(cid:142)(cid:3) Closure depends on approach used (see above). Complications (cid:142)(cid:3) Hemorrhage (cid:142)(cid:3) Injury of spleen, pancreas, cist erna chyli (chylous ascites) or bowel, or inadvertent ligature of superior mesenteric artery RADICAL NEPHRECTOMY AND NEPHROURETERECTOMY1 501 (cid:142)(cid:3) Thrombo-embolic complications (cid:142)(cid:3) Post-operative chest, wound or urinary tract infection (cid:142)(cid:3) Persistent urinary leak from the bladder in ne phroureterectomy (rare) (cid:142)(cid:3) Wound complications such as hernia, neuralgia or s agging of the flank due to nerve damage (cid:142)(cid:3) Local recurrence. Follow-up (cid:142)(cid:3) Adjuvant therapy in selected cases dependent on histology (cid:1 42)(cid:3) Initial wound and biochemistry check at 2 months (cid:142)(cid:3) Annual creatin ine clearance and urinary protein excretion and: (cid:142)(cid:3) TCC \200\224surveillance according to risk-stratified protocols for superficial urothelial malignancies may involve cystoscopies, upper tract imaging and urinary cytology (cid:142)(cid:3) RCC \200\224controversial: stage-based recommendations have been made. (cid:142)(cid:3) pT1 History and physical examination (H&P), liver functions (LFT) and chest X-Ray (CXR) every year (cid:142)(cid:3) pT2 H&P, LFTs, and CXR every 6 months for 3 years, then yearly. Thoracoabdominal CT scan at 24 and 60 months (cid:142)(cid:3) pT3 H&P, LFTs, and CXR at 3 months, then every 6 months until 3 years, then yearly. CT at 24 and 60 months Fig. 13.6 Exposure of renal vessels CHAPTER 13 Urology 502 Partial nephrectomy (cid:142)(cid:3) Preoperative imaging for full and accurate staging and anatomical in- formation is essential if this procedure is contemplated (cid:142)(cid:3) This operation can be performed extra-corporeally with auto- transplantation into the groin. Indications (cid:142)(cid:3) Bilateral tumors or inherited predisposition towards multiple renal tumourigenesis (eg Von Hippel \200\223Lindau disease) (cid:142)(cid:3) Small solitary renal tumors (controversial) (cid:142)(cid:3) Reduced renal reserve or solitary kidney (cid:142)(cid:3) Benign tumors. Position and approach Any described above, but vascular pedicle access has to be excellent. Procedure (cid:142)(cid:3) The renal pedicle is dissected and the vessels prepared for soft-clamping (cid:142)(cid:3) Crushed ice and mannitol may be used to prevent renal ischaemic damage. Sa fe warm ischaemic time is 30min. Effective renal cooling increases this six-fold but is not easily achieved. (cid:142)(cid:3) The tumor or moiety is identified (cid:142)(cid:3) Vessels are clamped (ci d:142)(cid:3) The capsule may be reflected, and parenchyma is incised and a polar or wedge resection taken with a 1cm margin around tumors. (cid:142)(cid:3) The collecting system is repaired watertight, often over a ureteral stent (cid:142)(cid:3) Arteries and veins are meticulously suture-ligated. (cid:142)(cid:3) Venou s clamps are removed, the renal parenchyma is closed and the incised capsule repaired with bolsters or an omental flap, then the ar- terial clamp is removed. Observe for a while to c onfirm haemostasis is near perfect. (cid:142)(cid:3) Drains and a catheter are often left post operatively (cid:142)(cid:3) The wound is closed in layers. Complications (cid:142)(cid:3) Hemorrhage, including major vessel injury (cid:142)(cid:3) T hrombo-embolic complications (cid:142)(cid:3) Loin pain secondary to clot colic or obstruct ion (cid:142)(cid:3) Postoperative chest, wound or urinary tract infection (cid:142)(cid:3) Leakage from collecting system causing urinoma or fistula (cid:142)(cid:3) Renal failure. Follow-up (cid:142)(cid:3) Initial wound and biochemistry check (cid:142)(cid:3) Follow up for cancer and familial syndromes involves regular imaging influenced also by pathological stage and margins (cid:142)(cid:3) Nephrological care may also be required. This page intentionally left blank CHAPTER 13 Urology 504 Radical cystectomy In men this is usually a cystoprostatectomy, and in women an anterior pe lvic exenteration. Indications (cid:142)(cid:3) Muscle invasive but locally confined tumors of the bladder (ci d:142)(cid:3) High grade superficial tumors or carcinoma in situ of the bladder not responsive to bladder sparing treatments (cid:142)(cid:3) As part of a pelvic exenteration for advanced pelvic malignant disease (ci d:142)(cid:3) Palliative treatment of haematuria, chronic pain or recurrent infection. Position (cid:142)(cid:3) Supine with stirrups or leg braces (cid:142)(cid:3) The operating table has a break at the level of the umbilicus producing additional lumbar lordosis and is tilted slightly head-down. Preparation (cid:142)(cid:3) The risks and alternatives and the types of reconstructions ar e discussed. (cid:142)(cid:3) The abdomen, perineum and genitalia (including vagina) are prepared with antiseptic solution (cid:142)(cid:3) A