Contributors of Campbell-Walsh-Wein, 12th edition
Reza Ghavamian, Charbel Chalouhy, Michael J. Schwartz, Jessica E. Kreshover, Brian Duty, Michael Joseph Conlin, Mcr, Roshan M. Patel, Kamaljot S. Kaler, and Jaime Landman
Adult complications
A wide array of physiologic, medical, and surgical complications may occur following urologic surgery. Although the growth of endourology and minimally invasive surgery has helped to minimize surgical morbidity, unique periprocedural complications have also emerged from these techniques.
Classification
Postoperative complications may be quantified based on standardized classification systems. The Clavien-Dindo Scale ( Table 31.1 ) is validated for urologic surgery and captures complication severity by the required management and the relative invasiveness of the management intervention.
| GRADE | DEFINITION |
|---|---|
| 1 |
|
| 2 |
|
| 3 | Requiring surgical, endoscopic, or radiologic intervention |
| 3A | Intervention not under general anesthesia |
| 3B | Intervention under general anesthesia |
| 4 | Life-threatening complication (including central nervous system complications) requiring intensive care or intensive care unit management |
| 4A | Single-organ dysfunction (including dialysis) |
| 4B | Multi-organ dysfunction |
| 5 | Death of a patient |
| Suffix “d” | If the patient has a complication at the time of discharge, the suffix “d” (for “disability”) is added to the respective grade of complication. This label indicates the need for a follow-up to fully evaluate the complication |
Neuromuscular complications
Positioning injuries.
Neuromuscular complications occur following 1%–3% of urologic surgeries. Positioning-related injuries typically result from prolonged nerve compression, excessive stretch, or ischemia. This may be exacerbated by extended operative time and inadequate pressure point padding. Obese patients are particularly vulnerable, given their increased weight and longer operative times. Specific patient positioning for various urologic surgeries may result in characteristic nerve compression injury patterns ( Table 31.2 ). Strategies for prevention of perioperative peripheral neuropathies are outlined by the American Society of Anesthesiologists ( Box 31.1 ).
| POSITION | NERVE AFFECTED | MECHANISM | DEFICIT | PREVENTION |
|---|---|---|---|---|
| Supine | Sciatic nerve |
|
|
|
| Radial nerve |
|
| ||
| Median nerve |
|
| ||
| Ulnar nerve |
|
| ||
| Lithotomy | Posterior tibial nerve | Compression of posterior knee against stirrups |
|
|
| Peroneal nerve | Compression of stirrups laterally around fibular neck |
| ||
| Pudendal nerve | Excess traction and compression against stirrups |
| ||
| Obturator | Hyperflexion of thigh at hip joint (exaggerated lithotomy position) |
| ||
| Peroneal nerve | Inadequate padding of dependent leg |
|
| |
| Brachial plexus |
|
|
| |
| Prone | Anterior tibial nerve | Extended period of plantarflexion | Foot drop |
|
| Lateral femoral cutaneous nerve | Excessive pressure on lateral thigh | Numbness of anterolateral thigh | ||
| Brachial plexus |
|
|
|
Preoperative assessment
- •
When judged appropriately, it is helpful to ascertain that patients can comfortably tolerate the anticipated operative position.
Upper extremity positioning
- •
Arm abduction should be limited to 90 degrees in supine patients; patients who are positioned prone may comfortably tolerate arm abduction greater than 90 degrees.
- •
Arms should be positioned to decrease pressure on the postcondylar groove of the humerus (ulnar groove). When arms are tucked at the side, a neutral forearm position is recommended. When arms are abducted on arm boards, either supination or a neutral forearm position is acceptable.
- •
Prolonged pressure on the radial nerve in the spiral groove of the humerus should be avoided.
- •
Extension of the elbow beyond a comfortable range may stretch the median nerve.
Lower extremity positioning
- •
Lithotomy positions that stretch the hamstring muscle group beyond a comfortable range may stretch the sciatic nerve.
- •
Prolonged pressure on the peroneal nerve at the fibular head should be avoided.
- •
Neither extension nor flexion of the hip increases the risk for femoral neuropathy.
Protective padding
- •
Padded arm boards may decrease the risk for upper extremity neuropathy.
- •
The use of chest rolls in laterally positioned patients may decrease the risk for upper extremity neuropathies.
