1.

Tatalaksana hyponatremia pada diuresis post obstruktif

The treatment of hyponatremia can be divided into two steps. First, the physician must decide whether
immediate treatment is required. This decision is based on the presence of symptoms, the degree of
hyponatremia, whether the condition is acute (arbitrarily defined as a duration of less than 48 hours) or
chronic, and the presence of any degree of hypotension. The second step is to determine the most
appropriate method of correcting the hyponatremia. Shock resulting from volume depletion should be
treated with intravenous isotonic saline. Acute severe hyponatremia (i.e., less than 125 mmol per L) usually is
associated with neurologic symptoms such as seizures and should be treated urgently because of the high risk
of cerebral edema and hyponatremic encephalopathy. The initial correction rate with hypertonic saline should
not exceed 1 to 2 mmol per L per hour, and normo/hypernatremia should be avoided in the first 48 hours. In
patients with chronic hyponatremia, overzealous and rapid correction should be avoided because it can lead
to central pontine myelinolysis. In central pontine myelinolysis, neurologic symptoms usually occur one to six
days after correction and often are irreversible. In most cases of chronic asymptomatic hyponatremia,
removing the underlying cause of the hyponatremia

Braun MM, Barstow CH, Pyzocha NJ. Diagnosis and management of sodium disorders: hyponatremia and
hypernatremia. Am Fam Physician. 2015;91(5):299-307.

2. Pemantauan elektrolit pasca radical prostat

Hyponatremia was a common electrolyte disorder after major urologic operations, especially in patients with
high-risk perioperative characteristics. Decreased sodium level was associated with increased risk of
progression to ESRD. A worse composite renal outcome was related to the development of postoperative
hyponatremia, and the results remained significant even after adjustment for multiple clinical factors.

Previous studies showed that postoperative hyponatremia was largely a phenomenon caused by surgical
stress, and that pathophysiologic changes in antidiuretic hormonal release play an important role in water
retention and decreased serum Na.

Longer surgical time was also significantly associated with the development of electrolyte disturbance, as the
patients might have experienced more hemodynamic changes during the perioperative period.

In addition, pre- and post-operative sCr levels or AKI might have been the most commonly considered
predictor for renal outcome, but the association of postoperative hyponatremia with poor renal prognosis
remained significant, even after adjusting for sCr values. The reasons for the above results include: 1) as
mentioned above, postoperative hyponatremia is related to stressful conditions during surgery [16], implying
that patients with an electrolyte imbalance would suffer from more postoperative complications and have a
worse clinical prognosis; 2) as patients with postoperative hyponatremia had more comorbidities, the
electrolyte imbalance might be an indicator of severe illness; however, our multivariable analysis suggested
that new-onset postoperative hyponatremia was an independent risk factor, even from pre- and post-
operative creatinine levels, for worse renal outcome; 3) patients with postoperative hyponatremia had longer
hospital stays, so exposure to additional in-hospital complications such as infection could have been
attributed to adverse outcomes [3, 4, 9]; and 4) although rare, direct complications of hyponatremia, such as
neurologic symptoms, might also have contributed to a worse prognosis

Source : Park J., Nam An J., Lee J.P., Oh Y.K., Kim D.K., Joo K.W., Kim Y.S., Lim C.S., Association between
postoperative hyponatremia and renal prognosis in major urologic surgery. 2017. Oncotarget.
3. Teknik Bourdenock
4. Management perdarahan pada radical prosat

Intraoperative Hemorrhage

 Intraoperative hemorrhage in radical prostatectomy mostly derived from venous structure. 

 It often can be controlled temporarily by packing, exposure, and suture or surgical clip ligation >
cardiovascular suture with 5.0 suture.
 If there is troublesome bleeding from the dorsal vein complex at any point, the surgeon should
completely divide the dorsal vein complex over the urethra and oversew the end. This is the single best
means to control bleeding from the dorsal vein complex.

Postoperative Hemorrhage

 Delayed bleeding rarely happened

 Exploration is not commonly performed, and patient was managed expectantly with blood tranfusion.

(Campbell 12th ed chapter 155)

 Transfusion
Dean LW, Tin AL, Chesnut GT, Assel M, LaDuke E, Fromkin J, Vargas HA, Ehdaie B, Coleman JA, Touijer K, Eastham
JA, Laudone VP. Contemporary Management of Hemorrhage After Minimally Invasive Radical Prostatectomy.
Urology. 2019 Aug;130:120-125. doi: 10.1016/j.urology.2019.04.021. Epub 2019 Apr 26. PMID: 31034916; PMCID:
PMC6660369.

 Arterial embolization
Source : Ierardi AM, Jannone ML, Brambillasca PM, Zannoni S, Damiani G, Rossi UG, Granata AM, Petrillo M,
Carrafiello G. Bleeding after prostatectomy: endovascular management. Gland Surg. 2019 Apr;8(2):108-114. doi:
10.21037/gs.2019.02.03. PMID: 31183320; PMCID: PMC6534764.
 5. Berapa jam menimbulkan BNC (bladder neck contracture) pasca operasi
 
 
According to a study by Msezane et al. [6], among 634 RARP cases, BNC occurred in 7 patients (1.1%) and the
operation time was significantly longer in the BNC group than in the non-BNC group (283 minutes vs. 225 minutes).
The authors suggested longer operative time with steep Trendelenburg position and pneumoperitoneal pressure
of 14 to 20 mmHg could result in local tissue ischemia and subsequent BNC occurrence. In the present study, the
patients who underwent LRP and those who underwent RARP showed differences in operation time as well as the
length of time before drain removal. However, only the operation time was significantly different in the
multivariate analysis. The number of LRP and RARP cases in the present study was too small to identify statistical
significance for operation time. Furthermore, each surgeon performed cystography at different times, so we could
not compare the length of time that it took for the anastomosis to become watertight after ORP, LRP, and RARP.
 
Source : Cho HJ, Jung TY, Kim DY, Byun SS, Kwon DD, Oh TH, Ko WJ, Yoo TK. Prevalence and risk factors of bladder
neck contracture after radical prostatectomy. Korean J Urol. 2013 May;54(5):297-302. doi:
10.4111/kju.2013.54.5.297. Epub 2013 May 14. PMID: 23700494; PMCID: PMC3659222.