catheter is placed in the bladder. Incision (cid:142)(cid:3) A midline lower abdominal incision is made skirting around the umbilicus (cid:142)(cid:3) Circumcision of the female urethral meatus, or total urethrectomy in the male may precede cystectomy. Procedure (cid:142)(cid:3) Incise skin, subcutaneous fat, and superficial and deep fascia. (cid:142)(cid:3) Continue through anterior rectus sheath and, following blunt separation of the rectus muscles, transversalis fascia, and peritoneum. (cid:142)(cid:3) Di vide the median umbilical ligament and the peritoneum along each side of the bladder. In fe males divide and ligate round ligament and ovarian vessels. (cid:142)(cid:3) Take down adhesions to the bladder, especially from the descending or sigmoid colon. (cid:142)(cid:3) In the male ligate and divide the vasa deferentia. (cid:142)(cid:3) Perfor m pelvic lymph node dissection. Ligate or clip lymphatics. (cid:142)(cid:3) Identify the ur eters and divide them with their distal ends tied. (cid:142)(cid:3) Ligate and divide super ior and inferior vesical pedicles. (cid:142)(cid:3) Mobilize anteriorly by teasing away per ivesical and periprostatic fat, incising endopelvic fascia and dividing the pubo-urethral or -prostatic ligaments (see Figs . 13.7A, B). (cid:142)(cid:3) In females incise the vagina at the posterior fornix (a swab in the vagina helps \200\224(see Fig. 13.7C)). The vaginal incision is continued inferiorly on each side to join the urethral dissection. Use haemostatic clamps and oversew vaginal vessels later. RADICAL CYSTECTOMY1 505 Fig. 13.7 Radical cystoprostatectomy CHAPTER 13 Urology 506 (cid:142)(cid:3) In males, ligate the \200\230dorsal venous complex \200\231 anterior to t he urethra using the maneuvers illustrated in Figs. 13.7D, E. (cid:142)(cid:3) Oversew the proximal end of the dorsal vein complex, and divide the urethra as shown in Fig. 13.7F. (cid:142)(cid:3) In males, retract the prostate using the urethral catheter, while dividing prostatic pedicles and dissecting Denonvilliers \200\231s fascia off the rectum. (cid:142)(cid:3) Remove the specimen and pack the pelvis for a few minutes before securing final haemostasis and repairing vagina. (cid:142)(cid:3) A urinary diversion or reconstruction is now be performed see Bladder substitution. (cid:142)(cid:3) Closure is in layers with continuous or interrupted sutures or clips to skin. Complications (cid:142)(cid:3) Vessel or bowel injury (especially rectal) (cid:142)(cid:3) Pulmonary, wound, or urinary infection (cid:142)(cid:3) Thrombo-embolic complications (cid: 142)(cid:3) Erectile dysfunction, vaginal stenosis (cid:142)(cid:3) Local recurrence. Follow-up (cid:142)(cid:3) Initial wound check and histology review (cid:142)(cid:3) Regula r upper tract surveillance and biochemistry monitoring (cid:142)(cid:3) May include adjuvan t therapy. This page intentionally left blank CHAPTER 13 Urology 508 Radical retropubic prostatectomy Indications Prostate cancer in patients who are likely to benefit by virtue of (cid:142)(cid:3) The disease being probably significant, but surgicall y curable, and (cid:142)(cid:3) The patient having appropriate life-expectancy and performa nce status. Position Supine with stirrups or leg braces and a 20(cid:13) break opening the abdominopelv ic angle Preparation (cid:142)(cid:3) The entire lower abdomen, perineum, and genitalia are prepared with antiseptic solution (cid:142)(cid:3) Autologous blood is taken for subsequent reinfusion, and volume replaced (cid:142)(cid:3) A catheter is placed in the bladder (cid:142)(cid:3) Antibiotics are given with anesthetic induction. Incision (cid:142)(cid:3) Low median, Pfannenstiel, or Turner Warwick (cid:142)(cid:3) The approach is extraperitoneal. Procedure (cid:142)(cid:3) Deepen the incision is through skin, sub-cutaneous fat, and supe rficial and deep fascia. (cid:142)(cid:3) Continue through anterior rectus sheath and, following blunt separa- tion of the rectus muscles, transversalis fascia. (cid:142)(cid:3) Apply retractors and dissect in the retropubic space. (cid:142)(cid:3) Car ry out pelvic lymphnode sampling or dissection, removing external iliac, common iliac and obturator nodes. (cid:142)(cid:3) Incise the endopelvic fascia lateral to the prostate (as marked in Fig. 13.8A). (cid:142)(cid:3) Divide the puboprostatic ligaments. (cid:142)(cid:3) Separate the \200 \230dorsal venous complex \200\231 from the urethra (Figs. 13.8B, C), ligate and divide it, and oversew both ends for security (Fig. 13.8D). (cid:142)(cid:3) In nerve-sparing procedu res the \200\230neurovascular bundle \200\231 posterolateral to the urethra is preserved d uring this and subsequent dissection. (cid:142)(cid:3) Divide the urethra below the prostatic apices. (cid:142)(cid:3) Posterior blunt dissection separates Denonvilliers \200\231s fascia and prostate from rectum and expo ses seminal vesicles and posterior bladder neck (Fig. 