A risk is de \201 ned as a material one (one that matters, one that is impor- tant) if a r easonable person in the patient \200\231s circumstances, if warned of that risk, would atta ch signi \201 cance to it (e.g. loss of the tip of a little \201 nger may be of little l ong-term consequence to many people, but for the concert pianist, it could be a disaster). In the words of Lord Scarman, disclosure is necessary: \200\230 where the risk is such that in the court \200\231s view, a prudent person in the patient \200\231s situation would have regarded it as signi \201 cant. \200\231 Thus, the amount and type of information you give is different in every case. Just because there is a less than 1 in 100 chance of a particular risk materializing does not mean you n eed not warn about this particular risk: \200\230When one refers to a \200\230signi \201 cant risk \200\231, it is not possible to talk in precise percentages. \200\231 (Lord Woolf in Pearce vs United Bristol HA 1996.)1 The obvious example is the need to warn of post-vasectomy pregnancy which occurs very infre quently (1 in 3000 cases). Failure to warn of such a risk would nowadays be regarded as sub standard care. Remember, it can be argued that the consent was not valid because the amount of information you gave was not enough or was in a form the patient could not understand. CONSENT: GENERAL PRINCIPLES 741 Recording Remember, record the consent discussion in the notes. If you do not record what y ou said, you might as well not bother saying it. If a patient later claims that they were n ot told of a particular risk or outcome, it will be dif \201 cult to refute this if your n otes do not record what you said. Writing \200\230risks explained \200\231 is inadequate. When cases do come to court, this is usually sev- eral years after the events in question. You will have forgotten precisely what you said to the patient and it will not take much ef fort on the part of a barrister to suggest that you might not have said everything that you thought you said! If you give a written information sheet, record that you have done so an d put a copy of the version you gave in the notes. The consent form The consent form is designed to record the patient \200\231s decision and to some extent, the discussions that took place during the consent process (although the sp ace available for recording the discussion, even on the new NHS consent form, is limited). It is not proof that the patient was properly informed \200\224that valid consent was obtai ned. Avoid, if possible, technical abbreviations such as TURBT. A patient could reasonably claim not to have understood what this was. Try to avoid standing over the patient waiting for them to sign the form. It is a good practice to leave the form with them and to return after a few minutes \200\224they will feel less pressured and can ask further questions if they wish. Children Children aged less than 16 may give consent as long as they fully under- stand wha t is involved in the proposed examination or treatment (a parent cannot override the compet ent child \200\231s consent to treatment). However, a child cannot refuse consent to treatm ent (i.e. a parent can override a child \200\231s refusal to consent \200\224the parent can consent on the child \200\231s behalf if the child refuses consent, although such situatio ns are rare). 1 Pearce and another v. United Bristol Healthcare NHS Trust, 48 BMLR 118. 1996. CHAPTER 17 Urological surgery and equipment 742 Cystoscopy A basic skill of the urologist. Allows direct visual inspection of the urethra a nd bladder. Indications \200 Haematuria. \200 Irritative LUTS (marked frequency and urgency) where intravesical pathology is suspected (e.g. carcinoma in situ, bladder stone). For bladder bi opsy. Follow-up surveillance of patients with previously diagnosed and treated bladder canc er. Retrograde insertion of ureteric stents and removal. Cystoscopic removal of stones. \200 \200 Technique \200 Flexible cystoscopy: \202 exible cystoscope is easily passed down the urethra and into th e bladder following instillation of lubricant gel (with or without local anesthetic \200 \224a meta-analysis of nine RCTs showed no difference in pain control between lidocaine gel and plain gel lubrication).11 Principally diagnostic, but small biopsies can be taken with a \202 exible biopsy forceps, small tumors can be fulgurated (with a diathermy probe) or vaporized (with a laser \201 bre), and JJ stents can be inserted and removed using this type of cystoscope. Rigid cystoscopy: rigid metal instrument which can be passed under loca l anesthetic in women (short urethra), but usually requires general anesthetic. Preferred o ver \202 exible cystoscopy