will be tailored to the individual case. This page intentionally left blank CHAPTER 13 Urology 478 Exploration of the \200\230acute scrotum \200\231 Indications Acute orchalgia where torsio n of the spermatic cord cannot be emphati- cally excluded from the differential diagnosis. Position (cid:142)(cid:3) Supine, Lloyd-Davies, or lithotomy. Preparation (cid:142)(cid:3) Attempt manual detorsion. (cid:142)(cid:3) Obtain consent for orchidectomy if necessary. Counsel appropriately. (cid:142)(cid:3) Pre- or intra-operative ultrasound scan may be helpful but avoid delaying exploration in order to obtain one. (cid:142)(cid:3) Prep the genitalia and groins with antiseptic solution and shave appropriately. Procedure (cid:142)(cid:3) Examine properly under anesthesia. (cid:142)(cid:3) If there is no suspicion of testicular neoplasm, make a median scrotal incision or a transverse one crossing the midline. If neoplasm is suspected, approach as de scribed under \200\230Inguinal orchidectomy. \200\231 (cid:142)(cid:3) Incise through Dartos and the scrotal septum, and explore the affected testis first. (cid:142)(cid:3) Develop the avascular plane around tunica vaginalis and incise it. (cid:14 2)(cid:3) Deliver testis and adnexae (Fig. 13.1A). Intravaginal torsion of the spermatic cord is obvious unless detorsion has occurred. Ecchymosis, congestion, and oedema , together with a generous, or narrow pedicle, provide sufficient justification to fix the testis. (cid:142)(cid:3) Torsion of a testicular appendage should be managed by removal of the appendage, but there is no need to explore the contralateral testis. (cid:142)(cid:3) If spermatic cord torsion is diagnosed, reduce the torsion, and wrap the t estis within a warm moist swab while the contralateral testis is explored and fixed. (cid:142)(cid:3) Fix the testis by everting the tunica vaginalis in the manner of Jaboulay, and place three nonabsorbable sutures between the tunica albuginea of the testis (the medi al side of the upper pole is safest) or paratesticular tissue and Dartos (Fig. 13.1B). (cid:142)(cid:3) If the torted testis becomes pink, it is treated similarly. If it is obviously necrotic, ligate cord structures and remove it. If its viability is uncertain, we leave it in situ, and obtain a Doppler ultrasound scan after 24 to 48 hours. (cid:142)(cid:3) Close Dartos and skin in layers using absorbable sutures. (cid:142)(cid:3) Where an unsuspected testicular neoplasm is discovered, management will depend on the pati ent \200\231s age. In the prepubertal child, testicular conservation may be appropriate and frozen section should be obtained. This situation is fraught with medico-legal hazard, and informed consent is worthwhile taking some time over. EXPLORATION OF THE \200\230ACUTE SCROTUM \200\2311 479 Complications (cid:142)(cid:3) Infection (cid:142)(cid:3) Haematoma (cid:142)(cid:3) Testic ular atrophy, anti-sperm antibody production (cid:142)(cid:3) Recurrent torsion. Follow-up (cid:142)(cid:3) At least one outpatient appointment is arranged for counseling a nd examination (cid:142)(cid:3) Laboratory investigations only where clinically indicated. (A) (B) Fig. 13.1 (A) Exposure and (B) fixation of testis. CHAPTER 13 Urology 480 Suprapubic catheter placement Trocar and cannula technique for Foley \200\231s catheter ins ertion. Indications Bladder drainage where the urethral route is unavailable or undesirable (e.g. s tricture). Position Supine. Preparation (cid:142)(cid:3) The bladder should be palpably full or sonographic guidance sh ould be obtained. (cid:142)(cid:3) Abdominal and pelvic examinations should precede placement of the cannula unless contraindicated or impossible (e.g. compound fractured pelvis). (cid:142)(cid:3) Prep the lower abdomen and suprapubic area with antiseptic solution. Procedure (cid:142)(cid:3) Identify and mark the site of cannula insertion at a point a sho rt dis- tance above the symphysis pubis or equidistant between the fundus of the bladder