13.8E). (cid:142)(cid:3) Incise the bladder near the bladder neck, and extend the dissection to sep arate bladder from prostate, taking care not to injure the ureters which are close by. (cid:142)(cid:3) Tailor the bladder neck if necessary, and evert bladder mucosa, before mak ing a urethrovesical anastomosis over a large Foley \200\231s catheter. Use 6 \200\2238 int errupted sutures, placed as illustrated in Fig. 13.8F. (cid:142)(cid:3) Drain the retropubic space and close the wound closed in layers. RADICAL RETROPUBIC PROSTATECTOMY1 509 Complications (cid:142)(cid:3) Intra-operative hemorrhage, vessel damage, rectal, or ureter al injury (cid:142)(cid:3) Pulmonary, wound, or urinary infection (cid:142)(cid:3) Thrombo- embolic complications (cid:142)(cid:3) Anastomotic leak or later a stricture (cid:142)(cid: 3) Urinary incontinence (cid:142)(cid:3) Erectile dysfunction. Follow-up (cid:142)(cid:3) Catheter is left a variable length of time (cid:142)(cid:3) Some surgeons perform post-op cystourethrography (cid:142)(cid:3) Pelvic floor exercises reduce incontinence (cid:142)(cid:3) Regular biochemical and possibly radiological surveillance. Fig. 13.8 Radical retropubic prostatectomy CHAPTER 13 Urology 510 Inguinal orchidectomy Indications Malignant tumors of the testes. Position Supine. Preparation (cid:142)(cid:3) Ensure tumor markers have been sent off preoperatively (cid:14 2)(cid:3) Lower abdomen and external genitalia are prepared and draped. Incision 2cm above and parallel to medial two thirds of inguinal ligament. Procedure (cid:142)(cid:3) Incise through the sub-cutaneous fat, Camper \200\231s, and Scar pa \200\231s fascia (cid:142)(cid:3) Incise external oblique from the external inguinal rin g, parallel with its fibers (cid:142)(cid:3) Identify and preserve the ilioinguinal nerve adjacent to the cord (cid:142 )(cid:3) Dissect the cord is to the internal ring and clamp it (cid:142)(cid:3) Deliver the testicle from the scrotum, and its scrotal attachments ligated and cut (cid:142)(cid:3) Inspect the testis without opening the tunica vaginalis (cid:142)(cid:3) L igate each component of the cord structures at the internal ring doubly and remove the specimen (cid:142)(cid:3) Closure is in layers with an undyed absorbable monofilament suture to skin. Complications (cid:142)(cid:3) Hemorrhage (cid:142)(cid:3) Infection. Follow-up (cid:142)(cid:3) Initial wound check (cid:142)(cid:3) Histology, imaging, and int erval repeat tumor markers (cid:142)(cid:3) Subsequent management will include intensive su rveillance or chemo- therapy, radiotherapy, lymph node dissection or combination. This page intentionally left blank CHAPTER 13 Urology 512 Partial penectomy Indications (cid:142)(cid:3) Carcinoma of the penis involving the glans a nd distal shaft (cid:142)(cid:3) Severe penile trauma. Position Supine or lithotomy. Preparation (cid:142)(cid:3) Penis and scrotum are prepared (cid:142)(cid:3) The tumor is i nvariably infected and is excluded from the operative field (cid:142)(cid:3) A tourniquet is placed at the base of the penis (cid:142)(cid:3) Antibioti cs are given. Incision (cid:142)(cid:3) The skin incision is circumferential (Fig. 13.9A) (cid:142)(cid:3 ) Allow at least 2cm margin from tumor. Procedure (cid:142)(cid:3) Ligate all longitudinal blood vessels (cid:142)(cid:3) Incise Bu ck \200\231s fascia and tunica albuginea penis, and transect the corpora cavernosa but pres erve corpus spongiosum at this level (Fig. 13.9B). (cid:142)(cid:3) Separate corpus spongio sum and urethra from the specimen, for about 1cm distally (cid:142)(cid:3) Suture the tunica albuginea penis and Buck \200\231s fascia as shown in Fig. 13.9C. (cid:142)(cid:3) Remove the tourniquet and spatulate the urethra (Fig. 13.9D). (cid:142)(ci d:3) Fashion a urethrocutaneous anastomosis using absorbable sutures and approximate skin dorsally (Fig. 13.9E). (cid:142)(cid:3) Insert a Foley \200\231s urethral catheter for 24 hours and apply non-adhe sive dressing. Complications (cid:142)(cid:3) Haematoma formation (cid:142)(cid:3) Infection (cid:142)(cid :3) Meatal stenosis. Follow-up (cid:142)(cid:3) Initial wound and anastomosis check (cid:142)(cid:3) May involve further surgery e.g. further radical penile surgery or lymph node dissection. PARTIAL PENECTOMY1 513 Fig. 13.9 Partial penectomy CHAPTER 13 Urology 514 Transurethral resection of the prostate (TURP) Indications (cid:142)(cid:3) Bothersome lowe r urinary tract symptoms unresponsive to medical therapy (cid:142)(cid:3) Complications of prostatic bladder outflow obstruction: (cid:142)(cid:3) Recurrent acute or acute-on-chronic urinary retention (cid:142)(cid:3) Rec urrent urinary tract infections (cid:142)(cid:3) Upper tract decompensation (renal failure or dilatation) (cid:142)(cid:3) Intractable haematuria of prostatic origin. Position Supine with the legs in lithotomy or Lloyd-Davies supports. Preparation (cid:142)(cid:3) Urine