(cid:142)(cid:3) Tunnel the distal ureters through a taenium, and then submucosally for 4 \200\2235cm, and suture the spatulated ends to colonic mucosa. Stents may be placed and bro ught out through the rectum with a large rectal tube (cid:142)(cid:3) Close the anterior wall of the reservoir, place abdominal drains and close the abdomen Complications See under Ileocystoplasty (p537), but also (cid:142)(cid:3) Stoma-related pro blems (kinking, stenosis, false passage), and note that (cid:142)(cid:3) Metabolic acidosis requiring treatment, and (cid:142)(cid:3) Development of malignancy (rectal carcinoma) are much commoner. Follow-up (cid:142)(cid:3) As for Ileocystoplasty, and (cid:142)(cid:3) Ann ual colonoscopy (cid:142)(cid:3) Follow-up appropriate to the primary disease (e.g. urothel ial cancer). Continent urinary diversion with continent catheterizable stoma \200\224the Mainz pouch Pre paration (cid:142)(cid:3) Requires a highly motivated patient fully informed about pouch ma in- tenance, complication, and reoperation rates, and with normal manual dexterity (cid:142)(cid:3) Otherwise as for Ileal conduit (p540). Procedure (cid:142)(cid:3) Mobilize ureters as for Ileal conduit. (cid:142)(cid:3) Isolate a segment of bowel consisting of ca ecum (15cm) and adjoining ileum (50cm) and mobilize on its vascular pedicle (Fig. 13.13A). (cid:142)(cid:3) Restore ileocolic continuity and close the mesenteric defect. (cid:142)(ci d:3) Open the caecum longitudinally anterior to the ileocaecal valve and the ileum for 30cm along its antimesenteric edge. (cid:142)(cid:3) Make a window in the mesentery beginning where the ileal incision ends (Fig. 13.13B). URINARY TRACT RECONSTRUCTION AFTER CYSTECTOMY1 527 Fig. 13.12 Mainz II Sigma rectum: preparation of sigmoidcolon Fig. 13.13 The Mainz pouch CHAPTER 13 Urology 528 (cid:142)(cid:3) Reconfigure the ileal and caecal segments as illustrated to create a hemisphere, leaving the ileocaecal valve intact. (cid:142)(cid:3) Intussuscept the ileal segment and draw the intussusceptum through the ileocaecal valve. The linear stapling device is usually used to fix this segment in pla ce (Fig. 13.13C). (cid:142)(cid:3) The free end of the ileum is brought out as a flush stoma for self catheterisation. (cid:142)(cid:3) Spatulate and implant ureters into caecum, via a 4 \200\2235cm submucosal tunnel, and make a stented mucosal anastomosis. (cid:142)(cid:3) Leave a large bore catheter in the reservoir via the catheterisable stoma, and bring the ureteral stents through reservoir and abdominal walls. (cid:142)(cid:3) Close the reservoir as illustrated (Fig. 13.13D). (cid:142)(cid:3) Place a bdominal drains and close the abdomen. Complications As for Ileocystoplasty. Follow-up (cid:142)(cid:3) As for Ileocystoplasty, and appropriate to the primary diagnosis (e.g. urothelial cancer) Orthotopic bladder substitution \200\224the Studer Ileal neobladder with proximal ileal con duit Indications As for Mainz pouch (above) but contraindications for retention of the nati ve urethra and its continence mechanisms must not exist, and the patient must be highly mot ivated and desirous of orthotopic diversion, and prepared to acknowledge and accept the ris k of associated complications. Preparation As for Mainz pouch. Procedure After cystectomy with preservation of urethra and its continence mechanism (cid:1 42)(cid:3) Mobilize a 56cm segment of ileum, avoiding the terminal 15cm. (cid:142)(cid:3) R estore ileal continuity and close the mesenteric defect above the segment. (cid:142)(cid:3) Close the distal end. (cid:142)(cid:3) Open the isolated segment on its an timesenteric side, from a point near the (closed) distal end, for about 40cm, leaving the proximal 15cm tubular as the isop eristaltic \200\230afferent limb \200\231 to prevent ureteral reflux. URINARY TRACT RECONSTRUCTION AFTER CYSTECTOMY1 529 (cid:142)(cid:3) Configure the opened segment like a \200\230U \200\231, and suture adjace nt walls. (cid:142)(cid:3) Anastomose ureters onto the afferent limb. A technique like that described above under Ileal conduit is acceptable. (cid:142)(cid:3) Bring the stents out through the wall of the \200\230afferent limb \200 \231 and the abdominal wall, and drain into a urostomy appliance. (cid:142)(cid:3) Anastomose the urethra to the edges of an incision made in the dependent portion of the detubularised ileal segment, using six to eight 3/0 monofilament a bsorbable sutures, and place a large caliber Foley \200\231s urethral catheter across the a nastomosis and insert a large suprapubic catheter through abdominal wall and the anterior w all of the neobladder. (cid:142)(cid:3) Close the anterior wall of the neobladder to form a spherical reservoir. (cid:142)(cid:3) Drain the pelvis and close the abdomen. Complications (cid:142)(cid:3) As for Mainz pouch, plus (cid:142)(cid:3) Urinary incontinence (stress and overflow type and n octurnal