Urologic Procedures in Patients with Cirrhosis

(1)

Center for Robotic and Advanced Laparoscopic Surgery, Glickman Urologic Institute, Cleveland Clinic, Cleveland, OH, USA

Keywords

UrologySurgeryCirrhosisLiver failure

Introduction

Surgery has recently become more commonplace in patients with liver cirrhosis, likely due to the improved survival of patients with cirrhosis over the past few decades [1]. Cirrhotic patients more commonly require surgical intervention for liver procedures, abdominal wall hernia, cholelithiasis, and peptic ulcer disease; however, urologic issues such as urinary calculus disease and genitourinary malignancy may also arise and require surgical intervention. The patient with liver cirrhosis is at increased risk for a host of life-threatening perioperative complications including infection, encephalopathy, bleeding, intractable ascites, liver decompensation, and multiorgan failure. There is a marked increase in surgical morbidity and mortality in patients with liver cirrhosis undergoing all types of surgery. Here we will address some of the specific considerations to be undertaken during urologic surgical procedures.

Preoperative Assessment and Preparations

Patients with mild to moderate liver disease are frequently asymptomatic. Further, patients are oftentimes unaware of the presence or severity of their liver dysfunction and will not report this on routine history questioning. Thus, preoperative questioning aimed to elucidate liver dysfunction should be performed, specifically regarding prior diagnoses of hepatitis as well as thorough review of systems inquiring about the presence of pruritus, excessive bleeding, abnormal abdominal distention, and inadvertent weight gain. Physical exam findings that suggest liver dysfunction include jaundice, scleral icterus, abdominal fluid wave, caput medusae, clubbing, spider angiomata, and palmar erythema.

Upon identification of the cirrhotic patient, the clinician can make an accurate assessment of the surgical morbidity and mortality using combination of both the Child–Pugh classification and the Model for End-Stage Liver Disease score [2]. Most urologic surgery is possible in well-compensated chronic liver disease patients; however, very little is possible in those with decompensated cirrhosis. For this reason, preoperative risk assessment is of utmost importance for those with liver disease.

It is important when planning retroperitoneal surgery one has a good knowledge of portosystemic collateral drainage that may exists in the retroperitoneum of cirrhosis patients. Apart from the classical collateral pathways, such as the left gastric, short gastric, recanalized umbilical, paraumbilical, and superior rectal veins, there exist nonclassical collateral pathways from the left gastric veins through the inferior phrenic and adrenal vein eventually reaching the left renal vein and into systemic circulation [3, 4]. Contrasted cross-sectional imaging of the abdomen is paramount in evaluating such patients for surgical planning.

Endoscopic Surgery in Patients with Cirrhosis

Urolithiasis

Cirrhotic patients are at increased risk for the development of calcium oxalate urinary calculi. This is attributed to the presence of multiple concurrent calculogenic states such as hyperoxaluria, malnutrition, intravascular volume depletion, and poor performance status [5]. Due to this, urolithiasis is among the most common surgical dilemmas encountered by an urologist in cirrhotic patients.

A study by Pattaras et al. presented data on a small series of 16 patients requiring 23 endoscopic surgeries for urolithiasis for patients with a diagnosis of liver cirrhosis. The cirrhosis in this series was significant enough the patients had previously been evaluated for liver transplant. The patients underwent both ureteroscopy and percutaneous nephrolithotripsy. The authors report a 26.1% complication rate, a 26.1% postoperative transfusion rate, and one mortality [5].

Benign Prostatic Hyperplasia

Lower urinary tract symptoms affect over half the population of aging men. Likewise about 30% of cirrhotic men will experience lower urinary tract symptoms [6]. Although the most bothersome lower urinary tract symptoms experienced by men with cirrhosis are largely attributed to diuretic use there are some who experience obstructive urinary symptoms. A Danish population-based study identified patients with the diagnosis of cirrhosis based on ICD codes that had then undergone transurethral resection of the prostate. They report a 30-day mortality rate of 6.7% in those men with cirrhosis following transurethral resection of the prostate [7]. It should be noted that transurethral resection of the prostate is an elective surgery to improve the patients quality of life through the relief of urinary tract symptoms. The undertaking of this procedure in the cirrhotic population should be done only in select cases and when nonsurgical options have proven unsuccessful.

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