Ap 5.1 Case Study
5.1 Common Complications
RNU may predispose a patient to complications such as pneumonia, hypertension, and acute renal insufficiency. The risk of pneumonia may be higher after renal surgery compared with other abdominal procedures, as patient’s postoperative pain with deep breathing may be substantial, leading to atelectasis and pneumonia. Early ambulation, incentive spirometry and adequate pain control should be encouraged in immediate postoperative period (17). The incidence of postoperative hypertension is <8%, usually mild, and it often resolves. Postoperative acute renal insufficiency may be multifactorial, relating to removal of an affected kidney, direct or indirect manipulation of the contralateral kidney, and rhabdomyolysis related to patient positioning. Postoperative acute renal insufficiency is usually brief but may need dialysis in rare cases. Long-term renal insufficiency is of minimal concern in patients with normal contralateral kidneys (17).
5.2 Venous thromboembolism
Venous thromboembolism (VTE) which includes deep venous thrombosis (DVT) and/or pulmonary embolism (PE) is an important postoperative complication that can be potentially life threatening after any urologic surgery. Postoperative DVT has been reported in 0.13% to 1.3% of patients, and …show more content…
PE in 0.08% to 1%(50, 51). Prophylaxis with pharmacologic agents such as unfractionated heparin (UFH) and fractionated heparin (FH), and mechanical methods, such as sequential compression devices (SCD) and compression stockings (52) are effective methods for reducing risk of VTE. Montgomery et al. in their retrospective comparison of SCD vs. FH found that in both groups the rate of thrombotic complication was 1.2% (50). Hemorrhagic complication was 9.3% in the FH group, of which 7.0% were major. The hemorrhagic complication rate was 3.5%, with 2.9% being major in the SCD group. The authors recommend some type of prophylaxis to reduce the incidence of DVT and PE after major open and laparoscopic surgery, however, the study was non-randomized and retrospective in nature (50). As per the AUA best practice statement, the decision on when and how to start prophylaxis for DVT must be based on the patient’s risk stratification but chemical DVT prophylaxis is strongly recommended in high-risk patients undergoing high-risk procedures such as RNU (51, 52).
5.3 Abscess
Intra-abdominal abscess formation can be a complication of any urologic surgery (28, 29, 45).
Risk factors include preoperative urinary tract infection, entry into gastrointestinal organs, entry into kidney parenchyma or collecting system, and postoperative renal hematoma. Adequate irrigation, prophylactic antibiotics, and surgical drain placement minimize the risk of abscess formation (17). In the presence of risk factors for infection, unexplained postoperative fever or leukocytosis should prompt a CT of the abdomen and pelvis to look for an abscess. Treatment involves percutaneous drainage and empiric antibiotics. Antibiotic coverage is adjusted when culture and sensitivity results become
available.
5.4 Anuria
Complete excision of the ureter with a cuff of bladder is a mandatory part of the procedure. The contralateral ureteral orifice may be damaged by the dissection of bladder cuff. This complication may result in anuria secondary to obstruction of the remaining ureter at the ureteral orifice. Management includes retrograde stent placement if possible or nephrostomy tube placement (17).
5.5 Urinary Leakage
Urinary leakage from the bladder is a potential complication after RNU which can be managed with urethral catheter drainage. A cystogram can also be considered at the time of urethral catheter removal. Persistent bladder leak can typically be managed with prolonged urethral catheter drainage. Rarely, persistent urinoma requires urinary diversion either by percutaneous drain or nephrostomy tube placement and allowing the bladder to heal. Urinary fistulas are uncommon but can also be managed in a similar fashion and allowing the fistula to close spontaneously (17).
5.6 Tumor Seeding
Low incidence of local recurrence after RNU has been reported in the literature but it can be a serious complication if principles of oncologic surgery are not followed. Laparoscopic approach does not result in a clinically significant increased risk of tumor spillage. Local recurrences can be prevented by minimizing tumor handling, using impermeable bag for specimen retrieval, fixation of trocar to avoid gas leakage, and avoiding laparoscopic surgery in patients with ascites (53).
CONCLUSIONS
Complications during RNU varies with the difficulty of the case, patient related factors and the surgeon’s experience. Serious complications can still occur even in competent hands. The incidence and effects of many complications can be minimized with meticulous attention to the anatomic details and proper surgical techniques. Adherence to oncologic principles is imperative to prevent local tumor recurrence.
