Complications of prostatec tomy

Complications of prostatec tomy

Local Haemorrhage is a major risk following prostatectomy what - ever the surgical approach. Care should be taken in applying diathermy to arterial bleeding points after TURP , and to any bleeding vessels at the bladder neck; they are often better seen - when the rate of infl o w of fl uid is decreased. Some of the venous bleeding due to deep resection can only be stopped by gentle traction via a Foley catheter balloon infl ated to 30–40 /uni00A0 mL and kept in the bladder. Sustained traction is applied by taping - the catheter to the anterior abdominal wall or thigh for 12–24 - hours. This causes compression of the prostatic tissue and veins and thus stops the bleeding. In the recovery room, one should check that the bladder is draining adequately; if it is not, this may indicate that a clot is blocking the eye of the catheter. The bladder should be promptly washed out using a strict aseptic technique. The catheter should be changed by the surgeon. Only rarely is it necessary to return the patient to - the operating room. Secondary haemorrhage tends to occur several days after the patient has been discharged. All men should be warned about this possibility and given appropriate advice to rest and to ha ve a high fl uid intake. It is usually minor in degree but if catheter passed and the bladder washed out. Perforation of the bladder or the prostatic capsule can occur at the time of transurethral surgery . This usually occurs from a combination of inexperience in association with a large prostate or heavy blood loss. If the field of vision becomes obscured by heavy blood loss, it is often prudent to achieve adequate haemostasis and abandon the operation, swallowing one’s pride on the understanding that a second attempt may be necessary . A large perforation with marked extravasation may require the insertion of a small suprapubic drain. Rectal perforation should be extremely rare. Sepsis Bacteraemia is common even in men with sterile urine and occurs in over 50% of men with infected urine, prolonged catheterisation or chronic retention. Sepsis can occur in these patients shortly after operation or when the catheter is removed. Routine use of prophylactic antibiotics is recommended based on local antimicrobial sensitivity profiles. The most worrying aspect of infection is the early rigor following surgery . If left undetected and untreated, this may progress to septic shock with profound hypotension. A blood culture should be taken and antibiotics given parenterally (e.g. amoxicillin plus cefurox ime, or gentamicin). Incontinence Incontinence is rare after BPH surgery; however, it is inevitable if the external sphincter mechanism is damaged. The bladder neck is rendered incompetent by any prostatectomy and, therefore, an intact distal sphincter mechanism is essential for continence. The verumontanum marks the proximal margin of the external sphincter. In some patients, detrusor instability contributes to the incontinence. The use of anticholinergic agents such as mirabegron/solifenacin/tolterodine may help. Mild degrees of stress incontinence usually reco ver in a few days to a few weeks. If physiotherapy is ine ff ective, then full assessment with cystoscopy and pressure studies including video urodynamics should be carried out befor e proceeding with o ff ering the patient the insertion of an artificial urinary sphincter or a sling to increase the resistance of the urethra. One should usually wait for 6 months to 1 year before any sling or sphincter is implanted. Retrograde ejaculation and erectile dysfunction Men with prior good sexual function are less likely to have erectile dysfunction following BPH surgery , but retrograde ejaculation occurs commonly (>75%) because of disruption to the bladder neck mechanism; occasionally , anejacula tion can occur as a result of disruption of the ejaculatory ducts. This should be discussed with all men before the surgery . Urethral stricture This may be secondary to prolonged catheterisation, the use of an unnecessarily large catheter, clumsy instrumentation or Fessenden Nott Otis , 1825–1900, nineteenth century American urologist. Jean Baptiste Camile Marion , 1869–1932, Professor of Urology , The Faculty of Medicine, Paris, France. period. These strictures arise either just inside the meatus or in the bulbar urethra. An early stricture can usually be managed by simple dila tation or urethrotomy if dense fibrosis is present. If the stricture recurs then urethroplasty is considered. The use of an Otis urethrotomy in the tight urethra prior to TURP can reduce the incidence of postoperative stricture. Bladder neck contracture Occasionally , a dense fibrotic stenosis of the bladder neck occurs following overaggressive resection of a small prostate. It may be due to the overuse of coagulating diathermy . This usually happens in the early postoperative period. Transurethral incision of the scar tissue is necessary using laser or diathermy .