Post operative complications in urology

1. Diagnosis and Management of
Post operative complications in
urology
Mathew Y. Kyei
Senior Lecturer/ consultant Urologist
Ghana Medical School

2. Outline
• Common procedures in urology
• Causes/ sources of complications
• The common complications
• Diagnosis/ identifying those complications
• Relevant investigations
• Treatment

3. Procedures in urology
• Diagnostic
• Definitive
• Open procedures
• Endoscopic procedures
• Laparoscopy
• Image guided procedures –
• Placement of supra pubic
catheters/nephrostomy tubes

4. Causes/ sources of complications
• Haemorrhage- relative large vessels supplying and close to organs of interest
• Urine- infected
• Bacteraemia
• Blockage of urine flow –retention of urine/Hydronephrosis/ renal failure
• Damage to surrounding structures- fistulae/pneumothorax/ erectile dysfunction
• Catheters/ stents
• Irrigation fluids
• Bowel in the urinary system
• stomas
• DVT

5. Haemorrhage
• Haematuria-
• Clot retention
• Acute kidney injury

6. Urine- infected
• Wound infection
• Urinary tract infection
• Peri-nephric abscess
• Fourniers gangrene

7. Bacteraemia
• Post endoscopy sepsis
• Post trus biopsy sepsis

8. Urine blockage
• Bladder dehiscence- post cystostomy procedures

9. Blockage of urine flow
• Ureteric injury ( open prostatectomy/ TURP/ - ureteroscopy)
• Strictures
– ureteric- restricture- (spatulation)=
-hydro-ureters, hydronephrosis
- urethral stricture - urethral catheterization, urethral instrumentation,
re-stricture post dilatation, internal urethrotomy, urethroplasty

10. Damage to surrounding structures-
• Bladder perforations- TURP/ TURBT (1%)
• Vomiting
• Excessive sweating
• Retro-pubic/ abdominal pains
• Sudden hypertension/ hypotension
• bradycardia
• Fistulae- vesico-cutaneous fistula, vesico vaginal fistula, entero-vesical
fistula, recto-prostatic fistula

11. Damage to surrounding structures-
• IVC, Aorta
• erectile dysfunction- bulbo-
cavernosal arteries, cavernosal
nerves, damage to tunica
albuginea

12. Catheters/ stents/ Nephrostomy tubes
• Urethral injury- inflation of
balloon in urethra
• Urinary tract infection
• Stuck catheters
• Allergic reaction/ urethritis/
stricture

13. Catheters/ stents/ Nephrostomy tubes
• Stents
• Migration
• Forgotten stents
• Encrustation/ stuck/ Calculi
• Fracture

14. Irrigation fluids
• TURP syndrome (Dilutional
hyponatraemia/ hypoosmality)-
monopoly TURP- 1.5% Glycine,
2.5% dextrose, Distilled water
• Occurs when>2l of fluid absorbed
• Na <120mmol/l = severe
<100mol/l
• Dependent on size of the venous
sinuses, amount of irrigation fluids,
hypotonic fluids, and duration of
resection (1-8%)
• Initially asymptomatic

15. Irrigation fluids
 Symptomatic
• Headaches
• Anxiety
• Confusion
• Dyspnoea
• Arrhythmia
• Hypotension
• Acute Intravascular haemolysis
• seizures
• coma
• Death (0.2-0.8%)

16. Bowel in the urinary system
• Early
• Mucus production/ mucous
plugs
• Anastomotic leaks
• Enteric fistula
• Bowel obstruction

17. Bowel in the urinary system
• Late
• Metabolic complications- Ileum/
colon – hypochoremia,
hypokalaemic metabolic acidosis
• uretero-intestinal junction
strictures / stenosis
• Upper tract calculi
• Bone demineralization
• Junctional adenocarcinoma

18. stomas
 Uriostomy
• Retraction
• Prolapse
• Stenosis
• Necrosis
• Parastomal hernias

19. DVT
• Dilemma

20. Diagnosis/ identifying those complications
• History
• Physical examination
• Bed side observation

21. Relevant investigations
• FBC
• Urine re
• Cultures ( Urine cs, blood cs, wound swab for cs)
• BUE and Cr
• Imaging – USG , KUB, contrast studies- ct scan/ MRI / stentogram
• Endoscopy

22. Treatment

23. Haemorrhage- Treatment
• Haematuria- GXM, blood
transfusion/ tranexamic acid
• Clot retention- bladder washout
/ tranexamic acid
• Acute kidney injury- fluid/ blood
replacement/ monitoring- CVP/
urine output / dialysis

