Morbidity and Mortality December 9, 2009

1. Morbidity and MortalityDecember 9, 2009 Presented by: Stephen Miller, DO and Karla Witzke, DO

2. Pt history • 56 y.o. C male • Hx CaP (Gleason 6, PSA 3.8) • Cryoablation of prostate July 2009 • Began c/o testicular and pelvic pain 2 months postoperative. • Diagnosed w/UTI by PCP and given Cipro • Urology diagnosed L epididymitis on SUS 9/09, Rx Levaquin, pt did not take secondary to cost.

3. History continued • Pt admitted to BH 9.30.09 with testicular pain. Gen Surgery eval, constipation. • Eval by urology, acute urinary retention • D/c’d with epididymitis and antibiotic • Followed up with Gen Surgery as outpt • CT ordered and reviewed, recommended urology follow up.

4. History continued • PMH • HTN, DMII, Cirrhosis of liver, Anemia • PSH • Liver transplant 2004, Hernia repair 2005, spinal fusion • Meds: • Glipizide, Lotrel, Atenolol, Prilosec, Neurontin, Narco, Fosamax, cellcept, rapamune • Social • ETOH (stopped 1 yr before transplant), ½ ppd

8. Procedure • TUIP planned for 12.2.09 secondary to continued pelvic pain and fluid in prostate. • Likely postoperative changes from cryoablation.

9. Procedure • Cystourethroscopy performed under general anesthesia, no changes in entire length of urethra. No abnormalities at verumontanum or prostatic urethra. • Bladder with large white/gray mass at dome. • Resectoscope inserted and tissue thick, unable to cut. • Attempt to identify stalk of mass, resected. • After irrigation, noted distention of abdomen. • Foley inserted and cystogram performed.

10. Cystogram

11. Management • Intraperitoneal bladder perforation identified. • Exploratory laparotomy • Washout of glycine, 3-5 Liters intraabdominally with NS. • Dissection into space of Retzius, Foley clamped, somewhat distended bladder, lesion identified at posterior dome. • Stay sutures placed, bladder opened and inspected, 8 x 7 cm portion of bladder removed and sent to pathology with abnormal tissue. • Bladder closed in two layers with 2.0 Vicryl • 16F Foley left in place, 10 JP drain inserted left LQ. • Fascia, dermal, subQ with standard closure (staples used)

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

13. Patient Course • Labs checked in recovery, K replaced 3.2 • Admit to GSF • Ambulate/BM POD #1 • Advanced to reg diet POD#1 • JP removed POD#3 • IVP pain meds converted to orals POD #4 • Pt given 2 units prbcs for hgb 7.4 (chronic anemia, hx liver transplant) • Discharge POD#5 • Leg bag, cystogram Rx, f/u approximately 10 days for staples and Foley removal • Detrol prn spasms, Colace, Bactrim to take before Foley removed, and Percocet prn pain.

14. Prevention of Complication • Accurately review imaging prior to procedure • Discuss with patient and family possibilities of complications with increased risk given location of the lesion, prepare them for hospitalization. • Biopsy and reschedule procedure for controlled laparotomy.

15. Review of Management of Bladder Perforation

16. Bladder Perforation • Overdistention • Resectoscope or Loop extended in a manner that does not follow the contour of the bladder surface • Obturator nerve stimulation • Inferior lateral tumor

17. Incidence • The cystogram showed contrast leaking compatible with bladder perforation in 17 (50%) cases. None of the perforations were recognized intraoperatively by the surgeon. All perforations were extraperitoneal and managed conservatively. There was no significant correlation between the incidence of bladder perforation and the patient age (p = 0.508), the tumor stage (p = 0.998), the tumor grade (p = 0.833), the number of lesions (p = 0.394), and the tumor size (p = 0.651). The only factor that had impact on the development of bladder perforation was tumor localization at the bottom of the bladder (p = 0.035; OR, 6750; 95% CI, 1.14, 39.8). (3) • 0.9% - 5% (1) • 36% (3)

18. Management Options • Small perforations with no clinical significance • Catheter drainage and Abx • Large Extraperitoneal • Catheter • Percutaneous drain • Intraperitoneal with concerns of bowel injury or signs of peritoneal irritation • Open exploration and repair

19. Complications of Repair • Urinary extravasation • Wound dehiscence • Hemorrhage • Pelvic infection • Small-capacity bladder • De novo urge incontinence

20. TURBT Syndrome • Peritoneum = Biological membrane • Dialysis affect • Fluid/solutes shift between capillary and intraperitoneum • Hyponatremia can be a net deficit rather than dilutional • Irrigant solutes  Intravascular to be metabolized  further decrease in plasma osmolarity and intravascular volume

21. TURBT Syndrome Cont. • Signs • Hypovolemia • Hypotension • Oliguria • Acute renal impairment • Metabolic Acidosis • Regional anesthesia • Abd. Discomfort • Shoulder pain • Nausea • Confusion • Blurred vision • Chest pain

22. TURBT Syndrome Mgmt • Early Recognition • Prevention of large fluid extravisation • Volume Expansion

23. References • “Bladder Perforation during TURBT More Common than Believed or Reported but Does Not Impose Significant Risks,” Urology Today, Michael Metro, MD, Decemeber 2005. • “Bladder Trauma,” E-medicine, Rackley, Raymond, MD et al Clevelenad Clinic, Aug2009 • “Evaluation of the Incidence of Bladder Perforation After TURBT in a Residency Setting,” Omar, R. El Hayek, J of Endourology,July 2009 • “Complications: Surgery of Bladder Cancer,” Campbell-Walsh, Chap 78 • “Transurethral Resection Syndrome after Bladder Perforation,” Dorotta, Ihab et al., Anesthesia & Analgesia, Vol 97 (5) 2003, pgs 1536-8.

24. Pathology • Focal transmural necrosis • Transmural edema, patchy acute and chronic inflammation and surface fat necrosis • Inflamed granulation tissue tract and reactive stromal fibrosis • Focus of non-inflamed intramural mucosal tissue suggestive of bladder diverticulosis • Neg for neoplasm • No intact surface urothelium