Morbidity & Mortality of a Urothelial Cancer Patient, during my clerkship in surgery department

1. M O R B I D I T Y
&
M O RTA L I T Y
P R E S E N T E R 陳 佳 菁
I N S T R U C T O R D R . S A M
A D V I S O R D R . L I N

2. A 耳 順 M A N W I T H
R E C U R R E N T U R O T H E L I A L
C A R C I N O M A
C O N F R O N T E D
H Y P O V O L E M I C S H O C K
A F T E R S U R G E RY

3. O U T L I N E
• Patient Profile
• HPI 1-9
• Discussion-1
• HPI 10-12
• Discussion-2
• Admission Events
• Discussion-3
• Analysis

4. PAT I E N T P R O F I L E
• 59-year-old Male, Mr. D
• Education: Junior high school
• 裝潢臨臨時⼯工, fair economic status
• Married, living with his wife and little son at Tainan;
Daughter is the nurse in SYSCC surgical ward
• No alcohol use; Tobacco: ½ -1PPD x 30 years, quit for
1 month; Betel nuts: for 2 years, quitted for 19 years

5. PA S T M E D I C A L & S U R G I C A L H I S T O RY
• No DM, CAD, TB, Hepatitis
• Hypertension (for 4 years) with SBP baseline 130
mmHg, under medication control with Norvasc
• Transient ischemic attack 6 months ago, still
with left sided facial numbness, with Aspirin
treatment
• Urinary bladder stone 5 cm in size treated with
vesicolithotripsy 20 years ago

6. C U R R E N T M E D I C AT I O N S
• Norvasc 5 mg PO QD
• Aspirin Hold for 2 weeks before admission

7. FA M I LY H I S T O RY
• Younger brother died of leukemia (?) in his 18
years old
• Parents both had DM and Hypertension in their
late 70s

8. H P I

9. H I S T O RY O F P R E S E N T I L L N E S S - 1
• Gross hematuria, weak stream with strain,
intermittency, dribbling, dysuria, frequency,
urgency, nocturia (3 times/night)
MARCH2013

10. H I S T O RY O F P R E S E N T I L L N E S S - 2
• Urinary bladder sonography: 5 cm tumor
• Renal impaired function: Creatinine 1.4 mg/dL
• Cytology, Biopsy: Urinary bladder non-invasive papillary
urothelial carcinoma
APRIL2013

16. C L I N I C A L I M P R E S S I O N - B L A D D E R
• Urinary bladder cancer with invasion of prostate
• Suspecting synchronous urothelial tumor at left renal
pelvis
• 當時很擔⼼心膀胱是 T2 Disease
APRIL2013

17. History of Present Illness - 2• Urinary bladder sonography: 5 cm tumor
• Renal impaired function: Creatinine 1.4 mg/dL
• Biopsy: Urinary bladder non-invasive papillary urothelial
carcinoma
• TURBT: High grade, cTa, treated with MMC x 6 (May. –
Aug.)
APRIL2013

18. H I S T O RY O F P R E S E N T I L L N E S S - 3
• Le. renal pelvis and Ureter: infiltra5ng papillary
carcinoma treated with nephroureterectomy +
bladder cuff excision: pT1
MAY2013

19. H I S T O RY O F P R E S E N T I L L N E S S - 4
• Right ureteroscopy: Normal
• Urinary bladder, TURBT: High grade, cTa (non-
invasive papillary urothelial carcinoma), treated with
Epirubicin x 5 (Aug. – Oct.)
2013 AUGUST

20. H I S T O RY O F P R E S E N T I L L N E S S - 5
• Urinary bladder, TURBT: High grade, cTa (non-
invasive papillary urothelial carcinoma), treated with
MMC x 6 (Oct. – Jan. 2014)
OCTOBER2013

21. H I S T O RY O F P R E S E N T I L L N E S S - 6
• Right ureteroscopy, retrograde pyelogram:
Normal
• Urinary bladder, TURBT: High grade, cT1(infiltra5ng
papillary urothelial carcinoma), treated with
Epirubicin x 6 (Feb. – Mar.)
FEBRUARY2014

22. H I S T O RY O F P R E S E N T I L L N E S S - 7
• Urinary bladder, TURBT: No malignancy, treated with
MMC x 3 (Apr. – Jun.)
2014 APRIL

23. H I S T O RY O F P R E S E N T I L L N E S S - 8
• Right ureteroscopy: Normal
• Urinary bladder, TURBT: High grade, cTa (non-
invasive papillary urothelial carcinoma), treated with
BCG x 6 (Jul. – Sep.)
2014 JULY

24. H I S T O RY O F P R E S E N T I L L N E S S - 9
• Urinary bladder, Cystoscopy: Low grade, cTa (non-
invasive papillary urothelial carcinoma), treated with
Epirubicin x 10 (Dec. – Aug. 2015)
2014 DECEMBER

