18 Postoperative Complications 18.1 Acute Postoperative Complications M. Seitz, B. Schlenker, Ch. Stief 18.1.1 Postoperative Bleeding 364 18.1.5 Abdominal Wound Dehiscence 403 18.1.1.1 Overview 364 18.1.5.1 Synonyms 403 18.1.1.2 Incidence and Risk Factors 365 18.1.5.2 Overview and Incidence 403 18.1.1.3 Detection and Clinical Signs 365 18.1.5.3 Risk Factors 404 18.1.1.4 Workup 366 18.1.5.4 Clinical Signs and Complications 404 18.1.1.5 Management 366 18.1.5.5 Prevention 405 18.1.1.6 Special Conditions 371 18.1.5.6 Management 405 18.1.2 Chest Pain and Dyspnea 373 18.1.6 Chylous Ascites 410 18.1.2.1 Overview 373 18.1.6.1 Overview 410 18.1.2.2 Cardiovascular System Disorders 373 18.1.6.2 Risk Factors and Pathogenesis 410 18.1.2.3 Postoperative Pulmonary Complications 373 18.1.6.3 Prevention 412 Pulmonary Embolism 373 18.1.6.4 Detection and Workup 413 Pleural Effusions 375 18.1.6.5 Management 413 Atelectasis 376 Infection/Pneumonia 376 18.1.7 Deep Venous Thrombosis 414 Tube Thoracostomy 376 18.1.7.1 Overview and Incidence 414 18.1.3 Acute Abdomen 377 18.1.7.2 Risk Factors 414 18.1.3.1 Initial Management 377 18.1.7.3 Detection and Clinical Findings 415 18.1.4 18.1.7.4 Management 415 Postoperative Fever 378 Unfractionated Heparin 415 18.1.4.1 Overview 378 Low-Molecular-Weight Heparin 415 18.1.4.2 Incidence 379 Long-Term Therapy 416 18.1.4.3 Definition 379 18.1.4.4 Risk Factors and Prevention 379 18.1.8 Lymphoceles 416 18.1.4.5 Detection and Work-Up 382 18.1.8.1 Anatomy and Physiology 416 Pulmonary 382 18.1.8.2 Overview 419 Urinary Tract 382 18.1.8.3 Risk Factors and Prevention 419 Central Venous Catheters and Catheter-Related 18.1.8.4 Clinical Signs 420 Infections 383 18.1.8.5 Diagnosis and Workup 420 Surgical(Wound)SiteInfection 383 18.1.8.6 Management 420 Intraabdominal Sepsis from Abscess 384 Bacteremia or Septicemia – Bloodstream References 421 Infection 384 18.1.4.6 Management 384 Current Treatment of Nosocomial Pneumonia 385 Treatment of CAUTI 385 18.1.1 Catheter-Related Infections 386 Postoperative Bleeding Surgical Site Infection: Wound Management 388 18.1.4.7 Special Conditions 389 18.1.1.1 Fever Due to Infective Endocarditis 389 Overview Fever Due to Postoperative Appendicitis 391 Fever Due to Forgotten Foreign Body Historically, major bleeding was a significant problem (Corpus Alienum: Rubber Drain, Gauze associated with radical retropubic prostatectomy and Sponge, Forceps, etc.) 392 cystectomy, TUR, and nephrectomy. Nowadays, major Fever Due to Intraabdominal Infections 393 life-threatening hemorrhage after urologic open and Fever Due to Skin and Soft-Tissue Infections 397 Fever Due to Impaired Drainage of Upper endoscopic surgery by expert surgeons is a rare event. Urinary Tract After Urologic Surgery 398 In some cases, the patient typically becomes hemody- Fever Due to Epididymitis After TUR, Brachythe- namicallyunstablesoonafterarrivalintherecovery rapy, Prostate Biopsy, and Open Surgery 399 room. On the other hand, sometimes hemorrhage Postoperative Fever of Unknown Origin 399 Appendix: How to Perform Blood Cultures 403 arises a few hours or days following the initial proce- dure. The surgeon must make a decision whether to 18.1 Acute Postoperative Complications 365 return immediately to the operating room or treat the 18.1.1.2 patient conservatively with blood and volume replace- Incidence and Risk Factors ment (Kaufman and Lepor 2005). Reasons for a signifi- cant major bleeding later on in the postoperative peri- See Table 18.1.1. od may be slipped ligatures or clips (e.g., from the re- nal pedicle or other major blood vessels) or in case of 18.1.1.3 partial nephrectomy, ruptured kidney. Also, removal Detection and Clinical Signs of drains days after surgery may induce significant bleeding, if the drains have been put primarily through Clinical findings that can be used to indicate the need a major blood vessel (e.g., epigastric). Reasons for for red cell transfusion may be subjective such as fa- early revisions may be insufficient ligatures or hemo- tigue and shortness of breath. Changes in respiratory stasis. rate and pulse can be difficult to interpret but can pos- Significant bleeding in a postoperative bleeding set- sibly be parameters indicating the need for blood ting is defined as patients requiring emergency blood transfusion. Estimated blood loss, blood pressure, as transfusion to maintain blood pressure during the well as the hemoglobin level must be taken into account postoperative period (Hedican and Walsh 1994; Kauf- since the decision to transfuse red cells is a complex man and Lepor 2005). one and depends on factors such as the patient’s ability to compensate for