where deeper biopsies will be required or as an antecedent to TURBT or cystolitholapxy where it is anticipated that other pathology will be found (tumor, stone). The \202 exible cystoscope uses \201 bre optics for illumination and image trans- missi on. It can be de \202 ected through 270 . Common post-operative complications and their management Mild burning discomfort and haemat uria are common after both \202 exible and rigid cystoscopy. It usually resolves within h ours. Bacteriuria after \202 ex- ible cystoscopy occurs in about 8 \200\2239% of patients (4 \200\2235% have bacteriuria before cystoscopy) and this rate is reduced by prophylactic antibiotics (see Table 17.1). BAUS procedure-speci \201 c consent form: recommended discussion of adverse events Serious or frequently occurring complications of \202 exible cystoscopy Warn the patient that if the cystoscopy is being done because of hae- maturia, it is possible that a bladder cancer may be found, which may require further treatment. You should speci \201 cally seek conse nt for biopsy (removal of tissue if an abnormality is found). CYSTOSCOPY 743 Common \200 Mild burning or bleeding on passing urine for a short period after operation. Biopsy of an abnormal area in the bladder may be required. Occasional \200 Rare \200 \200 \200 Infection of bladder requiring antibiotics. Temporary insertion of a catheter. Delayed bleeding requiring removal of clots or further s urgery. Injury to urethra causing delayed scar formation (a stricture). Serious or frequently occurring complications of rigid cystoscopy \200 \200 \200 As for \202 exible cystoscopy. The use of heat (diathermy) may be required to cauterize b iopsy sites. Very rarely, perforation of the bladder can occur, requiring temporary inserti on of a catheter or open surgical repair. 1 Patel AR, Jones JS, Babineau D (2008) Lidocaine 2% gel versus plain lubricating gel for p ain reduction during \202 exible cystoscopy: a meta-analysis of prospective, randomized c ontrolled trials. J Urol 179:986 \200\22390. CHAPTER 17 Urological surgery and equipment 744 Transurethral resection of the prostate (TURP) Indications \200 Bothersome LUTS which fail to respond to changes in lifestyle or medical therapy. Recurrent acute urinary retention. Renal impairment due to BOO (high-pressure retention). Recurrent haematuria due to BPE. Bladder stones due to prostatic obstruction. \200 chronic urinary \200 Post-operative care A 3-way catheter is left in situ after the operation, through which irr igation \202 uid (normal saline) is run to dilute the blood so that a clot will not form to block the catheter. The rate of in \202 ow of the saline is adjusted to keep the out \202 ow a pale pink ros color and as a rule, the rate of in \202 ow can be cut down afte r about 20min. The irrigation is continued for 12 \200\22324h. The catheter is removed the day after (second post-operative day) if the urine has cleared to a normal color (TWOC or t rial of void (TOV)). Common post-operative complications and their management Blocked catheter post-TURP Common The catheter may become blocked with clot or a prostatic \200\230chip \200\231 which was i nadvertently left in the bladder at the end of the operation. \200 Apply a bladder syringe to the end of the catheter to try to dislodge the obstruction. If t his fails, withdraw some irrigant into the syringe and \202 ush the catheter. If this fai ls, change the catheter. The obstructing chip of prostate may be found stuck in one of the eyeholes of the catheter. Pass a new catheter on an introducer. If the bladder has been allowed to become so full of clot that a simple bladder washout is unable to evacuate it all, return the patient to the theater for clot evacuation. Hemorrhage Minor bleeding after TURP is common and will stop spontaneously. A simple system to allow communication between staff is to describe the color of the urine draining throug h the catheter as the same as a ros wine (minor haematuria), a dark red wine (moderate ha ematuria), or frank blood (bright red bleeding, suggesting serious hemorrhage). The ros u rine requires no action. Dark red urine should be managed by increas- ing the \202 ow of irrigant and by applying gentle traction to the catheter (with the balloon in \202 ated to 40 \200\22350mL), thereby pulling it onto the blad- der neck or into the prostatic fossa t o tamponade bleeding for 20min TRANSURETHRAL RESECTION OF THE PROSTATE (TURP) 745 or so. This will usually result in the urine clearing. An attempt at controlling heavier bl eeding by these techniques may be tried, but at the same time, you should make preparations to return the patient to theater because it is unlikely that bleeding of this degree will stop. The