Morbidity and Morbidity and MortalityMortality

December 9, 2009December 9, 2009

Presented by: Stephen Miller, Presented by: Stephen Miller, DO andDO and

Karla Witzke, DOKarla Witzke, DO

Pt historyPt history

56 y.o. C male56 y.o. C male– Hx CaP (Gleason 6, PSA 3.8)Hx CaP (Gleason 6, PSA 3.8)– Cryoablation of prostate July 2009Cryoablation of prostate July 2009– Began c/o testicular and pelvic pain 2 Began c/o testicular and pelvic pain 2

months postoperative.months postoperative.– Diagnosed w/UTI by PCP and given CiproDiagnosed w/UTI by PCP and given Cipro– Urology diagnosed L epididymitis on SUS Urology diagnosed L epididymitis on SUS

9/09, Rx Levaquin, pt did not take 9/09, Rx Levaquin, pt did not take secondary to cost.secondary to cost.

History continuedHistory continued

Pt admitted to BH 9.30.09 with Pt admitted to BH 9.30.09 with testicular pain. Gen Surgery eval, testicular pain. Gen Surgery eval, constipation.constipation.– Eval by urology, acute urinary retention Eval by urology, acute urinary retention

D/c’d with epididymitis and antibioticD/c’d with epididymitis and antibiotic

Followed up with Gen Surgery as Followed up with Gen Surgery as outptoutpt– CT ordered and reviewed, recommended CT ordered and reviewed, recommended

urology follow up.urology follow up.

History continuedHistory continued

PMHPMH– HTN, DMII, Cirrhosis of liver, AnemiaHTN, DMII, Cirrhosis of liver, Anemia

PSHPSH– Liver transplant 2004, Hernia repair 2005, Liver transplant 2004, Hernia repair 2005,

spinal fusionspinal fusion Meds:Meds:

– Glipizide, Lotrel, Atenolol, Prilosec, Neurontin, Glipizide, Lotrel, Atenolol, Prilosec, Neurontin, Narco, Fosamax, cellcept, rapamuneNarco, Fosamax, cellcept, rapamune

SocialSocial– ETOH (stopped 1 yr before transplant), ½ ppdETOH (stopped 1 yr before transplant), ½ ppd

ProcedureProcedure

TUIP planned for 12.2.09 secondary TUIP planned for 12.2.09 secondary to continued pelvic pain and fluid in to continued pelvic pain and fluid in prostate.prostate.– Likely postoperative changes from Likely postoperative changes from

cryoablation.cryoablation.

ProcedureProcedure Cystourethroscopy performed under general Cystourethroscopy performed under general

anesthesia, no changes in entire length of anesthesia, no changes in entire length of urethra. No abnormalities at verumontanum urethra. No abnormalities at verumontanum or prostatic urethra.or prostatic urethra.

Bladder with large white/gray mass at dome.Bladder with large white/gray mass at dome. Resectoscope inserted and tissue thick, Resectoscope inserted and tissue thick,

unable to cut.unable to cut. Attempt to identify stalk of mass, resected.Attempt to identify stalk of mass, resected. After irrigation, noted distention of After irrigation, noted distention of

abdomen.abdomen. Foley inserted and cystogram performed.Foley inserted and cystogram performed.

CystogramCystogram

ManagementManagement Intraperitoneal bladder perforation identified.Intraperitoneal bladder perforation identified. Exploratory laparotomyExploratory laparotomy Washout of glycine, 3-5 Liters intraabdominally with Washout of glycine, 3-5 Liters intraabdominally with

NS.NS. Dissection into space of Retzius, Foley clamped, Dissection into space of Retzius, Foley clamped,

somewhat distended bladder, lesion identified at somewhat distended bladder, lesion identified at posterior dome.posterior dome.

Stay sutures placed, bladder opened and inspected, Stay sutures placed, bladder opened and inspected, 8 x 7 cm portion of bladder removed and sent to 8 x 7 cm portion of bladder removed and sent to pathology with abnormal tissue. pathology with abnormal tissue.