culture. Treat with appropriate antimicrobials preoperat ively if infected (cid:142)(cid:3) Antibiotics are given at induction of anesthesia (cid:142)(cid:3) Prep the external genitalia with antiseptic solution and a TUR drape allowing access for rectal manipulation of the prostate (cid:142)(cid:3) Glycine (1 \200\2231.5%) or Mannitol (3%) solution are so-called non- haem olytic irrigants, and are the visual medium for resection. Procedure (cid:142)(cid:3) Calibrate the urethra with Lister sounds and dilate or perform i nternal urethrotomy with the Otis urethrotome if necessary. (cid:142)(cid:3) Insert the resectoscope, either by using the obturator or under endoscopic vision. (cid:142)(cid:3) Perform endoscopic examination of bladder and prostatic urethra taking not e of landmarks (verumontanum, bladder neck, ureteral orifices). (cid:142)(cid:3) Begin at the bladder neck and, using the wire loop electrode, resect the m edian lobe until the circular fibers of the bladder neck can be seen, then resect the later al lobes in a stepwise manner. Finally, remove apical and anteriorly situated adenoma. Prev ent damage to the external sphincter by resecting only proximal to the verumontanum. Attend to haemostasis throughout resection to maintain excellent visibility. (cid:142)(cid:3) Remove resected tissue \200\230chips \200\231 with Ellik \200\231s evacua tor. (cid:142)(cid:3) Ensure excellent arterial haemostasis by cautery, if necessary using the rolling-ball electrode (cid:142)(cid:3) Insert a large-caliber (22 \200\22324Ch) triple-lumen Foley \200\231s cath eter and set up saline irrigation. Intermittent traction on the catheter can be used to arr est venous bleeding if necessary. Complications (cid:142)(cid:3) Hemorrhage (intra-or postoperative) with subsequent clot ret ention. (cid:142)(cid:3) Injury to bladder or rectum. TRANSURETHRAL RESECTION OF THE PROSTATE (TURP)1 515 (cid:142)(cid:3) TUR syndrome. (cid:142)(cid:3) This is a syndrome of mental confusion, nausea and vomiting, hyper- tensio n and bradycardia, with low serum sodium concentration (typically less than 125mEq/dL) seco ndary to absorption of irrigant via the opened venous channels of the prostate. (cid:142)(cid:3) The risk is greater during resections taking more than one hour. (cid:142)(cid:3) Postoperative chest or urinary tract infection. (cid:142)(cid:3) Thrombo-e mbolic complications. (cid:142)(cid:3) Sexual dysfunction \200\224retrograde ejaculation (c ommon), erectile dysfunction (rare). Follow-up (cid:142)(cid:3) Outpatient symptom review, physical exam, histology review after a few weeks. Investigations as clinically indicated. CHAPTER 13 Urology 516 Transurethral resection of bladder tumor (TURBT) Indications (cid:142)(cid:3) Curative trea tment and/or staging for newly diagnosed or recurrent bladder tumors (cid:142)(cid:3) Palliative treatment of haematuria secondary to bladder neoplasm. Position As for TURP. Preparation (cid:142)(cid:3) Preoperative upper tract evaluation for synchronous tumor is performed (cid:142)(cid:3) Antibiotics are given at induction of anesthesia (cid:142)(cid:3) The exte rnal genitalia are prepared and draped as for TURP. Procedure (cid:142)(cid:3) Perform bimanual examination under anesthesia, via vagina or rec tum. (cid:142)(cid:3) Avoid overdistension of the bladder and inadvertent resection of infolded bladder wall because of under-distension. (cid:142)(cid:3) Resect all exophytic tumor using a cutting current and resectoscope loop. (cid:142)(cid:3) Take care to resect deeply at the tumor base so that accurate, repre- sentative histology is obtained for staging. (cid:142)(cid:3) Where \200\230high risk disease \200\231 is suspected (not otherwise), ta ke additional biopsies from bladder urothelium and prostatic urethra. (cid:142)(cid:3) Specimens may be separated (tumor, base of tumor, selected-site biopsies) for examination. (cid:142)(cid:3) Obtain haemostasis, examine for bladder perforation. (cid:142)(cid:3) Repe at bimanual EUA if tumor was present before resection. (cid:142)(cid:3) Place a large calib er triple lumen Foley \200\231s catheter, and set up bladder irrigation if necessary. (cid:142)(cid:3) Document position and size of all lesions. Complications (cid:142)(cid:3) Hemorrhage (cid:142)(cid:3) Bladder perforation \200\224smal l and extraperitoneal perforations may be managed by catheter drainage (cid:142)(cid:3) Urinary tract infection (cid:142)(cid:3) Thrombo-embolic complications. TRANSURETHRAL RESECTION OF BLADDER tumor (TURBT) 1 517 Follow-up (cid:142)(cid:3) Immediate, postoperative intravesical Mitomycin C instillation r educes the risk of early recurrence of superficial transitional cell carcinoma. (cid:142)(cid:3) Guidelines have been published detailing surveillance strategies for superficial bladder cancer according to risk of disease recurrence and progression. Risk as sessment is commonly based on histological