anemia, the likelihood of further a Table 18.1.1. Incidence of Surgery Incidencea Incidenceb Author reintervention; incidenceb of blood transfusion Laparoscopic radical prosta- 0.5% 5% Rassweiler et al. 2006; Arai et tectomy al. 2003 Open radical prostatectomy 0.5%–1.2% 0.4%–2.4% Hedican and Walsh 1994; Kaufman and Lepor 2005; Koch and Smith 1996 Robotic radical prostatectomy 0%–0.5% 1%–1.3% Bhandari et al. 2005 Retropubic transvesical pros- 1.1%–3% 8.2% Adam et al. 2004; Serretta et tatectomy al. 2002 TURBT 0%–2.2% 2.3%–3.4% Collado et al. 2000; Nieder et al. 2005 TURP 2.2%–3.5% 2%–8.9% Gupta et al. 2006; Lim et al. 2004; Montorsi et al. 2004; Muzzonigro et al. 2004 Open nephron-sparing 2.6%–7.6% 5.3%–12% Becker et al. 2005; Heye et al. nephrectomy 2005; Steffens et al. 2005 Laparoscopic nephron-spar- 0.6%–3.5% 5.2%–17.8% Albaqami and Janet schek ing nephrectomy 2005; Desai et al. 2005; Guil- lonneau et al. 2003 Open radical nephrectomy 0%–2.7% 2.4%–9.8% Shuford et al. 2004 Laparoscopic radical nephrec- 1.6% 0.4% Vallancien et al. 2002; Wille tomy et al. 2004 Table 18.1.2. Classification of hypovolemic shock according to blood loss Class I Class II Class III Class IV Blood loss <15% (750 ml) 15%–30% (<1500 ml) 30%–40% (<2000 ml) >40% (>2000 ml) Blood pressure Systolic Unchanged Normal ↓↓↓↓ Diastolic Unchanged ↑↓↓↓↓ Pulse (beats/min) <100 100–120 120 (thready) >120 (very thready) Capillary refill Normal Slow (>2 s) Slow (>2 s) Undetectable Respiratory rate Normal Normal >20/min >20/min Urinary flow rate >30 ml/h 20–30 ml/h 10–20 ml/h 0–10 ml/h Extremities Normal Pale Pale Pale and cold Complexion Normal Pale Pale Ashen Adapted from Baskett 1990 366 18 Postoperative Complications blood loss, and the severity of the hypovolemic shock 18.1.1.5 (Table 18.1.2). In the early postoperative period, blood Management loss via the drains may be an important sign as well as an increase in the abdominal girth, unpaired body Acute anemia caused by intra- and postoperative blood shape, and blood loss via the surgical incision. Mea- loss should be treated by blood and fluid replacement. surement of hemoglobin in the drained fluid may be Clinical experience has shown that losses of up to helpful. 30%–40% can be treated by crystalloids alone in During the very early postoperative period after young healthy patients. Estimation of actual and like- open urologic surgery, major hemorrhage, although lyfurtherbloodlossisanimportantconsideration rare,isthemostcommoncomplication.Patientsfol- in the decision to administer a red cell transfusion in lowing nephron-sparing nephrectomy may present thetreatmentofacutebloodloss.Thebenefitofred with massive hematuria after surgery. Blood loss after cell transfusion is usually considered in terms of in- partial or radical nephrectomy is associated with acute creasing the oxygen-carrying capacity of the blood, flank pain or a significant decrease in the hemoglobin but a more relevant consideration is the avoidance of level and signs of shock. Hemorrhage in the perirenal tissue hypoxia. General complications of blood trans- space can be found in these patients – recognized either fusion are listed in Table 18.1.4. Indications for trans- by adequately placed suction drains or by noninvasive imaging techniques such as sonography. Bleeding may Table 18.1.3. Workup with noninvasive and invasive proce- be from the kidney or renal pedicle but is occasionally dures from unrecognized injury to a neighboring structure Hemoglobin level Table 18.1.5 such as the spleen, the liver, or a mesenteric vessel. An- (Hb) giography after partial nephrectomy enables not only the exact visualization of extravasation of contrast ma- Classification of Table 18.1.2 hypovolemic shock terial, but also the superselective embolization of the feeding arteries within the kidney. Ultrasound Coagulum within TURP, TURBT the bladder Significant bleeding according to its definition fol- lowing radical prostatectomy and cystectomy is a rare Fluid in the peri- Open and laparo- renal spaces, pel- scopic urologic event, with an incidence between 0.4% and 5% (Arai vic region surgery et al. 2003; Hedican and Walsh 1994; Kaufman and CT scan Visualization of Open and laparo- Lepor 2005; Koch and Smith 1996; Rassweiler et al. extravasation of scopic urologic 2006). contrast medium surgery Angiography Exact visualiza- Open and laparo- 18.1.1.4 tion of extravasa- scopic nephron- tion of contrast sparing nephrec- Workup medium tomy See Table 18.1.3. TURP transurethral prostatectomy, TURBT transurethral re- section of bladder tumors abc Fig. 18.1.1. CT-scan of a 76 years old female patient 12 days post partial nephrectomy.