bleeding vessel(s), if seen, is controlled with diathermy. If bleeding persists, open surgical control is required \200\224the prostatic capsule is opened, the bleeding ves sels sutured, and the prostatic bed packed. Post-operative bleeding requiring a return to t heater occurs in 0.5% of cases.1 BAUS procedure-speci \201 c consent form \200\224recommended discussion of adverse events Serious or frequently occurring complications of TURP \200 Temporary mild burning on passing urine, urinary frequency, haematuria. Retrograde ejaculat ion in 75% of patients. Failure of symptom resolution. Permanent inability to achieve an er ection adequate for sexual activity. UTI requiring antibiotic therapy. Ten percent of patie nts require redo surgery for recurrent prostatic obstruction. Failure to pass urine after t he post-operative catheter has been removed. In 10% of patients, prostate cancer is found o n subsequent pathological examination of the resected tissue. Urethral stricture formation requiring subsequent treatment. Incontinence (loss of urinary control) \200\224may be tempo rary or permanent. Absorption of irrigating \202 uid causing confusion and heart failure (TUR syndrome). Very rarely, perforation of the bladder requiring a temporary urinary cathe ter or open surgical repair. \200 \200 \200 \200 \200 Alternative therapy: observation, drugs, catheter, stent, laser prostatec- tomy, open opera tion. 1 Emberton M, Neal DE, Black N, et al. (1995) The National Prostatectomy Audit: the clinica l management of patients during hospital admission. Br J Urol 75:301 \200\22316. CHAPTER 17 Urological surgery and equipment 746 Transurethral resection of bladder tumor (TURBT) Indications \200 Local control of non-muscle-invasive bladder cancer (i.e. stops bleeding tumors). to determ ine whether the cancer is non- Staging of bladder cancer: muscle-invasive or muscle-invasiv e so that subsequent treatment and appropriate follow-up can be arranged. Post-operative care A 2- or 3-way catheter is left in situ after the operation, depending o n the size of the tumor and, therefore, on the likelihood that bleeding requiring irrigatio n will be required. As for TURP, normal saline is run through the catheter to dilute the bl ood so that a clot will not form to block the cath- eter. It is particularly important to a void catheter blockage post-TURBT since this could lead to distension of the bladder alread y weakened by resection of a tumor. The period of irrigation is usually shorter than that r equired after TURP and for small tumors, the catheter may be removed the day after the TURB T. For larger tumors, remove it 2 days later. Common operative and post-operative complications and their management Bladder perforation during TURBT Small perforations into the perivesical tissues (extraperitoneal) are not unco mmon when resecting small tumors of the bladder and so long as you have secured good haemos tasis and all the irrigating \202 uid is being recovered, no additional steps are require d, except that perhaps one should leave the catheter in for 4 rather than 2 days. Intraperitoneal perforations (through the wall of the bladder, through the peritoneum, and into the peritoneal cavity) are uncommon, but far more serious. Is it an extraperitoneal or intraperitoneal perforation? Establishing this can be dif \201 cult. Both can cause marked distension of the lower abdo- men \200\224an intraperitoneal p erforation by allowing escape of irrigating solu- tion directly into the abdominal cavity a nd an extraperitoneal perforation by expanding the retroperitoneal space, with \202 uid t hen diffusing directly into the peritoneal cavity. The fact that a suspected intraperitonea l per- foration was actually extraperitoneal becomes apparent only at laparot- omy when no hole can be found in the peritoneum overlying the bladder (the peritoneum over the bladder is not breached in an extraperitoneal perforation). When there is no abdominal distension, the volume of extravasated \202 uid is likely to b e low and if the perforation is small, it is reasonable to manage the case conservatively. Achieve haemostasis and pass a catheter. Make frequent post-operative assessments of the pa tient \200\231s vital signs and abdomen (worsening abdominal pain, distension, and tenderne ss suggest the need for laparotomy). TRANSURETHRAL RESECTION OF BLADDER tumor (TURBT) 747 Where there is marked abdominal distension, whether the perforation is extraperitoneal or i ntraperitoneal, explore the abdomen, principally to drain the large amount of \202 uid (w hich can compromise respiration in an elderly patient) by splinting the diaphragm, but also to check that loops of bowel adjacent to the site of perforation have not