Control of bleeding in upper urinary tract and retroperitoneal surgery

Surgery of the upper urinary tract and the retroperitoneal spaces is a constant invitation to potentially serious bleeding. An adequate well-organized exposure of the pathologic condition involved, detailed knowledge of the regional anatomy and its variations, careful gentle dissection of the major vessels, and a calm disposition of the surgeon are the critical factors in preventing intraoperative hemorrhage. Unexpected bleeding is at times unavoidable, and the urologic surgeon should have a well-prepared method for managing hemorrhage during each procedure. Temporary control with gauze packs, sponge sticks, or the surgeon's finger should be the initial step in the control of serious hemorrhage, and this will virtually stop most bleeding. The subsequent period should be used to communicate with the anesthesiologist, who must replace the blood already lost and forewarn the blood bank of future needs. The surgeon is obligated to improve exposure of the bleeding site, dissect out the vessel involved, obtain any additional necessary lighting and suction equipment, and call for a colleague to help secure the vascular rent while applying continued proximal and distal tamponade. Because serious intra-operative hemorrhage can be encountered by even the most skilled surgeon, consultation with an experienced colleague should be looked on as an integral part of the armamentarium for the optimal care of the urologic patient.