- •
Padding at the elbow and at the fibular head may decrease the risk for upper and lower extremity neuropathies, respectively.
Equipment
- •
Properly functioning automated blood pressure cuffs on the upper arms do not affect the risk for upper extremity neuropathies.
- •
Shoulder braces in steep head-down positions may increase the risk for brachial plexus neuropathies.
Postoperative assessment
- •
A simple postoperative assessment of extremity nerve function may lead to early recognition of peripheral neuropathies.
Documentation
- •
Charting specific positioning actions during the care of patients may result in improvements of care by (1) helping practitioners focus attention on relevant aspects of patient positioning and (2) providing information that continuous improvement processes can use to effect refinements in patient care.
Direct nerve injury.
Specific urologic procedures are associated with direct intraoperative nerve injury ( Table 31.3 ). Careful attention to patient and retractor positioning, as well as deliberate identification and avoidance of the nerves at risk may help avoid injury. Clips inadvertently placed on nerves must be removed, and transected nerves should be repaired in a tension-free manner with nonabsorbable suture. Postoperative physical therapy may optimize recovery of any resulting functional deficits.
| PROCEDURE | NERVES AT RISK | DEFICITS | AVOIDANCE |
|---|---|---|---|
| Psoas hitch | Genitofemoral nerve | Paresthesias or pain distributed along base of scrotum and penis, upper/medial thigh | Longitudinal placement of anchoring sutures parallel to psoas tendon |
| Femoral nerve | Weakness in knee extension, paresthesias or pain over anteromedial thigh | Careful placement of retractors, avoidance of compression on psoas muscle | |
| Inguinal orchiectomy; hernia repair | Ilioinguinal nerve | Paresthesias or pain of lateral hemiscrotum, groin | Careful identification, isolation, and preservation of nerve within inguinal canal |
| Pelvic lymph node dissection | Obturator nerve | Paresthesias or pain of medial thigh; weak thigh adduction | Complete visualization of nerve prior to clip placement |
Compartment syndrome.
Compartment syndrome of the gluteal or lower extremity compartments results from prolonged time in lithotomy position. Impaired tissue perfusion, tissue ischemia, and increased compartment pressures result. Risk factors include obesity, peripheral vascular disease, muscular build, and intraoperative blood loss or hypotension. Typical presenting symptoms include pain out of proportion to exam, swelling, and loss of lower extremity sensation. Management includes urgent orthopedic consult, compartment pressure monitoring, and urgent fasciotomy for compartment pressures >30 mm Hg. Irreversible damage may occur with prolonged pressures >50 mm Hg. Prevention includes intermittently relieving the legs from lithotomy position and minimizing operative time.
Rhabdomyolysis.
Prolonged operative time in lithotomy or flank position may result in rhabdomyolysis, resulting in release of intracellular myoglobin, creatine kinase, and lactate dehydrogenase into the bloodstream. Obese patients are at particularly high risk. Patients may present with myalgias, limb weakness, and myoglobinuria (“tea-colored urine”). Acute kidney injury, oliguria, or anuria may result. This should be managed expectantly with intravenous hydration and urinary alkalinization as needed.
Intraoperative complications
Trocar and veress needle-related injuries.
Similar rates of injury have been described for open Hassan technique and blind Veress needle placement. Careful attention to the angle of entry, sufficient skin incision, and rotational movement during trocar placement may all minimize risk of injury during trocar placement.
Subcutaneous emphysema, pneumothorax.
Subcutaneous emphysema develops owing to improper placement of the Veress needle or, more commonly, to leakage of carbon dioxide (CO 2 ) around ports. The pathognomonic sign is crepitus over the abdomen and thorax; in male patients, a pneumoscrotum may also develop. It is important to place each port so that it is pointing toward the surgical field, to avoid the continued forceful redirection of the port during the procedure that results in widening of the tissue tract around the port. The earliest signs of pneumothorax may be the development of subcutaneous emphysema, especially in the neck and chest area. More ominous signs, such as hypotension and decreased breath sounds with an increase in ventilatory pressure, are indicative of a tension pneumothorax.
Major vascular injury.
