated by penile hypoesthesia, penile hematoma, wound infection, and glandular ischemia. Plaque incision with vein grafting is able to achieve satisfactory clinical results a majority of men.60 Conversely, processed or prepackaged material (pericardium, dura mater, intestinal submucosa) offers the ability to tailor the graft specifically to

Shortening (%)

Recurrence (%)

2.9

Satisfaction (%)

85

the appropriate size, minimizes the host inflammatory response, and abrogates the need for harvesting tissue. Levine and Estrada61 published their experience with human cadaveric pericardium. Over a 4-year period, 40 men underwent penile curvature correction with pericardium. Postoperatively, 98% of these men had a straight penis and 95% were able to have penetrative sexual relations; 12 (30%) patients required pharmacologic assistance to achieve a penetration-quality erection. Most interesting is that no major complications occurred in this cohort of men.61 Breyer and Lue and their colleagues62 retrospectively reviewed outcomes with and complications of using intestinal submucosa in the correction of penile curvature in Peyronie’s disease. Nineteen patients were treated with tunical incision or excision and grafting with small intestine submucosa. Of these patients, 37% (7 of 19) had significant recurrent penile curvature, whereas 5 of 19 (26%) had recurrent Peyronie’s disease plaque. The investigators reported a 37% complication rate, including graft site hematoma and graft infection, as well as reoperation for Peyronie’s disease recurrence in a single patient.62 Despite the ease of use of small intestine submucosa, the high complication rate makes the use of this material less desirable. The results of these and other studies are presented in Table 53-3.

Penile Prosthesis Surgery Implant surgery for Peyronie’s disease is indicated when the patient has both Peyronie’s disease and erectile dysfunction that is not responsive to erectogenic pharmacotherapy. General complications of penile prosthesis insertion are listed elsewhere, but penile modeling deserves special comment. Modeling or molding entails powerfully bending the penis in an effort to break or crack the Peyronie’s plaque when residual curvature remains after inflation of the device intraoperatively. This method was embraced by Wilson and Delk63 in 1994 and showed an initial 86% success rate.

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626

Section IX  Complications of Reconstructive Surgery TABLE 53-3  Outcomes of Plaque Incision and Grafting Author

Year

No. Patients

Graft

Length Loss (%)

Correction Rate (%)

Kadioglu

1999

20

Vein

?

75

Montorsi

2000

50

Vein

40

80

Knoll

2001

12

Intestine

0

100

Egydio

2002

33

Pericardium

?

88

Levine

2003

40

Pericardium

?

98

Lue

2007

19

Intestine

63

63

TABLE 53-4  Outcomes of Penile Implant Surgery for Peyronie’s Disease Author

Year

No. Patients

Manual Modeling (%)

Levine

2000

46

54

Wilson

2001

104

100

Usta

2003

42

74

26

Akin-Olugbade

2005

18

20

100

The specific technique is begun with the device partially inflated and the tubing cross-clamped with rubber shod hemostats. The penis is forcibly bent in a direction opposite to the curvature in a maneuver similar to breaking a twig in both hands for 90 seconds. The procedure is repeated for another 90 seconds. The device is deflated and then reinflated to reseat the cylinders within the corporal bodies.64 Certain devices are ill advised when penile modeling may be required. The AMS Ultrex, with its girth- and length-expanding capabilities, may cause an increased risk of aneurysm formation when forcibly deformed. Furthermore, the Ultrex device lacks the axial rigidity to straighten a penile curvature.65 Follow-up studies by Wilson and associates64 confirmed that implantation and modeling appeared to provide permanent straightening without an increase in revisions as compared with implantation alone. The major complication of corporal modeling is urethral laceration, which occurs in approximately 4% of cases.64 This ulceration is usually visible and is repaired using fine absorbable sutures (Table 53-4).

Successful Correction (%)

Device

100

Two- and three-piece

—

Alpha 1, 700CX — 60%

KEY POINTS 1. Infection remains a significant concern, with rates between 1% and 8%. 2. In the setting of infection, device removal is highly recommended. Immediate reinsertion of the prosthesis is associated with long-term success in 45 of 55 patients in one study. 3. Despite the potential complications of the penile prosthesis, satisfaction rates remain high. 4. Peyronie’s disease surgery should be undertaken in the properly selected patient with realistic expectations of the potential outcome. 5. Complications of Peyronie’s procedures include hematoma formation, decreased penile sensation (anesthesia, dysesthesia), erectile dysfunction, and bother from palpable suture material, penile skin necrosis, penile length loss, and recurvature.

