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Urologic Complications of Surgery
Urologic Complications of Surgery From the Department of Urology, Massachusetts general Hospital, Boston
WYLAND F. LEADBETTER, M.D., F.A.C.S. Chief of Urology
GUY W. LEADBETTER, JR., M.D. Assistant in Urology
THE GENITOURINARY tract is a common source of complications incident to abdominal, gynecologic, vascular and neurosurgical operations. Complications may arise as the result of direct surgical injury to the urinary tract organs or to their vascular or nerve supply. Secondary disturbance of renal function may follow periods of renal ischemia due to aortic or renal artery occlusion in the course of vascular surgery, periods of hypotension, severe muscle trauma, and transfusion reactions. Anuria may result from the removal of a solitary kidney, or uremia may develop as a result of chronic renal disease or of the removal of one kidney in the presence of a functionally inadequate contralateral kidney. Unrecognized obstructions both in children and adults often come to light after operation which complicate an already precarious convalescence. The necessity for prolonged periods of catheter drainage may introduce infectious complications into the urinary tract which on occasion may be lethal or at the least very troublesome. THE FIRST STEP-PREVENTION
In these days of increasingly difficult and prolonged abdoIninal operations, some complications are impossible to anticipate or avoid but the vast majority of urologic complications can be prevented by an adequate knowledge of anatomical relations, appropriate preoperative study of the urinary tract, careful surgery, and proper primary repair of the urinary tract when injury has occurred. Primary repair is always preferable to secondary repair and should be done unless the condition of the patient prevents it or makes it hazardous. To insure this, the surgeon must either have experience in the performance of urological surgical technique 811
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or have a urological consultant within reach of the operating table. It is surprising how few surgeons are equipped by training to properly correct urinary tract surgical injuries. We believe that most preventable urinary tract complications occur as the result of inadequate preoperative evaluation due to insufficient imagination on the part of the surgeon and to too much dependence on the clinical history. Many chronic urinary tract troubles are either asymptomatic or symptoms are so minor as to be disregarded by the patient or erroneously interpreted. The history may be of no use in regard to the necessity of urologic investigation. The best plan, when major abdominal surgery is required and particularly when removal of a mass in involved, is to go further than simple examination of the urine and the findings on physical examination. Renal function studies are frequently indicated. The most useful preoperative procedure to evaluate the urinary tract, and this may be done on an emergency basis, is intravenous pyelography which will either reveal normal urinary tract function and structure or point to congenital or acquired abnormalities such as contracted kidneys, unilateral hypoplastic kidney, nonfunction of a kidney, hydronephrosis, anomalies of fusion, ectopic kidney, double kidney and ureter either unilateral or bilateral, stone, renal mass, displacement of the ureter, filling defect in the bladder, residual urine, extravasation of urine following injury, and many other minor changes which may be helpful to have in mind. Further urologic study by cystoscopy and retrograde pyelography may be indicated and can be done just prior to operation under the same anesthesia. The placement of indwelling catheters in one or both ureters may at times be desirable though this has not entirely eliminated ureteral injury. In any case, the information obtained forms a solid background for operative planning. One may state without question that, when masses in the flank, upper abdomen or pelvis are encountered or when severe abdominal trauma presents, an intravenous pyelogram should be obtained before surgery. If this is done, no kidney will be removed in the presence of inadequate contralateral kidney function or in the absence of a contralateral kidney. RENAL COMPLICATIONS DIRECT TRAUMA
Hemorrhage
Direct injury to the kidney parenchyma causing complications, such as might occur in the dissection of a tumor mass involving the upper retroperitoneum, is almost inconceivable since suture, partial nephrectomy or total nephrectomy will usually be required. Secondary hemorrhage from a total or partial nephrectomy can occur, but if partial nephrectomy is done the renal fossa should be drained through a separate stab wound in
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the flank which will prevent pocketing of urine. Secondary bleeding, depending on its degree, may require re-exploration. Since there is free venous anastomosis within the kidney, a segment of the renal vein or accessory veins may be ligated without functional disturbance of the kidney, but if an accessory renal artery has to be sacrificed the portion of the kidney supplied by this vessel must be removed. Total nephrectomy of course can be followed by secondary bleeding if the pedicle is inadequately ligated. This is an extreme surgical emergency. It is best, when nephrectomy is to be done, to ligate the renal artery and vein individually since mass ligation has occasionally been followed by arteriovenous aneurysm. Primary hemorrhage from the renal pedicle will not occur if good exposure is obtained and the artery and vein are dissected under vision. Large nonabsorbable sutures are undesirable. We have seen one patient who developed a persistent flank abscess which was ultimately found to contain a large silk suture which had sloughed from the pedicle. Chromic 0 catgut is sufficient. A double tie on each vessel with the external or second tie sutured to the vessel is safest to prevent the tie from slipping.
Ruptured Kidney Attempts to repair a ruptured kidney found in association with other visceral trauma, immediately or early after injury, usually end in nephrectomy because of the magnitude of bleeding. The best course, if a ruptured kindey is encountered in the course of abdominal exploration for trauma, is to either leave it alone or drain the flank. Secondary repair may be necessary depending on subsequent functional and pyelographic studies. This can best be done from a week to ten days after injury when all active bleeding has ceased. At this time excision of devitalized kidney, suture of parenchyma and removal of extravasated blood and urine can easily be done. Extravasated blood and urine is usually present within Gerota's fascia and tends to gravitate about the upper ureter. This should be carefully removed. A catastrophic complication in such a case is the removal of a potentially good kidney or portion of a good kidney in the absence of contralateral kidney or the presence of a functionally impaired kidney. Preoperative intravenous pyelograms or retrograde pyelograms will prevent this. If the removal of a solitary kidney is recognized in the course of subsequent exploration, the kidney should be replaced. This can be accomplished by vascular and ureteral reanastomoses. The aorta and ligated stumps of the renal artery and vein should be carefully and completely exposed. At the same time the assistant should gently flush the renal artery of the kidney with 1: 100 heparin solution in an effort to prevent vascular clotting. Renal vessels should then be reanastomosed. If enough length of artery or vein is not present to allow easy anastomosis, a small segment of saphenous vein may be used to supplement either
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renal artery or vein or the kidney may be placed in the iliac fossa, anastomosing the renal artery and vein to the hypogastric artery. and common iliac vein respectively. Ureteral reanastomosis must then be done after spatulating both ends of the ureter to obtain a large cross-sectional diameter. Chromic catgut sutures (6-0) are placed carefully to approximate the mucosa accurately and to make a watertight suture line. The technique is similar to vascular anastomosis but interrupted sutures should be used. Repair should be done over a polyethylene catheter of appropriate size, passed up to the kidney pelvis and then on into the bladder. The catheter may be removed from the bladder after healing has been completed by cystoscopic means. Complications of Needle Biopsy of the Kidney
Needle biopsy of the kidney is being done frequently these days and is not without serious complications. If an artery is lacerated or a section of artery is removed by the needle, perirenal hemorrhage occurs and may be of alarming proportions and sufficient to produce a large perirenal hematoma. Observation is usually all that is necessary but if a large flank mass develops and the patient requires transfusions, exploration to evacuate the hematoma and to suture bleeding points is necessary. Since infection in such a hematoma may develop, antibiotic coverage is desirable. Nephrectomy should never be necessary. We believe that open biopElY of the kidney through a small flank incision is preferable to needle biopsy. Injury to the Renal Pelvis Occasionally, in the course of retroperitoneal dissection, the renal pelvis may be incised. The edges of the pelvis should be carefully reapproximated with interrupted 6-0 chromic catgut sutures to make a watertight closure. Care must be exercised to be sure that no angulation or obstruction is produced at the ureteropelvic junction. Since, in spite of a good closure, urine leakage may occur the area must be separately drained by a stab wound through the flank. There will be no complications if such an injury is recognized at the time but, if it is missed, extravasation of urine will occur and require secondary drainage. Stricture may subsequently occur which will require further treatment. INDIRECT TRAUMA-ANURIA AND OLIGURIA
Anuria Anuria is usually due to obstruction. Patients frequently complain of flank discomfort, and palpation may reveal flank or costovertebral angle pain. If the bladder is found to be empty, ureteral obstruction is generally present. Cystoscopy and retrograde catheterization of the ureters are mandatory. The ureteral catheters should be passed to the points of
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obstruction and ureterograms made to demonstrate the location and nature of the obstruction. Occasionally a catheter can be passed beyond the obstruction if it is due to angulation or partial ligation. If catheters can be passed, only one should be left indwelling because infection is likely to follow and drainage of only one kidney will be sufficient to allow adequate urine flow. If catheters cannot be passed, either temporary nephrostomy drainage of one kidney will be necessary or, if the patient's condition permits, abdominal re-exploration and lysis of the ureters must be done. In some cases after a period of catheter drainage the ureters open and drain satisfactorily. In others, operative lysis of the ureters will be necessary. Delay in cystoscopy and the institution of proper urine drainage in such cases will lead to uremia and, if pyelonephritis is present, to an immediate severe febrile reaction.
