Monday, March 11, 2013

Augmentation Cystoplasty (part 10)


Intravenous (IV) fluids and nasogastric drainage are initially maintained for several days until the patient’s bowel function returns. Fluid status and electrolyte levels are monitored clinically. Nasogastric tube decompression is typically maintained until bowel function is recovered, though some studies have found that this does not decrease early postoperative complications.
Typically, a urethral Foley catheter and a suprapubic tube are used to drain the bladder, with the latter exiting the abdomen directly or through the catheterizable stoma. The bladder should be manually irrigated 3 times daily and as needed to clear mucus from the suprapubic tube and the urethral Foley catheter. The pelvic drain can be removed when concerns about urinary leakage have been eliminated, either by low output or by fluid chemistries indicating peritoneal fluid.
The patient is discharged with the capped suprapubic tube in place and a urethral catheter draining the bladder. Taping the suprapubic tube to the abdomen can prevent unintentional manipulation. Low-dose antibiotic prophylaxis is continued for about 3 weeks postoperatively, until all catheters and drains are removed. During the first few postoperative weeks, the urethral catheter is removed, and the patient should begin catheterization at 2- to 3-hour intervals. The suprapubic tube should be irrigated 3 times daily to clear mucus.
Cystography performed 2-3 weeks after surgery should confirm the augmented bladder’s integrity before the tube is removed. To avoid false-negative findings for urinary leakage, cystography should be performed with at least 300 mL of contrast.
After removal of the suprapubic tube, patients may gradually increase the interval between intermittent catheterizations to 4 hours. They should wake up at least once per night to catheterize.
Patients without neurologic deficits may try to void, but postvoid residual volumes must be checked to ensure adequate emptying.

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