REFERENCES Please see www.expertconsult.com

Chapter 

54

COMPLICATIONS OF SURGERY OF THE TESTICLE, VAS, EPIDIDYMIS, AND SCROTUM David Fenig

MD Associate Director, Male Fertility and Sexuality, Chesapeake Urology Associates, Baltimore, Maryland

Philip Werthman

MD Director, Center for Male Reproductive Medicine, Los Angeles, California

Since the last publication of this book, the performance of almost all surgical procedures involving the scrotum has transitioned from the hospital operating theater to outpatient surgical centers and physicians’ office procedure rooms. Although these procedures are considered minor, they can be fraught with morbidity and can result in significant amounts of pain, anxiety, and lost wages for those patients experiencing complications. In fact, scrotal surgical procedures generate significant amounts of litigation directed toward urologists. Finesse and forethought are necessary requisites for a surgeon to attain a level of proficiency with scrotal procedures. The subspecialty of male reproductive medicine has experienced significant growth paralleling that of reproductive endocrinology and has required general urologists to expand their knowledge base and skill in this area. Fertility-related procedures encompass a significant portion of scrotal surgery. Many procedures are best performed using an operating microscope and thus necessitate some degree of microsurgical training on the part of the surgeon. The goals of this chapter are to outline the basic principles of surgery of the scrotum and its contents, to describe the potential complications that may arise from each of the individual procedures, and to discuss the treatments of these complications. Most importantly, we hope to convey to the reader some of the pitfalls and situations that may lead to complications and the means to avoid these complications from the outset.

PRINCIPLES OF SCROTAL SURGERY As with any surgical procedure, patient selection is a key factor to a successful outcome and the avoidance of complications. Indications for surgery on the scrotum or its contents include suspicion of cancer, relief of

pain, improvement of fertility, contraception, and cosmesis. Regardless of the reasons for surgical treatment, certain issues must be similarly addressed before, during, and after the procedures, as discussed in this section. Preparing the patient for surgery must include obtaining informed consent. The surgeon should discuss in detail the procedure, the indications for performing the procedure, all the alternative treatments for the patient’s condition, the chances for successful outcome of each of the alternatives, and their advantages and drawbacks. It is important to discuss the recovery process in terms of the patient’s occupation and lifestyle. Expectations regarding the procedure and recovery should be realistic. Patients need to be made aware that even very minor procedures can have significant untoward ramifications. A discussion of all the potential risks and complications of a given procedure should be documented in the patient’s medical record. For the majority of scrotal procedures the risks include pain, bleeding, swelling, infection, failure of the procedure, testicular atrophy or loss, and potential undesired effects on the patient’s fertility or hormone production capacity. Other procedure-specific complications include hydrocele formation and groin or scrotal numbness. Patients should be informed of the small potential for development of chronic testicular or epididymal pain, especially after vasectomy. Patients should be instructed to discontinue aspirin and nonsteroidal anti-inflammatory medications 7 days before the date of the procedure. Even baby aspirin and some herbal supplements can result in platelet dysfunction that can lead to postsurgical bleeding. The scrotal skin should be shaved in the operating room immediately before the procedure to reduce the risk of infection. The patient should not shave the surgical area at home the day before the procedure. Investigators 627

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Section IX  Complications of Reconstructive Surgery have shown that small nicks in the skin can become infected and lead to a postoperative wound infection. Several choices of anesthesia induction are appropriate for these types of cases and include general anesthesia, local anesthesia with or without intravenous sedation, and spermatic cord block. Epidural or spinal anesthesia is hardly ever used in the outpatient setting. A newer needle-less technique using an air gun injector has been described to induce spermatic cord block for vasectomy. The most important considerations in anesthetic choice should include the patient’s comfort and anxiety level, safety, the ability to immobilize the patient especially for microsurgical procedures, the risks of the anesthetic technique on the patient’s health, and the recovery from the anesthetic. Some patients may have a high tolerance to local anesthesia such that it is difficult to induce or maintain a pain-free state. Patients who are candidates for local anesthesia should be asked whether they have had any anesthetic issues during dental procedures to identify whether they are resistant to the effects of local anesthetics or require significantly higher doses. Some patients report that local anesthesia wears off quickly. Performing a procedure using only a local anesthetic in the aforementioned groups should be avoided. The cornerstone of good scrotal anesthesia is the spermatic cord block. The ideal regimen is a 10-mL equal parts mixture of 0.5% bupivacaine with 1% or 2% lidocaine without epinephrine, infiltrated using a 25-gauge needle. The vas deferens is first isolated with the thumb and forefinger and 4 mL is injected around, but not into, the vas. Another 4 mL is then injected into the internal spermatic fascia. The needle is slowly advanced without the use of a back-and-forth motion because this maneuver can lead to hematoma formation. The area of the incision should be infiltrated with 1 or 2  mL to raise a skin wheel. On rare occasions a patient will require an additional injection. Before closing, 5 mL of anesthetic is instilled within the intratunical space and another 5  mL is instilled into the space between the dartos and tunica vaginalis layers. Reinfiltration of the skin incision is then performed before the closing sutures are placed. This regimen should keep the patient pain free for at least several hours and should allow him to leave the facility and return home in little discomfort. From a surgical standpoint, the scrotum can be an unforgiving area in that a small bleeding vessel can result in a very large expanding hematoma. The many layers of tissue within the scrotum can easy conceal a retracted vessel and can make hemostasis difficult to achieve. To ensure meticulous hemostasis, electrocautery should be used to incise each layer and veil of tissue. On occasion, bleeding can ensue from a spermatic cord block if the needle pierces a vein or more rarely a spermatic artery branch. This situation is more likely to occur in men with large varicoceles, and caution