Oliguria Oliguria may be the result of: (1) partial ureteral obstruction; (2) complete ureteral obstruction on one side in the presence of contralateral hypoplastic or damaged kidney; (3) inadequate blood and fluid replacement; (4) renal ischemia due to a period of hypotension during or after operation, prolonged clamping of renal vessels or aorta (renal or vascular surgery), tubular dysfunction incident to severe muscle trauma, or acute cortical necrosis (most common after delivery); (5) serum electrolyte disturbances, particularly potassium loss; (6) terminal renal diseasepyelonephritis, glomerulonephritis, polycystic disease; (7) very rarely renal arterial embolization due to (a) an embolus from the heart in a patient with endocarditis or auricular fibrillation or (b) embolization of atherosclerotic material in the course of or following aortic surgery. Bilateral occlusion is rare but unilateral occlusion is fairly common and may result in oliguria if the opposite kidney function is impaired. (8) Very rarely and principally in children renal vein thrombosis may occur. This is usually in association with caval thrombosis. It is characterized by oliguria and large amounts of albumin in the urine. Diagnosis is difficult. Treatment will probably be directed toward the use of anticoagulants because surgery is of questionable value. When the physician is confronted with oliguria, the first thing for him to do is to get complete serum electrolyte studies and a blood volume determination. It is imperative to make a diagnosis as quickly and as accurately as possible. If ureteral obstruction is suspected, cystoscopy and ureteral catheterization should be carried out promptly. If no obstruction is present, unilateral or bilateral retrograde pyelograms may be very helpful in delineating the size of the kidneys and the thickness of the renal cortices. A small kidney with a thin cortex indicates chronic renal disease of some sort. Bilateral pyelograms are important since one side may show a hypoplastic kidney and the other a normal sized kidney.
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This may have real bearing on treatment. If a normal sized kidney is present with a normally thick cortex, we must conclude that we are dealing with tubular dysfunction or arterial embolization. A good test to rule out lower nephron disease due to ischemia or transfusion reaction is to give rapidly 20 gm. of mannitol in 200 cc. of water. Since mannitol is an osmotic diuretic, renal secretion will occur even if blood volume is decreased but, if lower nephron disease is present, no diuresis will result. Renal embolization may be suspected in the presence of the sudden onset of costovertebral angle or flank pain and with a normal pelvis and normally thick cortex demonstrated on retrograde pyelography in the absence of renal secretion. Hematuria may be present. A renal angiogram must be done on an emergency basis if embolization is suspected, and followed by embolectomy or watchful waiting depending on the findings. Emboli in distal branches of the renal artery may cause oliguria due, perhaps, to general arterial spasm which may be followed later by gradual restitution of function. An embolus in the main renal artery should be removed even though some hours have elapsed since its probable onset. Patients with low blood volumes respond to appropriate administration of blood and fluid. Patients with chronic renal disease must be hydrated carefully, and electrolytes adjusted in the hope that function will improve enough to allow convalescence. One or more peritoneal dialyses may be indicated under these circumstances. Those with lower nephron disease from any cause can be expected to recover in most instances provided they can be managed without the development of pulmonary edema or potassium intoxication. The main points in therapy are restriction of fluids, regulation of electrolytes, and prevention of potassium intoxication by peritoneal dialysis or the use of exchange resins by mouth or as enemas. Simple rules are: 1. A daily intake of 300 cc. of fluid plus enough to compensate for urine and gastrointestinal losses. 2. Diet as tolerated consisting chiefly of carbohydrates with low potassium content. If the patient cannot take nourishment by mouth, concentrated glucose solution may be given through a small polyethylene tube introduced into a large vein. One hundred grams of glucose a day is usually sufficient. 3. Watch for low serum calcium! Muscular twitching due to low calcium may be corrected by administration of calcium gluconate or the use of Dilantin. 4. Weigh daily to make sure that overhydration does not occur. Weight should decrease daily if patient is managed correctly. 5. An electrocardiogram should be obtained daily or, in the presence of elevated potassium, more frequently, to check for potassium intoxication. 6. Serum electrolytes should be obtained every other day.
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7. Elevation of blood urea nitrogen may be ignored unless patient becomes toxic. 8. Strenuous efforts should be made to prevent infection. The patient should be in a single room. Strict aseptic care should be followed. Antibiotics should not be used prophylactically but should be given for specific reasons. One must remember that high blood and tissue levels are attained easily in the absence of normal excretion. If a catheter has been placed to follow urine output accurately, great care should be taken to keep the penis or vaginal area clean and wet with neomycin or Zephiran sponges. The catheter should not be irrigated. 9. Early use of peritoneal lavage or dialysis by artificial kidney should be considered as a means of maintaining patient in satisfactory condition, rather than employing it as a late therapeutic measure. Restitution of renal function may begin in a few days or only after two or three weeks. When diuresis begins, urine and serum electrolytes must be followed carefully. Sodium and chloride losses may be very great and require massive replacement. URETERAL INJURIES
The ureter may be injured at any level in t4e course of removal of retroperitoneal tumors or cancers involving the retroperitoneum, vascular surgery for replacement of the aorta or surgery for repair of renal vascular obstructions, but lower (pelvic) ureteral injuries are most frequent. These occur in the course of simple or radical hysterectomy, oophorectomy, abdominoperineal resection of the rectum or sigmoid for cancer, and repair of vesicovaginal fistulas. Obstetrical injuries are fortunately very rare. Late obstructions of one or both ureters may result from retroperitoneal sepsis and periureteral fibrosis. Injuries may occur through ligation, partial ligation, laceration, division, excision of a segment, crushing or devascularization. The principal cause is failure to recognize the ureters because of their displacement by a mass or because of bleeding which temporarily obscures the field and the control of which results in placing sutures, clamps, or cutting without good vision. The preoperative placement of ureteral catheters does not necessarily eliminate injury although they may be of real help in identifying the course of the ureters. The best course is to intentionally dissect out the ureters rather than to hope that they are safely out of the operative field. Ureters are most commonly injured at the level of the pelvic brim in relation to the infundibulopelvic ligament and in the broad ligament region where sutures are not infrequently passed about them or close to them in the course of clamping and suture ligating the uterine vessels. Division of a Ureter
Division of a ureter, unrecognized at operation, results
In
urinary
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extravasation into the wound or the development of a retroperitoneal accumulation which, following radical hysterectomy, often drains through the vagina to form a ureterovaginal fistula. This frequently results from devascularization of the ureter with slough following a radical hysterectomy. Such an occurrence is probably due to thrombosis of a section of the longitudinal artery of the ureter from pressure of a retractor or dissection of the ureter from its adventitial sheath. Ordinarily the ureter may be dissected ffom the renal pelvis to the bladder without disturbance of blood supply. Perhaps preoperative irradiation renders it more susceptible to this injury. Treatment is drainage of a retroperitoneal accumulation if this has not already occurred through the wound. One can usually pass a clamp into it. This will result in a ureterocutaneous fistula which will persist until the kidney and ureter are removed or the ureter is repaired which is rarely possible. Such injuries are usually low in the ureter (the exact point of injury can be determined by retrograde filling of the lower ureteral stump in the course of obtaining a ureterogram) allowing reimplantation into the bladder or anastomosis to a bladder flap made into a tube, the so-called Boari flap. N ephroureterectomy is necessary only if the kidney is badly damaged. Sometimes a ureterovaginal fistula following radical hysterectomy will heal if a catheter can be passed up the ureter by the fistula and left indwelling. Stricture will sometimes necessitate secondary surgery, though it is surprising how often normal urine drainage results. Division of a ureter which is recognized at operation usually permits primary repair over a splinting catheter unless division occurs close to the bladder. Reimplantation of the upper ureteral segment into the bladder is usually best in these cases and should be done through the open bladder with construction of the submucosal tunnel to form a valve. Excision of a Ureteral Segment
If -excision of a ureteral segment is recognized at operation and if a portion of pelvic ureter is lost, reanastomosis to a bladder tube is usually the best course. Loss of segments at the pelvic brim or higher pose a much more difficult problem. In an older patient with a good contralateral kidney, removal of the kidney and ureter is preferable, particularly if operation is for cancer. In younger patients or in individuals with poor renal function or in the absence of a contralateral kidney, preservation of the kidney is either desirable or imperative. Under these circumstances, a short segment of small bowel may be used to bridge the gap between the intact ureter above and the bladder below. Cutaneous ureterostomy may be resorted to as a temporary expedient if the patient's condition is poor, or, if the opposite ureter is intact, ureteroureterostomy may be done. Ureterosigmoidostomy can also be done but this is generally not desirable.