incontinence) (cid:142)(cid:3) Urethroileal anastomotic stricture. Follow-up (cid:142)(cid:3) Perioperati ve care as for Ileocystoplasty and Mainz pouch (cid:142)(cid:3) Begin pelvic floor exercise s immediately postoperatively (cid:142)(cid:3) Remove drains when drainage diminishes, sten ts after 1 \200\2232 weeks (cid:142)(cid:3) Remove urethral catheter and clamp suprapubic c atheter after 1 \200\2233 weeks (cid:142)(cid:3) Thereafter as for Mainz pouch. CHAPTER 13 Urology 530 Surgery for vesicovaginal fistula Vaginal approach Indication Benign vesicovaginal fistula. Position Extended lithotomy. Preparation (cid:142)(cid:3) Prep the vagina and vulva with antiseptic solution. Shave if n ecessary (cid:142)(cid:3) Place appropriate retractors e.g. Scott ring retractor and Auvard weighted retractor. Procedure (cid:142)(cid:3) Perform cystoscopy, and cannulate ureteral orifices if necessary . (cid:142)(cid:3) Make an inverted U incision in the anterior vaginal wall, including the fistula, and raise a flap of vaginal skin. (cid:142)(cid:3) Mobilize the fistulous tract through the perivesical fascia and excise it. (cid:142)(cid:3) Separate bladder, perivesical fascia, and vagina for a small distance. (c id:142)(cid:3) Close the bladder defect in the midline using interrupted absorbable sutures. (cid:142)(cid:3) Close the perivesical fascia transversely. (cid:142)(cid:3) Excise the fre e end of the vaginal skin flap, and advance it to cover the repair. Suture with interrupted absorbable suture material. (cid:142)(cid:3) Additional security can be obtained by the interposition of pedicled tissue flaps. (cid:142)(cid:3) In each case, the flap is tunneled deep to vaginal skin and sutured in place to separate vaginal and vesical repairs. (cid:142)(cid:3) The labial incision is then closed. (cid:142)(cid:3) A vaginal pack is lef t in place for 24 \200\22348 hours. Complications (cid:142)(cid:3) Fistula recurrence (cid: 142)(cid:3) Urinary tract infection (cid:142)(cid:3) Ureteral injury (cid:142)(cid:3) Hemor rhage, infection, thromboembolic disease. Follow-up (cid:142)(cid:3) Indwelling urethral or suprapubic catheter for 14 \200\22321 days. A cystogram may be obtained before removal of catheter. Abdominal approach Position Lithotomy Preparation (cid:142)(cid:3) The abdomen, vulva and vagina prepped with antiseptic solution and draped (cid:142)(cid:3) Cystoscopy is performed, the ureters maybe cannulated. Incision Pfannensti el or median (better for omentoplasty) SURGERY FOR VESICOVAGINAL FISTULA1 531 Procedure (cid:142)(cid:3) Mobilize the bladder anteriorly in the perivesical space and biv alve it sagittally. (cid:142)(cid:3) Dissect between bladder and vagina until the fistula tract can be ex- cised leaving healthy bladder, perivesical fascia and vagina separated for a distance aroun d the fistula. (cid:142)(cid:3) Repair bladder and perivesical fascia, taking care not to incorporate ureters into the repair and repair vagina if possible. (cid:142)(cid:3) Mobilize the right hemicolon. (cid:142)(cid:3) Separate the greater omentu m from the transverse colon and mobilize it as a pedicled flap based on the right gastroepiploic vessels. (cid:142)(cid:3) Place the omental flap behind the mobilized right hemicolon and fix it in place between vagina and bladder using absorbable sutures. (cid:142)(cid:3) Place a supr apubic or urethral catheter and abdominal drains. (cid:142)(cid:3) Close the abdomen in lay ers and insert a vaginal pack for 24 \200\22348 hours. Complications As for vaginal approac h plus abdominal wound complications. Follow-up As for vaginal approach. CHAPTER 13 Urology 532 Ureteroneocystostomy Indications (cid:142)(cid:3) Refluxing megaureter associated with perc eived risk of reflux nephropathy (cid:142)(cid:3) Trauma or disease involving the lower third of the ureter. Position Supine, with 25(cid:13) of additional lordosis at the lumbosacral level. Incision (cid:142)(cid:3) Pfannenstiehl, Turner Warwick, median, paramedian or Gibson (cid: 142)(cid:3) Transperitoneal or retroperitoneal approach. Procedure Many variations exist, whose specific application depends on the clinical setting and surgeon \200\231s preference \200\224the Politano \200\223Leadbetter procedure will be described as an example: (cid:142)(cid:3) Make a vesicotomy. (cid:142)(cid:3) Insert a tra ction suture into the ureter at the ureteral orifice and circumcise the mucosa around it. (cid:142)(cid:3) Incise the trigonal smooth muscle and attachments to Waldeyer \200\231s sheath, and then bluntly mobilize a length of ureter in the perivesical space. (cid:142)(cid:3) Pass a right angled or curved clamp through the ureteral hiatus, into the perivesical space, cephalad for a distance equal to 5 times the ureteral diameter. (cid:142)(cid:3) Incise the bladder urothelium over the tip of the instrument and spread the jaws to create a new hiatus. (cid:142)(cid:3) Draw a strong suture from the new through the