should be taken when inserting the needle into the internal spermatic bundle. The hematoma is usually discovered on entering the tunica vaginalis filled with blood. Persistent low-level bleeding can be stopped with several minutes of manual compression of the upper scrotum and spermatic cord. Brisk bleeding that does not abate with compression necessitates delivery of the testicle and exploration of the spermatic cord with cauterization or ligation of the breeched vessel. Care should be taken to avoid arterial injury while achieving hemostasis. On closure of the surgical site, all tissue layers should be individually reapproximated at their cut edges with a running suture technique. Minor bleeding at the skin edges can also be controlled in this manner or by placing a Babcock clamp over a gauze pad on the wound for several minutes. The resulting compression of the skin edges usually stops the bleeding. Use of surgical drains is generally not required for scrotal procedures unless the indication for surgery is to evacuate a hematoma or an infection of a closed space or to repair a large hydrocele. It is wise to consider leaving a drain in place after a procedure in which hemostasis has been less than optimal or when increased inflammation is encountered. Drain placement is easily accomplished by using a hemostat to puncture a hole through the tunica vaginalis, dartos, and skin layers at the base of the scrotum. A ¼-inch Penrose drain is pulled through the drain site and is laid on the posterior surface of the tunica vaginalis under the testicle in a dependant position. Caution must be taken not to incorporate the drain in the wound closure accidentally. A silk or nylon suture is used to secure the drain to the scrotal skin. Patients can be instructed to remove the drain at home on the first or second postoperative day. Scrotal incisions may be dressed with a small adhesive bandage followed by fluffed gauze and a scrotal support. Athletic supporters tend to be much more comfortable for the patient than do typical surgical supporters. These supporters also can accommodate an ice pack and hold it in place more readily. Turban dressings maintain excellent scrotal compression following bilateral orchiectomy. When increased amounts of postoperative swelling are anticipated, the scrotum can be sutured to the abdominal wall or upper thigh over a gauze roll. This type of dressing is not very practical for outpatient surgical procedures. Patients should be instructed to continue to use an athletic supporter and ice pack after undergoing any procedure on the scrotum. A variable period of 1 to 5 days of bed rest or light activity should be observed depending on the specific procedure. Postoperative pain can usually be controlled with acetaminophen or a mild narcotic. Ibuprofen and aspirin should be avoided because of their effect on platelet function. Patients should be able to shower on the day after the surgical procedure.

Chapter 54  Complications of Surgery of the Testicle, Vas, Epididymis, and Scrotum

VASECTOMY Vasectomy is a safe and effective method of permanent male contraception performed on >500,000 men annually in the United States.1 In the hands of an experienced practitioner, it is a quick, relatively pain-free, and low-risk procedure.2 An initial prevasectomy consultation consists of a thorough history and physical examination and a discussion of the procedure, treatment alternatives, and reversibility. Patients should be given a period of time to consider sterilization fully and it is therefore recommended that a vasectomy not be performed at the initial visit or in haste. Exaggerated emotional reactions associated with sterility may lead to an angry and litigious patient should complications arise. A Danish study found that 7.4% of men who underwent vasectomy regretted their decision and 39% of these men were 1  cm need not be excised because this may lead to increased bleeding, swelling, and recovery time. A fascial segment may be interposed after the vas ends are sutured back on themselves or are buried in the dartos layer. Hemostasis is meticulously achieved and the incisions are closed. The no-scalpel technique was developed in China in 1974 and has been demonstrated to decrease operative and recovery time as well as complications, including hematoma and postoperative pain.4-6 Anesthesia is induced as described earlier. After delivering the vas to the skin surface, it is grasped and transfixed in place to the skin with a no-scalpel vasectomy ring clamp. A sharp curved mosquito hemostat is used to pierce the skin, the dartos layer, and the vasal sheath. The vas is delivered out of the sheath and is incised. Ligation of the abdominal and testicular ends of the vas is performed with surgical hemoclips. It is not as important to interpose a segment of fascia or dartos between the cut ends of the vas particularly if surgical clips are used. Open-ended vasectomy, a procedure in which the testicular end of the vas segment is left untied, has been advocated by some surgeons in an attempt to decrease secondary epididymal obstruction, epididymitis, and pain,7,8 although it may actually lead to higher failure rates and sperm granuloma formation. Evidence suggests that fascial interposition and cauterization of the vasal ends reduce postoperative failure versus sutureligation and excision of a segment of vas alone.4,9 It is important to maintain constant control of the vas so it does not retract into the scrotum during the procedure. One technique is to have an extra ring clamp available to keep around the testicular end of the vas until the procedure is completed. Care should be taken to dissect the vas out of the vasal sheath and ligate only the vas itself. Incorporating the sheath into the ligature may result in chronic scrotal pain. It is advisable to leave a small hemostat on the vas after completion of the first side so that the same vas cannot be grasped and cut twice, a maneuver that would lead to vasectomy failure. With the no-scalpel vasectomy, skin closure is usually not necessary although the small hole in the dartos and skin may be cauterized to help achieve hemostasis and