24. Urine- infected – treatment
• Wound infection- antibiotics/
removal of stiches / opening
fascia closure
• Urinary tract infection-
antibiotics
• Peri-nephric abscess-
ultrasound guided drainage/
antibiotics

25. Urine- infected – treatment
• Fournier's gangrene- fluid
resuscitation/ debridement /
antibiotics / secondary closure/
skin grafting

26. Urinoma
• Urinoma- ultrasound guided
drainage/ placement of JJ stents

27. Bacteraemia- treatment
• Post endoscopy sepsis
• Post trus biopsy sepsis
Best prevented-
• Endoscopy when urine is sterile
• Prophylactic antibiotic- gentamycin, fluoroquinolones
 Treatment
• Admission / iv fluids/ empirical treatment and culture directed

28. Blockage of urine flow- Treatment
 Bladder dehiscence-
• maintain the urethral catheter
• exploration and closure
• treat associated infection

29. Blockage of urine flow- Treatment
• Ureteric injury ( open prostatectomy/ TURP/ ureteroscopy )-
prevention// jj stent- retrograde/ antegrade
• Stricture
– ureteric- re-stricture- (spatulation)=- nephrostomy tube placement/
urtero-ureterostomy, ureteric re-implantation( psoas hitch/ boari flap),
ileal interposition
-- ureteroscopy with dilation if partial
,- urethral stricture – suprapubic cystostomy, // dilatation, internal
urethrotomy, urethroplasty ( anastomotic / substitutive)

30. Damage to surrounding structures- Treatment
 Bladder perforations- TURP/ TURBT-
• urethral catheterization and continuous drainage if extra peritoneal
• intra peritoneal- open repair
 Fistulae- vesico-cutaneous fistula, vesico vaginal fistula, entero-vesical
fistula, recto-prostatic fistula-
• repair with omental or fascial interposition

31. Damage to surrounding structures- Treatment
• Pneumothorax- diaphragmatic injury- chest tube with diaphragmatic
repair
• IVC- repair with prolene
• Aorta- synthetic graft patches

32. Damage to surrounding structures- Treatment
• erectile dysfunction-
- bulbo-cavernosal
arteries,revascularition/
cavernosal nerves- nerve
repair,PDE 5 inhibitors/ intra
cavernosal injections/ vaccum
pum/ penile implants
- damage to tunica albuginea-
repair

33. Catheters/ stents/ Nephrostomy tubes
 Urethral Catheter
• Urethral injury- inflation of balloon in urethra- deflate and advance
• Urinary tract infection- culture – empirical/ culture directed
• Stuck catheters- ultrasound guided deflation
• Allergic reaction/ urethritis/ stricture- best prevented- silicon
catheters/ coated

34. Catheters/ stents/ Nephrostomy tubes
 Stents
• Migration – ureteroscopy and retrieval
• Fracture – ureteroscopy and retrieval
• Forgotten stents-
• Encrustation/ stuck/ Calculi- ureteroscopy with laser

35. Irrigation fluids –treatment
 TURP syndrome (Dilutional hyponatraemia)-
• Control bleeding
• Suspend operation
• Eliminate absorbed water- furosemide
• Correct hypoxaemia/ blood gas analysis
• Hypertonic saline (3% or 5%) ( severe- impaired consciousness,
convulsions)- based on serum Na concentrations ( <100ml/hr)
• Best managed at the ICU

36. Bowel in the urinary system- treatment
 Early
• Mucus production/ mucous
plugs- bladder washout
• Anastomotic leaks- conservative
/ drain in place
• Enteric fistula- conservative/
exploration- resection and re-
anastomosis
• Bowel obstruction- exploration

37. Bowel in the urinary system- treatment
 Late
• Metabolic complications- Ileum/ colon – hypochloremia,
hypokalaemic metabolic acidosis= oral sodium biocarbonate
• uretero-intestinal junction strictures / stenosis- stentogram= balloon
dilatation/ exploration
• Upper tract calculi- PCNL
• Bone demineralization – correct acidosis
• Junctional adenocarcinoma – stage dependent treatment

38. stomas
 Uriostomy
• Retraction
• Prolapse
• Stenosis
• Necrosis
• Parastomal hernias
• Treatment- exploration,
refashion,

39. • Summary
• Conclusion

40. References
• Campbell urology