and the pu bis. (cid:142)(cid:3) Remember that the bladder strips the anterior peritoneum from the abdominal wall as it fills, but that perivesical surgery, trauma or pathol- ogy may result in fixity and the interposition of bowel between bladder and abdominal wall. If in doubt us e sonographic guidance. (cid:142)(cid:3) Infiltrate the skin and subcutaneous tissue with 1 % lignocaine. (cid:142)(cid:3) Confirm site by aspirating via a small-gauge needle. (cid:14 2)(cid:3) Make a stab incision with an 11 blade, as deep as linea alba. (cid:142)(cid:3) Pl ace trocar and cannula in the incision, and firmly, but with fine control and accuracy, insert it into the bladder \200\224keep in mind the anatomical relati ons of the bladder. (cid:142)(cid:3) Remove the trocar and guide the Foley \200\231s catheter into the bladder, inflate the balloon and remove the guide. Complications (cid:142)(cid:3) Bleeding (cid:142)(cid:3) From the bladder (cid:142)(cid:3) From an enlarged intrusive prostate (cid :142)(cid:3) From perivesical venous plexus (cid:142)(cid:3) From the iliac vessels (cid:142)(cid:3) Rectal or enteric injury \200\224peritonitis or retroperitonitis (cid:142) (cid:3) Extravasation of urine (cid:142)(cid:3) Displacement or blockage of catheter (cid:1 42)(cid:3) Infection (cid:142)(cid:3) UTI (cid:142)(cid:3) Systemic sepsis (cid:142)(cid:3) Symphysitis pubis (now fortunately rare). SUPRAPUBIC CATHETER PLACEMENT1 481 Follow-up (cid:142)(cid:3) If the suprapubic catheter is regarded as definitive management, then simple replacement after an interval is possible without anesthetic or special equipm ent. (cid:142)(cid:3) Silicone catheters may be left in situ for three months and latex cathe- ters for one month. (cid:142)(cid:3) Special dressings are not necessary. Patients wear a cotton singlet, changed daily. (cid:142)(cid:3) If the placement of a suprapubic catheter was a temporizing measure, then, it may be removed when the primary condition has been satisfactorily treated. CHAPTER 13 Urology 482 Reduction of paraphimosis Position Supine. Preparation (cid:142)(cid:3) Analgesia, penile block, or general anesthesia (cid:142)(cid:3 ) If the condition has been neglected and become brawny, ulcerated, or inflamed give antibiotics (cid:142)(cid:3) Prep the skin with antiseptic solution, and drape. Procedure (cid:142)(cid:3) Gradual manual compression may be brought to bear on the oedema- tous foreskin as illustrated in Figs. 13.2A, B. (cid:142)(cid:3) When the volume of the foreskin has been reduced, simultanous traction may effect reduction. (cid:142)(cid:3) If this is not possible, make a dorsal slit: (cid:142)(cid:3) Identify the constriction ring in the midline dorsally and incise it through skin and Colles \200\231 fascia (Fig. 13.2C). (cid:142)(cid:3) Extend the incision proximal and distal to the constriction ring until all tension is removed. (cid:142)(cid:3) Obtain haemostasis and suture the longitudinal incision transversely (Fig. 13.2D). Complications (cid:142)(cid:3) Failure to relieve the constriction may result in ischaemia of the glans and necrosis (cid:142)(cid:3) Infection bleeding and haematoma formation. Follow-up Most patients are offered a definitive procedure such as circumcision, electively . REDUCTION OF PARAPHIMOSIS1 483 (A) (B) (C) (D) Fig. 13.2 Management of paraphimosis CHAPTER 13 Urology 484 Shunt procedures for priapism Indications Low-flow priapism that has not responded to medic al interventions and less invasive procedures such as cavernosal aspiration, irrigation, or intra- cavernosal vasoconstrictor injection. Position Supine. Preparation (cid:142)(cid:3) Prep from umbilicus to mid-thigh including groins and genitali a with antiseptic solution, and drape. (cid:142)(cid:3) A suprapubic or urethral catheter may be inserted for convenience and comfort postoperatively. (cid:142)(cid:3) Broad-spectrum antibiotics are given with induction. Procedures The Winter procedure T (cid:142)(cid:3) Use a Tru-Cut