Abstract
Radical urologic surgery describes surgery to remove malignant pathology of the urinary system and surrounding affected structures. This typically involves major open surgery; however, increasingly, laparoscopic options are becoming available, widening the patient cohorts to whom curative procedures are offered. We review the complications incumbent in these procedures and those related to the presenting pathology. Assessment with respect to renal function and its preservation is included using the AKIN criteria. Venous thromboembolism (VTE) risk and patient-specific risk factors are discussed. VTE is a major risk in patients with cancer, and we discuss the specific challenge or proximal thrombus formation, radical surgery, and major hemorrhage risk. In particular, the use of the Novick classification in preoperative planning as well as intraoperative strategies for reducing blood loss are described. Recognition and prevention of these complications, as well as those of sepsis, air embolus, and respiratory complications, are described, and an approach to practical management of each in the perioperative period is suggested.
Keywords
complications, hemorrhage, radical, urologic, venous thromboembolism
Case Synopsis
A 44-year-old man with treated hypertension and an extensive smoking history presents with malaise, weight loss, and painless hematuria. Computed tomography (CT) reveals a right-sided renal tumor with thrombus extending into the right renal vein and minimal extension into the inferior vena cava (IVC). He is listed for angioembolization of the kidney, radical nephrectomy, cavotomy, and IVC repair. On admission he is found to be dyspneic and in sinus tachycardia. His arterial blood gas (ABG) values are as follows:
pH: 7.47
P o 2 : 9.2 kPa (69 torr)
P co 2 : 3.9 kPa (29.25 torr)
HCO 3 : 22
Base excess (BE): −1.0
A CT pulmonary angiogram (CTPA) reveals multiple subsegmental pulmonary emboli. An intravenous heparin infusion is administered but stopped 4 hours before surgery. Conduct of anesthesia is uneventful until the surgeon mobilizes the renal vein and blood fills the surgical field. Invasive blood pressure is measured at 78/48 mm Hg, heart rate is 120 beats per minute, and pulse-oximetry saturations are 89% with a poor pulsatile waveform.
Acknowledgment
The authors wish to thank Dr. Terri G. Monk for his contribution to the previous edition of this chapter.
Problem Analysis
The tension exemplified in the case synopsis between bleeding risk and venous-thromboembolism risk is commonly problematic in the perioperative management of patients undergoing radical urologic surgery.
Definition
The term radical is typically used when describing surgery intended to remove malignant as opposed to benign pathology. It is expected that adjacent anatomic structures also affected by the cancerous organ are also removed. It should be noted that these surgeries are increasingly being performed by laparoscopic approach and as such the complications expected will differ in incidence and nature.
Radical Cystectomy
In females, radical cystectomy involves the removal of the bladder, pelvic lymph nodes, lower ureters, urethra, and anterior vaginal wall. The uterus, fallopian tubes, and ovaries may sometimes be removed. An ileal conduit may be performed as part of the procedure. In males, this is usually termed a cystoprostatectomy as structures removed are the bladder, prostate, pelvic lymph nodes, lower ureters, vas deferens, and seminal vesicles. It is typically performed for invasive transitional cell carcinoma of the bladder.
Radical Nephrectomy
The affected kidney is removed along with the whole of the surrounding Gerota fascia, perinephric fat, ipsilateral adrenal gland, and surrounding lymphatics. The vast majority (approximately 90%) of solid renal masses are renal cell carcinomas (RCCs) with the remainder being mainly transitional cell carcinoma or Wilms’ tumor in children.
Radical Prostatectomy
In contrast with transurethral resection of the prostate (TURP; see Chapter 52 ), the entire prostate, seminal vesicles, ejaculatory ducts, and a portion of the bladder neck are removed. Approximately 90% of prostate cancers are adenocarcinomas.
Laparoscopic Radical Urologic Surgery
Increasingly, all of the aforementioned procedures may be performed via open or laparoscopic approach. Laparoscopic procedural complications are discussed in detail in Chapter 46 . As with all major surgery, careful attention should be paid to patient positioning, avoidance of nerve injury, and prevention of pressure sores. A considered approach to mechanical ventilation is required, given the impact of surgical technique on intrathoracic pressures. A compromise may have to be made between allowing good surgical access and ideal ventilatory parameters. For example, in the lateral decubitus position for nephrectomy, insufflation of gas into the peritoneum for laparoscopy and requirement for steep Trendelenburg position will affect respiratory mechanics. Addressing this with high inspiratory pressures may cause barotrauma, hence acceptance of intraoperative respiratory acidosis may be a reasonable approach.
Recognition
The case synopsis alludes to two of the major complications of radical urologic surgery—venous thromboembolism (VTE) and major hemorrhage.
Venous Thromboembolism
Patient risk factors include malignancy, advancing age, and a smoking history. In addition to general risk factors, there are specific concerns surrounding extension of tumor and thrombus into the renal veins, iliac veins, IVC, and right atrium. The Novick classification of cavoatrial disease extension in RCC describes how far the tumor or thrombus has extended beyond the renal vein. It is unclear how directly this classification relates to prognosis or likelihood of pulmonary embolus. Approximately 4% to 10% of all RCCs have extension into the IVC at presentation ( Table 49.1 ).
| Level 1 | Thrombus into IVC but <2 cm above renal vein |
| Level 2 | Thrombus below the intrahepatic vena cava |
| Level 3 | Thrombus involves the intrahepatic vena cava but below the diaphragm |
| Level 4 | Thrombus involves the right atrium |
The rate of VTE in open urologic surgery has been reported as between 0.2% and 5%. Similar rates of between 0.3% and 4.8% have been reported for laparoscopic urologic surgery.
Presentation of VTE varies from asymptomatic cases to dyspnea, pleuritic chest pain, calf pain and swelling, cough and hemoptysis, and acute cardiovascular collapse. The latter group can be termed submassive or massive pulmonary embolism (PE) depending on degree of cardiovascular compromise. The investigation of such patients should include 12-lead electrocardiogram, chest radiograph, locally approved cardiac enzyme assay, and an ABG, in addition to a screening blood panel. An echocardiogram and CTPA may then be indicated ( Table 49.2 ).
| Signs | Symptoms |
|---|---|
| Tachypnea (70%) | Dyspnea (73%) |
| Tachycardia (30%) | Chest pain (66%) |
| Crepitations (51%) | Cough (37%) |
| Low-grade fever | Apprehension |
| Sweating |
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