\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. Technique A \202 exible cystoscope is passed into the bladder and rotated through 180 . This allows greater deviation of the end of the cystoscope and makes identi \201 cation of the ureteric ori \201 ce easier. A 0.9mm hydrophilic guidewire (Terumo Corporation, Japan ) is passed into the ureter under direct vision. The guidewire is manipulated into the rena l pelvis using C-arm digital \202 uoroscopy. The cystoscope is placed close to the ureter ic ori- \201 ce and its position, relative to bony landmarks in the pelvis, is recorded b y frame-grabbing a \202 uoroscopic image. The \202 exible cystoscope is then removed an d a 4 Ch ureteric catheter is passed over the guidewire into the renal pelvis. A small quan tity of non-ionic contrast medium is injected into the renal collecting system to outline i ts position and to dilate it. The Terumo guidewire is replaced with an ultra-stiff guidewir e (Cook UK Ltd, Letchworth, UK) and the 4 Ch ureteric catheter is removed. We use a variety of stent sizes, depending on the patient \200\231s size (6 \200\2238 Ch, 20 \200\22326cm; Boston Scienti \201 c Ltd, St Albans, UK). The stent is advanced to the renal pelvis under \202 uoroscopic control, using a \200\230pusher \200\231 (a hollow tube inserted over t he guidewire), checking that the lower end of the stent is not inad- vertently pushed up th e ureter by checking the position of the ureteric ori \201 ce on the previously frame-grab bed image. The guidewire is then removed while the pusher holds the stent in position (so t hat the stent is not pulled out along with the wire). Further reading Hellawell GO, Cowan NC, Holt SJ, Mutch SJ (2002) A radiation perspective for treating loin pain in pregnancy by double-pigtail stents. BJU Int 90:801 \200\2238. McFarlane J, Cowan N, Holt S, Cowan M (2001) Outpatient ureteric procedures: a new method f or retrograde ureteropyelography and ureteric stent placement. BJU Int 87:172 \200\2236. This page intentionally left blank CHAPTER 17 Urological surgery and equipment 764 Nephrectomy and nephro-ureterectomy Indications for nephrectomy \200 \200 \200 Renal cell cancer. Non-functioning kidney containing a staghorn calculus. Persistent hemorr hage following renal trauma. Indications for nephro-ureterectomy Transitional carcinoma of the renal pelvis and/or urete r. Anesthesia: general. Post-operative care Nephrectomy Cardiovascular status and urine output should be carefully monitored in the immediate post-operative period. Hemorrhage from the renal pedi- cle or fo r left-sided nephrectomy, the spleen, is rare, but will present with an increasing tachycar dia, cool peripheries, falling urine output, and eventually a drop in BP. A drain is usuall y not left in place, but if it is, there may be excessive drainage of blood from the drain. However, do not be lulled into a false sense of security by the absence of drainage \200 \224this does not mean that hemorrhage is not occurring as the drain may be blocked, but he morrhage may be ongoing. For nephrectomy via a posterolateral (rib-based) incision, watch for pneumothorax. Arrange a CXR on return from the recovery room. Arrange routine chest physiotherapy to reduce the r isk of chest infection. Regular chest examination is important, looking speci \201 cally f or pneumot- horax and pleural effusion. Mobilize the patient as quickly as possible to reduce the risk of DVT and PE. Nephro-ureterectomy Where the ureter has been excised from the bladder, a urethral catheter is left in place at the end of the procedure to allow the hole in the bladder to heal. Thi s is usually removed 10 \200\22314 days after surgery. Common post-operative complications and their management \200 Hemorrhage: \200 Wound in fection: underlying collection of pus is suspected, open the wound to allow free drainage a nd pack the wound daily. Pancreatic injury: rare, but would be indicated by excessive drain age of \202 uid from the drain, if present, which will have a high amylase level. If no d rain is present, an abdominal collection will develop which may be manifested by a prolonge d ileus. see Nephrectomy. rare. If super \201 cial, treat with antibiotics. If an NEPHRECTOMY AND NEPHRO-URETERECTOMY 765 BAUS procedure-speci \201 c consent form: recommended discussion of adverse events Serious or frequently occurring complications of nephrectomy/nephro-ureterectomy Simple nephrectom y \200 Common. \200 \200 Occasional. \200 \200 Rare. \200 Temporary insertion of a bladder catheter. Occasional insertion of a wound drain. Bleeding requiring further surgery or transfusion. Entry into lung, requiring temporary ins ertion of a drainage tube. Involvement or injury to nearby structures \200\224blood vessels, spleen, lung, liver, panc reas, bowel, requiring further extensive surgery. Infection, pain, or hernia of incision, r equiring further treatment. Anesthetic or cardiovascular problems, possibly requiring inten sive care admission (including chest infection, PE, stroke, DVT, heart attack). \200 Radical nephrectomy As above plus: \200 Occasional. \200 Rare. \200 Alternative thera py: laparoscopic approach. Alternative therapy: observation, laparoscopic approach. Need for further therapy for cancer. May be an abnormality other than cancer on microscopic analysis. observation, embolization, immunotherapy, Nephro-ureterectomy As above. CHAPTER 17 Urological surgery and equipment 766 Radical prostatectomy Indications: localized prostate cancer. Anesthesia: general or regional. Post-operative care Mobilize as quickly as possible and continue subcutaneous heparin and A K-TEDS until discharge to reduce the risk of DVT and PE. Remove the drains when drainage is minimal. If there is persistent leak of \202 uid from the drains, send a sample for urea and creatinine and if it is urine, get a cystogram to determine the size of the leak at th e vesicourethral junction. Urethral catheters are left in situ post-radical prostatectomy f or a variable time, depending on the surgeon who performs the operation. Some sur- geons le ave a catheter for 3 weeks and others for just 1 week. Common post-operative complications and their management Hemorrhage Managed in the usual wa y (transfusion; return to theater where bleeding persists or where there is cardiovascular compromise). Ureteric obstruction Usually results from oedema of the bladder, obstructing the ureteric o ri- \201 ces. Retrograde ureteric catheterization is rarely possible (this would require urethral catheter removal and it is dif \201 cult to see the ureteric ori \201 ces becaus e of the oedema). Arrange placement of percutaneous nephrostomies. Lymphocele Drain by radiologically assisted drain placement. If the lymphocele recurs after drain removal, create a window from the lymph collection into the peritoneal cavity so the lymph drains into the peritoneum from which it is absorbed. Displaced catheter post-radical prostatectomy If the catheter falls out a week after surger y, the patient may well void successfully and in this situation, no further action needs be taken. If, however, the catheter inadvertently falls out the day after surgery, gently att empt to replace it with a 12 Ch catheter which has been well lubricated. If this fails, pas s a \202 exible cystoscope under local anesthetic, into the bul- bar urethra and attempt to pass a guidewire into the bladder, over which a catheter can then safely be passed. If t his is not possible, another option is to hope that the patient voids spontaneously and doe s not leak urine at the site of the anastomosis. An ascending urethrogram may provide reass urance that there is no leak of contrast and that the anastomosis is watertight. If there i s a leak or the patient is unable to void, a suprapubic catheter can be placed (percutaneou sly or under general anesthetic via an open cystostomy). RADICAL PROSTATECTOMY 767 Fecal \201 stula Due to rectal injury, either recognized and repaired at the time of surg ery and later breaking down or not immediately recognized. Formal closure is often required . Contracture at the vesicourethral anastomosis Gentle dilatation may be tried. If the strict ure recurs, instruct the patient on ISC in an attempt to keep the stricture open. If this f ails, bladder neck incision may be tried. BAUS procedure-speci \201 c consent form: recommended discussion of adverse events Serious or frequently occurring complications of radical prostatectomy Common \200 \200 \200 Occasional \200 \200 Temporary insertion of a bladder catheter and wound drain. High chance of impotence due to unavoidable nerve damage. No semen is produced during orgasm, causing subfertility. Blood loss, requiring transfusion or repeat surgery. Urinary incontinence \200\224temporary or permanent, requiring pads or further surgery. Discovery that cancer cells are already o utside the prostate, needing observation or further treatment at a later date if required, including