biopsy needle to create cavernosum-spongiosum venous shunts at the glans. The El-Ghorab shunt (Fig. 13.3A) (cid:142)(cid:3) Incise the dorsum of the glans transverse ly over the \200\230domes \200\231 of the cavernosal distal ends and dissect off the spongy glanular tissue over a small area. (cid:142)(cid:3) Grasp each \200\230dome \200\231 with locking tissue forceps, or place a strong stay suture for traction. (cid:142)(cid:3) Excise a disc of tunica albuginea penis from each side, with a 5mm diameter and close only the skin of the glans with absorbable suture (Fig. 13.3B). Cavernosospongiosum shunt (cid:142)(cid:3) Expose the corpus spongiosum and one corpus cave rnosum by the incision of skin, Colles \200\231 and Buck \200\231s fascia \200\224just distal to the peno scrotal junction or more proximally. (cid:142)(cid:3) Separate corpus spongiosum from corpus cavernosum for a short distance, then excise an ellipse of investing tissue from each, exposing spongy tissue. (cid:142)(cid:3) Create a vascular anastomosis between the two corporal openings using continuous polypropylene 5/0 suture (cid:142)(cid:3) Close skin and fascia in layers Cavernososaphenous shunt (cid:142)(cid:3) Incise as for cavernosospongiosum shunt, and a second incision over the saphenous hiatus on the same side. (cid:142)(cid:3) Expose the saphenous vein, mobilize it for about 15cm, and divide it inferiorly between ligatures. (cid:142)(cid:3) Tunnel the saphenous vein between the two incisions and excise a disc of tunica albuginea. SHUNT PROCEDURES FOR PRIAPISM1 485 (cid:142)(cid:3) Trim the vein to length and make a vascular anastomosis with 5/0 polypropylene. (cid:142)(cid:3) Close skin and fascia. Complications Immediate (cid:142)(cid:3) Bleeding (cid:142)(cid:3) Cavernositis, loss of ph allus (cid:142)(cid:3) Persistent or recurrent tumescence Long-term (cid:142)(cid:3) Erecti le dysfunction from venous leak and/or fibrosis of spongy tissue. Follow-up (cid:142)(cid:3) Immediately post-operatively, intermittent penile compression ma y improve shunt patency rates. The use of a pediatric Dynamap machine may be helpful (cid:142)(cid:3) Long-term follow-up depends on outcome, potency, etiology of the priapism and patient expectations (A) (B) Fig. 13.3 The El-Ghorab shunt CHAPTER 13 Urology 486 Surgical approaches to the kidney, upper ureter, and adrenal gland Surgical anatomy (cid:14 2)(cid:3) The kidneys lie in the retroperitoneal space on the posterior abdominal wall with average dimensions of 11cm (cid:190) 6cm (cid:190) 3cm. (cid:142)(cid:3) The right kidney is found approximately 1cm more caudal than the left. (ci d:142)(cid:3) Each kidney is surrounded by a true fibrous capsule and a layer of perinephri c fat, all enveloped by the perirenal or Gerota \200\231s fascia. (cid:142)(cid:3) Posterio rly both kidneys are related to the diaphragm, quadratus lumborum, psoas major and transversus abdominis muscles. (cid:142)(cid:3) Three nerves also lie posterior to each kidney. These are the subcostal (T12), iliohypogastric and ilioinguinal (L1) nerves. (cid:142)(cid:3) Anteriorly the right kidney is related to the liver, the second part of the duodenum and the ascending colon. (cid:142)(cid:3) Anterior to the left kidney lie the stomach, spleen, tail of pancreas, and descending colon. (cid:142)(cid:3) The adrenal glands cap each kidney at its upper pole. (cid:142)(cid:3) The blood supply to the kidneys is via the renal arteries, which are paired branches of the aorta. (cid:142)(cid:3) Venous drainage is via the paired renal veins into the vena cava. The left renal vein arches in front of the aorta prior to joining the inferior vena cava. The left renal vein has both the left gonadal and left adrenal vein as tributaries. (cid:142)(cid:3) The blood vessels are found at the level of the renal hilum, which is situated at the middle of the medial border of each kidney. (cid:142)(cid:3) The renal pelvis also leaves the kidney at this level, which is found at the