Emergencies in Urology - part 6 docx

tion of the complex is difficult secondary to retraction into the deep pelvis and if patient positioning permits, pressure applied on the perineal body with a sponges- tick may push the complex into view. When bleeding persists, a large-caliber urinary catheter with a large balloon may be inserted and inflated with 20–30 ml of fluid and placed on temporary traction. 17.1.3 Intestinal Complications 17.1.3.1 Bowel Injury Reoperative surgery and surgery in irradiated patients can be technically challenging endeavors fraught with potential complications, intestinal injuries being the most common. Extensive intraabdominal and intrapel- vic adhesions often require tedious and meticulous ly- sis of adhesions prior to initiation of the primary oper- ative procedure. This frequently results in a maze of in- testinal loops that must be completely sorted out. The surgeon will find that by taking the necessary time ini- tially to release adhesions, the remainder of the opera- tion should proceed with greater ease and less opportu- nity for injuries. Often times, the surgeon will find that tissue planes will present themselves with a combina- tion of blunt and sharp dissection as the tissue is three- dimensionalized. Again, we emphasize the principle of actively preventing injuries and setting up the opera- tion for success. Enterotomies may be easily created but often poorly recognized. When bowel injury is noted, immediate re- pair is most prudent; however, a marking stitch may be placed for later repair. With small rents, a simple in- verting or figure-of-8 suture may be sufficient. For more extensive injuries, a short segment of intestine may be discarded with primary anastomosis. The au- thors prefer a hand-sewn technique using interrupted silk sutures in two layers. Injury to the second or third portion of the duode- num may occur during a radical nephrectomy, espe- ciallyontheright.Thiscanbepreventedbyadequate and careful mobilization of the small bowel mesentery in a cephalad direction starting at the region of the right lower quadrant with careful identification of the retroperitoneal portions of the duodenum. The Kocher maneuver can also be utilized to reflect the duodenum medially and away from the operative field. On the left side, this maneuver will allow careful reflection of the pancreas, thus avoiding injury. Retracting instruments andmoistspongesshouldbeutilizedtoreflecttheduo- denum and other intestinal loops. Forceful retraction should obviously be avoided to prevent bowel wall inju- ry. In cases of duodenal injury with violation of the bowelwall,carefulinspectionofthewalledgeswith sharpdebridementofnonviabletissuesisnecessary prior to repair. A two-layer closure with silk sutures in a transverse fashion should be performed to avoid nar- rowing of the lumen. An omental patch on the area of duodenal injury provides added security to reduce op- portunities for leak. Postoperative gastric decompres- sion with delayed enteral feeding is vital for proper healing. The authors prefer to place a gastrostomy tube when possible for patient comfort, which is detailed elsewhere (Buscarini et al. 2000). Rectal injuries may occur in the setting of radical prostatectomy or cystoprostatectomy, with increased incidences in those receiving previous definitive radia- tion (Stephenson et al. 2004). The technique of radical retropubic prostatectomy has been refined over the last two decades based on important anatomical studies de- tailed by Walsh and Donker (1982). Today, this proce- dure remains a standard therapeutic option in the treatment of prostatic tumors, affording excellent can- cer control with maintenance of sexual function and urinary continence. Rectal injuries are an important potential complication, although they are extremely rare in nonoperated, nonirradiated patients with low- stage disease. An important consideration during a nerve-sparing radical prostatectomy is the entrance in- to a proper plane of dissection along the lateral prostat- ic surface. Magnification loupes can aid in the visuali- zation of this plane. Additionally, proper control of the dorsal venous complex and its superficial branch prior to the delicate dissection of the neurovascular bundles will help maintain a relatively