original hiatus and attach it to the end of the ureter, then draw the ureter up and into the bladder via the ne w hiatus. (cid:142)(cid:3) Close the original detrusor hiatus with absorbable suture, leaving the urothelial defect open. (cid:142)(cid:3) Make a suburothelial tunnel from the original hiatus to the new, and draw the ureter through it. (cid:142)(cid:3) Anchor ureteral to trigonal smooth muscle and make a mucosa-to- mucosa ureterovesical anastomosis. (cid:142)(cid:3) Close urothelium over the new muscular hiatus. (cid:142)(cid:3) This urete roneocystostomy is usually stented for a few days or weeks. (cid:142)(cid:3) Close the vesi cotomy with continuous absorbable suture. (cid:142)(cid:3) Drain the perivesical space or ( if opened) peritoneal cavity, and leave a urethral or suprapubic catheter for 7 \200\22310 days. Complications (cid:142)(cid:3) Bleeding, injury to adjacent organs (cid:142)(cid:3) Uretera l kinking, stricture or necrosis (cid:142)(cid:3) Wound, urinary or chest infections (cid:1 42)(cid:3) Thromboembolic disease (cid:142)(cid:3) Persistent or recurrent vesicoureteral r eflux. URETERONEOCYSTOSTOMY1 533 Follow-up (cid:142)(cid:3) For vesicoureteral reflux, continue prophylactic antibiotics unt il the stent has been removed and cystography has confirmed reflux has ceased. (cid:142)(cid:3) Upper tract imaging at 6 weeks to exclude obstruction. (cid:142)(cid:3) Ch ildren with established reflux nephropathy potentially need life-long nephrological follow-up. CHAPTER 13 Urology 534 Pyeloplasty Indications Urodynamically significant, complicated, or symptomatic pelviureter ic junction (PUJ) obstruction. Preparation (cid:142)(cid:3) Radioisotope studies of renal function to confirm the diagnosi s and that the kidney is salvageable \200\224a period of ureteral stenting may be appropria te. (cid:142)(cid:3) Otherwise as for nephrectomy. Incision (cid:142)(cid:3) Flank, dorsal lumbotomy or subcostal depending on patient habitus and surgeon \200\231s preference. (cid:142)(cid:3) Approach can be transperitoneal or retroperitoneal. Procedure Anderson \200\223Hynes pyeloplasty is described here (cid:142)(cid:3) Expose the upper ureter, pelviureteric junction and renal pelvis taking care not to interfere with the ureteral blood supply (Fig. 13.14A \200\224note here the kidney is retracted forwards to e xpose its posterior aspect). (cid:142)(cid:3) Identify a roughly diamond-shaped area of ren al pelvis incorporating the PUJ, and place stay sutures at these points. (cid:142)(cid:3) Transect the ureter at the appropriate level and spatulate it by incising laterally for a distance appropriate for the planned anastomosis. (cid:142)(cid:3) Excise the redundant renal pelvis tissue as marked. (cid:142)(cid:3) Make a pelviureteric anastomosis as illustrated, starting by suturing the apex of the inferior p elvic flap into the V of the ureteral spatulation. Continue with a running fine absorbable suture along one side of the ureteral spatulation and then the other. (Fig. 13.14B). Comple te the repair by closing the renal pelvis above the ureteropelvic anastomosis including a 3 -point suture incorporating ureter (Fig. 13.14C). (cid:142)(cid:3) The repair may be stented. Drain the perirenal space. Complications (cid:142)(cid:3) Hemorrhage (cid:142)(cid:3) Injury to adjacent structures \200\224spleen, pancreas, duodenum, colon, great vessels, pleura, cisterna chyli (cid:142)(cid:3) Urinoma or urinary fistula (cid:142)(cid:3) Urinary, chest or wound infect ion (cid:142)(cid:3) Thromboembolic disease (cid:142)(cid:3) Recurrent PUJ obstruction. Follow-up (cid:142)(cid:3) Remove urethral catheter after 48 hours and drains when drainage is minimal (cid:142)(cid:3) Ureteral stents are removed after about 2 \200\2236 weeks (cid :142)(cid:3) No universal follow up protocol exists. Urogram or renogram at about 6 \200 \22312 weeks seems sensible with repeat imaging at 1 year and 5 years or as clinically indi cated. PYELOPLASTY1 535 Fig. 13.14 Anderson \200\223Hynes pyeloplasty CHAPTER 13 Urology 536 Procedures for hypospadias and chordee This is a large topic and many techniques are used. Essential principles are described here. Techniques include: MAGPI Meatal advance and glanuloplasty (Duckett 2002). (cid:142)(cid:3) Here the urethral m eatus is advanced and the glans reconfigured to give an approximation of the normal appearance (cid:142)(cid:3) It can only be applied where there is subcoronal hypospadias and no chordee (cid:142)(cid:3) It is a one-stage procedure and no stent or catheter is required. Onlay island flap (cid:142)(cid:3) Can be used when the meatus is rather proximal on the pe nile shaft, but there is little or no chordee and a good quality urethral plate is present distally (cid:142)(cid:3) An island of dorsal preputial skin on a proximally based pedicle of Colles \200\231 fascia can be raised and transposed anteriorly where it is sutured to the