Bladder closed in two layers with 2.0 Vicryl Bladder closed in two layers with 2.0 Vicryl 16F Foley left in place, 10 JP drain inserted left LQ.16F Foley left in place, 10 JP drain inserted left LQ. Fascia, dermal, subQ with standard closure (staples Fascia, dermal, subQ with standard closure (staples

used)used)

Post OP LabsPost OP Labs

Wbc: 7.6Wbc: 7.6 Hgb: 10.8 (9.7)Hgb: 10.8 (9.7) Na: 129 (17:20), 133 (18:39)Na: 129 (17:20), 133 (18:39) K: 3.2K: 3.2 BUN/Cr: 9/0.3BUN/Cr: 9/0.3 pH: 7.35pH: 7.35

Patient CoursePatient Course Labs checked in recovery, K replaced 3.2Labs checked in recovery, K replaced 3.2 Admit to GSFAdmit to GSF

– Ambulate/BM POD #1Ambulate/BM POD #1– Advanced to reg diet POD#1Advanced to reg diet POD#1– JP removed POD#3JP removed POD#3– IVP pain meds converted to orals POD #4IVP pain meds converted to orals POD #4– Pt given 2 units prbcs for hgb 7.4 (chronic anemia, hx Pt given 2 units prbcs for hgb 7.4 (chronic anemia, hx

liver transplant)liver transplant) Discharge POD#5Discharge POD#5

– Leg bag, cystogram Rx, f/u approximately 10 days for Leg bag, cystogram Rx, f/u approximately 10 days for staples and Foley removalstaples and Foley removal

– Detrol prn spasms, Colace, Bactrim to take before Foley Detrol prn spasms, Colace, Bactrim to take before Foley removed, and Percocet prn pain.removed, and Percocet prn pain.

Prevention of ComplicationPrevention of Complication

Accurately review imaging prior to Accurately review imaging prior to procedureprocedure

Discuss with patient and family Discuss with patient and family possibilities of complications with possibilities of complications with increased risk given location of the increased risk given location of the lesion, prepare them for lesion, prepare them for hospitalization.hospitalization.

Biopsy and reschedule procedure for Biopsy and reschedule procedure for controlled laparotomy.controlled laparotomy.

Review of Review of Management of Management of

Bladder PerforationBladder Perforation

Bladder PerforationBladder Perforation

OverdistentionOverdistention Resectoscope or Loop extended in a Resectoscope or Loop extended in a

manner that does not follow the manner that does not follow the contour of the bladder surfacecontour of the bladder surface

Obturator nerve stimulationObturator nerve stimulation– Inferior lateral tumorInferior lateral tumor

IncidenceIncidence The cystogram showed contrast leaking The cystogram showed contrast leaking

compatible with bladder perforation in 17 (50%) compatible with bladder perforation in 17 (50%) cases. None of the perforations were recognized cases. None of the perforations were recognized intraoperatively by the surgeon. All perforations intraoperatively by the surgeon. All perforations were extraperitoneal and managed were extraperitoneal and managed conservatively. There was no significant conservatively. There was no significant correlation between the incidence of bladder correlation between the incidence of bladder perforation and the patient age (perforation and the patient age (pp = 0.508), the = 0.508), the tumor stage (tumor stage (pp = 0.998), the tumor grade ( = 0.998), the tumor grade (pp = = 0.833), the number of lesions (0.833), the number of lesions (pp = 0.394), and = 0.394), and the tumor size (the tumor size (pp = 0.651). The only factor that = 0.651). The only factor that had impact on the development of bladder had impact on the development of bladder perforation was tumor localization at the bottom perforation was tumor localization at the bottom of the bladder (of the bladder (pp = 0.035; OR, 6750; 95% CI, = 0.035; OR, 6750; 95% CI, 1.14, 39.8). (1.14, 39.8). (3)3)

0.9% - 5% 0.9% - 5% (1)(1) 36% 36% (3)(3)

Management OptionsManagement Options

Small perforations with no clinical Small perforations with no clinical significancesignificance– Catheter drainage and AbxCatheter drainage and Abx