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Laceration and Crushing with a Clamp
When a ureter has been crushed by a clamp, removal of the clamp and ureterotomy with placement of a splinting catheter will usually allow restitution of function without slough, the development of extravasation or urinary fistula. It is best, however, simply to drain this area for a few days. If the clamp has been on for some time; and after removal the crushed area remains avascular, resection of this area and reanastomosis over a splinting catheter is necessary. Laceration (partial division) is handled by careful suture over a splinting catheter or by suture and a separate extraperitoneal drain to this area. Unrecognized injury by clamp or laceration will generally lead to extravasation and fistula, but healing of the fistula can be expected if a ureteral catheter can be passed up the ureter beyond the injury and left indwelling for several days. Ligation
Ligation of one ureter may escape notice unless the patient complains of flank pain or has or develops infection in the kidney. Intravenous pyelography will uncover the trouble. Cystoscopy and ureteral catheterization are necessary to locate the point of obstruction, which should be relieved surgically by deligation as soon as the patient's condition permits or by temporary nephrostomy if high fever necessitates prompt drainage. Occasionally a catheter may be passed if obstruction iEt not complete, with gradual release of the obstruction as suture material disintegrates. Bilateral ligation has been discussed previously. The question occasionally arises when a blocked ureter is discovered some weeks or months after surgery, whether the ureteral obstruction should be relieved, nephrostomy done, or the situation allowed to remain as it is. Undoubtedly, useful kidney function may be saved by a relief of obstruction several weeks later, and if the condition of the other kidney suggests the need for additional functioning nephrons, relief of the obstruction should be attempted. Evidence of infection in the kidney of course calls for nephrectomy. If function of the contralateral kidney is adequate and the patient has no symptoms from the obstructed kidney, probably nothing should be done. Ureteral Obstruction Developing from Retroperitoneal Sepsis or Fibrosis
Obstructions due to this cause must be differentiated from residual cancer. They are usually partial, may improve, and unless severe or associated with pain or pyelonephritis may be watched. If significant pyelonephritis is present or if obstruction is severe, the use of temporary indwelling catheters placed by cystoscopic manipulation and followed by open lysis after infection is under control will be necessary. Cystoscopic dilatation almost never gives lasting relief of extrinsic ureteral
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obstruction. Splinting catheters should generally be left in place from a week to ten days. BLADDER INJURIES
Bladder complications may be grouped as: (a) inadvertent incision into the bladder in the course of pelvic operations or in the course of repair of an inguinal hernia, either recognized or not at operation; (b) the placing of one or more sutures including full thickness of bladder and vagina or bladder and bowel; (c) the development of pelvic abscess in association with urinary extravasation; (d) the development of vesicocutaneous, vesicovaginal or vesicointestinal fistula following the above complications or planned partial cystectomy; (e) bladder dysfunction following major pelvic surgery, spinal surgery or spinal anesthesia; (f) postoperative urinary retention. Accidental Incisions; Misplaced Sutures; Fistulas
An unrecognized incision into the bladder will result in urinary extravasation or abscess and either vesicocutaneous or vesicovaginal fistula depending on the surgical procedure. The institution of proper catheter drainage may be all that is necessary to solve the situation. Injury of the bladder, properly repaired, is without complications. Watertight closure of the bladder is necessary and is best accomplished by placing three layers of sutures. The mucosal layer is closed with continuous 3-0 plain catgut, placed as a continuous interlocking suture. If no urine leak occurs into the muscular suture line, healing will occur without any leakage. The musculature is reapproximated with 3-0 chromic interrupted sutures which are also used to close the adventitia. The use of a suprapubic tube is generally unnecessary since a properly adjusted Foley bag catheter permits adequate drainage and may be removed safely in from three to five days. Vesicovaginal and vesicointestinal fistulas are either the result of a pelvic abscess perforating both viscera or of sutures placed through full thickness of both bladder and vagina or bladder and bowel. Fortunately, vesico-intestinal fistulas are rare. Closure rarely occurs without operative intervention, though a small vesicovaginal fistula may be caused to heal by catheter drainage alone, if the tract has not epithelized or its epithelium has been destroyed by fulguration or cauterization. All larger fistulas require either vaginal or suprapubic repair, depending on their location and the experience as well as likes and dislikes of the surgeon. Bladder Dysfunction
Bladder dysfunction is common after radical operation for removal of cancer of the rectum and cervix. This may be because the bladder is pulled backward, as scar contracts, to fill the space previously occupied
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by the rectum or uterus and cervix. AngUlation at the bladder neck results, since the prostate and female urethra are held anteriorly by the puboprostatic or pubo-urethral attachments. This accentuates mild prostatic obstruction due to median bar or prostatic hypertrophy. Or the dissection has resulted in partial or complete (rarely and in the most severe cases) division of the parasympathetic nerves passing from the second and third sacral roots to the bladder through its posterior pedicles which lie on either side of the rectum or the rectum and the vagina. Similar injury may occur in infants incident to mobilization of the rectum for cure of imperforate anus. When clear-cut bladder neck obstruction exists, it may be relieved by transurethral surgery. If prostatic obstruction is known to exist prior to operative intervention, its obstructive effect can be overcome by perineal prostatectomy performed at the time of posterior excision of the rectum. When partial or complete division of parasympathetic nerves has occurred, bladder function will never be normal, but minor degrees of disturbance of function may be compatible with interval voiding and continence even though residual urine is always present. The combination of bladder neck obstruction and neurogenic dysfunction is common. Relief of the obstruction, even though mild, by transurethral resection may be helpful. Cystometric studies may be desirable to determine the degree of neurological deficit and to estimate the possibility of recovery of function. Trouble occurs if vesico-ureteral reflux develops which may be the result of nerve damage or infection, or both. Occasionally urinary diversion by ileal conduit will be necessary or preferable to the use of an indwelling catheter or the continued presence of difficult voiding with large residual urine, particularly if infection and pyelonephritis are present and progress. Each case must be evaluated on the basis of the findings. Postoperative Urinary Retention
The immediate treatment of postoperative urinary retention is not a major problem, but the consequences of its relief may be. It is almost impossible to catheterize patients repeatedly or to leave an indwelling catheter in place for an extended period of time under current hospital conditions without infection being introduced into the urethra and bladder. The result, at the very least, is the development of prostatitis in the male and urethritis in the female. Many patients, particularly females, date the onset of persistent or recurrent urinary complaints from catheterization. At times, virulent organisms gain entrance which result in serious lower urinary tract infection; prostatic abscess, epididymitis, periurethral abscess. This may cause pyelonephritis either because of ascending infection or because of blood stream dissemination from the prostate or the urethra, localizing in the kidneys. More serious still are the instances of profound bacteremia and shock which may
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result from foci in the lower urinary tract, and which are associated with a high mortality. These sequelae make it desirable to use the catheter only when necessary and then under optimal conditions. There are several causes of postoperative urinary retention, some of which can be eliminated by preoperative treatment. For instance, there are individuals, particularly males, who find it difficult to void in the recumbent position. There are others, again males, without previous hospital experience, who are bashful and unable to void in the presence of a nurse. A brief discussion of voiding and postoperative voiding difficulties and actual practice by the patient in voiding in bed may solve this problem. Some male patients and even occasional female patients have bladder neck or urethral obstructions which are either not severe or are well compensated while the patients are ambulant. A good clinical history will elicit this point. A urethral stricture should be dilated before surgery. Men with developing prostatic obstruction often present with hemorrhoids or inguinal hernias. Sometimes prostatectomy might best be done before other surgical procedures or at the same time as hernial repair or hemorrhoidectomy. This has been suggested as a possible means of avoiding prostatic obstruction following rectal resection and has worked out very well in our experience. Perhaps a more important consideration is overhydration during and after a surgical procedure. In these days of blood transfusions and intravenous fluid administration, it is rare for a patient not to receive fluids at least during the course of operation. Many patients, after a moderately long operation, therefore, have a full bladder when they return to the recovery room, are still anesthetized, and are often given narcotics in the recovery room. If the anesthesia does not wear off quickly, and if too much sedative is given, the bladder may be overfilled making voiding difficult or impossible by the time sensation has returned. These patientf' might be saved the experience of an indwelling catheter by catheterization in the operating room under asceptic conditions before they are returned to the recovery room or ward. Catheterization on the ward may be difficult, painful or traumatic and is never as easily or as satisfactorily done as under anesthesia. There is no doubt that patients should have an indwelling catheter placed in the operating room after major pelvic surgery and that the catheter should be kept attached to sterile drainage, without irrigation, until they are ambulant and can be expected to void. The repeated removal and reintroduction of a catheter is not good practice and should be strongly discouraged. Any patient who cannot void after an operation should be catheterized before the bladder is distended beyond normal capacity because distention will simply make normal voiding less likely. A single catheterization is not likely to be enough in older patients, so that if catheterization becomes necessary a Foley bag catheter should be used and left indwelling for 24 hours at least. Orders