been injured at the same time. Failing to make the diagnosis of an intraperitoneal perforation, particularl y if the bowel has been injured, is a worse situation to be in than performing a laparotomy for a suspected intraperitoneal perforation, but then \201 nding that the perforation wa s \200\230only \200\231 extraperitoneal. Open bladder repair Pfannenstiel incision or lowe r midline abdominal incision, open the blad- der, evacuate the clot, control bleeding, and repair the hole. Open the peritoneum and inspect small and large bowel for perforations. Le ave a urethral catheter and a drain in place. Blocked catheter post-TURBT The catheter may become blocked with clot. Use the same techniq ue for unblocking it as for TURP, but avoid vigorous washouts of the bladder because of the risk of bladder perforation. Hemorrhage Minor bleeding after TURBT is common and will stop spontaneously. The only \200 \230technique \200\231 for controlling it is to ensure that an adequate \202 ow of irriga nt is maintained (to dilute the blood and thereby, preventing clots from forming). If bleed ing persists, return the patient to theater for endo- scopic control. TUR syndrome Uncommon after TURBT unless the tumor is large and the resection, therefore, l ong. BAUS procedure-speci \201 c consent form \200\224recommended discussion of adverse events Serious or frequently occurring complications of TURBT Common complications \200 \200 Mild burning on passing urine. Additional treatment (intravesical chemotherapy or immunothe rapy) may be required to reduce the risk of future tumor recurrence. UTI. No guarantee of b ladder cancer cure. Tumor recurrence is common. \200 \200 Rare complications \200 \200 Delayed bleeding requiring removal of clots or further surgery. Damage to drainage tubes fr om kidney (ureters) requiring additional therapy. Development of a urethral stricture. Blad der perforation requiring a temporary urinary catheter or open surgical repair. \200 Alternative treatment: open removal of bladder; chemotherapy, radiation. CHAPTER 17 Urological surgery and equipment 748 Optical urethrotomy Indications \200 \200 Bulbar urethral stricture. Also used for penile urethral strictures. Anesthesia: regional or general. Post-operative care \200 Leave a catheter for 3 \200\2235 days (longer catheterization does not reduce long-term res tricturing). Consider ISC for 3 \200\2236 months, starting several times daily, reducing to once or twice a week towards the end of this period. Common post-operative complications and their management \200 Septicaemia. \200 Restric turing: is the most common long-term problem occurring after optical urethrotomy. BAUS procedure-speci \201 c consent form \200\224recommended discussion of adverse events Common \200 \200 \200 Mild burning on passing urine for short periods of time after operation. Temporary insertio n of a catheter. Need for self-catheterization to keep the narrowing from closing down agai n. Occasional \200 \200 Infection of bladder requiring antibiotics. Permission for telescopic removal/biopsy of bla dder abnormality/ stone, if found. Recurrence of stricture necessitating further procedures or repeat incision. Rare: decrease in quality of erections, requiring treatment. Alternative therapy: observation, urethral dilatation, open (non-telescopic) repair of stri cture. This page intentionally left blank CHAPTER 17 Urological surgery and equipment 750 Circumcision Indications \200 Phimosis. \200 Recurrent paraphimosis. \200 Penile canc er con \201 ned to the foreskin. \200 Lesions on the foreskin of uncertain histological nature. Contraindications \200 \200 In neonates \200\224hypospadias, chordee with hypospadias, microphallus. In all patients \200\224bleeding diatheses. Circumcision in HIV prevention Male circumcision has a signi \201 cant protective effect a gainst HIV infection.1,2 This is thought to be due to the presence of large numbers of HIV- binding target cells being present on the inner layer of the prepuce compared to the glans and outer prepuce (which is lined by squamous epithelium). Clearly, mass circumcision programs in Africa and other high risk areas would be a huge tas k. In addition, concerns have been expressed that this bene \201 cial effect will be negat ed by increased behavior that increases HIV risk (e.g. a drop in condom use, a rise in sexu al partners). Anesthesia: local or general. Post-operative care A non-adhesive dressing may be applied to the end of the penis, but thi s is dif \201 cult to keep on for more than an hour or two and is unneces- sary. Warn the patient that the penis may be bruised and swollen after the operation, but that this resolv es spontaneously over a week or two. Sexual intercourse or