Access-related vascular injury is rare (0.04%–0.1% incidence). The left common iliac vessels are at greatest risk. Immediate recognition and expeditious management of vascular injury is critical. This includes direct pressure on the area of injury, increasing pneumoperitoneum pressure (to 25 mm Hg), and gaining proximal and distal control/exposure. Vascular surgery consultation should be done if the injury is significant. The trocar should be left in place because this may help tamponade bleeding and help identify the location of injury. Small Veress needle punctures may be self-limited and is simply managed by choosing a different site. However, trocar-related injuries are typically more extensive and nearly always require rapid conversion to open surgery for immediate repair.
Injury to epigastric vessels.
Delayed presentation of epigastric vessel injury is common after minimally invasive surgery because trocars may initially tamponade these vessels. Transillumination of the abdominal wall prior to trocar placement and careful inspection of lateral ports following trocar removal may help avoid or identify any potential injury. Minor bleeding may be managed with electrocautery; more significant bleeding may require direct suturing by laparoscopic approaches or the Carter-Thomason CloseSure system.
Gas embolus.
Gas embolus is a rare complication that may occur following Veress placement and accidental carbon dioxide insufflation into the vascular system. This manifests as sudden hypoxia, hypercarbia, and hypotension and a characteristic “mill wheel murmur.” Management includes immediate desufflation, administration of 100% FiO 2 , and repositioning of the patient in Trendelenberg and left lateral decubitus position (i.e., right side up), to trap the air bubble in the right atrium. The patient is hyperventilated with 100% oxygen. A central line should be placed to aspirate out the air embolus.
Bowel injury.
The initial signs of visceral injury consist of aspiration of blood, urine, or bowel contents through the Veress needle or, in the case of a solid organ, high pressures on initial insufflation. Bowel or bladder entry by the Veress needle needs no further treatment other than needle withdrawal. The first sign of this bowel insufflation is asymmetrical abdominal distention followed by flatus and insufflation of only a small amount of CO 2 (<2 L) before high pressures are reached. If this complication is suspected, then the insufflation line should be disconnected; the outflow of gas will immediately confirm bowel entry. The surgeon should routinely pass the laparoscope through the secondary port to inspect the puncture site of the initial port to identify possible through and through bowel injury.
Barotrauma.
Prolonged elevated pressures (>15 mm Hg) may result in barotrauma. Prolonged high pressures may be caused by insufficient and infrequent monitoring of CO 2 pressure, malfunction of the insufflator, or additional pressures produced by auxiliary devices. Furthermore, barotrauma may be caused by using positive end-expiratory pressure resulting in rupture of a pulmonary bleb or bulla. The initial sign of barotrauma may be hypotension caused by decreased cardiac output secondary to an acute drop in venous return caused by compression of the vena cava. Also, a pneumothorax or pneumomediastinum may develop because of the high ventilation pressures. The surgeon should desufflate the abdomen and, after the hemodynamic changes have been reversed, reinitiate the pneumoperitoneum.
Stapler malfunction.
The reported incidence of stapler malfunction is about 1%. The most common cause of malfunction is excessive thickness of the stapled tissue; thus, adequate dissection of vascular pedicles is critical to ensure proper stapler application. Clip placement should be avoided in the area of the staple line, and both stapler jaws should be visualized prior to staple firing. A jammed stapler may be rescued by a second staple fire if adequate room is maintained proximal to the initial staple line.
Vascular injury.
Most major vascular injuries occur intraoperatively and are immediately recognized and addressed. Risk factors include prior abdominal surgery, aberrant vascular anatomy, and concomitant abdominal pathology. Adequate exposure and identification of the injured vessel is critical. Controlled injuries may be managed laparoscopically or robotically by primary repair with selective use of vascular clamps or careful application of surgical clips or staplers ( Fig. 31.1 ). Conversion to hand-assist or laparotomy should be performed without delay. A Satinsky clamp can be used for larger injuries. Ligation may be performed without significant consequences if the injured vessel has adequate collateral circulation (e.g., internal iliac artery, inferior mesenteric artery). In contrast, injury to the superior mesenteric artery universally warrants immediate repair. There should be a low threshold for open conversion and vascular surgery consult, particularly for major injuries. Blood transfusion should be administered as needed. When suspected, it is important to immediately communicate the situation to anesthesia and nursing staff so they can prepare for resuscitation measures.
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