1 Chapter 25 Genitourinary Surgery. 2 Elsevier items and derived items © 2010, 2007 by Saunders, an...

1

Chapter 25Chapter 25

Genitourinary SurgeryGenitourinary Surgery

2 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Genitourinary

Review terms and definitions listed at beginning of chapter

Use your medical dictionary if necessary


Genitourinary

Surgical areas Female

• Urethra

• Bladder

• Ureters

• Kidney


Genitourinary

Surgical areas Male

• Urethra

• Bladder

• Ureters

• Kidney

• Prostate

• Testicles

• Penis

• Accessory structures


Genitourinary

Common surgical approaches Transurethral

• Cystoscopy

• Ureteroscopy

Open surgery Minimally invasive


Genitourinary

Kidney

Anatomy of the kidney.(From Brundage DJ: Renal disorders, St Louis, 1992, Mosby)


Genitourinary

Kidney Nephron

• Functional filtering unit of the kidney

Kidney stones• Precipitation of specific salts from the filtrate and

the urine


Genitourinary

(From Thibodeau G, Patton K: Anatomy and physiology, ed 6, St Louis, 2007, Mosby

Urinary bladder.


Genitourinary

Urethra Female

• Originating at the trigone

• Ending at the meatus

Male• Originating at the trigone

• Prostatic urethra

• Membranous urethra

• Cavernous urethra

• Ending at the meatus


Genitourinary

Male reproductive organs.

(From Herlihy B, Maebius NK: The human body in health and illness, ed 2, Philadelphia, 2003, Saunders.)


Genitourinary

Scrotum Lies at base of penis Protects the testicles


Genitourinary

Testicles Epididymis Vas deferens Seminal vesicles Prostate gland Bulbourethral glands


Genitourinary

Penis Male copulatory organ Highly vascular

• Flaccid except during sexual stimulation


Genitourinary

Vas deferens Forms a portion of the path that the seminal fluid

travels Continues across bladder and ureter

• Meets opening of seminal vesicle and forms ejaculatory duct


Genitourinary

Kidney dialysis Removal of waste products from the blood of the

patient with chronic kidney disease or end-stage renal disease

• Hemodialysis

• Peritoneal


Genitourinary

Diagnostic tests Urinalysis Blood test Glomerular filtration rate Blood urea nitrogen (BUN) Tissue biopsy Imaging studies


Genitourinary

Positioning Lithotomy

• Cystoscopy

Supine• Bladder, prostate

Lateral• Kidney and ureters

Prone• Nephroscopy


Genitourinary

Open Instruments

Open GU instruments. Left to right.A, Fine hemostatic forceps. Satinsky clamp. Herrick kidney clamp. Satinsky vascular clamp. Right-angle clamp. Mayo kidney clamp. (From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby.)

B, Nephrectomy and ureteroplasty. Left to right. Metzenbaum scissors. Potts scissors, probe and grooved director. Two nerve hooks. Two love nerve retractors, straight and right angle. Two little retractors. Four vein retractors.(From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby.)


Genitourinary

A,Cystourethroscope. B, Cystoscope and light guide.(From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby.)

Endoscopic Instruments


Genitourinary

The rigid cystourethroscope Fiberoptic light cable and source

• Light cable connects cystoscope to fiberoptic light source.

• Light sources used are same as those in other endoscopic procedures and include xenon and halide

• Cables are fiberoptic or liquid light

• As with all endoscopic equipment, light cords and camera cords should be handled carefully


Genitourinary

The rigid cystourethroscope (cont.) Obturator

• Metal rod with blunt, rounded tip

• Prevents end of sheath from abrading mucosal lining of urethra as it is inserted

• May be either straight or deflecting


Genitourinary

Resectoscope Transurethral instrument used to remove small

fragments of tissue• Endoscope

• Sheath

• Obturator

• Electrical loop


Genitourinary

(From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby.)

Left to right, enlarged tips:

- Cutting electrode with round wire

- Cutting electrode with pointed end

- Coagulating electrode with ball end

Electrosurgical Unit (ESU)


Genitourinary

Urinary CathetersA, Conical-tip urethral catheters.

B, Robinson urethral catheter.

C, Whistle-tip urethral catheter.

D, Coudé hollow olive-tip catheter.

E, Malecot self-retaining, four-wing urethral catheter.

F. Malecot self-retaining, two-wing catheter.

G, Pezzer self-retaining drain, open-end head, used for cystotomy drainage.

