E

Fig. 6.4. Extravesical anterior ureteroneocystostomy demonstrating mucosa-to-mucosa anastomosis of the ureter to the bladder mucosa and approximation of the detrusor muscle to create the anti-reflux tunnel.

antibiotic solution during the course of the procedure will help minimize wound infection. The patient can usually be extubed in the OR at the completion of the case.

D. Very Early Postoperative Management

Immediate postoperative care begins in the post-anesthesia recovery room with airway management as highest priority, ensuring successful extubation and airway protection. Pain control is administered. Vital signs are monitored frequently. A complete chemistry profile, complete blood count, coagulation survey, chest x-ray, and EKG are typically obtained. Observation and documentation of hourly urine output is critical to determine the early degree of initial function of the kidney transplant as well as anticipating the intravenous fluid replacement necessary. Urinary output can be as low as drops or greater than 1 liter per hour. Postoperative fluid replacement must be thoughtfully approached. Assessment of volume status is important to avoid volume overload or depletion. Central venous pressure monitoring is a useful guide to intravascular volume status. If a brisk diuresis is occurring, it is not uncommon for electrolyte abnormalities to develop including hypocalcemia and hypomagnesemia. Determination of serum potassium levels is very important. When urine output is very low, hyperkalemia should be anticipated. A brisk urine output may be associated with either hyper- or

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