transpyloric plane (the level of the first lumbar vertebra). Commonly used approaches t o the kidney, adrenal, and upper ureter (cid:142)(cid:3) When deciding on the surgical appr oach to be used, consideration should be given to the operation to be performed, underlying pathology and the patient \200\231s body habitus. (cid:142)(cid:3) The four most commonly used approaches to the kidney are flank, transabdominal, thoracoabdominal, and dorsal lumbotomy. Flank incision Advantages (cid:142)(cid:3) Minimal disturbance of other viscera (retro- or transperitoneal approach can be used) (cid:142)(cid:3) No contamination of the peritoneal cavity in retroperitoneal approach (cid :142)(cid:3) Useful in obese patients (cid:142)(cid:3) Can be extended for greater exposure . Disadvantages (cid:142)(cid:3) Large muscles divided (cid:142)(cid:3) Increased risk of n erve injury (cid:142)(cid:3) Poor exposure of the renal hilum (cid:142)(cid:3) May be unsui table for patients with respiratory disease (patient position). SURGICAL APPROACHES TO KIDNEY, URETER & ADRENAL GLAND1 487 Surgical approaches to kidney, u reter & adrenal gland Position (cid:142)(cid:3) Lateral position on operating table (cid:14 2)(cid:3) Upper leg extended, lower leg flexed at the knee (cid:142)(cid:3) 20(cid:13) \200 \22340(cid:13) break on operating table. Incision and approach (cid:142)(cid:3) Incise 1cm below the inferior border of 12th rib or directly over it if the rib is to be excised. (cid:142)(cid:3) Extend the incision anteriorly towards the lateral edge of the rectus shea th \200\224a slight caudal curvature to the lower part of the incision avoids intercostal n erve damage. (cid:142)(cid:3) Incise skin and subcutaneous fat. (cid:142)(cid:3) Incise and divide the superficial layer of muscle consisting of latissimus dorsi and external oblique. (cid:142)(cid:3) Divide the deeper muscle layer, consisting of serratus posterior infe- rior and internal oblique in the same fashion. (cid:142)(cid:3) Divide the musculofascial layer (consisting of lumbodorsal fascia poste- r iorly and transversus abdominis muscle anteriorly), and push the peri- toneum medially. (cid:142)(cid:3) Gerota \200\231s fascia is now exposed. (cid:142)(cid:3) Insert a self-ret aining retractor e.g. Finochietto \200\231s, to retain exposure. Procedures Procedures such as simple or partial nephrectomy, pyeloplasty, nephro- lithotomy, and adrenalectomy can al l be performed via this route. Closure (cid:142)(cid:3) \200\230Unbreak \200\231 the table (cid:142)(cid:3) This incision is normally closed in layers (cid:142)(cid:3) Drains can be brought out through a stab inc ision below the wound. Transperitoneal abdominal approach Median and subcostal incisions ar e described. Advantages (cid:142)(cid:3) Good exposure of renal pedicle (cid:142)(cid:3) Allows control of great vessels (cid:142)(cid:3) Rapid, and allows full abdominal exposure in trauma situa tion. Disadvantages (cid:142)(cid:3) Longer period of postoperative ileus (cid:142)(cid:3) Limited access in obese patients (cid:142)(cid:3) Long term risk of bowel adhesions. Positi on (cid:142)(cid:3) Patient is supine (cid:142)(cid:3) Padding under operating side with br eak in table especially if a sub costal approach is used. Incision and approach (cid:142)(cid:3) Median incision (cid:142)(cid:3) Incise in the midline from the xiphoid process, skirting the umbilicus inferiorly CHAPTER 13 Urology 488 (cid:142)(cid:3) Divide skin and subcutaneous fat (cid:142)(cid:3) Incise linea alba (cid:1 42)(cid:3) Open peritoneal cavity in the direction of original incision (cid:142)(cid:3) Di vide and ligate the ligamentum teres of the liver. (cid:142)(cid:3) Anterior subcostal incision (cid:142)(cid:3) Make an incision from tip of 11th rib posteriorly, curving upwards to a po int a third of the distance from the xiphoid to the umbilicus (cid:142)(cid:3) Incise and retract skin and subcutaneous fat (cid:142)(cid:3) Incise the m ost superficial musculofascial