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left for routine catheterization after eight hOurE, for instance, are unrealistic. Each patient should be treated as indicated on the basis of his 01 her problem. Retention of urine following radical hysterectomy, vaginal repairs, operations for urinary incontinence, and rectal resection is often of considerable duration. Patients need not be kept in the hospital simply for this but should he discharged on catheter drainage fitted with a plastic leg bag and followed in the office. The question always arises as to whether antibiotics should be given to the patient wearing a catheter to prevent infection. It seems best to rely first on adequate fluid intake, free urine drainage and the use of an appropriate sized urethral catheter that will permit free drainage of urethral secretions, and to use antibiotics only when active infection is demonstrated and a specific antibiotic or antibacterial drug can be chosen on the basis of culture and bacterial sensitivity studies. It may be best in male patients who tolerate a catheter poorly because of urethritis and in whom slow recovery of bladder function is to be expected, to place instead a small suprapubic tube by trocar punch. This is not only more comfortable, but may avoid a suppurative urethritis, prostatitis and epididymitis. This is particularly true in the case of diabetics. The tube might be placed at the termination of operation, just as one does a gastrostomy under certain circumstances. PRINCIPLES OF CATHETERIZATION. The management of catheters must be meticulous and as aseptic as possible. On the ward or in private accommodations, there is a tendency to have catheterization done by student nurses in the cases of female patients, and orderlies in male patients. This may be satisfactory under certain circumstances, but it is not the proper way to avoid complications. The doctor or a properly trained intern or resident should do catheterizations. It is pure folly to expect a young student nurse to properly catheterize with a floppy catheter an obese female lying in bed without proper light. Stat catheterization of a female should be done using a stiff catheter that may be easily passed into the urethra without contamination. If a Foley catheter is to be used, a clamp grasping the catheter 2 to 3 inches from the end allows easiest handling. When an indwelling catheter is placed in the female, it should be surrounded just outside the meatus and between the vulvar walls with sponges kept moist with Zephiran or 0.5 per cent neomycin solution. A large catheter should not be used. Usually a No. 16 or No. 18 catheter is quite satisfactory. In the male, the choice of catheters depends on the size of the penis or the urethra. A No. 14 or No. 16 catheter may be the largest that the urethra will accept to allow free drainage of urethral secretions, and probably no catheter larger than an No. 18 should be used. Precatheterization sedation is desirable and the use of an anesthetic lubricant is very helpful. For catheterization in the male we recommend a rubber coude
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tipped catheter which usually passes into and through the sphincter area of the membranous urethra without trauma and slides over a median bar or a midlobe with ease. The most common cause of urethral trauma and the usual difficulty encountered in catheterizing a male is spasm of the external sphincter which tends to direct the end of the catheter into the pocket of the bulb behind the external sphincter. A catheter or urethral instrument of any sort should never be forced except by an expert. Good sedation and the use of a local anesthetic lubricant will usually allow catheterization to be accomplished quickly, atraumatically and without pain. An indwelling catheter must always be seriously regarded as a portal of entry for organisms into the body, just as a surgical wound. The penis and genitalia should be kept scrupulously clean and the catheter adjacent to the penis kept wrapped in sponges moist with Zephiran or neomycin solution. Sterile plastic drainage tubes and urine containers which permit their change without contamination can and should be used. Irrigations should not be done except for evacuation of clots. Catheters for males will undoubtedly be developed which will be equipped with a penile sheath that can be left filled with antibacterial agents. COMPLICATIONS ARISING IN THE PROSTATE, PROSTATIC URETHRA AND SEMINAL VESICLES
Complications arising from injury to these structures result in abscess, fistula, obstruction, sterility or impotence. They arise from (1) direct injury in the course of removal of pelvic tumors-chordoma, congenital cysts of the W olffian and Mullerian ducts, sarcomas and rectal cancers, and in the course of repair of imperforate anus, rectovesical or rectourethral fistulas, operative treatment for pelvic injuries, and the use of a catheter or sound; and (2) from either local or more proximal nerve injury in the course of neurosurgical or pelvic surgical procedures involving either the sympathetic or parasympathetic innervation, or both. Abscess may occur either as a result of traumatic catheterization (difficulty introducing a catheter past the midprostatic lobe or contracted bladder neck causing false passage) often in the presence of pre-existing prostatitis or from devascularization in the course of partial prostatectomy and invasive rectal cancer (a poor operation for which radical prostatectomy is preferable). Cutaneous urinary fistula may develop if the prostatic urethra is entered in the course of the operation or if an abscess ruptures both into the urethra and the posterior wound. This may require operative closure. Removal of one or both seminal vesicles is possible without producing either impotence or sterility, if carefully done, but serious injury to the hypogastric plexus may result in poor erection or inallility to ejaculate, or both. Inability to ejaculate follows
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division or excision of the presacral (sympathetic) nerve, so commonly, deliberately and often unnecessarily done in the course of excision of rectal cancer. It may also follow retroperitoneal and aortic surgery if bilateral division of the parasympathetic chain occurs. Inability to have erections many times follows partial prostatectomy and always total prostatectomy; it is common after radical pelvic surgery in the course of which parasympathetic fibers from the second and third sacral roots are divided or badly traumatized. Stricture commonly results from imperfect repair of partial or complete division of the membranous urethra, often found in association with shearing fractures of the pubic rami so that it is almost better, if the condition of the patient will not allow spending the time necessary for an accurate repair, to simply do a cystostomy and plan secondary repair later. Otherwise, the patient is obliged to have life-long dilatations or a very difficult secondary repair after scar has set and no molding of the pelvic girdle is possible. COMPLICATIONS ARISING IN THE BULBOUS AND PENILE URETHRA
The most frequent urethral complications are urethritis, false passage, periurethral abscess, and late stricture with pronounced urethritis arising from traumatic catheterization or the use of an overly large catheter. When a catheter cannot be passed in the presence of a distended bladder with the patient conscious, catheterization or the use of filiforms and followers should be tried again under anesthesia. This will many times be successful, but if it is not, cystostomy must be done. The development of a severe urethritis with chills and fever, or of periurethral abscess calls for removal of the catheter and then cystostomy which may easily be accomplished by using a trocar and a straight tube. Late stricture should be recognized and treated by meatotomy, dilatation if occasional dilatation is all that is necessary, or open surgery using the Johanson procedure or some modification of it depending on its location. Incision of or injury to the urethral bulb may take place in the course of an anal operation and posterior resection of the rectum if dissection toward the bulb is necessary when the lesion has extended much beyond the rectal wall anteriorly. The best way to avoid division or incision is to either place a catheter or sound in the urethra to allow the exact location of the urethra to be palpated. If the urethra is incised or divided, careful repair over a No. 16 catheter using fine chromic catgut will generally avoid fistula or abscess. A drain need not be placed. INJURIES TO THE VAS, TESTIS, EPIDIDYMIS AND SCROTUM
Injury to the vas, epididymis or the blood supply to the testis may occur during orchidopexy and can be avoided only by careful dissection.