masturbation should be avoided u ntil the absorb- able skin sutures have dissolved. Common post-operative complications and their management You might think that circumcision is about as simple an operation as you can get, but it can cause both the patient (or, in t he case of little boys, their parents) and you considerable concern if the cosmetic result is not what was expected or if \200\230complications \200\231 occur about which the patien t was not warned. As with any procedure, it should be performed with care and with the pote ntial complications always in mind so that steps can be taken to avoid these. If complicati ons do occur, manage them appropriately. Hemorrhage Most frequently occurs from the frenular artery on the ventral surface of the pe nis. If local pressure does not stop the bleeding (and if it is from the frenular artery, i t usually won \200\231t), return the patient to theater and, either under ring block local anesthesia or general anesthesia, suture ligature the bleeding vessel. Be careful not to pl ace the suture through the urethra! CIRCUMCISION 751 Necrosis of the skin of the shaft of the penis In most cases of suspected skin necrosis, th ere is none. Not infrequently, a crust of coagulated blood develops around the circumferenc e of the penis after circumcision. As blood oxidizes, it turns black and this appear- ance can be mistaken for necrosis of the end of the penis. Reassurance of the patient (and the r eferring doctor!) is all that is needed. If necro- sis has occurred because, for example, a drenaline was used in the local anesthetic, wait for the necrotic tissue to demarcate befor e assessing the extent of the problem. The penis has a superb blood supply and has remarkab le healing characteristics. Separation of the skin of the coronal sulcus from the shaft skin If limited to a small area , this will heal spontaneously. If a larger circumfer- ence of the wound has \200\230dehis ced \200\231, resuture in theater. Wound infection: rare. Urethrocutaneous \201 stula: du e to haemostatic sutures (placed to control bleeding from the frenular) passing through the urethra, the wound later breaking down. Urethral damage: due to a stitch placed through the urethra as the frenu- lar artery is sut ure ligatured. Excessive removal of skin Re-epithelialization can occur if the defect between the glans an d the shaft skin is not too great. If the defect is too great, the end result will be a bur - ied penis \200\224the glans retracts towards the skin at the base of the penis. BAUS procedure-speci \201 c consent form \200\224recommended discussion of adverse events Serious or frequently occurring complications of circumcision \200 \200 \200 \200 \200 \200 \200 \200 Bleeding of the wound, occasionally needing a further procedure. Infection of incision requ iring further treatment. Permanent altered sensation of the penis. Persistence of absorbabl e stitches after 3 \200\2234 weeks, requiring removal. Scar tenderness, rarely long-term. Y ou may not be completely cosmetically satis \201 ed. Occasional need for removal of excess ive skin at a later date. Permission for biopsy of abnormal area of glans if malignancy is a concern. Alternative therapy: drugs to relieve in \202 ammation, leave uncircumcised. 1 Bailey RC, Moses S, Parker CB, et al. (2007) Male circumcision for HIV prevention in youn g men in Kisumu, Kenya: a randomized controlled trial. Lancet 369:643 \200\22356. 2 Gray RH, Kigozi G, Serwadda D, et al. (2007) Male circumcision for HIV prevention in men in Rakai, Uganda: a randomized trial. Lancet 369:657 \200\22366. CHAPTER 17 Urological surgery and equipment 752 Hydrocele and epididymal cyst removal Hydrocele repair (removal) Indications: primary (idio pathic) hydrocele repair; not indicated for sec- ondary hydrocele repair. Anesthesia: local or general. Techniques \200 Lord \200\231s plication technique: (minimal interference with surrounding scrotal tissues, which minimizes the risk of post-operative haematoma). Jaboulay procedure: for small- to medium-sized hydroceles for large hydroceles; excision of hydrocele sac. Hydrocele aspiration Strict attention to asepsis is vital since the introduction of infecti on into a closed space could lead to abscess formation. Avoid super \201 cial blood vessel s (if you hit them, a large haematoma can result). Post-operative care: nothing speci \201 c. Post-operative complications and their management \200 \200 Scrotal swelling: Haematoma formation: performed as spontaneous resolution may take many we eks. It can be dif \201 cult to identify the bleeding vessel. Leave a small drain to preve nt reaccumulation of the haematoma. Hydrocele recurrence. resolves spontaneously. if it is large, surgical