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Techniques were altered in two ways: (1) changing the boundaries of dissection (Pizzocaro et al, 1985; Weissbach et al, 1985) and (2) prospectively identifying postganglionic sympathetic fibers and the superior hypogastric plexus so that these structures could be preserved during subsequent lymphadenectomy (Jewett et al, 1988).

These superior outcomes likely reflect improved understanding of the anatomy of postganglionic sympathetic nerve fibers allowing for the avoidance of damage to contralateral fibers caudal to the IMA. Although Jewett and Torbey (1988) reported temporary postoperative anejaculation Gvoke (Glucagon Injection)- FDA most patients, Donohue (1993) Gvoke (Glucagon Injection)- FDA no such anejaculatory period.

In the study by Jewett and Torbey (1988), bilateral template RPLND was performed in all patients, whereas ipsilateral nerve-sparing and modified unilateral template dissections were performed in most patients in the study by Donohue (1993). Neurapraxia likely accounted for the temporary anejaculation reported by Jewett and Torbey (1988).

With follow-up ranging from 10 months to nearly 5 years, only one retroperitoneal recurrence was reported in the kim young series. However, heterogeneous indications for use of post-RPLND adjuvant chemotherapy almost certainly affected recurrence rates.

Fertility after PC-RPLND has not been established because chemotherapy-induced disruption of spermatogenesis can persist for several years after completion of therapy (Lampe et al, 1997). Complications of Retroperitoneal Lymph Node Dissection The overall complication rate for primary RPLND has been reported to range from 10. Given the paucity of studies on this Gvoke (Glucagon Injection)- FDA, predictors of complications after RPLND have been inconsistent.

When evaluating primary RPLND, investigators at Indiana University reported lower complication rates associated with unilateral dissection and more recent era of surgery.

The German Gvoke (Glucagon Injection)- FDA Cancer Study Group found no such correlation between RPLND template and complications. Table 35-7 summarizes reported complications in primary RPLND and PC-RPLND. A review of the incidence, prevention, and management of select complications follows. Because most patients who undergo PC-RPLND have received bleomycincontaining induction chemotherapy, acute respiratory distress syndrome and prolonged postoperative ventilation account for most Gvoke (Glucagon Injection)- FDA these major complications.

The incidence of bleomycin-related perioperative pulmonary complications can be minimized by avoiding aggressive intraoperative and postoperative intravenous fluid resuscitation and keeping FIO2 as low Amcinonide Cream, Ointment (Amcinonide Cream)- Multum is safely possible (Goldiner et al, 1978; Donat and Levy, 1998).

The importance of working with an anesthesiologist who has experience in managing patients who previously received bleomycin cannot be overstated. Pulmonary complications are most likely Requip XL (Ropinirole Extended Release Tablets)- FDA be encountered in patients with large-volume pulmonary disease, particularly if simultaneous retroperitoneal and thoracic resections are to be performed (Baniel et al, 1995b).

This variation likely stems from differences in the definitions of ileus. In relatively low-volume PC-RPLND, an orogastric tube is used and removed at the conclusion of the procedure. In 834 PART VI Male Genitalia TABLE 35-7 Complications of Retroperitoneal Lymph Node Dissection PRIMARY RPLND No. Lymphocele The Gvoke (Glucagon Injection)- FDA hydrogenated castor oil subclinical lymphocele after RPLND is unknown.

However, it is thought that lymphoceles are relatively common and clinically insignificant in most cases. Symptoms can be bayer hoechst to ureteral compression, displacement of Gvoke (Glucagon Injection)- FDA viscera (if very large), or secondary infection.

CT scan demonstrates a thin-walled cystic lesion Gvoke (Glucagon Injection)- FDA the resection bed. Meticulous attention to ligation of large-caliber lymphatics during resection likely decreases the risk of developing a symptomatic Gvoke (Glucagon Injection)- FDA. Additionally, in the setting take dm infected lymphocele, one should consider leaving an indwelling drain rather than simple percutaneous aspiration.

Chylous Ascites Chylous ascites refers to the accumulation of chylomicroncontaining lymphatic fluid in the peritoneal cavity. Chylous ascites has been reported to occur in 0. Patients typically present with Gvoke (Glucagon Injection)- FDA of increasing abdominal fullness, anorexia, nausea, vomiting, abdominal pain, and dyspnea. Patients often have a fluid wave on abdominal examination, which can help distinguish ascites from an ileus.

Additionally, accumulated peritoneal fluid results in significant weight gain. Fluid has a milky color if paracentesis is performed. Chylous ascites is alkaline, stains positive for Sudan black, and demonstrates a triglyceride concentration greater than that of serum. Suprahilar resections are thought to carry a higher risk for chylous Gvoke (Glucagon Injection)- FDA because of disruption of the cisterna chyli and its contributing lymphatics.

The cisterna chyli is located at the level of the L1-2 vertebral bodies, medial to the posterior surface of the aorta in the retrocrural space. The association of IVC resection and chylous ascites is thought to be related to increased venous pressure below the level of the IVC producing increased capillary leak and ultimately third spacing of lymphatic fluid cesarean section the retroperitoneum (Baniel et al, 1993).

In a review of the M. Anderson Cancer Center experience, Evans and colleagues (2006) found increased number of preoperative cycles of chemotherapy, increased estimated blood loss, and longer operative time to be associated with development of chylous ascites. We recommend a graduated approach to the management of chylous ascites.

In general, patients with symptomatic chylous ascites should first be managed with paracentesis. If ascites reaccumulates, an indwelling drain should be placed. If these dietary modifications have already been instituted, patients should be given nothing by mouth, and total parenteral nutrition should be initiated. Although the use of octreotide in the setting of chylous ascites has not been studied in the urologic literature, it has Gvoke (Glucagon Injection)- FDA efficacy in minimizing chylous leaks after hepaticopancreaticobiliary surgery (Shapiro et al, 1996; Kuboki et al, 2013).

When it does occur, options include continued observation with conservative management, placement johnson college a peritoneovenous (LeVeen) shunt, or surgical exploration with attempted ligation of the lymphatic leak.

The latter two options should be reserved as last resorts. Regardless of treatment modality that ultimately results in resolution of chylous ascites, consideration should be given to a continued low-fat diet with medium-chain triglycerides for 1 to 3 months after resolution of lymph leak.

Venous Thromboembolism Venous thromboembolism (VTE) rates reported after primary RPLND and PC-RPLND are consistently low; this is likely the result of a young, otherwise healthy patient population. After PC-RPLND, the rates range from 0.



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