stage and grade, tumor size and multiplicity, an d frequency of recurrence. Surveillance will involve various combinations of endoscopy, upp er tract imaging and urine cytology. (cid:142)(cid:3) Muscle-invasive tumors or high-risk superficial cancer may require radical surgery, radiotherapy or chemotherapy, or combinations thereof. CHAPTER 13 Urology 518 Transurethral litholapaxy Indications Bladder calculi \200\224the stones are often associat ed with bladder outlet obstruction and this procedure can be combined with TURP. Position As for TURP Preparation (cid:142)(cid:3) As for TURP (cid:142)(cid:3) Exclude and treat those metabolic abnormalities sometimes associated with bladder stones (hyperparathyroidism, malnutrition). Procedure (cid:142)(cid:3) Keep the bladder adequately filled and continuously irrigated. ( cid:142)(cid:3) The stone is grasped and crushed manually with stone crushing forceps or li thotrite. Avoid including bladder wall or bladder neck in the jaws of the instrument. (cid:142)(cid:3) Intravesical pneumatic or ultrasonic lithotripsy and lasers can also be used. (cid:142)(cid:3) Remove fragments with an Ellik \200\231s evacuator. (cid:142)(cid:3) Thoro ughly examine the bladder for injury and stop any bleeding. (cid:142)(cid:3) Perform TURP o r bladder-neck incision if indicated. Complications (cid:142)(cid:3) High complication rates have been reported from this operati on both in isolation and in combination with TURP (cid:142)(cid:3) Hemorrhage (cid:142)(cid:3) Blad der injury (cid:142)(cid:3) Urinary tract infection (cid:142)(cid:3) Urethral stricture (cid:142)(cid:3) Thrombo-embolic complications. Follow-up Depends on etiology: (cid:142)(cid:3) If obstructive, as for TURP (cid:142)(cid:3 ) If metabolic, refer appropriately. This page intentionally left blank CHAPTER 13 Urology 520 Bladder augmentation: ileocystoplasy Many techniques have been developed. One method of aug mentation, and one type of continent catheterisable stoma are described (see Blad- der reco nstruction \200\224Mitroffanoff appendicovesicostomy). The two are often used together. Indications Poorly compliant, high pressure and or small volume bladder often asso- ciated with neuropathic conditions. Position Supine. Preparation (cid:142)(cid:3) The patient should be capable of performing self-catheterisati on and bladder washout (cid:142)(cid:3) Check renal function is adequate for metabolic consequences of urine reabsorption (cid:142)(cid:3) Bowel prep (cid:142)(cid:3) Prep and drape the abdomen (cid:1 42)(cid:3) Antibiotics with induction. Incision (cid:142)(cid:3) Low median, or Pfannenstiel (cid:142)(cid:3) Transperitoneal appr oach. Procedure (cid:142)(cid:3) Choose a 20 \200\22325cm segment of ileum reaching the pelvis, a voiding the terminal 20cm. (cid:142)(cid:3) Isolate and mobilize this on its mesenteric pedicle. (cid:142)(cid:3) Rest ore ileal continuity using any proven anastomotic technique and close the mesenteric defect above the isolated segment. (cid:142)(cid:3) Wash out the isolated segment and incise the antimesenteric border. (cid:1 42)(cid:3) Configure the opened segment like an inverted \200\230U \200\231 and suture adj acent edges using continuous all-layers absorbable suture. (cid:142)(cid:3) Now fold the reconfigured segment so that the superior and inferior margin s are approximated, and suture part-way down each side from the fold towards the open end i nferiorly to make a \200\230cup \200\231. (cid:142)(cid:3) Bivalve the bladder using a midline sagittal incision from near the blad- der neck anteriorly to just above the interureteral ridge posteriorly. The ureters should b e cannulated to avoid injury during dissection. (cid:142)(cid:3) Suture the ileal \200\230 cup \200\231 to the bladder, beginning at the apex of the blad- der incision posteriorly, a nd using 3/0 continuous absorbable sutures. (cid:142)(cid:3) Insert large-caliber urethral and/or suprapubic Foley \200\231s catheters and perivesical peritoneal drain/s. (cid:142)(cid:3) Close the abdomen in layers. BLADDER AUGMENTATION: ILEOCYSTOPLASY1 521 Complications Perioperative (cid:142)(cid:3) Thromboembolic disease (cid:142)(cid:3) Anasto motic leak (cid:142)(cid:3) Graft necrosis (cid:142)(cid:3) Wound, urinary tract, or chest infection. Complications of the use of bowel in the urinary tract (cid:142)(cid:3) Chronic bacteriuria (cid:142)(cid:3) Urolithiasis (cid:142)(cid:3) Metabolic alterations (cid:142)(cid:3) Acidosis (cid:142)(cid:3) Bone demineralization (cid:142)(cid:3) Disturbances of gastrointestinal function (cid:142)(cid:3) Diarrhea (cid:142)(cid:3) Anemia (cid:142)(cid:3) Reservoir rupture (cid:142)(cid:3) Malignancy. Follow-up (cid:142)(cid:3) Initially 8 hourly bladder washouts are done to remove mucus. After 14 \200\22321 days the catheters are usually removed \200\224consider cystogram to confirm integrity (cid:142)(cid:3) Confirm that bladder emptying