650 CHAPTER 16 Urological surgery and equipment

Pyeloplasty

Indications

This is used for UPJ obstruction.

Anesthesia

General anesthesia is used.

Postoperative care

A JJ stent, bladder catheter, and a drain are left in situ. The bladder catheter serves to prevent reflux of urine up the ureter, which can lead to increased leakage of urine from the anastomosis site (reflux occurs because of the presence of the JJ stent).

The drain is removed when the drain output is minimal. The stent is left in position for 6 weeks.

Common postoperative complications and their management

Hemorrhage

This usually arises from the nephrostomy track (if a nephrostomy tube has been left in place—some surgeons leave a JJ stent and a perinephric drain, with no nephrostomy). Clamp the nephrostomy tube, in an attempt to tamponade the bleeding.

If the bleeding continues, consider angiography and embolization of the bleeding vessel if seen, or exploration.

Urinary leak

This can occur within the first day or so. If a urethral catheter has not been left in place, catheterize the patient to minimize bladder pressure and therefore the chance of reflux, which might be responsible for the leak. If the drainage persists for more than a few days, shorten the drain—if it is in contact with the suture line of the anastomosis it can keep the anastomosis open, rather than letting it heal.

If the leak continues, identify the site of the leak by either a nephrostogram (if a nephrostomy has been left in situ) or a cystogram (if a JJ stent is in place—contrast may reflux up the ureter and identify the site of leakage) or an IVP. Some form of additional drainage may help dry up the leak (a JJ stent if only a nephrostomy has been left in situ, or a nephrostomy if one is not already in place).

Obstruction at UPJ

This is uncommon, and if it occurs it is usually detected once all the tubes have been removed and a follow-up renogram has been done. If the patient had symptomatic UPJO but remains asymptomatic, then no further treatment may be necessary. If they develop recurrent flank pain, reoperation may be necessary.

Acute pyelonephritis

Manage with antibiotics.

PYELOPLASTY 651

Procedure-specific consent form—recommended discussion of adverse events

Serious or frequently occurring complications of pyeloplasty

Common

•Temporary insertion of a bladder catheter and wound drain

•Further procedure to remove ureteric stent, usually a local anesthetic

Occasional

• Bleeding requiring further surgery or transfusion

Rare

•Recurrent kidney or bladder infections

•Recurrence can occur, needing further surgery

Very rarely

•Entry into lung cavity requiring insertion of temporary drainage tube

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

•Need to remove kidney at a later time because of damage caused by recurrent obstruction

•Infection, pain, or hernia of incision requiring further treatment

Alternative therapy

This includes observation, telescopic incision, dilation of area of narrowing, temporary placement of plastic tube through narrowing, and laparoscopic repair.

652 CHAPTER 16 Urological surgery and equipment

Laparoscopic surgery

Virtually every urological procedure can be done laparoscopically. It is particularly suited to surgery in the retroperitoneum (nephrectomy for benign and malignant disease and for kidney donation at transplantation, pyeloplasty for UPJO), but is also suited to pelvic surgery (lymph node biopsy, radical prostatectomy).

Reconstructive surgery requiring laparoscopic suturing and using bowel is technically very challenging, but is possible. Laparoscopic surgery offers the following advantages over open surgery:

•Reduced postoperative pain

•Smaller scars

•Less disturbance of bowel function (less postoperative ileus)

•Reduced recovery time and reduced hospital stay

Contraindications to laparoscopic surgery

•Severe COPD (avoid use of CO2 for insufflation)

•Uncorrectable coagulopathy

•Intestinal obstruction

•Abdominal wall infection

•Massive hemoperitoneum

•Generalized peritonitis

•Suspected malignant ascites

Laparoscopic surgery is difficult or potentially hazardous in the morbidly obese (inadequate instrument length, decrease range of movement of instruments, higher pneumoperitoneum pressure required to lift the heavier anterior abdominal wall, excess intra-abdominal fat limiting the view); those with extensive previous abdominal or pelvic surgery (adhesions); those with previous peritonitis leading to adhesion formation; in those with organomegaly; in the presence of ascites; in pregnancy; in patients with a diaphragmatic hernia; and in those with aneurysms.

Potential complications unique to laparoscopic surgery

These include gas embolism (potentially fatal), hypercarbia (acidosis affecting cardiac function—e.g., arrhythmias), post-operative abdominal crepitus (subcutaneous emphysema), pneumothorax, pneomomediastinum, pneumopericardium, barotraumas.

Bowel, vessel (aorta, common iliac vessels, IVC, anterior abdominal wall injury), and other viscus injury are not unique to laparoscopic surgery, but are a particular concern during port access. Perforation of small or large bowel is the most common trocar injury. Rarely, the bladder is perforated.

Failure to progress with a laparoscopic approach or vessel injury with uncontrollable hemorrhage requires conversion to an open approach. Postoperatively, bowel may become entrapped in the trocar sites, or there may be bleeding from the sheath site.

An acute hydrocele can develop from irrigation fluid accumulating in the scrotum. It resorbs spontaneously. Scrotal and abdominal wall bruising commonly occurs.