bloodless operative field and optimize surgeon vision. Once the lateral pelvic fascia is identified and incised, gentle blunt dissection alternating with sharp dissection will successfully iso- late the bundle laterally and allow the posterior surface of the prostate to be freed up (Stein et al. 2001) (Fig. 17.1.7). The posterior plane between the rectum with the pe- rirectal fat and the posterior surface of the prostate with the leaflets of Denonvilliers fascia can be bluntly dissected when there has been no previous radiation. If this dissection does not occur easily additional force and traction should be avoided, as the correct plane may not be identified and injury to the rectal wall is possible. Following apical dissection of the prostate and transection of the urethra with placement of vesi- courethral anastomosis sutures, the rectourethralis fi- bers and lateral pillars of the prostate are encountered. These attachments should be carefully incised sharply as the apex of the prostate is gently retracted anteriorly and cranially. This maneuver should allow entry into the perirectal fat space previously identified during the lateral dissection. In patients who have undergone definitive primary radiation therapy for the treatment of prostatic adeno- carcinoma or other pelvic malignancies, the normal 17.1 Management of Intraoperative Complications in Open Procedures 319 Fig. 17.1.7. Incision of lateral prostatic fascia with blunt dissec- tion along prostatic surface with entry to correct plane posteri- orly (Fig. 17.1.7 and 8 © Hohenfellner 2007) planes of dissection are often obliterated and indiscern- ible. A preoperative mechanical bowel prep and enema is prudent in anticipation of possible rectal injury. The technique of radical prostatectomy is not significantly differentbut greater care must be observed in dissecting the periprostatic planes. Early ligation and division of the dorsal venous complex followed by division of the urethra allows the surgeon to reflect the prostate anteri- orlyandtovisualizetheprostate–rectalplane.This planeshouldbedissectedsharplymoresothanbluntly. In the event of a rectal injury, primary repair and clo- sure (in multiple layers) should be undertaken immedi- atelyoncetheprostateglandisremoved.Carefulin- spection of the rectal wall edges should guide the need for debridement prior to closure. Closure should be per- formedinatransversefashion.Theclosureshouldbe performed in two layers with careful reapproximation of mucosal and seromuscular edges using interrupted 3-0silksutures.Alternatively,theclosuremaybeper- formed in a continuous fashion. If obvious fecal spillage is noted the area should be copiously irrigated and a di- verting colostomy should be seriously considered. A di- verting colostomy is imperative in patients previously irradiated for prostate cancer resulting from poor heal- ing of tissues. An omental flap interposition may also be necessary in cases of larger injuries or significant fecal contamination. It is our experience that an omental flap basedofftheleftgastroepiploicarteryhasgreatermo- bility and reach into the deep pelvis (Figs. 17.1.8, 17.1.9). Fig. 17.1.8. Omental pedicle mobilized on left gastroepiploic ar- tery with ligation and division of short gastric arteries Fig. 17.1.9. Omental pedicle based on left gastroepiploic artery reaches deep pelvis with ease Suction drains should be considered in cases of fecal spillage with additional postoperative antibiotics to cover Gram-negative and anaerobic organisms. Fol- lowing completion of the operation, digital dilation of the anal sphincter while the patient remains anesthe- tized may further serve to protect the repair. 