is adequate or start intermittent self catheterisation (cid:142)(cid:3) The support of stoma therapist or specialist nurse is standard practice (c id:142)(cid:3) Urinary tract imaging is done at 6 weeks, 6 months and 1 year (cid:142)(cid: 3) Renal function and urine culture are done 3 monthly for 1 year, then annually (cid:142)(cid:3) Annual endoscopy should be done after 5 years. CHAPTER 13 Urology 522 Bladder augmentation: Mitroffanoff appendicovesicostomy Many methods have been described. O ne type of continent catheterisable stoma is described, often used together with the method of augmentation previously described (see Bladder augmentation \200\224ileocystoplasty). Indication (cid:142)(cid:3) An elegant means of access for intermittent catheterisation of a conti- nent reservoir, applicable to native bladder, augmented bladder, or continent pouc h (cid:142)(cid:3) Montie has described a similar technique using a tube of ileum \200\224 reconfigured so the plicae run longitudinally \200\224instead of appendix Preparation As for Ileocystoplasty. Position Supine or as appropriate for primary procedure. Incision As dictated by primary procedure \200\224usually Pfannenstiel, Turner-Warwick or m edian. Procedure (cid:142)(cid:3) The appendix is mobilized on its pedicle. Additional length can be obtained by including part of the caecum (Fig. 13.10A). (cid:142)(cid:3) The distal end of the appendix is placed into the reservoir in such a way that it forms a catheterisable conduit with a flap valve configura- tion for continence (Fi g. 13.10B). (cid:142)(cid:3) The caecal end is passed through the abdominal wall and sutured to skin us ing various means to make the anastomosis inconspicuous and resistant to stenosis e.g. VQZ flap, V flap. It may be concealed in the umbilicus. Complications (cid:142)(cid:3) As for the primary procedure, plus (cid:142)(cid:3) Appendic eal necrosis (cid:142)(cid:3) Stoma leakage (cid:142)(cid:3) Stenosis at skin level (cid:14 2)(cid:3) Urinary fistulas (cid:142)(cid:3) Mucus retention, chronic UTI and urolithiasis. Follow-up As for augmentation cystoplasty or continent urinary diversion. MITROFFANOFF APPENDICOVESICOSTOMY1 523 Mitroffanoff appendicovesicostomy (A) (B) Fig. 13.10 Bladder augmentation: Mitroffanoff appendicovesicostomy CHAPTER 13 Urology 524 Urinary tract reconstruction after cystectomy There are three commonly used groups of recon structions: (cid:142)(cid:3) Conduit urinary diversion (cid:142)(cid:3) Continent urinary d iversion (cid:142)(cid:3) Using the anal continence mechanism (cid:142)(cid:3) With continent cathet erisable stoma (cid:142)(cid:3) Orthotopic neobladder Conduit urinary diversion \200\224the ileal conduit Position As appropriate for the primary surgery (cystectomy), or supine. Preparation (cid:142)(cid:3) Appropriate counseling, marking of stoma site by stoma therapi st (cid:142)(cid:3) Bowel prep (cid:142)(cid:3) Antibiotics with induction (cid:142)(cid:3) Prep and drape the abdomen. Procedure (cid:142)(cid:3) Via a midline transperitoneal incis ion, incise the posterior peritoneum and mobilize ureters distally, preserving their blood supply. (cid:142)(cid:3) Digitally develop a tunnel through the retroperitoneum behind the sigmoid mesocolon, and pass the left ureter through it into the right iliac fossa (cid:142)(cid:3) Isolate a 12 \200\22315cm segment of ileum preserving its and adjacent bow el blood supply. Avoid using the distal 20cm of ileum. The pedicle should be longer towards the distal than the proximal end of the segment (Fig. 13.11). (cid:142)(cid:3) Restore ileal continuity using any proven anastomotic technique and close the mesenteric defect above the isolated segment. (cid:142)(cid:3) Spatulate each distal ureter for about 15mm and approximate adjacent edges of each spatulated portion using running full-thickness absorbable 4/0 sutur e. (cid:142)(cid:3) Pass a size 8Ch infant feeding tube or purpose-made ureteral stent up each ureter and fix to the inside of the lower ureter with absorbable suture. Pass the free end s through the conduit. (cid:142)(cid:3) Anastomose the proximal end of the conduit to the common ureteral opening using watertight continuous or interrupted 4/0 absorbable suture. (cid:142)(cid:3) Excise a disc of skin at the stoma site and make a cruciate incision throu gh subcutaneous fascia, rectus sheath, and transversalis fascia. (cid:142)(cid:3) If possib le, develop a space between the parietal peritoneum and the abdominal wall so that the conduit can be retroperitonealised. (cid:142)(cid:3) Bring the d istal end of the conduit out via the stoma incision for about 4 \200\2236cm and fix it to rectus sheath with 6 interrupted absorbable seromuscular sutures. (cid:142)(cid:3) Evert the end of the conduit and suture to the dermis. (cid:142)(cid:3) Dr ain the abdomen and retroperitoneum. (cid:142)(cid:3) Close the abdomen in layers and apply stoma appliance. URINARY