Prostatic surgery associated acute kidney injury

Table 1 Surgical approach to the treatment of benign prostatic hyperplasia and prostate cancer

Benign prostatic hyperplasia

Transurethral resection

Open simple prostatectomy

Electrovaporization

Laser prostatectomy

Holmium laser enucleation

GreenLight™ laser vaporization

Transurethral incision

Transurethral needle ablation

Prostate cancer

Radical Prostatectomy

Open (retropubic or perineal)

Minimally invasive

Laparoscopic

Robot-assisted

Table 2 Kidney disease improving global outcomes acute kidney injury definitions

AKI is defined as any of the following
Increase in serum creatinine by ≥ 0.3 mg/dL within 48 h; or
Increase in serum creatinine to ≥ 1.5 times baseline, which is known or presumed to have occurred within the prior 7 d; or
Urine volume < 0.5 mL/kg per hour for 6 h

AKI: Acute kidney injury.

Table 3 Suggestions for the prevention and management of transurethral resection of prostate syndrome

Preoperative

Estimate GFR using the CKD-EPI equation

Identify patient risk factors: large prostate gland (> 45 g), heart disease, CKD, and smoking

Advise bipolar TURP or laser techniques for high-risk patients

Intraoperative

Avoid D.W. and glycine as irrigating fluids. Sorbitol and mannitol are good options. Physiologic saline is a safe choice when feasible

Maintain low-pressure irrigation

Consider the use of intra-prostatic vasopressin injection in high-risk patients

Alert surgical team when surgery exceeds one hour

Monitor the volume of absorbed fluid. Consider aborting the procedure if the absorbed volume exceeds 1.0 L and suspend surgery if absorbed volume exceeds 2000 mL

Both spinal and general anesthesia are adequate

Avoid hypotension and central venous pressure reduction and closely monitor the vital signs

Post-operative

Assess serum sodium and serum creatinine in all patients in the immediate postoperative period

Apply KDIGO AKI definitions to AKI diagnosis

If TURP syndrome is diagnosed, initiate medical treatment:

Assess serum osmolality

Maintain asymptomatic and mildly symptomatic patients under close observation

Initiate hypertonic saline 3% infusion in symptomatic patients with marked hyponatremia, reduced osmolality and cerebral edema

Restrict diuretic use to treat fluid overload

If AKI occurs, test for hemolysis and rhabdomyolysis

Consider hemodialysis in symptomatic patients with severe renal disease

Patients that developed AKI should be followed and eGFR equations must be used to identify CKD

AKI: Acute kidney injury; CKD: Chronic kidney disease; CKD-EPI: Chronic Kidney Disease Epidemiology Collaboration; D.W.: Distilled water; GFR: Glomerular filtration rate; KDIGO: Kidney disease improving global outcomes; TURP: Transurethral resection of prostate.

Table 4 Suggestions for the prevention and management of surgical position-related rhabdomyolysis

Preoperative

Identify patient risk factors: obesity, hypovolemia, diabetes mellitus, hypertension, chronic kidney disease, peripheral vascular disease, expected surgery time longer than 5 h

The vascular status of the patient’s lower extremity should be carefully assessed with a well-documented preoperative vascular examination

The patient´s volume status should be evaluated

Intraoperative

Ensure correct patient positioning and protect all pressure points

Monitor lower extremities and vascular status

Reposition lower extremities every two hours

Adequate fluid reposition, avoiding hypovolemia

Monitor serum potassium levels

Appropriate operative time, completing the procedure as quickly as possible

Post-operative

Assess serum-CK and SCr 6 h and 18 h postoperatively in high-risk patients

Closely check serum creatinine, potassium levels, and acid-base disorders

Apply KDIGO AKI definitions to AKI diagnosis

Monitor signs of compartmental syndrome and consider fasciotomy if present

If RM syndrome is diagnosed, initiate medical treatment:

Initiate aggressive early fluid repletion;

Treat acid-base and electrolyte abnormalities;

Consider early RRT

CK: Creatine kinase; KDIGO: Kidney disease improving global outcomes; RM: Rhabdomyolysis; RRT: Renal replacement therapy; SCr: Serum creatinine. AKI: Acute kidney injury.