320 17 Intraoperative Complications Theauthors’preferredtechniqueofperformingadi- vertingileostomyistousetheTurnbullloopmethod. We utilize this routinely in the creation of ileal con- duits, as it provides superior fit for skin appliances and maintains better vascularity to the stoma to help pre- vent future stomal stenosis. Preoperative preparation for patients undergoing any stoma creation should fo- cus on proper location. The stoma should be located away from bony prominences, skin creases, scars, and areas of chronic skin irritation. It should also be posi- tioned so that an external appliance may be properly seated. After a suitable segment of bowel is identified and adequately mobilized for creation of the stoma, a circu- lar skin disk is excised by using the butt end of a 20-ml syringe plunger as a template. Underlying subcutane- ous fat is incised and retracted using narrow retractors to expose the anterior rectus sheath. Excision of fat from the subcutaneous layer should be routinely avoid- ed, as this may cause retraction of the stoma. The ante- rior rectus sheath is incised longitudinally over the bel- ly of the rectus abdominus muscle approximately 2–3 cm in length. The muscle is split along the fibers using curved Mayo scissors and the underlying trans- versalis fascia and peritoneum are incised. A proper opening should accommodate twofingers and avoid in- jury to the inferior epigastric vessels. The anterior rec- tus sheath can also be opened transversely for a short distance to create a cruciate. Four 2-0 Vicryl sutures are preplaced in the fascial corners, which will later be placed in the seromuscular layer of the loop. A narrow Penrose drain is placed through the mes- entery at the most mobile location of the ileal loop and theloopisdrawnthroughtheopening.Theknuckleof bowel should protrude 3–4 cm above the skin level and be secured in place with the preplaced fascial sutures. When properly oriented, the proximal aspect should be cephalad.Ifnecessary,astomarod,redRobinsoncath- eter, or Penrose drain may be used to support the loop while the stoma is everted and matured (Fig. 17.1.10). An incision is created along the seromuscular surface on the distal, defunctionalized aspect of the loop at the skin layer approximately four-fifths of the way across. Three 3-0 Vicryl sutures are placed in the subdermal layer on the cephalad aspect of the stoma opening and then passed through the corresponding seromuscular layer and the enterostomy edge of the proximal loop (Fig. 17.1.11). One 3-0 Vicryl suture is placed in the subdermal layer on the caudal aspect and then passed throughtheenterostomyedgeofthedistalloop.AnAl- lis clamp is placed into the lumen of the bowel and the mucosa is grasped on the anterior luminal surface. A second clamp is placed on the edge of the enterostomy and the inner clamp is pulled out as the outer clamp is used to evert the bowel edge (Fig. 17.1.12). Once evert- ed, the nipple stoma is matured using a series of inter- Fig. 17.1.10. Stoma rod used to support loop stoma (Fig. 17.1.10–12 © Hohenfellner 2007) Fig. 17.1.11. Loop ileostomy with Allis clamp grasping inner mucosa Fig. 17.1.12. Eversion of loop stoma using Allis clamp 17.1 Management of Intraoperative Complications in Open Procedures 321 Fig. 17.1.13. Mature Turnbull loop stoma (Fig. 17.1.13 and 14 © Hohenfellner 2007) Fig. 17.1.14. Creation of end-loop colostomy rupted 3-0 Vicryl sutures. Care must be taken to avoid sutures in the mesentery (Fig. 17.1.13). The ileostomy is closed by excising the stoma and properly mobilizing the proximal and distal loops from thefascialedges.Themesenteryoftheloopiscentrally locatedandmustbeavoidedtomaintainvascularityto the ileal segment. The segment of bowel is excised and the two fresh ends of intestine anastomosed together. Theloopcolostomyisconstructedinasimilarfash- ion with slight modifications to accommodate the bulkier and occasionally more dilated nature of the co- lon. Alternatively, an end-loop stoma may be con- structed by creating an end stoma flush with the skin using the proximal loop. The distal loop can be brought to the skin as a mucus fistula (Figs. 17.1.14, 17.1.15). Thistechniquestillprovidestheadvantagesofaloop stoma. Given the more solid nature of output from a co- lostomy, a nipple stoma is less crucial for appliance fit and surrounding skin care. The closure of a loop or end-loop colostomy is, again, similar to the ileostomy. Resectionoftheshortsegmentofcolonisoftenunnec- essary, as the anterior defect or enterostomy can be closed in two layers. In the technique of radical cystectomy, the same principle of dissection in proper planes will prevent in- advertent rectal injury. This is particularly important in males, as the bladder, prostate, and seminal vesicles are directly apposed to the rectum. In women, the vagi- na provides a buffer against any rectal injury. We have previously