TRACT RECONSTRUCTION AFTER CYSTECTOMY1 525 Complications Very similar to those of Ileocystoplasty (see pp536 \200\2237) Follow-up (cid:142)(cid:3) Drains can usually be removed after about 5 days. If copious dra inage persists, check creatinine level of drain fluid to exclude urine leak. (cid:142)(cid:3) The stents are removed after about 14 days. (cid:142)(cid:3) The support o f stoma therapist or specialist nurse is standard practice. (cid:142)(cid:3) Imaging is don e at 6 weeks, 6 months, and 1 year. (cid:142)(cid:3) Renal function is checked 3 monthly fo r 1 year, then annually. (cid:142)(cid:3) Follow up also according to the primary disease ( e.g. bladder cancer). Continent urinary diversion \200\224using the anal continence mechanism \200\224the Mainz I I sigma rectum Indications (cid:142)(cid:3) Continent urinary diversion in patients unsuita ble for other techniques of continent reconstruction or conduit diversion (cid:142)(cid:3) Note: (cid:142)(cid:3) High frequency of serious sequelae limits its application (cid:142)(cid:3) The reconfiguration of the sigmoid reduces luminal pressure and increases capacity (cid:142)(cid:3) Renal and liver failure are contraindications. Position As appropriate for the primary surgery/cystectomy, or supine. Fig. 13.11 Preparation of ileal conduit CHAPTER 13 Urology 526 Preparation (cid:142)(cid:3) Colonic assessment (colonoscopy), and assessment of anal conti nence mechanism (retain a 300ml soft-porridge enema for 2 hours) (cid:142)(cid:3) Otherwise, as for Ileal conduit. Procedure (cid:142)(cid:3) Incision and u reteral mobilization as for ileal conduit (except that the left ureter is not transposed) (cid:142)(cid:3) Open the sigmoid colon along a taenial line for 12cm, so that the sigmoid resembles an inverted \200\230U \200\231 shaped trough (cid:142)(cid:3) Approximate the adjacent free edges of the U with 2 layers of absorbable 3 /0 suture to form the posterior wall (Fig. 13.12) (cid:142)(cid:3) Tunnel the distal ureters through a taenium, and then submucosally for 4 \200\2235cm, and suture the spatulated ends to colonic mucosa. Stents may be placed and bro ught out through the rectum with a large rectal tube (cid:142)(cid:3) Close the anterior wall of the reservoir, place abdominal drains and close the abdomen Complications See under Ileocystoplasty (p537), but also (cid:142)(cid:3) Stoma-related pro blems (kinking, stenosis, false passage), and note that (cid:142)(cid:3) Metabolic acidosis requiring treatment, and (cid:142)(cid:3) Development of malignancy (rectal carcinoma) are much commoner. Follow-up (cid:142)(cid:3) As for Ileocystoplasty, and (cid:142)(cid:3) Ann ual colonoscopy (cid:142)(cid:3) Follow-up appropriate to the primary disease (e.g. urothel ial cancer). Continent urinary diversion with continent catheterizable stoma \200\224the Mainz pouch Pre paration (cid:142)(cid:3) Requires a highly motivated patient fully informed about pouch ma in- tenance, complication, and reoperation rates, and with normal manual dexterity (cid:142)(cid:3) Otherwise as for Ileal conduit (p540). Procedure (cid:142)(cid:3) Mobilize ureters as for Ileal conduit. (cid:142)(cid:3) Isolate a segment of bowel consisting of ca ecum (15cm) and adjoining ileum (50cm) and mobilize on its vascular pedicle (Fig. 13.13A). (cid:142)(cid:3) Restore ileocolic continuity and close the mesenteric defect. (cid:142)(ci d:3) Open the caecum longitudinally anterior to the ileocaecal valve and the ileum for 30cm along its antimesenteric edge. (cid:142)(cid:3) Make a window in the mesentery beginning where the ileal incision ends (Fig. 13.13B). URINARY TRACT RECONSTRUCTION AFTER CYSTECTOMY1 527 Fig. 13.12 Mainz II Sigma rectum: preparation of sigmoidcolon Fig. 13.13 The Mainz pouch CHAPTER 13 Urology 528 (cid:142)(cid:3) Reconfigure the ileal and caecal segments as illustrated to create a hemisphere, leaving the ileocaecal valve intact. (cid:142)(cid:3) Intussuscept the ileal segment and draw the intussusceptum through the ileocaecal valve. The linear stapling device is usually used to fix this segment in pla ce (Fig. 13.13C). (cid:142)(cid:3) The free end of the ileum is brought out as a flush stoma for self catheterisation. (cid:142)(cid:3) Spatulate and implant ureters into caecum, via a 4 \200\2235cm submucosal tunnel, and make a stented mucosal anastomosis. (cid:142)(cid:3) Leave a large bore catheter in the reservoir via the catheterisable stoma, and bring the ureteral stents through reservoir and abdominal walls. (cid:142)(cid:3) Close the reservoir as illustrated (Fig. 13.13D). (cid:142)(cid:3) Place a bdominal drains and close the abdomen. Complications As for Ileocystoplasty. Follow-up (cid:142)(cid:3) As for Ileocystoplasty, and appropriate to the primary diagnosis (e.g. urothelial cancer) Orthotopic bladder substitution \200\224the Studer Ileal neobladder with proximal ileal con duit Indications As for Mainz