layer, consisting of rectus sheath medially and external oblique muscle laterally (cid:142)(cid:3) Bluntly dissect through internal oblique and underlying transversus abdominis (cid:142)(cid:3) Incise peritoneum in the line of the incision. Procedures (cid:142)(cid:3) Most upper urinary tract operations can be performed via abdomi nal incisions (cid:142)(cid:3) The transperitoneal approach is essential in radical renal or adrenal surgery. Closure (musculofascial) (cid:142)(cid:3) May be closed in layers of polydioxanone or nonab sorbable suture material (cid:142)(cid:3) Sometimes mass abdominal closure for midline incision. Thoracoabdominal approach Advantages (cid:142)(cid:3) Advantageous for large tumors (especi ally right sided) (cid:142)(cid:3) Good exposure of upper pole and adrenal gland (cid:142)( cid:3) Access to retroperitoneal lymph nodes. Disadvantages (cid:142)(cid:3) Involves pleur otomy and therefore insertion of a chest drain may be necessary (cid:142)(cid:3) Time consuming incision and closure (cid:142)(cid:3) Longer hospital stay. Position (cid:142)(cid:3) Semi-oblique position on operating table (cid:142)(cid:3) Pelvis flat whilst upper torso is rotated approximately 30(cid:13), elevating the affected kidney (cid:142)(cid:3) Flank directly over 20 \200\22340(cid:13) break in operating table. Incisi on and approach (cid:142)(cid:3) Make an incision over the 9th or 10th rib, or the interspa ce between them. This runs from the costal angle posteriorly, across the costal margin, to the mid-point of the contralateral rectus muscle in the epigastrium. (cid:142)(cid:3) Incise skin and subcutaneous fat. (cid:142)(cid:3) Divide the superficial layer of muscles (latissimus dorsi, serratus poste- rior inferior, external oblique and rec tus abdominis) in the line of the skin incision. SURGICAL APPROACHES TO KIDNEY, URETER & ADRENAL GLAND1 489 (cid:142)(cid:3) Incise intercostal muscle or strip periosteum and remove the pertinent rib. At the costal margin, divide or separate the costal cartilages. (cid:142)(cid:3) Anter iorly, divide the deeper layer of muscle (internal oblique, transversus abdominis and posterior rectus sheath). (cid:142)(cid:3) Open pleura and incise the diaphragm circumferentially near to the chest wall. (cid:142)(cid:3) Complete the incision by opening the peritoneal cavity and retracting the liver or spleen superiorly. Procedures (cid:142)(cid:3) Radical surgery to adrenal gland or upper pole of kidney can be performed using this approach (cid:142)(cid:3) This exposure is useful especially if suprarenal portion of inferior vena cava needs to be accessed. Closure (cid:142)(cid:3) Diaphragm is closed with interrupted nonabsorbable mattress suture s tied on its inferior surface (cid:142)(cid:3) Chest wall and costal cartilage are reapproximated (cid:142)(cid:3) A ches t drain is brought out via a stab incision in posterior axillary line, and pleura closed (cid:142)(cid:3) Transected musculofascial layers are reapproximated in layers after placement of retroperitoneal drain (optional). Dorsal lumbotomy Advantages (cid:142)(cid:3) Ideal for open renal biopsy, removal of small kidneys, and open stone surgery (cid:142)(cid:3) No muscle transection and therefore less postoperative pain. Disadvantages (cid:142)(cid:3) Limited exposure (cid:142)(cid:3) Unsuitable for radical surgery. Positio n (cid:142)(cid:3) Lateral position on operating table (cid:142)(cid:3) Both knees flexed a t knee (cid:142)(cid:3) Optional minimal break on table. Incision and approach (cid:142)(ci d:3) Make a vertical lumbar incision from superior border of 12th rib inferi- orly towards iliac crest (cid:142)(cid:3) Incise and divide skin and subcutaneous tissue (cid:142)(cid:3) Retract pa ravertebral muscles medially and incise the lumbodorsal (cid:142)(cid:3) The kidney, within Gerota \200\231s fascia, is now exposed. Procedures (cid:142)(cid:3) Nephrectomy for small non-functioning kidney, open renal biopsy, pyeloplasty or open