radiotherapy or hormonal therapy. Rare \200 Anesthetic or cardiovascular problems possibly requiring intensive care admission (includin g chest infection, PE, stroke, DVT, heart attack). Pain, infection, or hernia in area of in cision. Rectal injury, very rarely needing temporary colostomy. \200 Alternative therapy: watchful waiting, radiotherapy, brachytherapy, hor- monal therapy, and perineal or laparoscopic removal. CHAPTER 17 Urological surgery and equipment 768 Radical cystectomy Indications \200 \200 \200 \200 Muscle-invasive bladder cancer. Adenocarcinoma of bladder (radioresistant). Squamous carcin oma of bladder (relatively radioresistant). Non-muscle-invasive TCC bladder, which has fail ed to respond to intravesical chemotherapy or immunotherapy. Recurrent TCC bladder post rad iotherapy. Combined with urethrectomy if: \200 Multiple bladder tumors. \200 Involvement of bladde r neck or prostatic urethra. Anesthesia: general. Post-operative care and common post-operative complications and their management Monitor ca rdiovascular status, urine output, and respiratory status care- fully in the \201 rst 48h . Routine chest physiotherapy is started early in the post-operative period to reduce the c hance of chest infection. Mobilize the patient as early as possible to minimize the risk of DVT and PE. Drains are removed when they stop draining. Some surgeons prefer to leave them for a week or so so that late leaks (urine, intestinal contents) will drain via the drain track and not cause peritonitis. Try to remove the nasogastric tube, if used, as soon as po ssible to assist respiration and reduce the risks of chest infection. The patient usually s tarts to resume their diet within a week or so. If the ileus is prolonged, start parenteral nutrition. Hemorrhage: persistent bleeding that fails to respond to transfusion should be managed by r e-exploration. Wound dehiscence: requires resuturing under general anesthetic. Ileus: common. Usually resolves spontaneously within a few days. Small bowel obstruction From herniation of small bowel through the mesenteric defect create d at the junction between the two bowel ends. Continue nasogastric aspira- tion. The obstru ction will usually resolve spontaneously. Re-operation is occasionally required where the o bstruction persists or where there are signs of bowel ischaemia. Leakage from the intestinal anastomosis Leading to: \200 Peritonitis: anastomosis. An enterocutaneous \201 stula: and through a \201 stulous tra ck onto the skin. If low-volume leak (<500mL/24h), will usually heal spontaneously. Normal (enteral) nutrition may be maintained until the \201 stula closes (which usually occurs w ithin a matter of days or a few weeks). If high-volume, spontaneous closure is less likely and re-operation to close the \201 stula may be required. requiring re-operation and repair or refashioning of the bowel contents leak from the intestine RADICAL CYSTECTOMY 769 Pelvic abscess Formal surgical (open) exploration of the pelvis is indicated with drainage of the abscess and careful inspection to see if the underlying cause is a rec- tal injury, in which case a defunctioning colostomy should be performed. Partial cystectomy Indications Primary, solitary bladder tumors at a site that allows 2cm o f normal tissue around it to be removed in a bladder that will have adequate capacity and c ompliance after operation. There should be: \200 \200 \200 No prior history of bladder cancer. No carcinoma in situ. A solitary muscle-invasive tumor located well away from the ureteral ori \201 ces, which includes 2cm of normal surrounding bladder. High-grade tumors should not be excluded if these criteria are met. The lesions most common ly amenable to partial cystectomy are G2 or G3 TCCs or adenocarcinomas located on the poste rior wall or dome. Contraindications Associated carcinoma in situ, deeply invasive tumors, tumors at the bladd er base (i.e. near the ureteric ori \201 ces). BAUS procedure-speci \201 c consent form: recommended discussion of adverse events Serious or frequently occurring complications of radical cystectomy See also consent for ileal con duit if this is the planned form of urinary diversion. Common \200 \200 Temporary insertion of a nasal tube, drain, and stent. High chance of impotence (lack of er ections) due to unavoidable nerve damage. No semen is produced during orgasm (dry orgasm), causing subfertility. Blood loss, requiring transfusion or repeat surgery. In women, pain