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Diagnosis and Management of
Post operative complications in
urology
Mathew Y. Kyei
Senior Lecturer/ consultant Urologist
Ghana Medical School
Outline
• Common procedures in urology
• Causes/ sources of complications
• The common complications
• Diagnosis/ identifying those complications
• Relevant investigations
• Treatment
Procedures in urology
• Diagnostic
• Definitive
• Open procedures
• Endoscopic procedures
• Laparoscopy
• Image guided procedures –
• Placement of supra pubic
catheters/nephrostomy tubes
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
Haemorrhage
• Haematuria-
• Clot retention
• Acute kidney injury
Urine- infected
• Wound infection
• Urinary tract infection
• Peri-nephric abscess
• Fourniers gangrene
Bacteraemia
• Post endoscopy sepsis
• Post trus biopsy sepsis
Urine blockage
• Bladder dehiscence- post cystostomy procedures
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
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
Damage to surrounding structures-
• IVC, Aorta
• erectile dysfunction- bulbo-
cavernosal arteries, cavernosal
nerves, damage to tunica
albuginea
Catheters/ stents/ Nephrostomy tubes
• Urethral injury- inflation of
balloon in urethra
• Urinary tract infection
• Stuck catheters
• Allergic reaction/ urethritis/
stricture
Catheters/ stents/ Nephrostomy tubes
• Stents
• Migration
• Forgotten stents
• Encrustation/ stuck/ Calculi
• Fracture
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
Irrigation fluids
 Symptomatic
• Headaches
• Anxiety
• Confusion
• Dyspnoea
• Arrhythmia
• Hypotension
• Acute Intravascular haemolysis
• seizures
• coma
• Death (0.2-0.8%)
Bowel in the urinary system
• Early
• Mucus production/ mucous
plugs
• Anastomotic leaks
• Enteric fistula
• Bowel obstruction
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
stomas
 Uriostomy
• Retraction
• Prolapse
• Stenosis
• Necrosis
• Parastomal hernias
DVT
• Dilemma
Diagnosis/ identifying those complications
• History
• Physical examination
• Bed side observation
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
Treatment
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
Urine- infected – treatment
• Wound infection- antibiotics/
removal of stiches / opening
fascia closure
• Urinary tract infection-
antibiotics
• Peri-nephric abscess-
ultrasound guided drainage/
antibiotics
Urine- infected – treatment
• Fournier's gangrene- fluid
resuscitation/ debridement /
antibiotics / secondary closure/
skin grafting
Urinoma
• Urinoma- ultrasound guided
drainage/ placement of JJ stents
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
Blockage of urine flow- Treatment
 Bladder dehiscence-
• maintain the urethral catheter
• exploration and closure
• treat associated infection
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)
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
Damage to surrounding structures- Treatment
• Pneumothorax- diaphragmatic injury- chest tube with diaphragmatic
repair
• IVC- repair with prolene
• Aorta- synthetic graft patches
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
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
Catheters/ stents/ Nephrostomy tubes
 Stents
• Migration – ureteroscopy and retrieval
• Fracture – ureteroscopy and retrieval
• Forgotten stents-
• Encrustation/ stuck/ Calculi- ureteroscopy with laser
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
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
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
stomas
 Uriostomy
• Retraction
• Prolapse
• Stenosis
• Necrosis
• Parastomal hernias
• Treatment- exploration,
refashion,
• Summary
• Conclusion
References
• Campbell urology

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Post operative complications in urology.pptx

  • 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
  • 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
  • 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,