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Section IX  Complications of Reconstructive Surgery reduce its size. A small adhesive bandage is placed over the breach in the skin. Scrotal ice packs and a scrotal supporter are used for ≥24 hours postoperatively, and strenuous activity and sexual activity are avoided for 1 week. Patients are instructed to ejaculate a minimum of 20 times to clear the reproductive tract of sperm. Follow-up semen analyses are mandatory and should begin at 6 weeks after vasectomy. Patients are counseled to use contraception until azoospermia is documented on two consecutive semen analyses. According to a policy statement of the American Urological Association (AUA), it is not necessary to store or send a segment of the removed vas for pathology examination. It is also important to not overcauterize the testicular end of the vas because that can cause necrosis at the surgical clip site and can result in leakage of sperm with subsequent granuloma formation. Postoperative success is ultimately determined by a negative semen analysis; pathologic confirmation of the vas does not guarantee success. In fact, recanalization may be responsible for failures regardless of the technique performed. Smith and colleagues10 reported a 1 in 2000 risk of paternity after vasectomy despite postoperative azoospermia.

Specific Complications and Their Treatment Postoperative hematoma occurs in ≤2% of patients but the rate is slightly higher when fascial interposition is used. This is typically a self-limiting process and a conservative approach is recommended. Initial treatment is with bed rest, ice packs, and a scrotal supporter. Resolution of hematoma occurs over several weeks to months, and patients often require significant reassurance that no permanent sequelae will occur. If the hematoma is expanding, surgical exploration is warranted. After evacuation of hematoma and achievement of hemostasis, a ¼-inch Penrose drain may be placed for 24 to 48 hours. Many times the source of active bleeding is not found. An appropriate cephalosporin is administered. Wound infection is an infrequent event, occurring in 2  mL or 20% of testicular volume is considered abnormal19 and usually reverses following corrective surgical procedures.20,21 Varicocele has been demonstrated to increase sperm DNA fragmentation and correction has been shown to improve the damage. It is important to rule out other causes of infertility in men with severe oligospermia and concomitant varicocele. Patients with bilateral varicoceles have a greater improvement in seminal parameters if they undergo bilateral repair as opposed to unilateral repair. The treatment options for patients with a clinically significant varicocele include surgical ligation and percutaneous embolization (Box 54-2). Surgical correction may be performed through a retroperitoneal, inguinal, subinguinal, or transperitoneal laparoscopic approach. The goal of varicocele surgery should be to ligate all veins including small branches to prevent recurrence while preserving the arterial supply and lymphatic drainage to optimize testicular function and decrease risk of hydrocele formation. Use of a small incision without cutting the muscle or entering the peritoneum or retroperitoneum decreases pain and recovery time as well as the risks of serious morbidity. When one evaluates the different techniques in terms of outcomes, recurrence rates and risks, microsurgical inguinal repair appears to be superior to all others. The use of an operating microscopic during the procedure

BOX 54-2 Surgical Pearls: Varicocelectomy 1. Rule out other causes of infertility or pain before varicocele repair. 2. Identify the ilioinguinal nerve in the inguinal canal during inguinal repair. 3. Identify the internal spermatic artery, its branches, and the vas deferens before proceeding with vein ligation. 4. Ligate all internal and external spermatic veins; varicose veins around the vas deferens must be ligated as well. 5. Spare the lymphatic channels. 6. Use of an operating microscope and a Doppler microprobe will decrease recurrence and complications.

has demonstrated benefit in reducing both recurrences and complications.22,23 In an attempt to reduce varicocele recurrence through collateral vessels further, delivery of the testis with ligation of the gubernacular and external spermatic veins has been advocated.24 Although laparoscopic varicocelectomy is associated with recurrence rates of