Complications of urological procedures

Lithotripsy

• PC – Abdo or flank pain, haematuria, nausea, vomiting, skin ecchymosis and fever
• Haematuria is usually self-limited <24 hours
• Perinephric and renal haematomas (usually secondary to subcapsular haemorrhage with rupture) are serious complications
  • Suspect if severe flank pain, flank haematoma on skin, fall in haematocrit, hypotension or syncope
  • Needs US or CT
• Steinstrasse (street of stone)
  • Postlithotripsy dispersal of stone fragments
  • Can lodge causing renal colic +- urinary obstruction +- superimposed infection
  • Can be visualised on XR or CT
  • Rx – Conservative, repeat lithotripsy or percutaneous nephrostomy
• Rare events may include bowel perforation, GI mucosal ulcerations/haemorrhage, ureteric perforations, splenic subcapsular haemorrhage, psoas abscess and pseudoaneurysm of the SMA

Vasectomies

• Bleeding and scrotal haematoma
• Local wound infection
• Epididymitis
• Painful sperm granulomas
• Persistent testicular pain and/or congestive epididymitis months to years later
• Rx – Analgesia +- antibiotics (esp if immunocompromised)

Post-prostate surgery

• Haematuria, clot retention, urethral strictures and UTI’s are common
• Prolonged irrigation requires monitoring of serum sodium

IDC – Infection

• 1-2% risk of infection if in place <24 hours
• 100% bacteriuria within 30 days
• 3-10% incidence of bacteriuria for each day catheter is in place
• Short-term: E. coli, Klebsiella, Pseudomonas, Enterobacter, Staphylococci
• Long-term: Polymicrobial E. coli, Proteus, Pseudomonas, Morganella morganii and Candida
• Guidelines suggest treatment for symptomatic bacteriuria only when IDC in place (unless pregnant or pending urological procedure)
• Pyuria is universal if IDC in place for 30 days
• Haematuria is a better indicator of infection
• Replace if been in place for >2 weeks and remove if at all possible

IDC – Obstruction and Leakage

• Often intraluminal encrustations during long-term placement leads to obstruction and leakage around tube
• Management options:
  • Repeated bladder irrigations
  • Change of catheter
• Always check for infection as encrustations often suggest urea-splitting bacteria presence
• If flushes easily, suggests bladder spasm rather than obstruction causing periurethral leakage. This can be treated with oxybutynin

Percutaneous nephrostomy

• Indications:
  • Supravesical or ureteral obstruction secondary to malignancy, pyonephrosis, GU stones and ureteral strictures
  • Used as an adjunct to lithotripsy and ureteral stents
  • Also for urinary diversion with vesical fistulas, ureteral transection and trauma
• During insertion
  • Injury can occur to lungs (PTX), liver, spleen and bowel (perforation)
• Bleeding
  • Especially if coagulopathic
  • Often managed conservatively with irrigation to clear nephrostomy of blood clots

Percutaneous nephrostomy

• Infectious complications
  • Bacteriuria, pyelonephritis, renal abscess, bacteraemia and urosepsis
• Mechanical complications (CT helpful for diagnosis)
  • Catheter dislodgement
  • Tube obstruction
  • Residual stone fragments

Ureteral stents

• Indications:
  • Relieve ureteral obstruction and maintain ureteral patency
  • Original obstruction may be due to stones, strictures, trauma, malignancy or retroperitoneal fibrosis
  • Also used as adjuncts to lithotripsy
• Infection: Promotes FB reaction and encrustation
  • Stents do not cause fever on their own
  • Most minor infections require only outpatient oral antibiotics as for IDC-related UTI and do NOT require stent removal
  • Do not use the same antibiotic as used for periprocedural prophylaxis
  • If pyelo/systemic illness is suspected, need IV antibiotics and CT to determine position of stent +- collection

Ureteral stents

• Irritation
  • Mild flank pain, dysuria, urgency, frequency, incontinence and pain during voiding are common when stents are in place
  • Analgesics, anticholinergics and excluding UTI are key
  • New severe pain or change in symptoms requires evaluation for stent migration, infection or obstruction
• Gross haematuria
  • Suggests stent migration or ureteral erosion and warrants CT
• Fistularisation
  • Vascular fistularisation can rarely occur and must be assumed if haemodynamic instability exists

Urinary diversion and orthotopic bladder substitution

• Most commonly ileal conduit
• Post-operative complications (66% of patients)
  • Reduced kidney function (27%)
  • Bowel obstruction (24%)
  • Pyelonephritis (23%)
  • Skin breakdown at stoma site
  • Stenosis of stoma (24%)
  • Inflammatory changes of upper renal tract due to reflux of urine back into ureters
• 85% suffer bacteriuria post-procedurely, mostly with skin-flora
• Culture of pathological organisms >10^4 CFU/HPF or symptomatic UTI/pyelo warrant antibiotic therapy

Last Updated on October 9, 2020 by Andrew Crofton