described our technique of radical cystopro- statectomy and will emphasize key points of the poste- rior dissection (Fig. 17.1.16). (Stein and Skinner 2004) Following the division of the lateral vascular pedicles (anterior branches of the hypogastric artery), attention is directed toward entry of the pouch of Douglas. The surgeon elevates the bladder anteriorly with a gauze Fig. 17.1.15. End-loop colostomy with mucus fistula 322 17 Intraoperative Complications Fig. 17.1.16. Posterior plane of dissection should be carried out between Denonvilliersfasciaand the perirectal fat (© Hohenfellner 2007) sponge in his left hand as the assistant retracts the peri- toneum and rectosigmoid colon cephalad. With the peritoneum on tension, it is sharply incised from lateral to medial from both sides. At this point, a clear under- standing of fascial planes is critical in the remainder of the dissection. The anterior and posterior peritoneal reflections converge at the pouch of Douglas to form Denonvilliers fascia. Denonvilliers fascia itself is com- posed of an anterior and posterior sheath with the pos- terior sheath adjacent to the perirectal fat. This is the correct plane of dissection that must be entered to suc- cessfully separate the bladder and prostate specimen from the rectum. The anterior sheath of Denonvilliers fascia is adjacent to the seminal vesicles, vasa, and prostate and does not separate easily. In order to enter the proper plane of dissection, the peritoneum should therefore be incised slightly on the rectal side, rather than on the bladder side. Once the plane between the anterior rectal wall and the posterior sheath of Denon- villiers fascia is entered, a combination of blunt and sharp dissection should reliably carry the dissection down to the apex of the prostate. Again, sharp dissec- tion under direct vision is favored over blind blunt dis- section. The assistant’s role is critical at this juncture, astheworkingspaceislimitedandlightingmaybeless than ideal. Constant retraction on the rectosigmoid co- lonandsuctionofbloodandfluidswillmaintainthe surgeon’s vision. The rectum will more likely be tented up to the prostate in the midline and therefore should be sharply incised in this area. Blunt dissection in a sweeping motion from prostate to rectum is relatively safe on either side of the midline. When the perirectal space has been adequately developed, the posterior pedicles of the bladder will be easily identified for liga- tion and division. 17.1.4 Solid Organ Injury 17.1.4.1 Spleen Radicalsurgeryforaleft-sidedrenalcellcarcinoma and/or adrenal tumor may sometimes involve injury or removalofthespleen.Notuncommonly,malignanttu- morsmaylocallyinvadeorcloselyabutadjacentor- gans, including the spleen, pancreas, or duodenum. In- juries can be avoided with judicious use of retracting instruments with blunt edges and soft curves. Assis- tants should monitor the degree of force placed on re- tractors, which may frequently become excessive as at- tention is focused on the operation itself. Mobilization ofthespleenmaybenecessarytoexposeadrenaland large upper pole renal tumors. This is first accom- plished mobilizing the colon and dividing the splenore- nal and phrenocolic ligaments. When dividing the at- tachments of the splenorenal ligament, care must be taken to avoid avulsion or transection of the splenic vessels that run with this ligament. Additionally, mobi- lizationofthespleencanalsocauseunduemobilization of the tail of the pancreas with subsequent injury. When a splenic injury does occur, splenorrhaphy should be primarily performed when feasible. Gentle manual compression of the splenic hilum will provide temporary hemostasis for repair. Simple rents in the splenic capsule with concomitant bleeding can usually be controlled with electrocautery followed by suturing of the capsular defect using chromic catgut or silk sutures. Large defects are best repaired with sutures and bolsters of Gelfoam, NuKnit, or Surgicel placed in the defects. Omental patches can also provide substance to both fill and stop bleeding when repairing capsular defects. With larger injuries not amenable to repair, splenec- tomyshouldbeandcanbesafelyperformed.Thepost- operative risk of sepsis is rare, especially in nonpedia- tric patients; however, appropriate