urethra l plate and forms the anterior wall of the \200\230neo-urethra \200\231 (cid:142)(cid:3) Glans wings are raised and approximated over the flap, and penile skin is transposed from dorsally and sutured ventrally. Parameatal based flap (Mathieu) (cid:142)(cid:3) For distal hypospadias with minimal chorde e and healthy, well-perfused anterior skin and fascia (cid:142)(cid:3) A distally-based fascio-cutaneous flap is raised, based around the urethral meatus and sutured to the urethral plate (cid:142)(cid:3) Glans \200\230wings \200\231 are raised and approximated over the flap (c id:142)(cid:3) Redundant dorsal penile and preputial skin is transposed anteriorly to make up the deficit created by the flap (cid:142)(cid:3) A catheter or dribble tube is left in for 2 days. Tubularized flap techniq ues (cid:142)(cid:3) May be used for one-stage repair in cases of proximal hypospadias wher e release of chordee results in proximal displacement of the urethral meatus and disruption of the urethral plate. Pedicled flaps of preputial and penile skin can be tubularised over a stent or catheter and anastomosed to healthy urethra (cid:142)(cid:3) The distal end may be tunneled through a glans channel or glans \200\230w ings \200\231 can be raised and approximated over the tubularised flap. PROCEDURES FOR HYPOSPADIAS AND CHORDEE1 537 Incised plate hypospadias repair (cid:142)(cid:3) This technique has been advocated for: (cid:142)(cid:3) Cases of distal hypospadias without chordee and where a good quality urethral plate exists, and (cid:142)(cid:3) Cases of more proximal hypospadias where severe ventral curva- ture is not present after penile degloving, and where a good quality urethral plate is pres ent (cid:142)(cid:3) The urethral plate is deeply incised ventrally to near the corpora cavernosa and tubularised over a 6Ch stent (cid:142)(cid:3) A pedicled dartos flap is used to cover the repair, and glans flaps are raised and approximated over the urethra (cid:142)(cid:3) Dorsally based penile skin flaps are transposed ventrally to cover the shaft. Hypospadias free grafts (cid:142)(cid:3) Where genital skin is unavailable or insufficient (such as after failed surgery), tubularised free grafts or onlay grafts of extragenital tis sue can be used. (cid:142)(cid:3) These include bladder mucosal grafts, and buccal mucosal grafts (the latte r appears superior in durability and in having less tendency to shrink. (cid:142)(cid:3) A well-vascularised recipient bed is essential which may necessitate mobilizing pedicled flaps such as tunica vaginalis. CHAPTER 13 Urology 538 Urethral surgery for stricture: urethroplasty Many procedures have been developed and are i n common use. The essentials of some commonly used techniques are: Position Lithotomy or extended lithotomy. Preparation (cid:142)(cid:3) A full urethral assessment may include proximal and distal urethroscopy and urethrography (cid:142)(cid:3) Urinary infection must be treated preoperatively if possible (cid:142)(cid :3) Suprapubic access is an advantage (cid:142)(cid:3) Shave perineum and scrotum, prep wit h antiseptic and drape, carefully excluding the anus (cid:142)(cid:3) Use a Scott retractor or sutures for retraction in the perineum. Incision Depends on the site and extent of stricture and the technique to be used \200\224u sually either circumcision incision or perineo-scrotal inverted Y incision or both. Procedure (cid:142)(cid:3) Incise the skin and subcutaneous tissue. (cid:142)(cid:3) Perine o scrotal incisions (cid:142)(cid:3) Separate the bulbospongiosus muscles (cid:142)(cid:3) Mobilize the urethra (Fig. 13.15) (cid:142)(cid:3) Using sounds or flexible cystoscope, identify the site and e xtent of the stricture. (cid:142)(cid:3) Penile incisions (cid:142)(cid:3) Circumcise and deglove the penis by dissecting deep to Colles \200\231 fascia (cid:142)(cid:3) Identify the site and extent of stricture, incise Buck \200\231s fascia an d mobilize the urethra as necessary. Techniques used include: One stage procedures (cid:142)(cid:3) Stricture excision and primary reanastomosis. (cid:142)(cid:3) Usually for relatively short strictures proximal to the penile suspensory ligament. (cid:142)(cid:3) The urethral ends are spatulated for a centimeter (proximal end dorsally, distal end ventrally) and re-anastomosed over a catheter or stent using one or two layers o f absorbable suture material. (cid:142)(cid:3) Proximally, additional functional length can be obtained by means such as separating the crura of the corpora cavernosa, resecting part of the inferior aspect of the symphysis pubis, or transposing urethra behind one of the co rpora cavernosa. URETHRAL SURGERY FOR STRICTURE: URETHROPLASTY1 539 Fig. 13.15 Mobilizing the urethra for urethroplasty CHAPTER 13 Urology 540 (cid:142)(cid:3) Dorsal or ventral onlay pedicled flaps or free grafts. (cid:142)(cid:3) Penile or preputial skin is mobilized, usually on a