o r dif \201 culty with sexual intercourse due to narrowing or shortening of vagina and need for removal of uterus and ovaries (causing premature menopause in those who have not reach ed menopause). \200 Occasional \200 \200 Rare \200 \200 Cancer may not be cured with surgery alone. Need to remove penile urinary pipe as part of p rocedure. Infection or hernia of incision, requiring further treatment. Anesthetic or cardiovascular problems, possibly requiring intensive care admission (including chest infection, PE, strok e, DVT, heart attack). Decreased renal function with time. CHAPTER 17 Urological surgery and equipment 770 Very rarely \200 \200 Rectal injury, very rarely needing temporary colostomy. Diarrhea due to shortened bowel, vi tamin de \201 ciency requiring treatment. Bowel and urine leak, requiring re-operation. Sc arring of bowel or ureters, requiring operation in the future. Scarring, narrowing, or hern ia formation around stomal opening, requiring revision. \200 \200 Alternative treatment: radiotherapy, neobladder formation, rather than ileal conduit urinar y diversion. Formation of neo-bladder with bowel Common: need to perform ISC if bladder fails to empty. This page intentionally left blank CHAPTER 17 Urological surgery and equipment 772 Ileal conduit Indications \200 \200 For urinary diversion following radical cystectomy. Intractable incontinence for which anti -incontinence surgery has failed or is not appropriate. Post-operative care and common post-operative complications and their management Oliguria o r anuria: try a \202 uid challenge. Wound infection: treat with antibiotics and wound car e. Open the super- \201 cial layers of the wound to release pus. Wound dehiscence: rare. Requires resuturing in theater under general anesthetic. Ileus: common. Usually resolves sp ontaneously within a few days. Small bowel obstruction: from herniation of small bowel thro ugh the mesenteric defect created at the junction between the two bowel ends. Continue naso gastric aspiration. The obstruction will usually resolve spon- taneously. Re-operation is o ccasionally required where the obstruction persists or where there are signs of bowel ischa emia. Leakage from the intestinal anastomosis: Leading to: \200 Peritonitis: anastomosis. An enterocutaneous \201 stula: and through a \201 stulous tra ck onto the skin. If low-volume leak (<500mL/24h), will usually heal spontaneously. Normal (enteral) nutrition may be maintained until the \201 stula closes (which usually occurs w ithin a matter of days or a few weeks). If high-volume, spontaneous closure is less likely and re-operation to close the \201 stula may be required. requiring re-operation and repair or refashioning of the bowel contents leak from the intestine Leakage from the uretero-ileal junction May be suspected because of a persistently high out put of \202 uid from the drain. Test this for urea. Urine will have a higher urea and cre atinine concentration than serum. If the \202 uid is lymph, the urea and creatinine conce ntration will be the same as that of serum. Arrange a loopgram (conduitogram). This will co n \201 rm the leak. Place a soft, small catheter (12 Ch) into the conduit to encourage ant egrade \202 ow of urine and assist healing of the uretero-ileal anastomosis. If the leaka ge continues, arrange bilateral nephrostomies to divert the \202 ow of urine away from th e area and encourage wound healing. Occasionally, a uretero-ileal leak will present as a urinoma (this causes a persistent ileu s). Radiologically assisted drain insertion can result in a dramatic resolution of the ileu s, with subsequent healing of the uretero- ileal leak. ILEAL CONDUIT 773 Hyperchloraemic acidosis May be associated with obstruction of the stoma at its distal end or from infrequent emptying of the stoma back (leading to back pressure on the conduit). Ca theterize the stoma \200\224this relieves the obstruction. In the long term, the conduit ma y have to be surgically shortened. Acute pyelonephritis Due to the presence of re \202 ux combined with bacteriuria. Stomal stenosis The distal (cutaneous) end of the stoma may become narrowed, usually as a r esult of ischaemia to the distal part of the conduit. Revision surgery is required if this stenosis causes obstruction, leading to recurrent UTIs or back pressure on the kidneys. Parastomal hernia formation Around the site through which the conduit passes, through the f ascia of the anterior abdominal wall. Many hernias