drainage is best Epididymal cyst removal (spermatocelectomy) \200 Avoid in young men who wish to maintain fertility since epididymal obstruction can occur. A n alternative to surgical removal is aspiration, though recurrence is usual. BAUS procedure-speci \201 c consent form: recommended discussion of adverse events Hydroce le removal Occasional \200 \200 Recurrence of \202 uid collection can occur. Collection of blood around the testes that r esolves slowly or requires surgical removal. Possible infection of incision or testis requi ring further treatment. Alternative therapy \200 Observation. \200 Removal of \202 uid with a needle. HYDROCELE AND EPIDIDYMAL CYST REMOVAL 753 Epididymal cyst removal Occasional \200 \200 Recurrence of \202 uid collection can occur. Collection of blood around the testes that r esolves slowly or requires surgical removal. Possible infection of incision or testis requi ring further treatment. Rare \200 Scarring can damage the epididymis causing subfertility. Alternative therapy: observation, removal of \202 uid with a needle. CHAPTER 17 Urological surgery and equipment 754 Nesbit \200\231s procedure Penile straightening procedure for correcting penile curvature. Wait for at least 6 months after the patient has experienced no more pain and wait for the penile curvature to stabilize (there is no point in repairing the curvature if it is still progressing). Indications: Peyronie \200\231s disease. Anesthesia: local or general. Post-operative care: avoid intercourse for 2 months. Oedema can be managed with cold compre sses. BAUS procedure-speci \201 c consent form: recommended discussion of adverse events Serious or frequently occurring complications Common \200 \200 \200 Occasional \200 \200 \200 Rare \200 \200 Some shortening of the penis. Possible dissatisfaction with the cosmetic or functional resu lt. Temporary swelling and bruising of the penis and scrotum. Circumcision is sometimes required as part of the procedure. There is no guarantee of total correction of the bend. may require further treatment. Bleeding or infection: Impotence or dif \201 culty maintaining an erection. Nerve injury with temporary or perman ent numbness of penis. Alternative treatment: observation, drugs, other surgical procedures. This page intentionally left blank CHAPTER 17 Urological surgery and equipment 756 Vasectomy and vasovasostomy Vasectomy This is the removal of a section of the vas deferens from each side with the aim of achieving infertility. Indications: a method of birth control. Anesthesia: local or general. Post-operative care and common post-operative complications and their management Post-opera tive haematoma can occur. If large, evacuation may be required. Infection can occur, but is usually super \201 cial. Two semen samples are required, usually at 10 and 12 weeks post- vasectomy, before unprotected intercourse can take place. Viable sperm can remain distal to the site of vasectomy (in the distal vas deferens or seminal vesicles) for some weeks afte r vasectomy and even longer. Occasionally, a persistently positive semen analysis is an ind ication that the vas was not correctly identi \201 ed at the time of surgery and has not b een ligated (or very rarely, that there were two vas deferens on one side). The potential f or fertility remains in those with positive semen analysis and re-exploration is indicated. Warn the patient that the vas deferens can later recanalize, thereby restoring fertility. Sperm granuloma: a hard, pea-sized lump in the region of the cut ends of the vas, forming a s a result of an in \202 ammatory response to sperm leaking out of the proximal cut end of the vas. It can be a cause of persistent pain in which case, it may have to be excised or evacuated and the vas cauter- ized or re-ligated. Vasovasostomy Vasectomy reversal. Anesthesia: this tends to be done under general or spinal anesthesia as it takes far longer than a vasectomy. Post-operative care and common post-operative complications and their management Much the s ame as for vasectomy. The patient should avoid sexual inter- course for 2 weeks or so. Vasectomy: BAUS procedure-speci \201 c consent form \200\224recommended discussion of adve rse events Serious or frequently occurring complications Common \200 \200 \200 Irreversible. Small amount of scrotal bruising. Two semen samples are required before unpro tected intercourse, both of which must show no spermatozoa. VASECTOMY AND VASOVASOSTOMY 757 Occasional \200 Rare \200 \200 \200 Bleeding requiring further surgery or bruising. In \202 ammation or infection of testis or epididymis, requiring antibiotics. Rejoining of vas ends, resulting in fertility and pregnancy (1 in 2000). Chronic testicular pain (5%) o r