Ureters

Fibrin sealant has been successfully used for haemostasis, in addition to anastomosis or reconstruction of the ureters.8 Iatrogenic perioperative injury of a ureteric artery (which is a very rare condition) can be successfully managed by percutaneous interventional techniques, with trans-catheter embolisation. This embolisation may be performed using micro particles, coils, glue, or gelfoam depending on the anatomical configuration ofthe injured vessel. In one reported case, 350 to 500 ¡m polyvinyl alcohol particles were used to control

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Fig. 4 Reproduced with permission from Sir A. Cuschieri and Springer Surg Endosc (1999) 13: 298-302, Safety of adrenal vein ligation during endoscopic adrenalectomy, A. Pietrabissa, A. Cuschieri, A. Carobbi, U. Boggi, F. Vistoli and F. Mosca.

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Fig. 4 Reproduced with permission from Sir A. Cuschieri and Springer Surg Endosc (1999) 13: 298-302, Safety of adrenal vein ligation during endoscopic adrenalectomy, A. Pietrabissa, A. Cuschieri, A. Carobbi, U. Boggi, F. Vistoli and F. Mosca.

retroperitoneal haemorrhage caused by injury to a lower ureteric

artery.35

Bladder Open surgery

Radical cystectomies have been associated with significant blood loss, due to the many vascular pedicles that have to be divided, in removing a bladder and prostate or uterus. Controlled hypotensive anaesthesia has been shown to reduce blood loss in radical cystectomy for bladder cancer. In addition, Ahlering et al. also showed that the requirement for blood transfusions was markedly lower in the controlled hypotensive anaesthesia group.36 Surgeons are constantly looking for new methods of reducing intra-operative blood loss and requirement for blood transfusion in major open surgery. One such method is a new stapling device, Compact Flex Articulating Linear Cutter (Ethicon Endo-Surgery, Cincinnati, Ohio), which showed significant reduction in blood loss and transfusion requirement.37 Where no reconstruction on the urethral stump is contemplated, haemostasis may be achieved by balloon tamponade of the deep dorsal venous complex (often a major source of bleeding), using a simple large calibre Foley catheter and gentle traction.

Argon beam coagulation can also be used for haemostasis after anterior exenteration, for bladder cancer, as it can for haemostasis following partial nephrectomy.20

Partial cystectomy, diverticulectomy, and open bladder stone surgery all present a lower risk in terms of bleeding, but require the usual vigilance and attention to intra-operative haemostasis as would any open or laparoscopic surgical procedure.

Endoscopic procedures

Intractable haemorrhage from the bladder wall during Trans-Urethral Resection of Bladder Tumour (TURBT) is uncommon, but potentially catastrophic. Embolisation of branches of the internal iliac artery, a minimally invasive technique, has been successfully used peri-operatively to control such bleeding.38 Air insufflation may be used if bleeding obscures vision, as it enables adequate visualisation of the bladder while the blood settles at the bottom of the bladder. Electro-vaporisation of bladder TCC can be carried out safely, with minimal risk of perforation and almost no bleeding. A combination of electro-surgical tissue vaporisation and coagulation and electro-vaporisation can achieve the same biological effects as laser treatment, but at considerably lower cost.39

Haematuria

Haemorrhage, diffusely from the bladder urothelium can be a difficult problem to tackle, and several methods have been advocated in the past including intravesical instillations of caustic agents, such as, phenol, silver nitrate, or formalin. Intravesical formalin solution has been used to control bleeding due to massive haematuria, in terminal cases of inoperable bladder cancer.40 Formaldehyde in its natural state is a gas, and the maximum concentration in solution is 37%. A 100% solution of formalin is equivalent to a 37% solution of formaldehyde. This is then diluted to give the required strength. It is instilled under general or spinal anaesthesia and has been used in varying concentrations with different types of follow on solutions. The volume instilled was 10 to 300 ml and contact time was 3 to 30 min. Among the variables the concentration remains the most important, as complication rates increase as the concentration used increases.41 Fair reported a higher complication rate with 10% formalin and, therefore, advocated using a1to2% solution with a contact time of 10 min. No complications were reported then.42

A group in the Netherlands recommended the use of alum irrigation before instituting invasive methods. Alum, an astringent that acts by protein precipitation over the bleeding surface is simple, efficient, less expensive, and non-toxic.43 Alum as a 1% solution is generally safe and well-tolerated. Local side effects, such as, supra-pubic pain or bladder spasm can be controlled by analgesics and anti-spasmodics. Haemorrhagic cystitis may also be managed by Argon beam coagulation. This can be used as an alternative to conventional methods of haemostasis, whenever there is a diffusely bleeding operative site.20

Radiation injury to the bladder causes progressive obliterative endarteritis, hypoxic surface damage, ulceration, and bleeding. Hyperbaric oxygen, by causing hyperoxia, reverses radiation induced damage by promoting neo-vascularisation, healthy granulation tissue, and generalised vasoconstriction.44 Post-radiation haemorrhagic cystitis may be treated with hyperbaric oxygen, which offers a non-invasive therapeutic alternative in patients.45 Hyperbaric oxygen therapy has been shown to improve angiogenesis and promote healing in radiation injured tissue, including the bladder. It is well-tolerated even in patients debilitated with advanced cancer. Blood loss and long-term remission can be achieved in the majority of patients with haemorrhagic radiation cystitis not responding to other modalities of treatment.46

Nd:YAG laser energy has been used for laser coagulation of a bladder haemangioma associated with Klippel-Weber syndrome and causing gross haematuria.47 Nd:YAG laser coagulation has also been used to successfully treat radiation induced haemorrhagic cystitis. The laser power used was < 30 W and pulse duration < 3 s.48

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