proximally based pedic le of Colles \200\231 fascia and transposed to bridge a defect where urethra has been incis ed. (cid:142)(cid:3) Normal urethral caliber is restored. The repair remains stented for a peri od depending on the technique and surgeon \200\231s preference. (cid:142)(cid:3) Free graft s of split skin, bladder mucosa or buccal mucosa are used in the same setting, quilted to Buck \200\231s fascia covering the tunica albuginea of the penis. (cid:142)(cid:3) Tubularized pedicled flaps or free grafts. (cid:142)(cid:3) In general these are associated with higher complication and attri- tion rates than onlay grafts or flaps. Two stage procedures (cid:142)(cid:3) In principle, transposed tissue is given time to \200\230bed in \200\231 and acquire local blood supply before being tubularised to restore continuity. (cid:142)(cid:3) In the penile urethra, the availability of hairless skin makes it possi- ble to incise skin and urethra in the midline, and suture urethral mucosa and corpus spongiosum to adjacent Colles \200 \231 fascia and skin edge. After a minimum of 6 months eccentric flaps of medially (periure thrally) based skin are raised, tubularised over a catheter, and covered with Colles fascia and skin. Eccentric flaps are used so suture lines are not superimposed. (cid:142)(cid:3) In the bulbar urethra, hairless split skin, bladder, or buccal mucosa is u sed to augment the opened urethra, and subsequently tubular- ised under bulbospongiosus mus cle, fascia and scrotum. Complications (cid:142)(cid:3) Wound or urinary tract infection (cid:142)(cid:3) Recurrent stricture \200\224all techniques have a \200\230rate of attrition \200\231 (cid:142)(cid:3 ) Urinary extravasation, urethrocutaneous fistula. Follow-up After catheter removal, interv al uroflowmetry, and endoscopy are pru- dent measures as symptoms may be misleading. This page intentionally left blank CHAPTER 13 Urology 542 Procedures for stress urinary incontinence Burch colposuspension Indications Genuine stress urinary incontinence with urethral and bladder neck hypermobility. Position Lithotomy with legs abducted. Preparation (cid:142)(cid:3) Counsel regarding the possibility of urinary retention and nee d for self catheterisation (cid:142)(cid:3) Treat UTI preoperatively (cid:142)(cid:3) Prep and drape lower abdomen, vu lva and vagina and drape excluding anus. Incision (cid:142)(cid:3) Low median, Turner-Warwick, or Pfannenstiel (cid:142)(cid:3) Extr aperitoneal approach. Procedure (cid:142)(cid:3) Perform cystoscopy and place a large Foley catheter in the bladder with the balloon inflated \200\224use this to help locate the blad der neck. Also place a suprapubic catheter. (cid:142)(cid:3) Place appropriate retractors and develop the retropubic perivesical space. (cid:142)(cid:3) Tease away perivesical and perivaginal fat, until the endopelvic, perive- sical and perivaginal fascia and pectineal ligaments are demonstrated (Fig. 13.16A). (cid:142)(cid:3) Insert two fingers or a sponge-stick into the vagina to elevate it, and place a suture into vagina laterally at the level of mid urethra, on each side, excluding \200\230mucosa \200\231. Pass each suture through the pectineal liga- ment also, but do not pull up yet \200\224apply clamps (Fig. 13.16B). (cid:142)(cid:3) Do the same with at least one more suture on each side, at the level of th e urethrovesical junction, but lateral to it. There may be consider- able venous bleeding d uring this maneuver. (cid:142)(cid:3) Ensure that bladder and urethra have not been included in any suture, and then approximate the vagina and pectineal ligament by tightening the sutures while elevatin g vagina from within. (cid:142)(cid:3) The correct position has been achieved when the urethra and bladder neck a re suspended behind the symphysis pubis, but are not com- pressed. The vagina need not be i n contact with pectineal ligament (Fig. 13.16C). (cid:142)(cid:3) Place perivesical drains and close the abdomen. Remove the urethral catheter. Complications (cid:142)(cid:3) Hemorrhage and haematoma (cid:142)(cid:3) Bladder or urethra l injury PROCEDURES FOR STRESS URINARY INCONTINENCE1 543 Fig. 13.16 Burch procedure for stress urinary incontinence CHAPTER 13 Urology 544 (cid:142)(cid:3) Vesicovaginal fistula (cid:142)(cid:3) Delayed voiding or urinary retentio n requiring long-term intermittent catheterisation (cid:142)(cid:3) Venous thrombosis or embolism (cid:142)(cid:3) Wound or urinary tract infe ction. Follow-up (cid:142)(cid:3) Drains are removed after a day or two when the drainage d iminishes (cid:142)(cid:3) Clamp the suprapubic catheter and monitor post-void residual bla dder volumes as soon as the patient is comfortable and mobile (cid:142)(cid:3) In the event of delayed voiding, she will commence self-catheterisation until the residual volumes decrease (cid:142)(cid:3) This can be followed up by a specialist nurse or stoma therapist, and at