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The epididymis is often somewhat separated from the testis and must be carefully identified to avoid its incision or division. Thrombosis of the spermatic veins may develop if the testis is fixed under too much tension in the scrotum, as may happen particularly in the Torek operation. This may result in the loss of the testis from lack of collateral venous circulation owing to its complete dissection from surrounding tissues. Tension on the testis if used should be only enough to keep it in the dependent part of the scrotum. If a testis cannot be brought down easily to the dependent part of the scrotum, it should be allowed to remain at the level where it can easily be held and a second operation performed later which will usually result in proper and easy placement of the testis. A cut vas should be loosely approximated or carefully sutured depending on its size, or suture should be done later if development of the testis warrants it. Injury to the blood supply to the testis in the adult in the course of herniorrhaphy or other intra-abdominal operations is of little moment because of collateral circulation, but division of the vas calls for careful suture using very fine steel wire or arterial silk. This is most important in the event of an atrophic testis on the opposite side. Loss of portions of the scrotum in the case of any surgical procedure, unless very extensive, is of no moment so long as the testes can be covered. Scrotal surgery is often complicated by the development of edema and hematomas. Therefore, all scrotal surgery calls for the most exacting hemostasis. Drains should not generally be used but rather prevention of swelling should be the main consideration and is best accomplished by using a snug suspensory tightened as necessary to form a good pressure dressing about the scrotum. This is a good technique to follow after hernial repair as well. Massachusetts General Hospital Boston 14, Massachusetts
WYLAND F. LEADBETTER, M.D., F.A.C.S. Chief of Urology
GUY W. LEADBETTER, JR., M.D. Assistant in Urology
THE GENITOURINARY tract is a common source of complications incident to abdominal, gynecologic, vascular and neurosurgical operations. Complications may arise as the result of direct surgical injury to the urinary tract organs or to their vascular or nerve supply. Secondary disturbance of renal function may follow periods of renal ischemia due to aortic or renal artery occlusion in the course of vascular surgery, periods of hypotension, severe muscle trauma, and transfusion reactions. Anuria may result from the removal of a solitary kidney, or uremia may develop as a result of chronic renal disease or of the removal of one kidney in the presence of a functionally inadequate contralateral kidney. Unrecognized obstructions both in children and adults often come to light after operation which complicate an already precarious convalescence. The necessity for prolonged periods of catheter drainage may introduce infectious complications into the urinary tract which on occasion may be lethal or at the least very troublesome. THE FIRST STEP-PREVENTION
In these days of increasingly difficult and prolonged abdoIninal operations, some complications are impossible to anticipate or avoid but the vast majority of urologic complications can be prevented by an adequate knowledge of anatomical relations, appropriate preoperative study of the urinary tract, careful surgery, and proper primary repair of the urinary tract when injury has occurred. Primary repair is always preferable to secondary repair and should be done unless the condition of the patient prevents it or makes it hazardous. To insure this, the surgeon must either have experience in the performance of urological surgical technique 811
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or have a urological consultant within reach of the operating table. It is surprising how few surgeons are equipped by training to properly correct urinary tract surgical injuries. We believe that most preventable urinary tract complications occur as the result of inadequate preoperative evaluation due to insufficient imagination on the part of the surgeon and to too much dependence on the clinical history. Many chronic urinary tract troubles are either asymptomatic or symptoms are so minor as to be disregarded by the patient or erroneously interpreted. The history may be of no use in regard to the necessity of urologic investigation. The best plan, when major abdominal surgery is required and particularly when removal of a mass in involved, is to go further than simple examination of the urine and the findings on physical examination. Renal function studies are frequently indicated. The most useful preoperative procedure to evaluate the urinary tract, and this may be done on an emergency basis, is intravenous pyelography which will either reveal normal urinary tract function and structure or point to congenital or acquired abnormalities such as contracted kidneys, unilateral hypoplastic kidney, nonfunction of a kidney, hydronephrosis, anomalies of fusion, ectopic kidney, double kidney and ureter either unilateral or bilateral, stone, renal mass, displacement of the ureter, filling defect in the bladder, residual urine, extravasation of urine following injury, and many other minor changes which may be helpful to have in mind. Further urologic study by cystoscopy and retrograde pyelography may be indicated and can be done just prior to operation under the same anesthesia. The placement of indwelling catheters in one or both ureters may at times be desirable though this has not entirely eliminated ureteral injury. In any case, the information obtained forms a solid background for operative planning. One may state without question that, when masses in the flank, upper abdomen or pelvis are encountered or when severe abdominal trauma presents, an intravenous pyelogram should be obtained before surgery. If this is done, no kidney will be removed in the presence of inadequate contralateral kidney function or in the absence of a contralateral kidney. RENAL COMPLICATIONS DIRECT TRAUMA
Hemorrhage
Direct injury to the kidney parenchyma causing complications, such as might occur in the dissection of a tumor mass involving the upper retroperitoneum, is almost inconceivable since suture, partial nephrectomy or total nephrectomy will usually be required. Secondary hemorrhage from a total or partial nephrectomy can occur, but if partial nephrectomy is done the renal fossa should be drained through a separate stab wound in
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the flank which will prevent pocketing of urine. Secondary bleeding, depending on its degree, may require re-exploration. Since there is free venous anastomosis within the kidney, a segment of the renal vein or accessory veins may be ligated without functional disturbance of the kidney, but if an accessory renal artery has to be sacrificed the portion of the kidney supplied by this vessel must be removed. Total nephrectomy of course can be followed by secondary bleeding if the pedicle is inadequately ligated. This is an extreme surgical emergency. It is best, when nephrectomy is to be done, to ligate the renal artery and vein individually since mass ligation has occasionally been followed by arteriovenous aneurysm. Primary hemorrhage from the renal pedicle will not occur if good exposure is obtained and the artery and vein are dissected under vision. Large nonabsorbable sutures are undesirable. We have seen one patient who developed a persistent flank abscess which was ultimately found to contain a large silk suture which had sloughed from the pedicle. Chromic 0 catgut is sufficient. A double tie on each vessel with the external or second tie sutured to the vessel is safest to prevent the tie from slipping.
Ruptured Kidney Attempts to repair a ruptured kidney found in association with other visceral trauma, immediately or early after injury, usually end in nephrectomy because of the magnitude of bleeding. The best course, if a ruptured kindey is encountered in the course of abdominal exploration for trauma, is to either leave it alone or drain the flank. Secondary repair may be necessary depending on subsequent functional and pyelographic studies. This can best be done from a week to ten days after injury when all active bleeding has ceased. At this time excision of devitalized kidney, suture of parenchyma and removal of extravasated blood and urine can easily be done. Extravasated blood and urine is usually present within Gerota's fascia and tends to gravitate about the upper ureter. This should be carefully removed. A catastrophic complication in such a case is the removal of a potentially good kidney or portion of a good kidney in the absence of contralateral kidney or the presence of a functionally impaired kidney. Preoperative intravenous pyelograms or retrograde pyelograms will prevent this. If the removal of a solitary kidney is recognized in the course of subsequent exploration, the kidney should be replaced. This can be accomplished by vascular and ureteral reanastomoses. The aorta and ligated stumps of the renal artery and vein should be carefully and completely exposed. At the same time the assistant should gently flush the renal artery of the kidney with 1: 100 heparin solution in an effort to prevent vascular clotting. Renal vessels should then be reanastomosed. If enough length of artery or vein is not present to allow easy anastomosis, a small segment of saphenous vein may be used to supplement either
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renal artery or vein or the kidney may be placed in the iliac fossa, anastomosing the renal artery and vein to the hypogastric artery. and common iliac vein respectively. Ureteral reanastomosis must then be done after spatulating both ends of the ureter to obtain a large cross-sectional diameter. Chromic catgut sutures (6-0) are placed carefully to approximate the mucosa accurately and to make a watertight suture line. The technique is similar to vascular anastomosis but interrupted sutures should be used. Repair should be done over a polyethylene catheter of appropriate size, passed up to the kidney pelvis and then on into the bladder. The catheter may be removed from the bladder after healing has been completed by cystoscopic means. Complications of Needle Biopsy of the Kidney
Needle biopsy of the kidney is being done frequently these days and is not without serious complications. If an artery is lacerated or a section of artery is removed by the needle, perirenal hemorrhage occurs and may be of alarming proportions and sufficient to produce a large perirenal hematoma. Observation is usually all that is necessary but if a large flank mass develops and the patient requires transfusions, exploration to evacuate the hematoma and to suture bleeding points is necessary. Since infection in such a hematoma may develop, antibiotic coverage is desirable. Nephrectomy should never be necessary. We believe that open biopElY of the kidney through a small flank incision is preferable to needle biopsy. Injury to the Renal Pelvis Occasionally, in the course of retroperitoneal dissection, the renal pelvis may be incised. The edges of the pelvis should be carefully reapproximated with interrupted 6-0 chromic catgut sutures to make a watertight closure. Care must be exercised to be sure that no angulation or obstruction is produced at the ureteropelvic junction. Since, in spite of a good closure, urine leakage may occur the area must be separately drained by a stab wound through the flank. There will be no complications if such an injury is recognized at the time but, if it is missed, extravasation of urine will occur and require secondary drainage. Stricture may subsequently occur which will require further treatment. INDIRECT TRAUMA-ANURIA AND OLIGURIA
Anuria Anuria is usually due to obstruction. Patients frequently complain of flank discomfort, and palpation may reveal flank or costovertebral angle pain. If the bladder is found to be empty, ureteral obstruction is generally present. Cystoscopy and retrograde catheterization of the ureters are mandatory. The ureteral catheters should be passed to the points of
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obstruction and ureterograms made to demonstrate the location and nature of the obstruction. Occasionally a catheter can be passed beyond the obstruction if it is due to angulation or partial ligation. If catheters can be passed, only one should be left indwelling because infection is likely to follow and drainage of only one kidney will be sufficient to allow adequate urine flow. If catheters cannot be passed, either temporary nephrostomy drainage of one kidney will be necessary or, if the patient's condition permits, abdominal re-exploration and lysis of the ureters must be done. In some cases after a period of catheter drainage the ureters open and drain satisfactorily. In others, operative lysis of the ureters will be necessary. Delay in cystoscopy and the institution of proper urine drainage in such cases will lead to uremia and, if pyelonephritis is present, to an immediate severe febrile reaction.