stone surgery (including access to upper ureter). Closure (cid:142)(cid:3) Lumbodorsal fascia is reapproximated (cid:142)(cid:3) Retracted mu scles are returned to their anatomical position. CHAPTER 13 Urology 490 Simple nephrectomy Indications (cid:142)(cid:3) Poorly- or non-functioning kidney due to ch ronic infection, obstruction or trauma, and associated with symptoms (pain) or complication s (recurrent UTI, hypertension) (cid:142)(cid:3) Treatment of renovascular hypertension (cid:142)(cid:3) As a quick surgica l alternative to more prolonged reconstructive procedures if patient \200\231s medical cond ition does not permit these. Incision Flank, abdominal or dorsal lumbotomy (see above). Preparation (cid:142)(cid:3) Fractional renal function and creatinine clearance (cid:142)(c id:3) Treat UTI (cid:142)(cid:3) Prep and drape skin. Procedure (cid:142)(cid:3) Expose the perinephric space (cid:142)(cid:3) Incise Gerota \200 \231s fascia overlying the kidney laterally (cid:142)(cid:3) Bluntly dissect perinephric fa t to expose the renal capsule (cid:142)(cid:3) Mobilize the kidney and identify ureter and hilar vessels (cid:142)(cid:3) During mobilization, especially near the poles, always look out for aberrant blood vessels (cid:142)(cid:3) Divide and ligate the ureter (cid:142)(cid:3) Isolate hilar vessels. Clamp , double-ligate and divide them (vein first) (cid:142)(cid:3) Free remaining adhesions and remove the specimen (cid:142)(cid:3) Close wound as described above (cid:142)(cid:3) An opt ional retroperitoneal tube drain may brought out via stab incision below the wound. Complications (cid:142)(cid:3) Bleeding (cid:142)(cid:3) Atelectasis/pneumonia (cid:142)(ci d:3) Prolonged ileus (cid:142)(cid:3) Wound infection/dehiscence (cid:142)(cid:3) DVT/PE (c id:142)(cid:3) Incisional hernia. Follow-up (cid:142)(cid:3) Initial wound and biochemistry check (cid:142)(cid:3) Further fo llow-up depends on original indication. This page intentionally left blank CHAPTER 13 Urology 492 Inguinal orchidopexy Indication (cid:142)(cid:3) Imperfectly descended testes (cid:142)(cid :3) Inguinal orchidopexy is done for ectopic, annular or canalicular testis (cid:142)(cid:3 ) The current standard of care is that it should be done before 18 months of age. Position Supine. Preparation (cid:142)(cid:3) Imaging may be used to confirm the approach is appropriate if the testis is impalpable (cid:142)(cid:3) Prep and drape the lower abdomen and genitalia. Procedure (cid:142)(cid:3) Make a small incision from the superolateral margin of external inguinal ring, extending laterally for 2 \200\2234cm in the skin crease (cid:142)(cid:3) Dissect through subcutaneous and Scarpa \200\231s fascia, taking care not to injure an ectopic testis (cid:142)(cid:3) Incise and reflect the external oblique aponeurosis (Figs. 13.4A, B) (cid: 142)(cid:3) Grasp the tunica vaginalis and divide its attachments to adjacent structures, preserving cord and its coverings (cid:142)(cid:3) Mobilize them to their emergence at the internal inguinal ring above inferior epigastric vessels (cid:142)(cid:3) Divide cremaster muscle fibers and strip them from the cord (Fig. 13.4C) (cid:142)(cid:3) Identify the processus vaginalis, and dissect it upwards as illustrated, pushing the cord structures posteriorly away from peritoneum above the internal ring. Ensur e it is empty, and ligate it flush with peritoneum (Fig. 13.4D) (cid:142)(cid:3) Open the tunica vaginalis and evert it (cid:142)(cid:3) Digitally develop a tunnel from the inguinal region into the scrotum, and incise the skin (Fig. 13.4E) (cid:142)(cid:3) Develop a space within the Dartos fascia (Fig. 13.4F) and insert a haemostat through it into the groin wound (cid:142)(cid:3) Draw the testis into the Dartos pouch which should retain it (Fig. 13.4G) \200\224additional fixation is often helpful (cid:142)(cid:3) Close the groin wound in layers and skin (scrotal and groin) with fine subcuticular undyed absorbable sutures. Complications (cid:142)(cid:3) Haematoma, wound infection (cid:142)(cid:3) Injury to vessel s, resulting in testicular atrophy (cid:142)(cid:3) Unsatisfactory position. Follow-up (cid :142)(cid:3) Ensure position is satisfactory \200\224a second procedure may help (cid:142)( cid:3) High risk of neoplasia must be acknowleged \200\224encourage vigilance. INGUINAL ORCHIDOPEXY1 493 (A) (B) (C) (D) (E) (F) (G) Fig. 13.4 Inguinal orchidopexy CHAPTER 13 Urology 494 Circumcision Indications (cid:142)(cid:3) Phimosis (cid:142)(cid:3) Religious or cultural. Position Supine. Preparation (cid:142)(cid:3) Genitalia are prepared with antiseptic solution and the field draped (cid:142)(cid:3) Keep some aqueous antiseptic for cleaning under the prepuce. Procedure (cid:142)(cid:3) Dilate the phimosis and separate prepucio-glanular adhesions usi ng a blunt probe or artery forceps, and clean away smegma (Fig. 13.5A shows planned incisio n) (cid:142)(cid:3) Compress the prepubic fat pad to show true penile length and mark out the planned external skin incision at the level of the coronal sulcus, with a V-shaped extension ventrally (Fig. 13.5B) (cid:142)(cid:3) Retract the foreskin and superficially incise the inner surface of the foreskin proximal to the fusion of Colles \200\231 and Buck \200\231s fascia (cid:142)(cid:3) Divide the frenulum, ligate or coagulate frenular vessels (cid:142)(cid:3) Reduce the foreskin and incise the external skin as marked (Fig. 13.5C) (cid:142)(cid:3) D issect in Colles \200\231 fascia to excise the skin between the two incisions (cid:142)(cid :3) Secure meticulous haemostasis using ligatures and cautery (bipolar is safer) (cid:142)(cid:3) Use a neat row of fine fascio-cutaneous interrupted absorbable sutures, with a \200\230triangulation suture \200\231 in the midline ventrally (Fig. 13.5D ) (cid:142)(cid:3) A dressing may be applied but will often fall off in the recovery room. Complications (cid:142)(cid:3) Bleeding (cid:142)(cid:3) Infection (cid:142)(cid:3) Acute u rinary retention (cid:142)(cid:3) Adhesions, meatal stenosis (cid:142)(cid:3) Urethrocutane ous fistula. Follow-up Wound and histology check. CIRCUMCISION1 495 Fig. 13.5 Circumcision CHAPTER 13 Urology 496 Correction of hydrocele Jaboulay correction Position Supine or in lithotomy. Preparation (cid:142)(cid:3) Preoperative ultrasound scanning may be necessary to exclude a malignant cause (cid:142)(cid:3) The lower abdomen and external genitalia are prepared with antiseptic solution. Incision Midline sagittal or unilateral transverse scrotal incision. Procedure (cid:142)(cid:3) Incise through skin and Dartos muscle (cid:142)(cid:3) Meticulou sly deal with bleeding vessels encountered (cid:142)(cid:3) Dissect in the avascular plane between spermatic fascia and Dartos to expose the hydrocele, and partly or completely deliver it. (cid:142)(cid:3) Incise tunica vaginalis and its fascia away from the epididymis and vessels (cid:142)(cid:3) Excise excess hydrocele sac (cid:142)(cid:3) Oversew the cut edge of the r emaining sac with a continuous haemostatic absorbable suture (cid:142)(cid:3) Prevent re-apposition of the edges by suturing the sac edges behind the testis and cord (see Fig. 13.1B) (cid:142)(cid:3) Return the testis to the scrotum (cid:142)(cid:3) Drainage is optional and seldom necessary (cid:142)(cid:3) Close the scrotum with two layers of absorbable suture ( cid:142)(cid:3) Non-adherent dressing and scrotal support is applied. Complications (cid:142)(cid:3) Haematoma formation (cid:142)(cid:3) Injury to cord, testis or adnexae (cid:142)(cid:3) Recurrence is rare. Follow-up Wound check only. This page intentionally left blank CHAPTER 13 Urology 498 Vasectomy (cid:142)(cid:3) Many methods of performing this procedure exist including the \200\230no scalpel \200\231 technique, favored by one of the authors. A standard vasectomy is described (cid:142)(cid:3) Most vasectomies are performed under local anesthetic on a day-case basis (cid:142)(cid:3) Careful