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Complications of Radical Urologic Surgery


Case Synopsis

A 44-year-old man with treated hypertension and an extensive smoking history presents with malaise, weight loss, and painless hematuria. Computed tomography (CT) reveals a right-sided renal tumor with thrombus extending into the right renal vein and minimal extension into the inferior vena cava (IVC). He is listed for angioembolization of the kidney, radical nephrectomy, cavotomy, and IVC repair. On admission he is found to be dyspneic and in sinus tachycardia. His arterial blood gas (ABG) values are as follows:

  • pH: 7.47

  • P o 2 : 9.2 kPa (69 torr)

  • P co 2 : 3.9 kPa (29.25 torr)

  • HCO 3 : 22

  • Base excess (BE): −1.0

A CT pulmonary angiogram (CTPA) reveals multiple subsegmental pulmonary emboli. An intravenous heparin infusion is administered but stopped 4 hours before surgery. Conduct of anesthesia is uneventful until the surgeon mobilizes the renal vein and blood fills the surgical field. Invasive blood pressure is measured at 78/48 mm Hg, heart rate is 120 beats per minute, and pulse-oximetry saturations are 89% with a poor pulsatile waveform.

Acknowledgment

The authors wish to thank Dr. Terri G. Monk for his contribution to the previous edition of this chapter.

Problem Analysis

The tension exemplified in the case synopsis between bleeding risk and venous-thromboembolism risk is commonly problematic in the perioperative management of patients undergoing radical urologic surgery.

Definition

The term radical is typically used when describing surgery intended to remove malignant as opposed to benign pathology. It is expected that adjacent anatomic structures also affected by the cancerous organ are also removed. It should be noted that these surgeries are increasingly being performed by laparoscopic approach and as such the complications expected will differ in incidence and nature.

Radical Cystectomy

In females, radical cystectomy involves the removal of the bladder, pelvic lymph nodes, lower ureters, urethra, and anterior vaginal wall. The uterus, fallopian tubes, and ovaries may sometimes be removed. An ileal conduit may be performed as part of the procedure. In males, this is usually termed a cystoprostatectomy as structures removed are the bladder, prostate, pelvic lymph nodes, lower ureters, vas deferens, and seminal vesicles. It is typically performed for invasive transitional cell carcinoma of the bladder.

Radical Nephrectomy

The affected kidney is removed along with the whole of the surrounding Gerota fascia, perinephric fat, ipsilateral adrenal gland, and surrounding lymphatics. The vast majority (approximately 90%) of solid renal masses are renal cell carcinomas (RCCs) with the remainder being mainly transitional cell carcinoma or Wilms’ tumor in children.

Radical Prostatectomy

In contrast with transurethral resection of the prostate (TURP; see Chapter 52 ), the entire prostate, seminal vesicles, ejaculatory ducts, and a portion of the bladder neck are removed. Approximately 90% of prostate cancers are adenocarcinomas.

Laparoscopic Radical Urologic Surgery

Increasingly, all of the aforementioned procedures may be performed via open or laparoscopic approach. Laparoscopic procedural complications are discussed in detail in Chapter 46 . As with all major surgery, careful attention should be paid to patient positioning, avoidance of nerve injury, and prevention of pressure sores. A considered approach to mechanical ventilation is required, given the impact of surgical technique on intrathoracic pressures. A compromise may have to be made between allowing good surgical access and ideal ventilatory parameters. For example, in the lateral decubitus position for nephrectomy, insufflation of gas into the peritoneum for laparoscopy and requirement for steep Trendelenburg position will affect respiratory mechanics. Addressing this with high inspiratory pressures may cause barotrauma, hence acceptance of intraoperative respiratory acidosis may be a reasonable approach.

Recognition

The case synopsis alludes to two of the major complications of radical urologic surgery—venous thromboembolism (VTE) and major hemorrhage.

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