Oliguria Oliguria may be the result of: (1) partial ureteral obstruction; (2) complete ureteral obstruction on one side in the presence of contralateral hypoplastic or damaged kidney; (3) inadequate blood and fluid replacement; (4) renal ischemia due to a period of hypotension during or after operation, prolonged clamping of renal vessels or aorta (renal or vascular surgery), tubular dysfunction incident to severe muscle trauma, or acute cortical necrosis (most common after delivery); (5) serum electrolyte disturbances, particularly potassium loss; (6) terminal renal diseasepyelonephritis, glomerulonephritis, polycystic disease; (7) very rarely renal arterial embolization due to (a) an embolus from the heart in a patient with endocarditis or auricular fibrillation or (b) embolization of atherosclerotic material in the course of or following aortic surgery. Bilateral occlusion is rare but unilateral occlusion is fairly common and may result in oliguria if the opposite kidney function is impaired. (8) Very rarely and principally in children renal vein thrombosis may occur. This is usually in association with caval thrombosis. It is characterized by oliguria and large amounts of albumin in the urine. Diagnosis is difficult. Treatment will probably be directed toward the use of anticoagulants because surgery is of questionable value. When the physician is confronted with oliguria, the first thing for him to do is to get complete serum electrolyte studies and a blood volume determination. It is imperative to make a diagnosis as quickly and as accurately as possible. If ureteral obstruction is suspected, cystoscopy and ureteral catheterization should be carried out promptly. If no obstruction is present, unilateral or bilateral retrograde pyelograms may be very helpful in delineating the size of the kidneys and the thickness of the renal cortices. A small kidney with a thin cortex indicates chronic renal disease of some sort. Bilateral pyelograms are important since one side may show a hypoplastic kidney and the other a normal sized kidney.
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This may have real bearing on treatment. If a normal sized kidney is present with a normally thick cortex, we must conclude that we are dealing with tubular dysfunction or arterial embolization. A good test to rule out lower nephron disease due to ischemia or transfusion reaction is to give rapidly 20 gm. of mannitol in 200 cc. of water. Since mannitol is an osmotic diuretic, renal secretion will occur even if blood volume is decreased but, if lower nephron disease is present, no diuresis will result. Renal embolization may be suspected in the presence of the sudden onset of costovertebral angle or flank pain and with a normal pelvis and normally thick cortex demonstrated on retrograde pyelography in the absence of renal secretion. Hematuria may be present. A renal angiogram must be done on an emergency basis if embolization is suspected, and followed by embolectomy or watchful waiting depending on the findings. Emboli in distal branches of the renal artery may cause oliguria due, perhaps, to general arterial spasm which may be followed later by gradual restitution of function. An embolus in the main renal artery should be removed even though some hours have elapsed since its probable onset. Patients with low blood volumes respond to appropriate administration of blood and fluid. Patients with chronic renal disease must be hydrated carefully, and electrolytes adjusted in the hope that function will improve enough to allow convalescence. One or more peritoneal dialyses may be indicated under these circumstances. Those with lower nephron disease from any cause can be expected to recover in most instances provided they can be managed without the development of pulmonary edema or potassium intoxication. The main points in therapy are restriction of fluids, regulation of electrolytes, and prevention of potassium intoxication by peritoneal dialysis or the use of exchange resins by mouth or as enemas. Simple rules are: 1. A daily intake of 300 cc. of fluid plus enough to compensate for urine and gastrointestinal losses. 2. Diet as tolerated consisting chiefly of carbohydrates with low potassium content. If the patient cannot take nourishment by mouth, concentrated glucose solution may be given through a small polyethylene tube introduced into a large vein. One hundred grams of glucose a day is usually sufficient. 3. Watch for low serum calcium! Muscular twitching due to low calcium may be corrected by administration of calcium gluconate or the use of Dilantin. 4. Weigh daily to make sure that overhydration does not occur. Weight should decrease daily if patient is managed correctly. 5. An electrocardiogram should be obtained daily or, in the presence of elevated potassium, more frequently, to check for potassium intoxication. 6. Serum electrolytes should be obtained every other day.
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7. Elevation of blood urea nitrogen may be ignored unless patient becomes toxic. 8. Strenuous efforts should be made to prevent infection. The patient should be in a single room. Strict aseptic care should be followed. Antibiotics should not be used prophylactically but should be given for specific reasons. One must remember that high blood and tissue levels are attained easily in the absence of normal excretion. If a catheter has been placed to follow urine output accurately, great care should be taken to keep the penis or vaginal area clean and wet with neomycin or Zephiran sponges. The catheter should not be irrigated. 9. Early use of peritoneal lavage or dialysis by artificial kidney should be considered as a means of maintaining patient in satisfactory condition, rather than employing it as a late therapeutic measure. Restitution of renal function may begin in a few days or only after two or three weeks. When diuresis begins, urine and serum electrolytes must be followed carefully. Sodium and chloride losses may be very great and require massive replacement. URETERAL INJURIES
The ureter may be injured at any level in t4e course of removal of retroperitoneal tumors or cancers involving the retroperitoneum, vascular surgery for replacement of the aorta or surgery for repair of renal vascular obstructions, but lower (pelvic) ureteral injuries are most frequent. These occur in the course of simple or radical hysterectomy, oophorectomy, abdominoperineal resection of the rectum or sigmoid for cancer, and repair of vesicovaginal fistulas. Obstetrical injuries are fortunately very rare. Late obstructions of one or both ureters may result from retroperitoneal sepsis and periureteral fibrosis. Injuries may occur through ligation, partial ligation, laceration, division, excision of a segment, crushing or devascularization. The principal cause is failure to recognize the ureters because of their displacement by a mass or because of bleeding which temporarily obscures the field and the control of which results in placing sutures, clamps, or cutting without good vision. The preoperative placement of ureteral catheters does not necessarily eliminate injury although they may be of real help in identifying the course of the ureters. The best course is to intentionally dissect out the ureters rather than to hope that they are safely out of the operative field. Ureters are most commonly injured at the level of the pelvic brim in relation to the infundibulopelvic ligament and in the broad ligament region where sutures are not infrequently passed about them or close to them in the course of clamping and suture ligating the uterine vessels. Division of a Ureter
Division of a ureter, unrecognized at operation, results
In
urinary
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extravasation into the wound or the development of a retroperitoneal accumulation which, following radical hysterectomy, often drains through the vagina to form a ureterovaginal fistula. This frequently results from devascularization of the ureter with slough following a radical hysterectomy. Such an occurrence is probably due to thrombosis of a section of the longitudinal artery of the ureter from pressure of a retractor or dissection of the ureter from its adventitial sheath. Ordinarily the ureter may be dissected ffom the renal pelvis to the bladder without disturbance of blood supply. Perhaps preoperative irradiation renders it more susceptible to this injury. Treatment is drainage of a retroperitoneal accumulation if this has not already occurred through the wound. One can usually pass a clamp into it. This will result in a ureterocutaneous fistula which will persist until the kidney and ureter are removed or the ureter is repaired which is rarely possible. Such injuries are usually low in the ureter (the exact point of injury can be determined by retrograde filling of the lower ureteral stump in the course of obtaining a ureterogram) allowing reimplantation into the bladder or anastomosis to a bladder flap made into a tube, the so-called Boari flap. N ephroureterectomy is necessary only if the kidney is badly damaged. Sometimes a ureterovaginal fistula following radical hysterectomy will heal if a catheter can be passed up the ureter by the fistula and left indwelling. Stricture will sometimes necessitate secondary surgery, though it is surprising how often normal urine drainage results. Division of a ureter which is recognized at operation usually permits primary repair over a splinting catheter unless division occurs close to the bladder. Reimplantation of the upper ureteral segment into the bladder is usually best in these cases and should be done through the open bladder with construction of the submucosal tunnel to form a valve. Excision of a Ureteral Segment
If -excision of a ureteral segment is recognized at operation and if a portion of pelvic ureter is lost, reanastomosis to a bladder tube is usually the best course. Loss of segments at the pelvic brim or higher pose a much more difficult problem. In an older patient with a good contralateral kidney, removal of the kidney and ureter is preferable, particularly if operation is for cancer. In younger patients or in individuals with poor renal function or in the absence of a contralateral kidney, preservation of the kidney is either desirable or imperative. Under these circumstances, a short segment of small bowel may be used to bridge the gap between the intact ureter above and the bladder below. Cutaneous ureterostomy may be resorted to as a temporary expedient if the patient's condition is poor, or, if the opposite ureter is intact, ureteroureterostomy may be done. Ureterosigmoidostomy can also be done but this is generally not desirable.