prophylactic immu- nizationsshouldbeadministered.Tosafelyperforma splenectomy, the entire spleen should be mobilized an- teriorly and medially. This is best accomplished by ligat- ing and dividing the short gastric vessels and by rotat- ing the spleen and tail of the pancreas medially to ex- pose the major splenic vessels. The artery and veins should be separately ligated and divided when possible, starting with the artery. This can be performed by uti- lizing small clamps and free silk or Vicryl sutures. Note that the splenic vessels are best divided close to the hi- lum of the spleen to prevent injury to the pancreatic tail. 17.1.4.2 Pancreas As in the case of the duodenum and spleen, specific measures should be taken through the course of an op- 17.1 Management of Intraoperative Complications in Open Procedures 323 eration to adequately mobilize the pancreatic tail or head to optimize exposure as well as protect the pancre- as. This is especially important for large tumors of the kidney and retroperitoneum. Careful mobilization of the tail or head of the pancreas and using padded re- tractors with gentle force will minimize the opportunity for injury. Gross inspection of the pancreatic surface should alert the surgeon for any signs of contusion, con- gestion, or laceration. Postoperatively, a prolonged ileus or intense abdominal pain, out of proportion to the site and extent of the incision, should raise suspicion to the possibility of pancreatitis and pancreatic injury. Fig. 17.1.17. Involvement of the pancreatic tail by a large right renal mass Fig. 17.1.18. Transection of the pancreatic tail using a gastrointestinal stapler Occasionally,itmaybenecessarytoresectaportion of the pancreas in the surgical treatment of tumors in- volving the kidney, adrenal gland, and retroperitone- um (Fig. 17.1.17). For right-sided tumors that involve the head of the pancreas as well as the duodenum, an en bloc resection may be indicated. Preoperative planning and imaging should alert the surgeon for probable con- sultation with a hepatobiliary surgeon. In cases of left- sided tumors involving the tail of the pancreas, simple resection with repair can be safely performed. In cases of injury to the tail of the pancreas, debridement of the injured portion should be performed followed by visu- 324 17 Intraoperative Complications al identification of the pancreatic duct. The duct should be individually ligated or oversewn if visible and the edges of the gland can be reapproximated with inter- rupted silk sutures. Absorbable sutures should be avoided because of the enzymatic breakdown that may occur prior to complete healing. When formal resection of the pancreatic tail is neces- sary,wehavefoundsuccessinusingastaplingandcut- ting device such as a GIA stapler (U.S. Surgical, Norwalk, Fig. 17.1.19. Reinforcement of pancreatic tail utilizing Tefl on ple dg elet s Fig. 17.1.20. Complete repair of pancreatic tail CT, USA) or Proximate Linear Cutter (Johnson & John- son, Cincinnati, OH, USA) (Fig. 17.1.18). The transected stump is reinforced with Teflon pledgets securely sewn in place with number-0 silk sutures in a horizontal mattress fashion (Figs. 17.1.19, 17.1.20). The pancreatic duct is ef- fectively ligated and divided with the stapling device. Whenever repair or resection of the pancreas is per- formed, a closed suction drain should be left in place with close monitoring of outputs postoperatively. 17.1 Management of Intraoperative Complications in Open Procedures 325 17.1.4.3 Diaphragm Resection of large retroperitoneal masses including re- nal masses may require partial removal of the adjacent diaphragm. Typically, division of the diaphragm is nec- essaryforadequateexposureinthethoracoabdominal incision and can be easily repaired. The diaphragm is reapproximated in two layers with nonabsorbable su- tures. Interrupted mattress sutures or an interlocking continuous suture may be used. When a large defect is present because of resection, reconstruction is per- formed by incorporation of synthetic mesh with non- absorbable suture to provide stability. We prefer to lay a greater omental apron to cover the mesh on the ab- dominal side to protect the abdominal organs and facil- itate the diaphragm closure. Extended chest tube drainage may be required