pouch (above) but contraindications for retention of the nati ve urethra and its continence mechanisms must not exist, and the patient must be highly mot ivated and desirous of orthotopic diversion, and prepared to acknowledge and accept the ris k of associated complications. Preparation As for Mainz pouch. Procedure After cystectomy with preservation of urethra and its continence mechanism (cid:1 42)(cid:3) Mobilize a 56cm segment of ileum, avoiding the terminal 15cm. (cid:142)(cid:3) R estore ileal continuity and close the mesenteric defect above the segment. (cid:142)(cid:3) Close the distal end. (cid:142)(cid:3) Open the isolated segment on its an timesenteric side, from a point near the (closed) distal end, for about 40cm, leaving the proximal 15cm tubular as the isop eristaltic \200\230afferent limb \200\231 to prevent ureteral reflux. URINARY TRACT RECONSTRUCTION AFTER CYSTECTOMY1 529 (cid:142)(cid:3) Configure the opened segment like a \200\230U \200\231, and suture adjace nt walls. (cid:142)(cid:3) Anastomose ureters onto the afferent limb. A technique like that described above under Ileal conduit is acceptable. (cid:142)(cid:3) Bring the stents out through the wall of the \200\230afferent limb \200 \231 and the abdominal wall, and drain into a urostomy appliance. (cid:142)(cid:3) Anastomose the urethra to the edges of an incision made in the dependent portion of the detubularised ileal segment, using six to eight 3/0 monofilament a bsorbable sutures, and place a large caliber Foley \200\231s urethral catheter across the a nastomosis and insert a large suprapubic catheter through abdominal wall and the anterior w all of the neobladder. (cid:142)(cid:3) Close the anterior wall of the neobladder to form a spherical reservoir. (cid:142)(cid:3) Drain the pelvis and close the abdomen. Complications (cid:142)(cid:3) As for Mainz pouch, plus (cid:142)(cid:3) Urinary incontinence (stress and overflow type and n octurnal incontinence) (cid:142)(cid:3) Urethroileal anastomotic stricture. Follow-up (cid:142)(cid:3) Perioperati ve care as for Ileocystoplasty and Mainz pouch (cid:142)(cid:3) Begin pelvic floor exercise s immediately postoperatively (cid:142)(cid:3) Remove drains when drainage diminishes, sten ts after 1 \200\2232 weeks (cid:142)(cid:3) Remove urethral catheter and clamp suprapubic c atheter after 1 \200\2233 weeks (cid:142)(cid:3) Thereafter as for Mainz pouch. CHAPTER 13 Urology 530 Surgery for vesicovaginal fistula Vaginal approach Indication Benign vesicovaginal fistula. Position Extended lithotomy. Preparation (cid:142)(cid:3) Prep the vagina and vulva with antiseptic solution. Shave if n ecessary (cid:142)(cid:3) Place appropriate retractors e.g. Scott ring retractor and Auvard weighted retractor. Procedure (cid:142)(cid:3) Perform cystoscopy, and cannulate ureteral orifices if necessary . (cid:142)(cid:3) Make an inverted U incision in the anterior vaginal wall, including the fistula, and raise a flap of vaginal skin. (cid:142)(cid:3) Mobilize the fistulous tract through the perivesical fascia and excise it. (cid:142)(cid:3) Separate bladder, perivesical fascia, and vagina for a small distance. (c id:142)(cid:3) Close the bladder defect in the midline using interrupted absorbable sutures. (cid:142)(cid:3) Close the perivesical fascia transversely. (cid:142)(cid:3) Excise the fre e end of the vaginal skin flap, and advance it to cover the repair. Suture with interrupted absorbable suture material. (cid:142)(cid:3) Additional security can be obtained by the interposition of pedicled tissue flaps. (cid:142)(cid:3) In each case, the flap is tunneled deep to vaginal skin and sutured in place to separate vaginal and vesical repairs. (cid:142)(cid:3) The labial incision is then closed. (cid:142)(cid:3) A vaginal pack is lef t in place for 24 \200\22348 hours. Complications (cid:142)(cid:3) Fistula recurrence (cid: 142)(cid:3) Urinary tract infection (cid:142)(cid:3) Ureteral injury (cid:142)(cid:3) Hemor rhage, infection, thromboembolic disease. Follow-up (cid:142)(cid:3) Indwelling urethral or suprapubic catheter for 14 \200\22321 days. A cystogram may be obtained before removal of catheter. Abdominal approach Position Lithotomy Preparation (cid:142)(cid:3) The abdomen, vulva and vagina prepped with antiseptic solution and draped (cid:142)(cid:3) Cystoscopy is performed, the ureters maybe cannulated. Incision Pfannensti el or median (better for omentoplasty) SURGERY FOR VESICOVAGINAL FISTULA1 531 Procedure (cid:142)(cid:3) Mobilize the bladder anteriorly in the perivesical space and biv alve it sagittally. (cid:142)(cid:3) Dissect between bladder and vagina until the fistula tract can be ex- cised leaving healthy bladder, perivesical fascia and vagina separated for a distance aroun d the fistula. (cid:142)(cid:3) Repair bladder and perivesical fascia, taking care not to incorporate ureters into the repair and repair vagina if possible.