sperm granuloma. Alternative treatment: other forms of contraception (male or female). Vasovasostomy: BAUS procedure-speci \201 c consent form \200\224recommended discussion of adverse events Serious or frequently occurring complications Common \200 \200 \200 \200 Occasional \200 Rare \200 \200 Small amount of scrotal bruising. No guarantee that sperm will return to semen. Sperm may r eturn, but pregnancy not always achieved. If storing sperm, check that appropriate forms ha ve been \201 lled out. Bleeding requiring further surgery In \202 ammation or infection of testes or epididymis, requiring antibiotics. Chronic test icular pain (5%) or sperm granuloma. Alternative therapy: IVF, sperm aspiration, ICSI. CHAPTER 17 Urological surgery and equipment 758 Orchidectomy Indications Two types \200\224radical orchidectomy and simple orchidectomy. Radical (inguinal) orchidectomy For excision of testicular cancer. This approach is used fo r three reasons. \200 To allow ligation of the testicular lymphatics as high as possible as they pass in the spermatic cord and through the internal inguinal ring, thereby removing any cancer cells which might have started to metastasize along the cord. To allow cross-cl amping of the cord prior to manipulation of the testis which, theoretically at least, could promote dissemination of cancer cells along the lymphatics. (In reality, this probably doe sn \200\231t occur.) To prevent the potential for dissemination of tumor cells into the lym phatics that drain the scrotal skin that could occur if a scrotal approach is used. These l ymphatics drain to inguinal nodes. Thus, direct spread of tumor to scrotal skin and \200 \230violation \200\231 of another lymphatic \201 eld (the groin nodes) are avoided. Histo rically, this was important because the only adjuvant therapy for metastatic disease was ra diotherapy. The morbidity of groin and scrotal irradiation was not inconsiderable (severe s kin reactions to radiotherapy, irradiation of femoral artery and nerve). Obtain serum markers before surgery (A-fetoprotein, BHCG, and lactic acid dehydrogenase (LD H)) and get a CXR. For full staging CT scan, wait till after surgery. If the contralateral testis has been removed or is small, offer sperm storage \200\224there is usually time to d o this. Warn the patient that, very occasionally, what appears clinically and on ultrasound to be a malignant testis tumor turns out to be a benign tumor on subsequent histological e xamination. Simple orchidectomy For hormonal control of advanced prostate cancer. Done via a scrotal in cision, with ligation and division of the cord and complete removal of the testis and epidi dymis. Alternatively, a subcapsular orchidectomy may be done, where the tunica of the testi s is incised and the seminiferous tubules contained within are excised. There is the potent ial with this approach to leave a small number of Leydig cells which can continue to produc e testosterone. Anesthesia: local, regional, general. Few men will require or opt for local. Post-operative care and common post-operative complications and their management For both s imple and radical orchidectomy: scrotal haematoma. Drain it if large or enlarging or if the re are signs of infection (fever, discharge of pus from the wound). For radical orchidectom y: damage to the ilioinguinal nerve, leading to an area of loss of sensation overlying the scrotum. ORCHIDECTOMY 759 Orchidectomy testicular implant: BAUS procedure-speci \201 c consent form \200\224recom mended discussion of adverse events Serious or frequently occurring complications Occasiona l \200 \200 Cancer, if found, may not be cured by orchidectomy alone. There may be a need for additiona l surgery, radiotherapy, or chemotherapy. Loss of future fertility. Biopsy of contralateral testis may be required if an abnormality is found (small testis or history of maldescent). \200 Rare \200 On pathological examination, cancer may not be found or the pathologic diagnosis may be unc ertain. Infection of incision may occur, requiring further treatment and possibly removal o f implant if this has been inserted. Pain requiring removal of implant. Cosmetic expectatio n not always met. Implant may lie higher in the scrotum than the normal testis did. A palpa ble stitch may be felt at one end of the implant. Long-term risks of silicone implants are not known. \200 \200 \200 \200 CHAPTER 17 Urological surgery and equipment 760 Urological incisions Midline, transperitoneal Indications: access to peritoneal cavity and pelvis for radical nephrectomy, cystectomy, reconstructive procedures, etc. Technique Divide skin, subcutaneous fat. Divide fascia in midline. Find the midline between the rectus muscles. Dissect the muscles