25. S U M M A RY
B L A D D E R T U M O R + L E F T R E N A L
P E LV I S U R O T H E L I A L C A R C I N O M A
T U R B T X 6

26. 2013. Mar
2013. Apr
2013. May
2013. Apr -
2014. Jul
Symptoms
Surgery
TURBT

27. B L A D D E R T U M O R + L E F T R E N A L
P E LV I S U R O T H E L I A L C A R C I N O M A
T U R B T X 6
S U M M A RY
03
01
02
04
05
06
2013.4
2013.8
2013.10
2014.2
2014.4
2014.7
B L A D D E R T U M O R + L E F T R E N A L
P E LV I S U R O T H E L I A L C A R C I N O M A
T U R B T X 6

28. D I S C U S S I O N - 1

33. H I S T O RY O F P R E S E N T I L L N E S S - 1 0
2015 MARCH
• CT Urography of bladder: A filling defect about
0.3cm in right renal pelvis, probably
metachronous UC or other nature; new

35. H I S T O RY O F P R E S E N T I L L N E S S - 1 0
2015 MARCH
• Biopsy: Right renal pelvis non-invasive papillary
urothelial carcinoma, high grade

36. Q U A L I T Y O F L I F E : H E M O D I A LY S I S
• 3 times a week, 4 hours per time
• Control of salt and water
• Potassium intake (Fruits, the way of processing
food)
• Cramping, N/V, Headache, Prutitis…

37. H I S T O RY O F P R E S E N T I L L N E S S - 1 0
2015 MARCH
• Treated with ureteroscopic laser ablation (renal
function preservation) + Intra-renal pelvis MMC
instillation x 3 (Mar. - Apr.)
• Biopsy: Right renal pelvis non-invasive papillary
urothelial carcinoma, high grade

38. ⼀一 年年 半 快 樂 時 光
• Apr. 2015 – Oct. 2016
• CT Urography of bladder, Cystoscopy, Right
retrograde pyelography: No evidence of disease
2015 2016

39. H I S T O RY O F P R E S E N T I L L N E S S - 1 1
• Gross hematuria off and on --- For 1 week
2016 NOVEMBER

40. H I S T O RY O F P R E S E N T I L L N E S S - 1 2
2016 DECEMBER
• Urine cytologic diagnosis: Suspicious malignant, rare
highly atypical cells

41. H I S T O RY O F P R E S E N T I L L N E S S - 1 2
2016 DECEMBER
• MRI Abdomen + contrast:
(1)Left nephrectomy status - No reccurence
(2)Right renal sinus lower calyx - 21mm iso-signal
lesion, no hydronephrosis or hydroureter
(3)Liver, lymph nodes, other upper abdominal
organs: Normal

44. H I S T O RY O F P R E S E N T I L L N E S S - 1 3
• Bone scan: No evidence of bony metastasis
• Flexible ureteroscopy biopsy: Recurrent right renal
pelvis non-invasive papillary urothelial carcinoma, high
grade
• Left A-V shunt creation
2017 JANUARY

45. S U M M A RY
B L A D D E R T U M O R + R I G H T R E N A L
P E LV I S U R O T H E L I A L C A R C I N O M A

46. 2015. Mar
2015. Apr
l
2016.Oct
2016. Nov 2017. Jan
2016. Dec
Workup
Treatment
Hematuria
Workup
Biopsy
A-V shunt

47. D I S C U S S I O N - 2

48. H I S T O RY O F P R E S E N T I L L N E S S - 1 4
2017 0223
A D M I S S I O N

49. A D M I T T I N G D I A G N O S I S
1. Right renal pelvis papillary urothelial carcinoma;
treated with ureteroscopic laser ablation (Mar. 2015)
+ intra-renal pelvis MMC instillation with recurrence
(Nov. 2016)
2. Urinary bladder papillary urothelial carcinoma;
treated with TURBT x 6, intravesical MMC,
Epirubicin, BCG instillation (Apr. 2013 - Dec. 2014)
3. Left renal pelvis and ureter papillary urothelial
carcinoma treated with left nephroureterectomy +
bladder cuff excision (May. 2013)
4. Hypertension with TIA history

50. 2013. Apr
2013. May
2013. Apr - Now
2015. Mar
2016. Nov

51. 術前 Lab

53. 0 8 : 3 0 - 1 1 : 3 0
L A PA R O S C O P Y
N E P H R O U R E T E R E C T O M Y

57. 8 : 3 0 - 1 1 : 3 0

59. 8 : 3 0 - 1 1 : 3 0

60. 0 8 : 0 0 - 1 1 : 3 0
• Right kidney was removed completely without
exposure of the tumor
• 前半段拿下腎臟、輸尿尿管時沒什什麼流⾎血，Blood
loss < 50 c.c.
• 換姿勢