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Laceration and Crushing with a Clamp
When a ureter has been crushed by a clamp, removal of the clamp and ureterotomy with placement of a splinting catheter will usually allow restitution of function without slough, the development of extravasation or urinary fistula. It is best, however, simply to drain this area for a few days. If the clamp has been on for some time; and after removal the crushed area remains avascular, resection of this area and reanastomosis over a splinting catheter is necessary. Laceration (partial division) is handled by careful suture over a splinting catheter or by suture and a separate extraperitoneal drain to this area. Unrecognized injury by clamp or laceration will generally lead to extravasation and fistula, but healing of the fistula can be expected if a ureteral catheter can be passed up the ureter beyond the injury and left indwelling for several days. Ligation
Ligation of one ureter may escape notice unless the patient complains of flank pain or has or develops infection in the kidney. Intravenous pyelography will uncover the trouble. Cystoscopy and ureteral catheterization are necessary to locate the point of obstruction, which should be relieved surgically by deligation as soon as the patient's condition permits or by temporary nephrostomy if high fever necessitates prompt drainage. Occasionally a catheter may be passed if obstruction iEt not complete, with gradual release of the obstruction as suture material disintegrates. Bilateral ligation has been discussed previously. The question occasionally arises when a blocked ureter is discovered some weeks or months after surgery, whether the ureteral obstruction should be relieved, nephrostomy done, or the situation allowed to remain as it is. Undoubtedly, useful kidney function may be saved by a relief of obstruction several weeks later, and if the condition of the other kidney suggests the need for additional functioning nephrons, relief of the obstruction should be attempted. Evidence of infection in the kidney of course calls for nephrectomy. If function of the contralateral kidney is adequate and the patient has no symptoms from the obstructed kidney, probably nothing should be done. Ureteral Obstruction Developing from Retroperitoneal Sepsis or Fibrosis
Obstructions due to this cause must be differentiated from residual cancer. They are usually partial, may improve, and unless severe or associated with pain or pyelonephritis may be watched. If significant pyelonephritis is present or if obstruction is severe, the use of temporary indwelling catheters placed by cystoscopic manipulation and followed by open lysis after infection is under control will be necessary. Cystoscopic dilatation almost never gives lasting relief of extrinsic ureteral
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obstruction. Splinting catheters should generally be left in place from a week to ten days. BLADDER INJURIES
Bladder complications may be grouped as: (a) inadvertent incision into the bladder in the course of pelvic operations or in the course of repair of an inguinal hernia, either recognized or not at operation; (b) the placing of one or more sutures including full thickness of bladder and vagina or bladder and bowel; (c) the development of pelvic abscess in association with urinary extravasation; (d) the development of vesicocutaneous, vesicovaginal or vesicointestinal fistula following the above complications or planned partial cystectomy; (e) bladder dysfunction following major pelvic surgery, spinal surgery or spinal anesthesia; (f) postoperative urinary retention. Accidental Incisions; Misplaced Sutures; Fistulas
An unrecognized incision into the bladder will result in urinary extravasation or abscess and either vesicocutaneous or vesicovaginal fistula depending on the surgical procedure. The institution of proper catheter drainage may be all that is necessary to solve the situation. Injury of the bladder, properly repaired, is without complications. Watertight closure of the bladder is necessary and is best accomplished by placing three layers of sutures. The mucosal layer is closed with continuous 3-0 plain catgut, placed as a continuous interlocking suture. If no urine leak occurs into the muscular suture line, healing will occur without any leakage. The musculature is reapproximated with 3-0 chromic interrupted sutures which are also used to close the adventitia. The use of a suprapubic tube is generally unnecessary since a properly adjusted Foley bag catheter permits adequate drainage and may be removed safely in from three to five days. Vesicovaginal and vesicointestinal fistulas are either the result of a pelvic abscess perforating both viscera or of sutures placed through full thickness of both bladder and vagina or bladder and bowel. Fortunately, vesico-intestinal fistulas are rare. Closure rarely occurs without operative intervention, though a small vesicovaginal fistula may be caused to heal by catheter drainage alone, if the tract has not epithelized or its epithelium has been destroyed by fulguration or cauterization. All larger fistulas require either vaginal or suprapubic repair, depending on their location and the experience as well as likes and dislikes of the surgeon. Bladder Dysfunction
Bladder dysfunction is common after radical operation for removal of cancer of the rectum and cervix. This may be because the bladder is pulled backward, as scar contracts, to fill the space previously occupied
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by the rectum or uterus and cervix. AngUlation at the bladder neck results, since the prostate and female urethra are held anteriorly by the puboprostatic or pubo-urethral attachments. This accentuates mild prostatic obstruction due to median bar or prostatic hypertrophy. Or the dissection has resulted in partial or complete (rarely and in the most severe cases) division of the parasympathetic nerves passing from the second and third sacral roots to the bladder through its posterior pedicles which lie on either side of the rectum or the rectum and the vagina. Similar injury may occur in infants incident to mobilization of the rectum for cure of imperforate anus. When clear-cut bladder neck obstruction exists, it may be relieved by transurethral surgery. If prostatic obstruction is known to exist prior to operative intervention, its obstructive effect can be overcome by perineal prostatectomy performed at the time of posterior excision of the rectum. When partial or complete division of parasympathetic nerves has occurred, bladder function will never be normal, but minor degrees of disturbance of function may be compatible with interval voiding and continence even though residual urine is always present. The combination of bladder neck obstruction and neurogenic dysfunction is common. Relief of the obstruction, even though mild, by transurethral resection may be helpful. Cystometric studies may be desirable to determine the degree of neurological deficit and to estimate the possibility of recovery of function. Trouble occurs if vesico-ureteral reflux develops which may be the result of nerve damage or infection, or both. Occasionally urinary diversion by ileal conduit will be necessary or preferable to the use of an indwelling catheter or the continued presence of difficult voiding with large residual urine, particularly if infection and pyelonephritis are present and progress. Each case must be evaluated on the basis of the findings. Postoperative Urinary Retention
The immediate treatment of postoperative urinary retention is not a major problem, but the consequences of its relief may be. It is almost impossible to catheterize patients repeatedly or to leave an indwelling catheter in place for an extended period of time under current hospital conditions without infection being introduced into the urethra and bladder. The result, at the very least, is the development of prostatitis in the male and urethritis in the female. Many patients, particularly females, date the onset of persistent or recurrent urinary complaints from catheterization. At times, virulent organisms gain entrance which result in serious lower urinary tract infection; prostatic abscess, epididymitis, periurethral abscess. This may cause pyelonephritis either because of ascending infection or because of blood stream dissemination from the prostate or the urethra, localizing in the kidneys. More serious still are the instances of profound bacteremia and shock which may
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LEADBET'l'ER, GUY W. LEADBETTER, JR.