free from the underlying peritoneum. Place two cli ps on either side of the midline, pinch between the two to ensure no bowel has been trapped , elevate the clips, and divide between them with a knife. Extend the incision in the perit oneum up and down, ensuring no bowel is in the way. Closure: use a non-absorbable (e.g. nyl on) or very slowly absorbable (e.g. PDS) suture, using Jenkins rule to reduce the risk of d ehiscence (suture length 4 times wound length). Speci \201 c complications: dehiscence (cl assically around day 10 post-opera- tively and preceded by pink serous discharge, then sudd en herniation of a bowel through incision). Lower midline, extraperitoneal Indications: access to pelvis (e.g. radical prostatectomy, c olposuspension). Technique: divide skin, subcutaneous fat. Divide fascia in midline. Find t he midline between the rectus muscles and dissect the muscles free from the underlying peri toneum. If you make a hole in it, repair the defect with vicryl. Divide the fascia posterio r to the rectus muscles in the midline, so exposing the extravesical space. Closure: as for midline, transperitoneal. Pfannenstiel Indications: access to pelvis (e.g. colposuspension, open prostatectomy, open cystolithotomy). Technique: divide the skin 2cm above the pubis and the tissues down to the rectus sheath which is cut in an arc, avoiding the inguinal canal. Apply clips to the top \202 ap (and afterwards the bottom \202 ap) and use a combi- nation of scissors and you r \201 ngers to separate the rectus muscle from the sheath. For maximum exposure, you mus t elevate the anterior rectus sheath from the recti cranially to just below the umbilicus a nd caudally to the pubis. Take care to diathermy a perforating branch of the inferior epiga stric artery on each side. Apply two Babock \200\231s forceps to the inferior belly of the rectus on either side of the midline. Elevate and cut in the mid- line, the lower part of t he fascia (transversalis fascia) between the recti. Separate the recti in the midline (do n ot divide them). Closure: tack the divided transversalis fascia together and then close the transversely divided rectus sheath with vicryl. UROLOGICAL INCISIONS 761 Supra-12th rib incision Indications: access to kidneys, renal pelvis, upper ureter. Technique: make the incision over the tip of the 12th rib through skin and subcutaneous fas cia. Palpate the tip of the 12th rib. Make a 3cm cut with diathermy through the muscle (lat issimus dorsi) overlying the tip of the 12th rib so you come down onto the tip of the 12th rib and then cut anterior to the tip of the 12th rib, down through external and internal ob lique, transversus abdominis, to Gerota \200\231s fascia, and the perirenal fat. Sweep ante riorly with a \201 nger to push the peritoneum and intraperito- neal organs out of harm \200\231s way. Cut the muscles overlying the rib, cutting centrally along the length of the rib, in so doing avoiding the pleura. Cut with scissors along the top edge of the rib to f ree the intercostal muscle from the rib \200\224beware the pleura! Insert a Gillie \200\231 s forceps between the pleura and overlying intercostal muscle and divide the muscle \201 bres, so protecting the pleura. Dissect \201 bres of the diaphragm away from the inner su rface of the 12th rib \200\224as you do so, the pleura will rise upwards with the detached diaphragmatic \201 bres out of harm \200\231s way. At the posterior end of the incision, feel for the sharp edge of the costovertebral ligament. Insert heavy scissors, with the bla des just open on the top of the rib (to avoid the XIth intercostal nerve), and divide the c ostovertebral ligament. You should now be on top of Gerota \200\231s fascia. Speci \201 c complications \200 Damage to the pleura: the end of the operation. Pass a small bore catheter (e.g. Jacques) t hrough the hole, close all the muscle layers, in \202 ate the lung, and then before closin g the skin, remove the catheter. if you make a hole in the pleura, repair it at Complications common to all incisions Hernia, wound infection, chronic wound pain. CHAPTER 17 Urological surgery and equipment 762 JJ stent insertion Preparation Can be done under sedation or general anesthetic, using eith er a rigid or \202 exible cystoscope. The latter is particularly useful for patients who are not \201 t enough for a general anesthetic. The technique described is that used with the \202 exible cystoscope, but this is essentially the same if using a rigid scope. With sedation Oral cipro \202 oxacin 250mg; lidocaine gel for urethral anesthesia and lubr i- cation; sedoanalgesia (diazemuls 2.5 \200\22310mg IV, pethidine 50 \200\223100mg IV). Mo nitor pulse and oxygen saturation with a pulse oximeter.