can be left alone. The indica- tions for repairing a hernia are: \200 \200 \200 Bowel obstruction. Pain. Dif \201 culty with applying the stoma bag (distortion of the ski n around the stoma by the hernia can lead to frequent bag detachment). Repair the hernia defect by placing mesh over the hernia site, via an inci- sion sited as f ar as possible from the stoma itself, so as to reduce the risk of wound infection. BAUS procedure-speci \201 c consent form: recommended discussion of adverse events Serious or frequently occurring complications of ileal conduit formation Common \200 \200 Occa sional \200 \200 \200 Rare \200 \200 \200 Temporary drain, stents, or nasal tube. Urinary infections, occasionally requiring antibiot ics. Diarrhea due to shortened bowel. Blood loss, requiring transfusion or repeat surgery. Infec tion or hernia of incision, requiring further treatment. Bowel and urine leakage from anastomosis, requiring re-operation. Scarring to bowel or uret ers, requiring operation in future. Scarring, narrowing, or hernia formation around urine o pening, requiring revision. Decreased renal function with time. Alternative treatment: catheters, continent diversion of urine. CHAPTER 17 Urological surgery and equipment 774 Percutaneous nephrolithotomy (PCNL) Indications \200 \200 Stones >3cm in diameter. Stones that have failed ESWL and/or an attempt at \202 exible ur eteroscopy and laser treatment. Staghorn calculi. Preoperative preparation \200 CT scan to assist planning the track position and to identify a retrorenal colon.1 Stop asp irin 10 days prior to surgery. Culture urine (so appropriate antibiotic prophylaxis can be given). Cross-match 2 units of blood. Start IV antibiotics the afternoon before surgery to reduce the chance of septicaemia (many of the stones treated by PCNL are infection stones). If urine is culture-negative, use 1.5g IV cefuroxime tds and once daily IV gentamicin (3mg /kg). Routine antibiotic prophylaxis also reduces the incidence of post-operative UTI.2 \200 \200 \200 Post-operative management Once the stone has been removed, a nephrostomy tube is left in si tu for several days (Fig. 17.15). This drains urine in the post-operative period and tampon ades bleeding from the track. So-called \200\230tubeless \200\231 PCNL (no nephrostomy tub e, although a J stent is often inserted, which has a cer- tain morbidity) can be used in se lect patients (no infection \200\224therefore, not suitable for infection staghorn stones). Less requirement for post- operative analgesia and earlier discharge has been reported. Complications of PCNL and their management Bleeding Some bleeding is inevitable, but that s evere enough to threaten life is uncommon. In most cases, it is venous in origin and stops following place- ment of a nephrostomy tube (which compresses bleeding veins in the track). If bleeding persists, clamp the tube for 10min. If bleeding continues despite this, arrang e urgent angiography, looking for an arteriovenous \201 s- tula or pseudoaneurysm, both o f which will require selective renal artery embolization (required in 1% of PCNLs)3 or open exposure of kidney to control bleeding by suture ligation, partial nephrectomy, or nephrec tomy. Septicaemia Occurs in 1 \200\2232% of cases. Incidence is reduced by prophylactic antibioti cs. Track damage. Essentially minimal. Cortical loss from track is estimated to be <0.2% of total renal cortex in animal studies.4 Colonic perforation The colon is usually lateral or anterolateral to the kidney and is, the re- fore, not usually at risk of injury unless a very lateral approach is made. The colon i s retrorenal in 2% of individuals (more commonly in thin females with little retroperitonea l fat).1 The perforation usually occurs in PERCUTANEOUS NEPHROLITHOTOMY (PCNL) 775 Fig. 17.15 A Malecot catheter which has wide drainage eyeholes and an extension at the dist al end, which passes down the ureter to prevent fragments of stone from passing down the ur eter. an extraperitoneal part of the colon and is managed by JJ stent placement and withdrawal of the nephrostomy tube into the lumen of the colon to encourage drainage of bowel contents a way from that of the urine, thereby encouraging healing without development of a \201 stu la between bowel and kidney. A radiological contrast study a week or so later con- \201 r ms that the colon has healed and that there is no leak of contrast from the bowel into the renal collecting system. Damage to the liver or spleen: very rare in the absence of splenomegaly or hepatomegaly. Damage to the lung and pleura, leading to pneumomothorax or pleural effusion: can occur wit h supra-12th rib puncture. Nephrocutaneous \201 stula When the nephrostomy tube is removed from the kidney, a few da ys after surgery, the 1cm incision usually closes within a few hours to a day or so. Occasi onally, urine continues to drain percutaneously for a few days and a small \200\230stoma \200\231 bag must be worn. In the majority of such cases, the urine leak will stop spontane ously, but if it fails to do so after a week or so, place a JJ stent to encourage antegrade drainage of urine. CHAPTER 17 Urological surgery and equipment 776 Outcomes For small stones, the stone-free rate after PCNL is in the order of 90 \200\22395% . For staghorn stones, the stone-free rate of PCNL, when combined with post-operative ESWL for residual stone fragments, is in the order of 80 \200\22385%. BAUS procedure-speci \201 c consent form \200\224recommended discussion of adverse events Serious or frequently occurring complications of PCNL Common \200 Temporary insertion of a bladder catheter and ureteric stent/kidney tube, needing later rem oval. Transient haematuria. Transient temperature. \200 Occasional \200 \200 \200 Rare \200 More than one puncture site may be required. No guarantee of removal of all stones and need for further operations. Recurrence of stones. Severe kidney bleeding requiring transfusion, embolization, or, at last resort, surgical re moval of kidney. Damage to lung, bowel, spleen, liver, requiring surgical intervention. Kid ney damage or infection, needing further treatment. Over absorption of irrigating \202 ui ds into blood system, causing strain on heart function. \200 \200 Alternative treatment: external shock wave treatments, open surgical removal of stones, obs ervation. 1 Hopper KD, Sherman JL, Williams MD, et al. (1987) The variable anteroposterior position o f the retroperitoneal colon to the kidneys. Invest Radiol 22:298 \200\223302. 2 J Endourol 2:59 \200\22362. Inglis JA, Tolly DA (1988) Antibiotic prophylaxis at the time of percutaneous stone surgery . 3 Martin X (2000) Severe bleeding after nephrolithotomy: results of hyperselective embolisa tion. Eur Urol 37:136 \200\2239. 4 Clayman J (1987) Percutaneous nephrostomy: Assessment of renal damage associated with sem i-rigid (24F) and balloon (36F) dilation. J Urol 138:203 \200\2236. This page intentionally left blank CHAPTER 17 Urological surgery and equipment 778 Ureteroscopes and ureteroscopy The instruments Two types of ureteroscope in common use \200 \224the semi-rigid ureteroscope and the \202 exible ureteroscope. Semi-rigid ureteroscopes Have high-density \201 bre optic bundles for light ( \200\230non -coherently \200\231 arranged) and image transmission ( \200\230coherently \200\231 arrange d to maintain image quality). For equivalent light and image transmission using glass rod l enses, thicker lenses are required than with \201 bre optic bundles. As a consequence, se mi- rigid ureteroscopes can be made smaller while maintaining the size of the instrument ch annel. In addition, the instrument can be bent by several degrees without the image being d istorted. The working tip of most current models is in the order of 7 \200\2238 Ch, with the proximal end of the scope being in the order of 11 \200\22312 Ch. There is usually at least one wor king channel of at least 3.4 Ch. Flexible ureteroscopes The \201 bre optic bundles in \202 exible ureteroscopes are the same as those in semi-rigid scopes, only of smaller diameter. Thus, image quality and light transmission are not as good as with semi-rigid scopes, but are usually adequate. The working tip of most current models is in the order of 7 \200\2238 Ch, with the proximal end of the scope being in the order of 9 \200\22310 Ch. There is usually at least one work ing channel of at least 3.6 Ch. The great advantage of the \202 exible ureteroscope over the semi-rigid variety is the ab ility to perform controlled de \202 ection of the end of the scope (active de \202 ection ). Behind the actively de \202 ecting tip of the scope is a segment of the scope which is more \202 exible than the rest of the shaft. This section is able to undergo passive de \202 ection \200\224when the tip is fully actively de \202 ected by advancing the scope fu rther, this \202 exible segment allows even more de \202 ection. Flexible ureteroscopes have recently been developed