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Fig. 6.5. Extravesical anterior ureteroneocystostomy utilizing the single stitch technique and anti-reflux tunnel.

hypokalemia. In the latter case, replacement of potassium in intravenous fluid must be approached with caution. In patients with voluminous urine output, the urinary concentration of potassium may be unexpectedly low. It is prudent to measure urinary potassium concentration prior to considering adding potassium to the intravenous fluids. Often replacement fluids are administered according to the rate of urine output. In that case, the potassium concentration in the intravenous replacement fluids should not exceed that in the urine.

An abrupt cessation of brisk urinary output must be quickly assessed. Suspicion that the Foley is occluded by a blood clot should prompt immediate irrigation. Importantly, an acute renal arterial thrombus will manifest as abrupt cessation of urine output. Very early vascular problems may be reversed and the kidney salvaged if acute renal artery thrombosis is suspected (usually in the recovery room) and the patient is immediately surgically re-explored.

Early significant postoperative bleeding would manifest as hypotension, tachycardia, decreased urine output, and lower than expected hemoglobin level. When the patient is stable and the early postoperative laboratory evaluation complete, the patient is typically transferred to the transplant general care unit. Routine intensive care unit observation is usually not required, however, there are individual cases in which it is sometimes required.

E. Surgical Complications

1. Wound Complications

Risk factors for, and the morbidity of, wound complications in the transplant patient are significant. Avoiding a wound complication begins with the forethought of correct surgical technique in opening the wound, dissection in correct tissue planes, gentle handling of tissue, meticulous attention to hemostasis, keeping the wound edges moist with antibiotic solution during the case; and ends with secure approximation of the deep fascia and careful approximation of the skin edges during closure. Wound complications may be a source of significant morbidity especially if ignored until deep and extensive facial necrosis and abscess develops. Wound complications initially appear as superficial drainage. It is important to differentiate between superficial and deep wound problems. Superficial wound infections must be opened and a sample of fluid submitted to microbiology for identification of the infectious organism and its sensitivity to antibiotics. Superficial infections can be treated successfully with local wound care. The fully granulated wound may then be allowed to heal by secondary intention or the patient brought back to the operating room for closure. Wound dehiscence requires urgent surgical repair.

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