outpatient clinics. Sling procedures Indications Genuine stress urinary incontinence as a consequence of urethr al and bladder neck hypermobility as well as intrinsic sphincter dysfunction. Position and preparation (cid:142)(cid:3) As for the Burch colposuspension (cid:142)(cid:3) Some synthetic slings may be placed under local anesthesia. Procedure (cid:142)(cid:3) Var iations exist: (cid:142)(cid:3) Using autologous tissue, processed cadaveric tissue, processed xenografts, semi-synthetic or synthetic materials, and (cid:142)(cid:3) Placing the sling at the level of the bladder neck or mid urethra and (cid :142)(cid:3) Via retropubic or vaginal approaches, or by means of a combination of vaginal, endoscopic and percutaneous techniques. (cid:142)(cid:3) In principle, the sling is placed (via a vaginal incision) deep to the vag i- nal skin and fascia, and passes through the pubocervical fascia on each side, literally slinging the urethra or urethrovesical junction. (cid:142)(cid:3) Tension is counterproductive \200\224the sling is designed to restore the urethrovesical junction or bladder to the correct anatomical position, not to compress it. (cid:142)(cid:3) The sling is held in position by friction and subsequent fibrosis, or by fixation to the abdominal wall or pelvis. (cid:142)(cid:3) Cystoscopy may be used to ensure that bladder and urethra have not been injured. (cid:142)(cid:3) A urethral or suprapubic catheter may be left in situ for a period postoperatively. Complications (cid:142)(cid:3) Inadvertent injury to adjacent structures (bowel, iliac vess els) (cid:142)(cid:3) Bleeding, haematoma (cid:142)(cid:3) Urinary retention or delayed voi ding (cid:142)(cid:3) Urethral erosion, vesicovaginal or urethrovaginal fistula. Follow-up As for Burch colposuspension This page intentionally left blank CHAPTER 13 Urology 546 Procedures for Peyronie \200\231s disease Techniques used depend on the patient \200\231s e rectile function and phallus size, and on the expertise and experience of the operator. The y include plication of tunica albuginea penis, excision of the plaque and substitution with dermis, or insertion of a penile prosthesis. Penile plication is described. Indication Used for severe angulation of the penis, where length and erectile func- tion ar e acceptable. Position Supine or in lithotomy with legs abducted. Preparation (cid:142)(cid:3) Antibiotics with induction of anesthesia if prosthesis is to b e used (cid:142)(cid:3) Thromboembolism prophylaxis (cid:142)(cid:3) Prep and drape penis a nd scrotum. Incision Circumcision with degloving proximally, deep to Colles \200\231 fascia. Procedure (cid:142)(cid:3) Produce artificial erection by application of tourniquet and int racaver- nosal sterile saline injection (cid:142)(cid:3) Estimate the number and size of the ellipses that must be excised opposite the plaque in order to produce straightening of the penis. (cid:142)(cid:3) Mark t hese on the penis and then check the effect by grasping the tunica albuginea penis with Allis clamps so as to produce reversible plication. Urethral mo bilization may be required (cid:142)(cid:3) When the correct effect is produced, incise Buck \200\231s fascia, excise ellipses of tunica albuginea as marked and close the defects with strong nonabsorbable or p olydioxanone suture material (cid:142)(cid:3) Obtain haemostasis then replace Colles \200\231 fascia and skin and suture as for circumcision. Complications (cid:142)(cid:3) Haematoma (cid:142)(cid:3) Urethral injury (cid:142)(cid:3) Cavernositis (cid:142)(cid:3) Over- or under-correction (cid:142)(cid:3) Shortening of the penis (a given complication) (cid:142)(cid:3) Waisting with loss of erectile turgour distal ly or abnormal flexibility at the waist (cid:142)(cid:3) Loss of penile sensation. Follow-up Review at specialized andrology or male sexual dysfunction clinic. This page intentionally left blank CHAPTER 13 Urology 548 Percutaneous surgery of the upper urinary tract Indications (cid:142)(cid:3) Drainage of co llections outside the urinary tract (cid:142)(cid:3) Perinephric abscess, urinoma (cid:142)(cid:3) Percutaneous nephrostomy (cid:142)(cid:3) Urgent proximal drainage of the upper urinary tract in the presence of ren al failure or sepsis, usually anticipating definitive treatment (cid:142)(cid:3) Antegrade placement of ureteral stents (eg when the ureteral ori- fice cannot be cannulated retrograde) (cid:142)(cid:3) Percutaneous nephrolithotomy (PCNL) (cid:142)(cid:3) Management of upper tract stones not appropriate for ESWL (see below) because of \200\224 Large size or complexity (staghorn calculi) \200\224 Hardness (cystine, calcium oxalate monohydrate) \200\224 Calculi in calyceal diverticula (cid:142)(cid:3) Percutaneous treatment of infundibular, PUJ, or ureteral stenosis (see Ureterorenoscopic procedures) (cid:142)(cid:3) Percutaneous management of upper tract transitional cell carcinoma (controversial). Position (cid:142)(cid:3) Generally prone or semi-prone (cid:142)(cid:3) Retrograde placeme nt of ureteral guidewires or catheters may require the lithotomy position initially. Preparation (cid:142)(cid:3) Inform the patient of pertinent risks and alternatives (cid:14 2)(cid:3) Attempt to optimize their fitness for the procedure by means such as stopping ant icoagulants, treating hypertension or UTI etc. However, the urgency of the situation (pyone phrosis for example) may make this impractical and delay unwise (cid:142)(cid:3) Give broad-spectrum intravenous antibiotics regardless of whether local or general anesthesia is to be used (cid:142)(cid:3) Prepare the area for percutaneous access and position fluoroscopic tube and monitors (cid:142)(cid:3) For PCNL: (cid:142)(cid:3) General anesthesia is given (cid:142)(cid:3) A ureteral balloon catheter i s advanced via a cystoscope over a guidewire and inflated at the PUJ to occlude it, and (cid:142)(cid:3) A Foley \200\231s urethral catheter is inserted to drain the bladder (cid: 142)(cid:3) The patient is repositioned, prepped, and draped as above. PERCUTANEOUS SURGERY OF THE UPPER URINARY TRACT1 549 Procedure Access (cid:142)(cid:3) Fluoroscopy and ultrasonography are used to guide the pla cement of the appropriate guidewires, cannulas and catheters. (cid:142)(cid:3) For drainage of pyonephrosis, generally a lower pole posterior calyx is punctured for convenience and safety. (cid:142)(cid:3) For other indications, the placement of a retrograde ureteral catheter all ows opacification and dilatation of the pelvicalyceal system, and the most appropriate caly x or calyces are punctured. Note that more than one tract may be used. (cid:142)(cid:3) A guidewire is advanced into the collecting system, and an attempt made to maneuver it down the ureter. (cid:142)(cid:3) The nephrostomy tract is dilated by a variety of techniques: (cid:142)(cid:3) For placement of nephrostomy catheters or antegrade placement of ureteral stents, graduated fascial dilators are advanced over the guidewire until the correct calibe r is obtained. (cid:142)(cid:3) For percutaneous surgery involving nephroscopy further dilatation is achie ved with telescopic dilators, coaxial dilators or (most safely) with a balloon dilator, ove r which a 30 Ch sheath is advanced to maintain the tract. The balloon \200\224but not the g uidewire \200\224is removed. Nephrostomy tube drainage (cid:142)(cid:3) Usually, a pigtail nephrostomy catheter is advan ced over the guidewire to the appropriate position under fluoroscopy, and the guidewire is removed. The tube is secured within the collecting system by its \200\230pig- tail \200 \231 curl (which may have a strong \200\230memory \200\231 or a locking mechanism to preve nt unraveling) and at skin level. (cid:142)(cid:3) A similar technique is used for perinephric abscess or urinoma. PCNL (cid: 142)(cid:3) A large sheath is placed to maintain the tract. (cid:142)(cid:3) The rigid neph roscope is passed though the sheath alongside the guidewire. Saline is the usual irrigant. (cid:142)(cid:3) Stones or fragments less than 10mm in diameter can be grasped and removed. (cid:142)(cid:3) Larger stones are fragmented using ultrasonic, electrohydraulic, laser or pneumatic lithotripsy and removed piecemeal. The balloon catheter at the PUJ prevents fr agment migration during this procedure. (cid:142)(cid:3) All stone is removed \200\224sometimes via several tracts. Flexible nephro - scopy and fluoroscopy confirm stone clearance and exclude major collecting system injury. (cid:142)(cid:3) The ureteral balloon catheter is removed. (cid:142)(cid:3) A purpose-made double pigtail ureteral stent with attached coaxial large-bore nephrostomy catheter (Counci ll) is placed antegrade. (cid:142)(cid:3) Hemorrhage from the nephrostomy tract may be tamponaded with a Kaye balloon catheter. CHAPTER 13 Urology 550 Complications (cid:142)(cid:3) Hemorrhage, loss of renal parenchyma or kidney (cid:142)(cid :3) Perforation of the collecting system (cid:142)(cid:3) Loss of access to the collecting system (cid:142)(cid:3) Injury to adjacent structures \200\224bowel, pancreas, liver, splee n, major vessels (cid:142)(cid:3) Urosepsis (cid:142)(cid:3) Persistent obstruction and urinary fist ula. Follow-up (cid:142)(cid:3) Intensive monitoring in the immediate postoperative period (cid: 142)(cid:3) Urography after 24 \200\22348 hours to confirm stone-free status and urinary tract integrity (cid:142)(cid:3) Further procedures may be required including further nephroscopy or ESWL (cid:142)(cid:3) The nephrostomy tube and ureteral stent can be removed if imaging result is favorable and bleeding insignificant (cid:142)(cid:3) After a few hours observation, discharge for outpatient follow up in a fortnight. This page intentionally left blank CHAPTER 13 Urology 552 Extracorporeal shockwave lithotripsy (ESWL) Indications (cid:142)(cid:3) Small