Septic shock: a rare complication of endoscopic ureteral detachment from nephroureterectomy
Perioperative complications related to endoscopic ureteral detachment during open or laparoscopic nephroureterectomy are rare, and, in particular, are related to the handling bladder (early and late hematuria, urinary retention clots or irritation of prostate adenoma partially obstructing, small urinoma or uro-perivesical hematoma). The Authors report an abnormal complication, not referred in literature : septic shock secondary to retroperitoneal urinoma subsequent to persistence of bladder fistula. The analysis of recent literature report others complications, local or systemic: wound infection (6%) , urinary retention (3%), urinary tract infection (1%), chest infection (1%), arterial thromboembolism (2%), venous thromboembolism, wound hematoma (1%) , prolonged ileus, incisional ernia.
Methods and results
I. F. S. aged 71 was first observed for a severe anemia due to recurrent hematuria for approximately 1 year . After the patient is stabilized with blood transfusions and being subjected to catheterization to evacuate the clots, it is performed UROTC showing multifocal obstructive malignancy of the urinary tract right ( renal pelvis and iliac ureter) with severe hydronephrosis . Ureteroscopy shows a solid neoplasm iliac ureter on which are made multiple samples . After histological confirmation ( multifocal high-grade ureteral tumor of the pelvis and the ureter) , the patient is undergoing open nephroureterectomy for retroperitoneal preceded by endoscopic ureteral detachment . The postoperative course was regular and in the seventh day the patient is discharged, after removing the catheter. After about 48 hours the patient undergoes a severe septic shock with a severe hypotension leading to urgent hospitalization . As soon as clinical conditions improve it is performed ultrasound that shows the presence of a retroperitoneal collection . TC confirmed the presence of this collection , associated with the presence of bladder globe . The bladder catheterism , associated with diuretics and antibiotics leads to an immediate improvement in clinical conditions and 48 hours CT shows the almost complete disappearance of the retroperitoneal collection .
The literature data described complication rates for the pluck technique varying between 3.2% and 12.5%. The endoscopic ureteral detachment during open or laparoscopic nephroureterectomy is performed routinely by us if the tumor does not involve the distal ureter . The procedure is simple and associated with reduced operative time and morbidity compared with open bladder cuff excision . We reviewed the cases we treated with this technique over the past 5 years. There have been 96 nephroureterectomy including 61 open and 35 laparoscopic . In 70 cases was made endoscopic ureteral detachment (45 resection of the terminal 2 cm of the ureter , 25 perimeatal incision Collins loop ); in 26 cases the terminal ureter was treated by open surgery (in all these cases had involved the pelvic ureter and in 15 cases (high grade) has been associated with the iliac and pelvic lymphadenectomy. Perioperative complications related to endoscopic ureteral detachment during open or laparoscopic nephroureterectomy are rare. In 3 cases we reported gross hematuria with clots and necessity for endoscopic revision. In 5 cases occurred acute urinary retention to the removal of the catheter ( patients with BPH in failure phase). In 2 cases there was a pelvic lymphocele (treated conservatively). In 1 case a perivesical urinoma next infected and treated with CT guided drainage . The case described is interpreted as a complication of urinary retention (among other things, the patient urinating and has mystified his condition) with extravasation and urinoma in a patient already in a precarious clinical condition.
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