RNU may predispose a patient to complications such as pneumonia, hypertension, and acute renal insufficiency. The risk of pneumonia may be higher after renal surgery compared with other abdominal procedures, as patient’s postoperative pain with deep breathing may be substantial, leading to atelectasis and pneumonia. Early ambulation, incentive spirometry and adequate pain control should be encouraged in immediate postoperative period (17). The incidence of postoperative hypertension is <8%, usually mild, and it often resolves. Postoperative acute renal insufficiency may be multifactorial, relating to removal of an affected kidney, direct or indirect manipulation of the contralateral kidney, and rhabdomyolysis related to patient positioning. Postoperative acute renal insufficiency is usually brief but may need dialysis in rare cases. Long-term renal insufficiency is of minimal concern in patients with normal contralateral kidneys (17).
5.2 Venous thromboembolism
Venous thromboembolism (VTE) which includes deep venous thrombosis (DVT) and/or pulmonary embolism (PE) is an important postoperative complication that can be potentially life threatening after any urologic surgery. Postoperative DVT has been reported in 0.13% to 1.3% of patients, and …show more content…
PE in 0.08% to 1%(50, 51). Prophylaxis with pharmacologic agents such as unfractionated heparin (UFH) and fractionated heparin (FH), and mechanical methods, such as sequential compression devices (SCD) and compression stockings (52) are effective methods for reducing risk of VTE. Montgomery et al. in their retrospective comparison of SCD vs. FH found that in both groups the rate of thrombotic complication was 1.2% (50). Hemorrhagic complication was 9.3% in the FH group, of which 7.0% were major. The hemorrhagic complication rate was 3.5%, with 2.9% being major in the SCD group. The authors recommend some type of prophylaxis to reduce the incidence of DVT and PE after major open and laparoscopic surgery, however, the study was non-randomized and retrospective in nature (50). As per the AUA best practice statement, the decision on when and how to start prophylaxis for DVT must be based on the patient’s risk stratification but chemical DVT prophylaxis is strongly recommended in high-risk patients undergoing high-risk procedures such as RNU (51, 52).
5.3 Abscess
Intra-abdominal abscess formation can be a complication of any urologic surgery (28, 29, 45).
Risk factors include preoperative urinary tract infection, entry into gastrointestinal organs, entry into kidney parenchyma or collecting system, and postoperative renal hematoma. Adequate irrigation, prophylactic antibiotics, and surgical drain placement minimize the risk of abscess formation (17). In the presence of risk factors for infection, unexplained postoperative fever or leukocytosis should prompt a CT of the abdomen and pelvis to look for an abscess. Treatment involves percutaneous drainage and empiric antibiotics. Antibiotic coverage is adjusted when culture and sensitivity results become
available.
5.4 Anuria
Complete excision of the ureter with a cuff of bladder is a mandatory part of the procedure. The contralateral ureteral orifice may be damaged by the dissection of bladder cuff. This complication may result in anuria secondary to obstruction of the remaining ureter at the ureteral orifice. Management includes retrograde stent placement if possible or nephrostomy tube placement (17).
5.5 Urinary Leakage
Urinary leakage from the bladder is a potential complication after RNU which can be managed with urethral catheter drainage. A cystogram can also be considered at the time of urethral catheter removal. Persistent bladder leak can typically be managed with prolonged urethral catheter drainage. Rarely, persistent urinoma requires urinary diversion either by percutaneous drain or nephrostomy tube placement and allowing the bladder to heal. Urinary fistulas are uncommon but can also be managed in a similar fashion and allowing the fistula to close spontaneously (17).
5.6 Tumor Seeding
Low incidence of local recurrence after RNU has been reported in the literature but it can be a serious complication if principles of oncologic surgery are not followed. Laparoscopic approach does not result in a clinically significant increased risk of tumor spillage. Local recurrences can be prevented by minimizing tumor handling, using impermeable bag for specimen retrieval, fixation of trocar to avoid gas leakage, and avoiding laparoscopic surgery in patients with ascites (53).
CONCLUSIONS
Complications during RNU varies with the difficulty of the case, patient related factors and the surgeon’s experience. Serious complications can still occur even in competent hands. The incidence and effects of many complications can be minimized with meticulous attention to the anatomic details and proper surgical techniques. Adherence to oncologic principles is imperative to prevent local tumor recurrence.