which have two actively de \202 ecting segments. Flexible ureteroscopes are intrinsically more intricate and are, there- fore, less durable than semi-rigid scopes. Ureteroscopic irrigation systems Normal saline is used (high-pressure irrigation with glyci ne or water would lead to \202 uid absorption from pyelolymphatic or venous back \202 ow ). Irrigation by gravity pressurization alone (the \202 uid bag suspended above the patie nt without any applied pressure) will produce \202 ow that is inad- equate for visualizat ion because the long, \201 ne bore irrigation channels of modern ureteroscopes are inhere ntly high resistance. Several methods are available \200\224hand-in \202 ated pressure bag s, foot pumps, and hand-operated syringe pumps. Whatever system is chosen, use the minimal \202 ow required to allow a safe view so as to avoid \202 ushing the stone out of the u reter and into the kidney, from where you may not be able to retrieve it. URETEROSCOPES AND URETEROSCOPY 779 Ureteric dilatation Some surgeons do, others don \200\231t. Those who don \200\231t argue t hat dilatation is unnecessary in the era of modern, small-caliber ureteroscopes. Those who do cite a higher chance of being able to pass the ureteroscope all the way up to the kidney . Ureteric dilatation may be helpful where mul- tiple passes of the ureteroscope up and dow n the ureter are going to be required for stone removal (alternatively, use a ureteric acce ss sheath). Some surgeons prefer to place two guidewires into the ureter, one to pass the u reteroscope over ( \200\230railroading \200\231) and the other to act as a safety wire so t hat access to the kidney is always possible if dif \201 culties are encoun- tered. The sec ond guidewire is most easily placed via a dual lumen cath- eter which has a second channel through which the second guidewire can be easily passed into the ureter without requiring r epeat cystoscopy. This dual lumen catheter has the added function of gently dilating the ur eteric ori \201 ce to about 10 Ch. There is probably no long-term harm done to the ureter as a consequence of dilatation.1 Ureteric access sheaths, which have outer diameters from 10 to 14 Ch, may facilitate access to the ureter and are particularly useful if it is antici- pated that the ureteroscope wil l have to be passed up and down the ure- ter on multiple occasions (to retrieve fragments o f stone). In addition, they facilitate the out \202 ow of irrigant \202 uid from the pel vis or the kidney, thereby maintaining the \201 eld of view and decreasing intrarenal pre ssures. Patient position The patient is positioned as \202 at as possible on the operating table to \200\230iron out \200\231 the natural curves of the ureter. A cystoscopy is performed w ith either a \202 exible or rigid instrument. A retrograde ureterogram can be done to out line pelvicalyceal anatomy. A guidewire is then passed into the renal pelvis. We use a Sens or guidewire (Microvasive, Boston Scienti \201 c) which has a 3cm long \202 oppy, hydrop hilic tip which can usually easily be negotiated up the ureter. The remaining length of the wire is rigid and cov- ered in a smooth PTFE. Both properties aid passage of the ureterosc ope. Technique of \202 exible ureteroscopy and laser treatment for intrarenal stones Flexible ureteroscopy and laser treatment can be performed with topical urethral local anesthesia an d sedation. However, trying to fragment a mov- ing stone with the laser can be dif \201 cu lt and ideally, therefore, ureteroscopy is most easily done under general anesthesia with e ndotracheal intubation (rather than a laryngeal mask) to allow short periods of suspension of respi- ration and so stop movement of the kidney and its contained stone. Empty the bladder to prevent \200\230coiling \200\231 of the scope in the bladder. Pass th e scope over a guidewire. This requires two people \200\224the surgeon holds the shaft of t he scope and the assistant applies tension to the guidewire to \201 x the latter in posit ion without pulling it down. This allows the scope to progress easily up the ureter. The as sistant also ensures that acute angulation of the scope where the handle meets the shaft do es not occur. The \202 exible ureteroscope should slide easily up the ureter and into the renal pelvis. With modern active secondary de \202 ection ureteroscopes, access to most, if not all, parts of the renal collecting system is possible. CHAPTER 17 Urological surgery and equipment 780