H, Foley-type balloon catheter.

I, Foley-type, three-way balloon catheter.

(Modified from Walsh PC, Retik AB, Vaughan ED, et al: Campbell's urology, ed 8, Philadelphia, 2002, Saunders.)

Catheters


Genitourinary

Catheters (cont.) In-dwelling urinary catheters

• Most hospitals use prepackaged one-time-use catheters

• Catheter is hollow tube of flexible synthetic material

• Variety may be used during genitourinary (GU) procedures


Genitourinary

Ureteral Catheters A. Round-tip

B. Olive-tip

C. Spiral-tip

D. Conical- or "bulb-tip"

(B from Walsh PC, Retik AB, Vaughan ED, et al: Campbell's urology, ed 8, Philadelphia, 2002, Saunders.)

Catheters (cont.)


Genitourinary

Catheters (cont.) Ureteral catheters

Ureteral stent with tether.(A from Nagle GM: Genitourinary surgery: Perioperative nursing series, St Louis, 1997, Mosby.)


Genitourinary

Equipment Electrosurgical unit Microscope Laser


Genitourinary

Transurethral surgery Cystoscopy

• Use of a rigid or flexible cystoscope

Ureteroscopy• Use of a rigid or flexible ureteroscope


Genitourinary

Diagnostic cystoscopy Goal of cystourethroscopy (cystoscopy) –

to examine inside of urinary bladder and urethra for evidence of disease


Genitourinary

Ureteral dilation and urethrotomy Urethra is dilated to relieve a stricture

• Phillips filiforms and followers

• Graduated sounds

• Balloon dilators

Urethrotomy—Small incision made in internal urethra to release scar tissue


Genitourinary

Management of bladder calculi using the

Cystourethroscope Bladder calculi or stones are removed because of

pain or urinary blockage

Lithotrite Specialized instrument that grasps and crushes

the stone


Genitourinary

Management of Bladder Calculi

Top, left • Mayo dissecting scissors, curved.

Bottom, left to right• Crile hemostatic forceps, straight.• Crile hemostatic forceps, curved.• Five Van Buren urethral sounds,

male, sizes 8 to 16.

Right, top to bottom• Two nonperforating towel forceps.• Ellik evacuator.


Genitourinary

(From Rothrock JC: Alexander’s care of the patient in surgery, ed 17, St. Louis, 2007, Mosby.)

Transurethral Resection of the Prostate (TURP)


Genitourinary

Transurethral Resection of the Prostate (TURP) (cont.)

Left to right, enlarged tips: • Cutting electrode with round wire.

• Cutting electrode with pointed end.

• Coagulating electrode with ball end.

(From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby.)


Genitourinary

Tissue biopsy Performed to determine if tissue specimen is

benign or malignant


Genitourinary

Tumor removal Removal of neoplasm can be performed by

fulguration or by using the holmium:YAG (yttrium aluminum garnet) laser.

Laser precautions must be observed


Genitourinary

Circumcision in the adult Removal of the prepuce (foreskin), which is done

to improve and to abide by cultural and religious reasons.


Genitourinary

Chordee repair A congenital downward curvature of the penis

cause by a band of connective tissue between the opening of the penis and the glans penis

Release of the connective tissue allowing the penis to assume a normal position


Genitourinary

Incisions are approximated, and the intervening strip of tunica albuginea and suture knots are buried.(From Walsh PC, Retik AB, Vaughan ED, et al: Campbell's urology, ed 8, Philadelphia, 2002, Saunders.)

Hypospadias Repair


Genitourinary

A, Preparation of the reservoir. B, Placement of the reservoir and cuff in the perineal incision.Courtesy American Medical Systems, Minnetonka, Minn.

Insertion of Penile Implant


Genitourinary

Insertion of Penile Implant (cont.)

C. The reservoir and the pump are filled with Hypaque to the appropriate volume. D. The pump is tested.Courtesy American Medical Systems, Minnetonka, Minn.


Genitourinary

Varicocelectomy High ligation of gonadal veins of testes

• To reduce venous backflow of blood into the venous plexus of the testes and to improve spermatogenesis


Genitourinary

Hydrocelectomy.

(Rothrock J: Alexander’s care of the patient in surgery, ed 17, St Louis 2007, Mosby)


Genitourinary

Orchiectomy Surgical removal of one or both testicles


Genitourinary

Vasectomy.