result from foci in the lower urinary tract, and which are associated with a high mortality. These sequelae make it desirable to use the catheter only when necessary and then under optimal conditions. There are several causes of postoperative urinary retention, some of which can be eliminated by preoperative treatment. For instance, there are individuals, particularly males, who find it difficult to void in the recumbent position. There are others, again males, without previous hospital experience, who are bashful and unable to void in the presence of a nurse. A brief discussion of voiding and postoperative voiding difficulties and actual practice by the patient in voiding in bed may solve this problem. Some male patients and even occasional female patients have bladder neck or urethral obstructions which are either not severe or are well compensated while the patients are ambulant. A good clinical history will elicit this point. A urethral stricture should be dilated before surgery. Men with developing prostatic obstruction often present with hemorrhoids or inguinal hernias. Sometimes prostatectomy might best be done before other surgical procedures or at the same time as hernial repair or hemorrhoidectomy. This has been suggested as a possible means of avoiding prostatic obstruction following rectal resection and has worked out very well in our experience. Perhaps a more important consideration is overhydration during and after a surgical procedure. In these days of blood transfusions and intravenous fluid administration, it is rare for a patient not to receive fluids at least during the course of operation. Many patients, after a moderately long operation, therefore, have a full bladder when they return to the recovery room, are still anesthetized, and are often given narcotics in the recovery room. If the anesthesia does not wear off quickly, and if too much sedative is given, the bladder may be overfilled making voiding difficult or impossible by the time sensation has returned. These patientf' might be saved the experience of an indwelling catheter by catheterization in the operating room under asceptic conditions before they are returned to the recovery room or ward. Catheterization on the ward may be difficult, painful or traumatic and is never as easily or as satisfactorily done as under anesthesia. There is no doubt that patients should have an indwelling catheter placed in the operating room after major pelvic surgery and that the catheter should be kept attached to sterile drainage, without irrigation, until they are ambulant and can be expected to void. The repeated removal and reintroduction of a catheter is not good practice and should be strongly discouraged. Any patient who cannot void after an operation should be catheterized before the bladder is distended beyond normal capacity because distention will simply make normal voiding less likely. A single catheterization is not likely to be enough in older patients, so that if catheterization becomes necessary a Foley bag catheter should be used and left indwelling for 24 hours at least. Orders
Urologic Complications of Surgery
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left for routine catheterization after eight hOurE, for instance, are unrealistic. Each patient should be treated as indicated on the basis of his 01 her problem. Retention of urine following radical hysterectomy, vaginal repairs, operations for urinary incontinence, and rectal resection is often of considerable duration. Patients need not be kept in the hospital simply for this but should he discharged on catheter drainage fitted with a plastic leg bag and followed in the office. The question always arises as to whether antibiotics should be given to the patient wearing a catheter to prevent infection. It seems best to rely first on adequate fluid intake, free urine drainage and the use of an appropriate sized urethral catheter that will permit free drainage of urethral secretions, and to use antibiotics only when active infection is demonstrated and a specific antibiotic or antibacterial drug can be chosen on the basis of culture and bacterial sensitivity studies. It may be best in male patients who tolerate a catheter poorly because of urethritis and in whom slow recovery of bladder function is to be expected, to place instead a small suprapubic tube by trocar punch. This is not only more comfortable, but may avoid a suppurative urethritis, prostatitis and epididymitis. This is particularly true in the case of diabetics. The tube might be placed at the termination of operation, just as one does a gastrostomy under certain circumstances. PRINCIPLES OF CATHETERIZATION. The management of catheters must be meticulous and as aseptic as possible. On the ward or in private accommodations, there is a tendency to have catheterization done by student nurses in the cases of female patients, and orderlies in male patients. This may be satisfactory under certain circumstances, but it is not the proper way to avoid complications. The doctor or a properly trained intern or resident should do catheterizations. It is pure folly to expect a young student nurse to properly catheterize with a floppy catheter an obese female lying in bed without proper light. Stat catheterization of a female should be done using a stiff catheter that may be easily passed into the urethra without contamination. If a Foley catheter is to be used, a clamp grasping the catheter 2 to 3 inches from the end allows easiest handling. When an indwelling catheter is placed in the female, it should be surrounded just outside the meatus and between the vulvar walls with sponges kept moist with Zephiran or 0.5 per cent neomycin solution. A large catheter should not be used. Usually a No. 16 or No. 18 catheter is quite satisfactory. In the male, the choice of catheters depends on the size of the penis or the urethra. A No. 14 or No. 16 catheter may be the largest that the urethra will accept to allow free drainage of urethral secretions, and probably no catheter larger than an No. 18 should be used. Precatheterization sedation is desirable and the use of an anesthetic lubricant is very helpful. For catheterization in the male we recommend a rubber coude
824
WYLAND
F.
LEADBETTER, GUY W. LEADBETTER, JR.
tipped catheter which usually passes into and through the sphincter area of the membranous urethra without trauma and slides over a median bar or a midlobe with ease. The most common cause of urethral trauma and the usual difficulty encountered in catheterizing a male is spasm of the external sphincter which tends to direct the end of the catheter into the pocket of the bulb behind the external sphincter. A catheter or urethral instrument of any sort should never be forced except by an expert. Good sedation and the use of a local anesthetic lubricant will usually allow catheterization to be accomplished quickly, atraumatically and without pain. An indwelling catheter must always be seriously regarded as a portal of entry for organisms into the body, just as a surgical wound. The penis and genitalia should be kept scrupulously clean and the catheter adjacent to the penis kept wrapped in sponges moist with Zephiran or neomycin solution. Sterile plastic drainage tubes and urine containers which permit their change without contamination can and should be used. Irrigations should not be done except for evacuation of clots. Catheters for males will undoubtedly be developed which will be equipped with a penile sheath that can be left filled with antibacterial agents. COMPLICATIONS ARISING IN THE PROSTATE, PROSTATIC URETHRA AND SEMINAL VESICLES
Complications arising from injury to these structures result in abscess, fistula, obstruction, sterility or impotence. They arise from (1) direct injury in the course of removal of pelvic tumors-chordoma, congenital cysts of the W olffian and Mullerian ducts, sarcomas and rectal cancers, and in the course of repair of imperforate anus, rectovesical or rectourethral fistulas, operative treatment for pelvic injuries, and the use of a catheter or sound; and (2) from either local or more proximal nerve injury in the course of neurosurgical or pelvic surgical procedures involving either the sympathetic or parasympathetic innervation, or both. Abscess may occur either as a result of traumatic catheterization (difficulty introducing a catheter past the midprostatic lobe or contracted bladder neck causing false passage) often in the presence of pre-existing prostatitis or from devascularization in the course of partial prostatectomy and invasive rectal cancer (a poor operation for which radical prostatectomy is preferable). Cutaneous urinary fistula may develop if the prostatic urethra is entered in the course of the operation or if an abscess ruptures both into the urethra and the posterior wound. This may require operative closure. Removal of one or both seminal vesicles is possible without producing either impotence or sterility, if carefully done, but serious injury to the hypogastric plexus may result in poor erection or inallility to ejaculate, or both. Inability to ejaculate follows
Urologic Complications of Surgery
825
division or excision of the presacral (sympathetic) nerve, so commonly, deliberately and often unnecessarily done in the course of excision of rectal cancer. It may also follow retroperitoneal and aortic surgery if bilateral division of the parasympathetic chain occurs. Inability to have erections many times follows partial prostatectomy and always total prostatectomy; it is common after radical pelvic surgery in the course of which parasympathetic fibers from the second and third sacral roots are divided or badly traumatized. Stricture commonly results from imperfect repair of partial or complete division of the membranous urethra, often found in association with shearing fractures of the pubic rami so that it is almost better, if the condition of the patient will not allow spending the time necessary for an accurate repair, to simply do a cystostomy and plan secondary repair later. Otherwise, the patient is obliged to have life-long dilatations or a very difficult secondary repair after scar has set and no molding of the pelvic girdle is possible. COMPLICATIONS ARISING IN THE BULBOUS AND PENILE URETHRA
The most frequent urethral complications are urethritis, false passage, periurethral abscess, and late stricture with pronounced urethritis arising from traumatic catheterization or the use of an overly large catheter. When a catheter cannot be passed in the presence of a distended bladder with the patient conscious, catheterization or the use of filiforms and followers should be tried again under anesthesia. This will many times be successful, but if it is not, cystostomy must be done. The development of a severe urethritis with chills and fever, or of periurethral abscess calls for removal of the catheter and then cystostomy which may easily be accomplished by using a trocar and a straight tube. Late stricture should be recognized and treated by meatotomy, dilatation if occasional dilatation is all that is necessary, or open surgery using the Johanson procedure or some modification of it depending on its location. Incision of or injury to the urethral bulb may take place in the course of an anal operation and posterior resection of the rectum if dissection toward the bulb is necessary when the lesion has extended much beyond the rectal wall anteriorly. The best way to avoid division or incision is to either place a catheter or sound in the urethra to allow the exact location of the urethra to be palpated. If the urethra is incised or divided, careful repair over a No. 16 catheter using fine chromic catgut will generally avoid fistula or abscess. A drain need not be placed. INJURIES TO THE VAS, TESTIS, EPIDIDYMIS AND SCROTUM
Injury to the vas, epididymis or the blood supply to the testis may occur during orchidopexy and can be avoided only by careful dissection.
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F.
LEADBETTER, GUY
W.
LEADBETTER, JR.
The epididymis is often somewhat separated from the testis and must be carefully identified to avoid its incision or division. Thrombosis of the spermatic veins may develop if the testis is fixed under too much tension in the scrotum, as may happen particularly in the Torek operation. This may result in the loss of the testis from lack of collateral venous circulation owing to its complete dissection from surrounding tissues. Tension on the testis if used should be only enough to keep it in the dependent part of the scrotum. If a testis cannot be brought down easily to the dependent part of the scrotum, it should be allowed to remain at the level where it can easily be held and a second operation performed later which will usually result in proper and easy placement of the testis. A cut vas should be loosely approximated or carefully sutured depending on its size, or suture should be done later if development of the testis warrants it. Injury to the blood supply to the testis in the adult in the course of herniorrhaphy or other intra-abdominal operations is of little moment because of collateral circulation, but division of the vas calls for careful suture using very fine steel wire or arterial silk. This is most important in the event of an atrophic testis on the opposite side. Loss of portions of the scrotum in the case of any surgical procedure, unless very extensive, is of no moment so long as the testes can be covered. Scrotal surgery is often complicated by the development of edema and hematomas. Therefore, all scrotal surgery calls for the most exacting hemostasis. Drains should not generally be used but rather prevention of swelling should be the main consideration and is best accomplished by using a snug suspensory tightened as necessary to form a good pressure dressing about the scrotum. This is a good technique to follow after hernial repair as well. Massachusetts General Hospital Boston 14, Massachusetts