as intraperitoneal fluid shifts into the ipsilateral thorax during the postoperative pe- riod. 17.1.5 Conclusion Surgical morbidity is significantly minimized with careful surgeon preparation and sound operative tech- niques. By adhering to basic principles of surgery and patient care, the urologist will avoid many operative misadventures. Thorough preoperative planning with appropriate radiographic imaging will elucidate any potential surprises (vascular or anatomical variances) that may lead to vessel or organ injury. Complete knowledge of anatomical relationships is imperative, especially in situations where normal anatomy is dis- rupted because of large tumors, previous surgery, in- fection, or irradiation. The appropriate incision must be employed when patient pathology requires it. Inade- quateexposurewillnotonlyincreasethepotentialfor complications, but will also hamper the efforts to effec- tively address them. Lastly, when an operation is per- formed the exact same way each time, the surgeon and assistant will not only operate more efficiently but also prevent many complications. References Ahlering TE, Skinner DG (1989) Vena caval resection resection in bulky metastatic germ cell tumors. J Urol 142:1497 Buscarini et al (2000) Tube gastrostomy following radical cy- stectomy with urinary diversion: surgical technique and ex- perience in 709 patients. Urology 56:150 Crawford ED, Skinner DG (1980) Salvage cystectomy after ra- diation failure. J Urol 123:32 Donohue JP (1989) Postchemotherapy retroperitoneal lym- phadenectomy for bulky tumor including extended suprahi- lar posterior mediastinal dissection and/or major vessel re- section. In: McDougal WS (ed) Difficult problems in urolog- ic surgery. Year Book Medical Publishers Hoeltl W, Hruby W, Aharinejad S (1990) Renal vein anatomy and its implications for retroperitoneal surgery. J Urol 143:1108 Killion LT (1989) Management of intraoperative hemorrhage from open surgery of bladder and prostate. In: McDougal WS (ed) Difficult problems in urologic surgery. Year Book Medical Publishers Pruthi RS, Chun, Richman M (2004) The use of a fibrin tissue sealant during laparoscopic partial nephrectomy. BJU Int 93:813 Quek ML, Stein JP, Skinner DG (2001) Surgical approaches to venous tumor thrombus. Sem Uro Onc 19:88 Richter F, Schnorr D, Deger S, Trk I, Roigas J, Wille A, Loening SA (2003) Improvement of hemostasis in open and laparo- scopically performed partial nephrectomy using a gelatin matrix-thrombin tissue sealant (FloSeal). Urology 61:73 Skinner DG (1970) Complications of lymph node dissection. In:SmithRB,SkinnerDG(eds)Complicationsofurologic surgery: prevention and management. WB Saunders, Phila- delphia, p 422 Stein JP et al (2001) Contemporary surgical techniques for con- tinent urinary diversion continence and potency preserva- tion. Atlas Urol Clin of N Am 9:147 Stein JP,Skinner DG (2004) Surgical atlas radical cystectomy. B J Urol 94:197 Stephenson et al (2004) Morbidity and functional outcomes of salvage radical prostatectomy for locally recurrent prostate cancer after radiation therapy. J Urol 172:2239 Touma NJ, Izawa JI, Chin JL (2005) Current status of loc l sal- vage therapies following radiation failure for prostate can- cer. J Urol 173:373 Walsh PC, Donker PJ (1982) Impotence following radical pros- tatectomy: Insight into etiology and prevention. J Urol 128:492 Yoon GH, Stein JP, Skinner DG (2005) Retroperitoneal lymph node dissection in the treatment of low-stage nonsemino- matous mixed germ cell tumors of the testicle: An update. Urol Oncol 23:168 326 17 Intraoperative Complications 17.2Complications in Endoscopic Procedures F.Wimpissinger,W.Stackl 17.2.1 Complications of Percutaneous Nephro- lithotomy 327 17.2.1.1 Intraoperative and Early Postoperative Complications 327 Infection and Sepsis 327 Complications with the Percutaneous Nephrostomy Tract 327 Injury of the Colon 327 Injury of the Pleura 330 Injury of the Liver, Gallbladder, or Spleen 330 Bleeding 330 Perforation of the Renal Pelvis 330 Residual Stones 330 Absorption of Irrigation Fluid 330 Nephrostomy Tubes 330 17.2.1.2 Late Postoperative Complications 330 Renal Function Impairment 330 Urinomas 331 17.2.2 Complications of Ureterorenoscopy 331 17.2.2.1 Intraoperative and Early Postoperative Complications 