640 CHAPTER 16 Urological surgery and equipment

Ileal conduit

Indications

•For urinary diversion following radical cystectomy

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

Postoperative care and common postoperative complications and their management

Oliguria or anuria: Try a fluid challenge.

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

Wound dehiscence is rare. It requires resuturing in the operating room, under general anesthetic.

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

Small bowel obstruction

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

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

Leakage from the intestinal anastomosis

This can lead to the following:

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

•An enterocutaneous fistula—bowel contents leak from the intestine and through a fistulous track onto the skin. A low-volume leak (<500 mL/24 hr) will usually heal spontaneously. Normal (enteral) nutrition may be maintained until the fistula closes (which usually occurs within a matter of days or a few weeks). If high volume, spontaneous closure is less likely, and reoperation to close the fistula may be required.

Leakage from the ureteroileal junction

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

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

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

642 CHAPTER 16 Urological surgery and equipment

Percutaneous nephrolithotomy (PCNL)

Indications

•Stones >3 cm in diameter

•Stones that have failed ESWL and/or an attempt at flexible ureteroscopy and laser treatment

•Staghorn calculi

Preoperative preparation

•CT scan to assist planning the track position and to identify a retrorenal colon1

•Stop aspirin 10 days prior to surgery

•Culture urine (so appropriate antibiotic prophylaxis can be given)

•Cross-match 2 units of blood

•Start IV antibiotics the afternoon before surgery to reduce the chance of septicemia (many stones treated by PCNL are infection stones). If urine is culture negative, use 1.0 g IV ampicillin and IV gentamicin (1.5 mg/kg). Routine antibiotic prophylaxis also reduces the incidence of postoperative UTI.2

Postoperative management

Once the stone has been removed, a nephrostomy tube is left in situ for several days (Fig. 16.15). This drains urine in the postoperative period and tamponades bleeding from the track.

Complications of PCNL and their management

Bleeding

Some bleeding is inevitable, but an amount severe enough to threaten life is uncommon. In most cases it is venous in origin and stops following placement of a nephrostomy tube (which compresses bleeding veins in the track).

If bleeding persists, clamp tube for 10 minutes. If bleeding continues despite this, order urgent angiography, looking for an arteriovenous fistula or pseudoaneurysm, both of which require selective renal artery embolization (required in 1% of PCNLs3) or open exposure of kidney to control bleeding by suture ligation, partial nephrectomy, or nephrectomy.

Septicemia

This occurs in 1–2% of cases. Incidence is reduced by prophylactic antibiotics. Track damage; it is essentially minimal. Cortical loss from track is estimated to be <0.2% of total renal cortex in animal studies.4

1 Hopper KD, Sherman JL, Williams MD, et al. (1987). The variable anteroposterior position of the retroperitoneal colon to the kidneys. Invest Radiol 22:298–302.

2 Inglis JA, Tolly DA (1988). Antibiotic prophylaxis at the time of percutaneous stone surgery. J Endourol 2:59–62.

3 Martin X (2000). Severe bleeding after nephrolithotomy: results of hyperselective embolisation. Eur Urol 37:136–139.

644 CHAPTER 16 Urological surgery and equipment

Damage to the lung and pleura leading to pneumomothorax or pleural effusion can occur with supra-12th rib puncture.

Nephrocutaneous fistula

When the nephrostomy tube is removed from the kidney, a few days after surgery, the 1 cm incision usually closes within 2 days or so.

Occasionally, urine continues to drain percutaneously for a few days and a small stoma bag must be worn. In most of these cases the urine leak will stop spontaneously, but if it fails to do so after a week or so, place a JJ stent to encourage antegrade drainage of urine.

Outcomes

For small stones, the stone-free rate after PCNL is on the order of 90–95%. For staghorn stones, the stone-free rate of PCNL, when combined with postoperative ESWL for residual stone fragments, is on the order of 80–85%.

Procedure-specific consent form—recommended discussion of adverse events

Serious or frequently occurring complications of PCNL

Common

•Temporary insertion of a bladder catheter and ureteric stent or kidney tube needing later removal

•Transient hematuria

•Transient temperature

Occasional

•More than one puncture site may be required

•No guarantee of removal of all stones and need for further operations

•Recurrence of stones

Rare

•Severe kidney bleeding requiring transfusion, embolization, or, at last resort, surgical removal of kidney

•Damage to lung, bowel, spleen, or liver requiring surgical intervention

•Kidney damage or infection needing further treatment

•Overabsorption of irrigating fluids into the blood system, causing strain on heart function

Alternative treatment includes external shock wave treatments, open surgical removal of stones, observation.

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