61. 1 1 : 3 0 - 1 7 : 0 0
O P E N
C Y S T O P R O S TAT E C T O M Y

62. 1 1 : 4 5

63. 1 4 : 0 0 AV S H U N T P O O R

64. • Left forearm AV shunt occlusion was
suspected during the operation (no
thrills but pulsation+)
• BP cuff was placed at right hand,
anesthesiologist inserted double-
lumen catheter over right neck for
hemodialysis
1 4 : 0 0 AV S H U N T P O O R

65. 1 1 : 3 0 - 1 5 : 0 0

67. 1 5 : 0 0 - 1 6 : 4 3

68. 1 6 : 4 3
•Urinary bladder and
prostate was resected with
preservation of bilateral
neurovascular bundles
•Peritoneal oozing

69. O P E R AT I V E F I N D I N G S :
1. R I G H T K I D N E Y WA S R E M O V E D C O M P L E T E LY W I T H O U T E X P O S U R E O F T H E T U M O R .

70. 1 6 : 5 3 @ PA C U
•Sodium Chloride 0.9% 1000
ml Total: 1000 ml, IVF STAT
•Pantoprazole (40mg) give
40 mg IVF

71. R E C O G N I T I O N O F
T H E C O M P L I C AT I O N

72. 122
79
122
79

73. 2 / 2 4 1 8 : 0 6
B L O O D T R A N S F U S I O N S TAT: 2 U P R B C
F R E S H F R O Z E N P L A S M A 4 U
S I N G L E D O N O R A P H E R E S I S P L AT E L E T S : 1 2 U

75. B R I E F S U M M A RY
• The patient's BP dropped to around 60-70 /40-50
mmHg at PACU and iv hydration, PRBC 2U only
elevated BP to around 80-90mmHg.
• JP ball continuous fresh blood bleeding was
noticed.
• After explanation to the patient and his children,
explore laparotomy under general anesthesia was
done since 1930-2200.

76. 1 9 : 3 0 - 2 2 : 0 0
E X P L O R E L A PA R O T O M Y

77. 1 9 : 3 0

79. 1 9 : 3 0 - 2 2 : 0 0

80. 2 1 : 5 2
• Operative Findings：
1. Bleeding from the stump of the right renal
arteries and veins and controlled by hemoclip
2. Slow bleeding from the left prostatic vessels
and controlled by chromic suture
3. Diffuse oozing from the renal bed and
controlled by electrocauterization
4. The patient was on ventilator and transferred
to ICU

81. 2 2 : 0 0
• Chest AP (Supine): Completely
anuria (s/p bilateral nephrectomy)
with bleeding s/p massive blood
transfusion for checkup if
pulmonary edema or ARDS.

82. 2016. Dec 2017. Feb

84. S U M M A RY
01
02
03
04
0501
02
03
04
05
0800
1130
1130
1643
1643
1930
1930
2200
2200
l

85. D I S C U S S I O N - 3

88. A N A LY S I S
R O O T C A U S E A N A LY S I S
• Intra-operational bleeding due to:
1. Stretch of right renal hilum vessels during the latter
radical cystoprostatectomy -> Retroperitoneal
bleeding
2. Intention of bilateral neurovascular bundles
preservation -> Loss of control of the closure of the
plexus
3. Change of position of the patient between 2
procedures

89. R E C O M M E N D AT I O N S
P R O P O S E D A C T I O N S T O P R E V E N T F U T U R E S I M I L A R P R O B L E M S
• Re-checking bleeding after operation completion if
patient’s position changes due to multiple procedure
sites
• Evaluation the pliability and adverse effects of
preservation neurovascular bundles which are highly
risky of hemorrhage
• Comprehensive assessment the bleeding risk and
relevant symptoms and signs

90. A N A LY S I S
R O O T C A U S E A N A LY S I S
Bleeding
Individual factors
Cause Effect
Team factors Pa?ent factors
Environment Policy/Procedure Organiza?on
Re-checking the
etroperitoneum
ding after changing
Position
Reminder from the
Operation assistants or
Nurses in the surgery room
Complexity increased
Due to the identity ->
Preservation of the
Neurovascular bundles
Physical and mental
Requirement after the
Time-consuming
Procedure
he surgical equipment
e..g., clips or stumps
Insufficient training or
Information regarding
Recurrent urothelial
Carcinoma surgery

91. R E V I E W O F L I T E R AT U R E
E V I D E N C E - B A S E D P R A C T I C E

92. R E V I E W O F L I T E R AT U R E
A DV E R S E E F F EC T S O F S U R G I C A L B L E E D I N G
• Visual obstruction of the surgical field
• Need for blood transfusions
• Reduction in core temperature
• Thrombocytopenia
• Hypovolemic shock
• Economic consequences

93. S U P P L E M E N T S
• Bladder Cancer: T Staging
• NCCN Guideline