331 Infection, Sepsis 331 Avulsion and Intussusception of the Ureter 331 Injury of Neighboring Organs 332 Ureteric Perforation 332 False Passage 332 Bleeding 332 Narrowing of the Ureter and Difficult Access 332 Residual Stones 332 17.2.2.2 Late Postoperative Complications 332 Ureteric Stricture 332 Forgotten Ureteric Stent 333 References 334 17.2.1 Complications of Percutaneous Nephrolithotomy 17.2.1.1 Intraoperative and Early Postoperative Complications The first nephroscope for percutaneous renal access was introduced 1981 by Marberger et al. (1981, 1982). Since that time, percutaneous nephrolithotomy (PCNL) has evolved as a standard procedure in kidney stone therapy. In this chapter, we will focus on the com- plications of this procedure. Infection and Sepsis Infection and sepsis are very rare complications in PCNL, occurring in up to 2.2% (Lewis and Patel 2004). As in all other invasive stone procedures, preexisting urinary tract infection is treated at least 2 days in ad- vance. Cases of obstruction and infection should pri- marily be managed by percutaneous drainage. PCNL is delayed until the infection has been treated successfully (urinary culture, hematologic signs of recovery from sepsis). During PCNL, we recommend prophylactic an- tibiotics in all cases. Antibiotic agents are selected ac- cording to local bacteria strain spectrum and resis- tancepatterns,whichshouldbemonitoredonaregular basis. At our institution, we commonly use fourth-gen- eration chinolones, amoxicillin plus clavulanic acid, or an aminoglycoside. Care must be taken to avoid high-pressure irrigation duringtheprocedure,asthiscanleadtobacteriemia and subsequent sepsis. To avoid high-pressure irriga- tion, we use a continuous flow nephroscope. The irriga- tion container must not be mounted higher than 40 cm above kidney level (Kukreja et al. 2002; Troxel and Low 2002). Complications with the Percutaneous Nephrostomy Tract The most severe complication of PCNL is puncturing other organs, especially colon, pleura, liver, gallblad- der, or spleen. If the injury is recognized during the procedure, the complication can usually be handled straightforwardly. Unfortunately, most of these compli- cations are diagnosed with a delay of several hours or even days. Injury of the Colon Routinepreoperativeultrasoundshowstheanatomical relation of the colon and the kidney and is an important tool to prevent injury. Previous intraabdominal or re- nal surgery is associated with a higher risk of injury of the colon and may warrant preoperative CT of the ab- domen to define anatomic relations. 17 Intraoperative Complications Fig. 17.2.1. Perforation of the left colon during PCNL. Note extravasation of contrast medium from renal collect- ing system into the descend- ing colon Needle perforation of the colon is usually not recog- nized. Colonic perforation with the nephroscope is rec- ognized after contrast filling of bowel at the nephrosto- gram at the end of the procedure (Fig. 17.2.1). Further- more, bowel perforation must be suspected in all pa- tients with abdominal pain postoperatively. The ana- tomic compartment of perforation – retroperitoneal or intraperitoneal – is differentiated by CT scan (distribu- tion of air, fluid; Figs. 17.2.2–17.2.4). A water soluble contrast enema study can also be a valuable diagnostic tool. Needle perforation is usually managed conserva- tively by observation of the patient. In case of a retro- peritoneal perforation of the colon, placement of a nephrostomytubeshouldbeavoided,andthecollect- ing system of the kidney may be drained by a double-J stent. Intraabdominal perforation of the colon requires surgical intervention in almost all cases – usually a transient colostomy (Vallancien et al. 1985). Fig. 17.2.2. AbdominalCT:retroperitonealairafterperforation of the left colon during PCNL 328 17 Intraoperative Complications [...]