Large ExtraperitonealLarge Extraperitoneal– Catheter Catheter – Percutaneous drainPercutaneous drain

Intraperitoneal with concerns of bowel Intraperitoneal with concerns of bowel injury or signs of peritoneal irritationinjury or signs of peritoneal irritation– Open exploration and repairOpen exploration and repair

Complications of RepairComplications of Repair

Urinary extravasation Urinary extravasation Wound dehiscence Wound dehiscence Hemorrhage Hemorrhage Pelvic infection Pelvic infection Small-capacity bladder Small-capacity bladder De novo urge incontinenceDe novo urge incontinence

TURBT SyndromeTURBT Syndrome

Peritoneum = Biological membranePeritoneum = Biological membrane– Dialysis affectDialysis affect– Fluid/solutes shift between capillary and Fluid/solutes shift between capillary and

intraperitoneumintraperitoneum– Hyponatremia can be a net deficit rather Hyponatremia can be a net deficit rather

than dilutionalthan dilutional– Irrigant solutes Irrigant solutes Intravascular to be Intravascular to be

metabolized metabolized further decrease in further decrease in plasma osmolarity and intravascular plasma osmolarity and intravascular volumevolume

TURBT Syndrome Cont.TURBT Syndrome Cont. SignsSigns

– HypovolemiaHypovolemia– HypotensionHypotension– OliguriaOliguria– Acute renal impairmentAcute renal impairment– Metabolic AcidosisMetabolic Acidosis

Regional anesthesiaRegional anesthesia– Abd. DiscomfortAbd. Discomfort– Shoulder painShoulder pain– NauseaNausea– ConfusionConfusion– Blurred visionBlurred vision– Chest painChest pain

TURBT Syndrome MgmtTURBT Syndrome Mgmt

Early RecognitionEarly Recognition Prevention of large fluid extravisationPrevention of large fluid extravisation Volume ExpansionVolume Expansion

ReferencesReferences

1)1) ““Bladder Perforation during TURBT More Bladder Perforation during TURBT More Common than Believed or Reported but Does Not Common than Believed or Reported but Does Not Impose Significant Risks,” Urology Today, Impose Significant Risks,” Urology Today, Michael Metro, MD, Decemeber 2005.Michael Metro, MD, Decemeber 2005.

2)2) ““Bladder Trauma,” E-medicine, Rackley, Bladder Trauma,” E-medicine, Rackley, Raymond, MD et al Clevelenad Clinic, Aug2009Raymond, MD et al Clevelenad Clinic, Aug2009

3)3) ““Evaluation of the Incidence of Bladder Evaluation of the Incidence of Bladder Perforation After TURBT in a Residency Setting,” Perforation After TURBT in a Residency Setting,” Omar, R. El Hayek, J of Endourology,July 2009Omar, R. El Hayek, J of Endourology,July 2009

4)4) ““Complications: Surgery of Bladder Cancer,” Complications: Surgery of Bladder Cancer,” Campbell-Walsh, Chap 78Campbell-Walsh, Chap 78

5)5) ““Transurethral Resection Syndrome after Bladder Transurethral Resection Syndrome after Bladder Perforation,” Dorotta, Ihab et al., Anesthesia & Perforation,” Dorotta, Ihab et al., Anesthesia & Analgesia, Vol 97 (5) 2003, pgs 1536-8.Analgesia, Vol 97 (5) 2003, pgs 1536-8.

PathologyPathology

Focal transmural necrosisFocal transmural necrosis– Transmural edema, patchy acute and chronic Transmural edema, patchy acute and chronic

inflammation and surface fat necrosisinflammation and surface fat necrosis– Inflamed granulation tissue tract and Inflamed granulation tissue tract and

reactive stromal fibrosisreactive stromal fibrosis Focus of non-inflamed intramural Focus of non-inflamed intramural

mucosal tissue suggestive of bladder mucosal tissue suggestive of bladder diverticulosisdiverticulosis

Neg for neoplasmNeg for neoplasm No intact surface urotheliumNo intact surface urothelium