(From Walsh PC, Retik AB, Vaughan ED et al: Campbell’s urology, ed 8, Philadelphia, 2002, WB Saunders).


Genitourinary

Vasovasostomy Reversal of the vasectomy by surgical

anastomosis of the vas deferens to restore continuity of flow of sperm


Genitourinary

Implantation of testicular implants Following an orchiectomy, testicular implants are

placed via a suprapubic approach


Genitourinary

Suprapubic cystostomy Insertion of a suprapubic catheter via a

percutaneous or open approach into the bladder for drainage of urine


Genitourinary

Cystectomy Total or partial removal of the bladder.


Genitourinary

Ileal Conduit Procedure for urinary diversion where a functional

bladder is constructed with a loop of bowel that is brought out of the abdominal wall

(From Garden O, Bradbury A, Forsythe J, Parks R: Principles and practice of surgery, ed 5, Edinburgh, 2007, Churchill Livingstone Elsevier.)


Genitourinary

Vesicourethral suspension of the bladder Performed to treat urinary stress incontinence in

the female • When caused by reduction in the angle

at the urethrovesical junction


Genitourinary

Vesicourethral suspension (Marshall-Marchetti-Krantz) procedure.

(From Walsh PC, Retik AB, Vaughan ED et al: Campbell’s urology, ed 8, Philadelphia, 2002, WB Saunders)


Genitourinary

Pubovaginal sling Suspension of the bladder neck with a biosynthetic

strip or fascia graft that is attached to the abdominal wall


Genitourinary

Types of prostatectomy Prostatectomy is performed to treat benign

prostatic hypertrophy (BPH) and for cancer of the prostate

• Perineal prostatectomy

• Suprapubic prostatectomy

• Retropubic prostatectomy

• Laparoscopic or robot-assisted prostatectomy

• Transuretheral resection prostatectomy (TURP)


Genitourinary

Perineal Prostatectomy

A, Incision through the perineum, B, Exposure of the central tendon. C, The preprostatic fascia (gray) has been incised to expose the prostatic capsule. D, Mobilization of the vascular pedicle. E, The vascular bundle is severed. F, Closure of the bladder neck. (Rothrock J: Alexander’s care of the patient in surgery, ed 17, St Louis 2007, Mosby)


Genitourinary

Suprapubic prostatectomy Removal of the prostate through a

suprapubic incision


Genitourinary

Retropubic prostatectomy Patient is placed in supine position, prepped, and

draped as for suprapubic prostatectomy In this approach, bladder is not entered for access

to prostate


Genitourinary

Ureteral diversion Pyeloplasty

• Strictures in ureter are relieved by fine electrosurgical or laser devices introduced through the endoscope


Genitourinary

Ureteral diversion (cont.) Urethrotomy

• If urethrotomy (release of structure) is planned, optical urethrotome is inserted into stricture, and blade incises scar tissue


Genitourinary

Ureteral diversion (cont.) Ureteroplasty

• Reconstruction of the ureter


Genitourinary

Ureteral diversion (cont.) Ureterostomy

• Anastomosis of the ureter with another hollow structure to provide continuity


Genitourinary

Ureteral diversion (cont.) Transureterureterostomy

• Crossing one ureter to another and creating an anastomosis between the two ureters

• May also be referred to as a ureterureterostomy


Genitourinary

Ureteral diversion (cont.) Vesicoureterostomy

• Reimplantation of the ureter into the bladder

• Helps prevent subsequent renal failure

Causes of renal obstructions• Congenital malformations

• Stasis

• Metabolic imbalances


Genitourinary

Percutaneous nephrolithotomy (PCNL) Insertion of a nephroscope via a small incision in

the skin for the purpose of removal of stones from the kidney or the upper ureter


Genitourinary

Simple nephrectomy (flank approach) Removal of one kidney


Genitourinary

Laparoscopic radical nephrectomy Removal of the kidney and lymph nodes via a

laparoscopic approach


Genitourinary

Kidney transplant Removal of kidney from living donor or cadaver Implantation of kidney to surgical patient Performed for acute or chronic end-stage renal

failure


Genitourinary

Kidney transplant (cont.) Ideal tissue donor

• Young

• Free of drugs and alcohol

• History is known

• Tissue and blood type match the recipient’s


Genitourinary

Adrenalectomy Adrenal diseases often life threatening Procedure has potential for many postoperative

metabolic complications

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