... glycine is then metabolized in liver and kidneys to ammonia and glyoxylic acid, which is mainly responsible for 17.3 TUR-Related Complications central nervous symptoms such as blurred vision or other vision impairments, which are mainly seen in patients irrigated with glycine Interestingly, all symptoms of TUR syndrome are seen in patients irrigated with ether glycine-containing or non-glycine-containing... recognized intraoperatively Bleeding from parenchymatous organ injury can cause hemodynamic problems and abdominal pain Therapy should follow the same principles as in trauma to these organs In rare cases of intraoperative recognition of organ injury – usually due to hemodynamic instability – the procedure is terminated and the organ injury managed according to surgical principles Bleeding Bleeding is... predictor of access-related complications (Peters 19 96) However, Cadeddu et al (2001) showed that intensive laparoscopic training prior to commencing clinical practice decreased the impact of the learning curve The complication rate (access-related and non-access-related) of surgeons who completed at least 12 months of dedicated training in urological laparoscopy did not differ according to initial vs subsequent... Following ureterorenoscopic stone surgery, strictures occur in 0.0 % – 4.0 % (Stackl and Marberger 19 86; Beaster 19 86) Ureterorenoscopic treatment of upper tract transitional cell carcinoma is associated with a higher stricture rate, ranging from 0 % to 16. 2 % (Elliott et al 19 96, 2001; Martinez-Pinero et al 19 96; Chen and Bagley 2000) Stricture formation should be prevented by minimizing ureteral injury... becoming impossible, abdominal distension, lower abdominal pain, and blood pressure changes This injury is usually recognized immediately after the cut, assuming the operation is performed under good circumstances including good visual control This complication normally means immediately ending the operation, inserting a transurethral catheter into the bladder, and performing CT-guided percutaneous drainage... 17.2 Complications in Endoscopic Procedures Urinomas Small – asymptomatic – urinomas are absorbed without late sequelae Larger and symptomatic urinomas require ultrasound- or CT-guided drainage (Titton et al 2003) In general, postoperative urinomas are treated in the same way as traumatic urinomas 17.2.2 Complications of Ureterorenoscopy Since P´rez-Castro Ellendt and Mart´nez-Pi˜ eiro introe ı n duced... irrigation absorption in the case of beginning fluid absorption Other means to control the intravesical pressure are the so called low-pressure TURP This can be reached using a continuous-flow resectoscope in conjunction with an irrigation/suction pump that controls the irrigation inflow by measuring the intravesical pressure or by the insertion of a suprapubic trocar for continuous drainage of irrigation... malpositioning of the needle and may lead to the diagnosis or the suspicion of an injury to an intraabdominal organ If the intraabdominal pressure reading at the beginning of the insufflation is not below 8 – 10 mm Hg, incorrect needle position or at least contact of the needle tip with intraabdominal structures must be suspected and the needle should be repositioned It is particularly important to stay in. .. consequence is impaired vision during the procedure Major bleeding during ureterorenoscopy is extremely rare Minor bleeding occurred in 0.3 % – 2.1 % in three large series (Blute et al 1988; Abdel-Razzak and Bagley 1992; Grasso 2000) Bleeding can require termination of the procedure It is usually managed by double-J stenting Narrowing of the Ureter and Difficult Access Fig 17.2 .6 Intussesception (and avulsion)... above-delineated steps must be reversed in a stepwise fashion, which means removing the catheter tension, decreasing the fluid in the balloon, decreasing continuous bladder irrigation, and removing the catheter 8 If the bleeding still persists after that, the patient must be returned to the operating room During a second look, transurethral hemostasis inspection always shows adherent blood clots in the . 16. 2% (Elli- ott et al. 19 96, 2001; Martinez-Pinero et al. 19 96; Chen and Bagley 2000). Stricture formation should be pre- vented by minimizing ureteral injury and postopera- tive stenting in. hemodynamic instability – the procedure is terminated and the organ injury managed according to surgical principles. Bleeding Bleeding is the most common complication in PCNL, occurring in 0 .6% –2.3%. challenging endeavors fraught with potential complications, intestinal injuries being the most common. Extensive intraabdominal and intrapel- vic adhesions often require tedious and meticulous ly- sis