preoperative counseling must be provided. Indications Permanent contraception. Position Supine. Preparation (cid:142)(cid:3) The external genitalia are prepared with antiseptic solution ( cid:142)(cid:3) The vas is identified by palpation and manipulated to a superficial position directly under the scrotal skin (cid:142)(cid:3) Local anesthetic is introduced around the isolated vas (cid:142)(cid:3) It may be helpful to secure the vas with an Allis clamp. Incision A stab incision made directly over the vas, and may be enlarged by open- ing the j aws of a small arterial clamp. Procedure (cid:142)(cid:3) The surrounding sheath is bluntly dissected off the vas (cid:142 )(cid:3) A small segment of the vas deferens is excised (for histology) (cid:142)(cid:3) Th e epithelium of the cut ends is fulgurated (the suture needle can be used to do this), and ligated (cid:142)(cid:3) Fascial interposition techniques are often used providing a physical barri er between the two ends of the vas-spermatic fascia is closed over the caudal end, while th e cephalad end is sutured to the external surface of spermatic fascia (cid:142)(cid:3) The Dartos and skin do not need to be sutured. Complications (cid:142)(cid:3) Haematoma (cid:142)(cid:3) Fertility! (cid:142)(cid:3) Sperm granuloma (cid:142)(cid:3) Chronic scrotal pain. Follow-up (cid:142)(cid:3) Alternative contraception must be used until semen analysis twic e confirms azoospermia (usually at 16 and 18 weeks post-op) (cid:142)(cid:3) Histological pro of that vas has been removed from both sides. This page intentionally left blank CHAPTER 13 Urology 500 Radical nephrectomy and nephroureterectomy Indications (cid:142)(cid:3) Malignant tumors of the kidney (cid:142)(cid:3) Nephroureterectomy is performed for urothelial tumors of the u pper urinary tract Position and approach (cid:142)(cid:3) Dependent on size and location of tumor and body hab itus (cid:142)(cid:3) Commonly used approaches are transabdominal and thoracoabdomi- nal (see above) Procedure (cid:142)(cid:3) For left sided operations reflect the colon medially via incisio n of the line of Toldt and divide the splenocolic ligaments. (cid:142)(cid:3) Divide the lienorenal ligament and retract the spleen and pancreatic tail upwards. (cid:142)(cid:3) For surgery on the right side mobilize the colon to the hepatic flexure and Kocherise the duodenum. (cid:142)(cid:3) Expose the renal pedicle and double ligate the vessels. (cid:142)(cid:3) L igate the arteries first and palpate veins for tumor thrombus before ligation. (cid:142)(cid:3) Tumor thrombus can extend as far proximally as the heart and must be remov ed before ligation of the vein, so cardiothoracic or vascular specialists may be needed. (cid:142)(cid:3) Large right renal tumors overlapping the vena cava may restrict ac- cess to the renal artery or arteries at the hilum. Retract the left renal vein upward and t he vena cava towards the right to obtain access, and ligate the inter-aortocaval right rena l artery in continuity. See Fig. 13.6. (cid:142)(cid:3) In radical nephrectomy, ligate and divide the ureter where convenient. (cid:142)(cid:3) In radical nephroureterectomy, dissect the ureter distally \200\224a second incision may be required. Alternatively circumcise th e ureteral orifice endoscopically using the Colling \200\231s knife, then retrieve the dist al ureter by blunt dissection from above. Avoid tumor spillage. Drain the blad- der and per ivesical space for 10 days. (cid:142)(cid:3) Mobilize the kidney within Gerota \200\231s fascia, and divide the adrenal vessels. (cid:142)(cid:3) Remove the specimen, check the renal bed for bleeding. (cid:142)(cid:3) A classical radical nephrectomy involves a regional lymphadenectomy and ipsilateral en-bloc a drenalectomy but these are probably not nec- essary unless (in the case of adrenalectomy) t he tumor involves the upper renal pole or there is suspected adrenal involvement. (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.