urinary trac t calculi (<2cm in the kidney, <1cm in the ureter), in the absence of obstruction or acute urinary tract infection. Note \200\224Hard stones may be difficult to fragment and the management of small lower pol e calyx calculi remains controversial. Position (cid:142)(cid:3) Depends on the stone position within the urinary tract and the ty pe of lithotripter (not all can accommodate a prone patient) (cid:142)(cid:3) Supine for renal and upper ureteral stones (cid:142)(cid:3) Prone for lowe r and midureteral stones and bladder stones (cid:142)(cid:3) Ensure excellent contact betwe en the patient \200\231s skin and the shockwave transmitting device. Preparation (cid:142)(cid:3) Confirm appropriateness of procedure and exclude (relative or abso- lute) contraindications (cid:142)(cid:3) Pregnancy (cid:142)(cid:3) Abdominal aortic aneury sm (cid:142)(cid:3) Bleeding diathesis or anticoagulation (cid:142)(cid:3) Urinary tract in fection or obstruction (cid:142)(cid:3) Antibiotics may be given orally preoperatively (cid :142)(cid:3) For non-opaque calculi, urinary tract opacification may be achieved by intravenous or retrograde pyelography (cid:142)(cid:3) Stone localization may be achieved using biplanar fluoroscopy and/or ultrasonography (cid:142)(cid:3) The need for sedation and analgesia or anesthesia depends on the patient and the type of lithotripter to be used. Procedure (cid:142)(cid:3) Position the patient so that the calculus is at the focal point of the shock wave (cid:142)(cid:3) Commence treatment at low power if the patient is awake (cid:142)(cid:3) R epeat imaging at intervals to confirm that the stone is still within the focal point, and to monitor fragmentation. Complications (cid:142)(cid:3) Failure to fragment calculus, or clear fragments (cid:142)(c id:3) Uro sepsis (cid:142)(cid:3) Steinstrasse \200\224a logjam of fragments, usually near the vesicoureteral junction or PUJ (cid:142)(cid:3) Haematoma, haematuria (cid:142)(cid:3) Significant injury to adjacent stru ctures (growth-plates in children, lung, bowel, panceas, liver, spleen, uterus, ovaries) \200\224fortunately very rare. This page intentionally left blank CHAPTER 13 Urology 554 Ureterorenoscopic procedures Indications Diagnostic (cid:142)(cid:3) Ureterorenoscopy (usin g rigid or flexible instrument) (cid:142)(cid:3) Urothelial biopsy Therapeutic (cid:142)(ci d:3) Removal or fragmentation of upper tract urinary calculi (cid:142)(cid:3) Resection or destruction of upper urinary tract urothelial neoplasms (cid:142)(cid:3) Treatment of obstr uctive lesions (congenital or acquired) of (cid:142)(cid:3) Calyceal infundibulum (cid:142)(cid:3) Ureteropelvic junction (cid:142)(ci d:3) Ureter. Position Dorsal lithotomy. Preparation (cid:142)(cid:3) If endopyelotomy is contemplated imaging of the related vascul ar anatomy is prudent (cid:142)(cid:3) Appropriate counseling and consent (cid:142)(cid:3) Arrange intraoperative fluoroscopy (cid:142)(cid:3) Treat UTI (cid:142)(cid:3) Antibiotics with anesthetic induct ion (cid:142)(cid:3) Prepare perineum and genitalia with antiseptic solution, perform EUA, and drape. Procedure (cid:142)(cid:3) Perform rigid cystoscopy, and, if appropriate, retrograde pyelog raphy. (cid:142)(cid:3) Pass a guidewire into the ureter. (cid:142)(cid:3) Dilatation of th e ureteral orifice and intramural ureter \200\224if necessary \200\224 may be done most safely using a balloon dilator. (cid:142)(cid:3) A ureteral access sheath may be helpful, especially for flexible ureteroscopic procedures, and is placed, using the Seldinger technique over a tapered dilat or and guidewire. The dilator is then removed. (cid:142)(cid:3) Pass the ureteroscope eithe r over the guidewire, or alongside it, under direct endoscopic vision with fluoroscopic control. (cid:142)(cid:3) Choose the device most appropriate for the job and pass it along the working channel of the ureteroscope. (cid:142)(cid:3) Visibility is achieved by irrigating through the ureteroscope. Irrigant flow is improved by intermittent pressure provided by a blood pump or manually using a syri nge or other device. (cid:142)(cid:3) Small calculi can be retrieved using a variety of graspers or wire baskets. (cid:142)(cid:3) Larger calculi (>5mm) are fragmented using one of the following: (cid:142)(cid:3) Electrohydraulic, laser (pulsed-dye or holmium YAG), ultrasonic or ballistic (Swiss lithoclast) lithotripsy. (cid:142)(cid:3) The first two can be used with flexible or rigid instruments, the last two with rigid instruments only. URETERORENOSCOPIC PROCEDURES1 555 (cid:142)(cid:3) Biopsies can be taken using cold forceps. (cid:142)(cid:3) Tumor can be va porized using the holmium YAG laser or resected using a ureteroscopic resectoscope. (cid:142)(cid:3) Strictures can be dilated using balloon dilators, or incised either under endoscopic vision using cold knife, electrosurgical knife, laser, or the Accucise device.