- •Hematuria II: causes and investigation
- •Hematospermia
- •Lower urinary tract symptoms (LUTS)
- •Nocturia and nocturnal polyuria
- •Flank pain
- •Urinary incontinence in adults
- •Genital symptoms
- •Abdominal examination in urological disease
- •Digital rectal examination (DRE)
- •Lumps in the groin
- •Lumps in the scrotum
- •2 Urological investigations
- •Urine examination
- •Urine cytology
- •Radiological imaging of the urinary tract
- •Uses of plain abdominal radiography (KUB X-ray—kidneys, ureters, bladder)
- •Intravenous pyelography (IVP)
- •Other urological contrast studies
- •Computed tomography (CT) and magnetic resonance imaging (MRI)
- •Radioisotope imaging
- •Post-void residual urine volume measurement
- •3 Bladder outlet obstruction
- •Regulation of prostate growth and development of benign prostatic hyperplasia (BPH)
- •Pathophysiology and causes of bladder outlet obstruction (BOO) and BPH
- •Benign prostatic obstruction (BPO): symptoms and signs
- •Diagnostic tests in men with LUTS thought to be due to BPH
- •Why do men seek treatment for their symptoms?
- •Watchful waiting for uncomplicated BPH
- •Medical management of BPH: combination therapy
- •Medical management of BPH: alternative drug therapy
- •Minimally invasive management of BPH: surgical alternatives to TURP
- •Invasive surgical alternatives to TURP
- •TURP and open prostatectomy
- •Indications for and technique of urethral catheterization
- •Indications for and technique of suprapubic catheterization
- •Management of nocturia and nocturnal polyuria
- •High-pressure chronic retention (HPCR)
- •Bladder outlet obstruction and retention in women
- •Urethral stricture disease
- •4 Incontinence
- •Causes and pathophysiology
- •Evaluation
- •Treatment of sphincter weakness incontinence: injection therapy
- •Treatment of sphincter weakness incontinence: retropubic suspension
- •Treatment of sphincter weakness incontinence: pubovaginal slings
- •Overactive bladder: conventional treatment
- •Overactive bladder: options for failed conventional therapy
- •“Mixed” incontinence
- •Post-prostatectomy incontinence
- •Incontinence in the elderly patient
- •Urinary tract infection: microbiology
- •Lower urinary tract infection
- •Recurrent urinary tract infection
- •Urinary tract infection: treatment
- •Acute pyelonephritis
- •Pyonephrosis and perinephric abscess
- •Other forms of pyelonephritis
- •Chronic pyelonephritis
- •Septicemia and urosepsis
- •Fournier gangrene
- •Epididymitis and orchitis
- •Periurethral abscess
- •Prostatitis: presentation, evaluation, and treatment
- •Other prostate infections
- •Interstitial cystitis
- •Tuberculosis
- •Parasitic infections
- •HIV in urological surgery
- •6 Urological neoplasia
- •Pathology and molecular biology
- •Prostate cancer: epidemiology and etiology
- •Prostate cancer: incidence, prevalence, and mortality
- •Prostate cancer pathology: premalignant lesions
- •Counseling before prostate cancer screening
- •Prostate cancer: clinical presentation
- •PSA and prostate cancer
- •PSA derivatives: free-to-total ratio, density, and velocity
- •Prostate cancer: transrectal ultrasonography and biopsies
- •Prostate cancer staging
- •Prostate cancer grading
- •General principles of management of localized prostate cancer
- •Management of localized prostate cancer: watchful waiting and active surveillance
- •Management of localized prostate cancer: radical prostatectomy
- •Postoperative course after radical prostatectomy
- •Prostate cancer control with radical prostatectomy
- •Management of localized prostate cancer: radical external beam radiotherapy (EBRT)
- •Management of localized prostate cancer: brachytherapy (BT)
- •Management of localized and radiorecurrent prostate cancer: cryotherapy and HIFU
- •Management of locally advanced nonmetastatic prostate cancer (T3–4 N0M0)
- •Management of advanced prostate cancer: hormone therapy I
- •Management of advanced prostate cancer: hormone therapy II
- •Management of advanced prostate cancer: hormone therapy III
- •Management of advanced prostate cancer: androgen-independent/ castration-resistant disease
- •Palliative management of prostate cancer
- •Prostate cancer: prevention; complementary and alternative therapies
- •Bladder cancer: epidemiology and etiology
- •Bladder cancer: pathology and staging
- •Bladder cancer: presentation
- •Bladder cancer: diagnosis and staging
- •Muscle-invasive bladder cancer: surgical management of localized (pT2/3a) disease
- •Muscle-invasive bladder cancer: radical and palliative radiotherapy
- •Muscle-invasive bladder cancer: management of locally advanced and metastatic disease
- •Bladder cancer: urinary diversion after cystectomy
- •Transitional cell carcinoma (UC) of the renal pelvis and ureter
- •Radiological assessment of renal masses
- •Benign renal masses
- •Renal cell carcinoma: epidemiology and etiology
- •Renal cell carcinoma: pathology, staging, and prognosis
- •Renal cell carcinoma: presentation and investigations
- •Renal cell carcinoma: active surveillance
- •Renal cell carcinoma: surgical treatment I
- •Renal cell carcinoma: surgical treatment II
- •Renal cell carcinoma: management of metastatic disease
- •Testicular cancer: epidemiology and etiology
- •Testicular cancer: clinical presentation
- •Testicular cancer: serum markers
- •Testicular cancer: pathology and staging
- •Testicular cancer: prognostic staging system for metastatic germ cell cancer
- •Testicular cancer: management of non-seminomatous germ cell tumors (NSGCT)
- •Testicular cancer: management of seminoma, IGCN, and lymphoma
- •Penile neoplasia: benign, viral-related, and premalignant lesions
- •Penile cancer: epidemiology, risk factors, and pathology
- •Squamous cell carcinoma of the penis: clinical management
- •Carcinoma of the scrotum
- •Tumors of the testicular adnexa
- •Urethral cancer
- •Wilms tumor and neuroblastoma
- •7 Miscellaneous urological diseases of the kidney
- •Cystic renal disease: simple cysts
- •Cystic renal disease: calyceal diverticulum
- •Cystic renal disease: medullary sponge kidney (MSK)
- •Acquired renal cystic disease (ARCD)
- •Autosomal dominant (adult) polycystic kidney disease (ADPKD)
- •Ureteropelvic junction (UPJ) obstruction in adults
- •Anomalies of renal ascent and fusion: horseshoe kidney, pelvic kidney, malrotation
- •Renal duplications
- •8 Stone disease
- •Kidney stones: epidemiology
- •Kidney stones: types and predisposing factors
- •Kidney stones: mechanisms of formation
- •Evaluation of the stone former
- •Kidney stones: presentation and diagnosis
- •Kidney stone treatment options: watchful waiting
- •Stone fragmentation techniques: extracorporeal lithotripsy (ESWL)
- •Intracorporeal techniques of stone fragmentation (fragmentation within the body)
- •Kidney stone treatment: percutaneous nephrolithotomy (PCNL)
- •Kidney stones: open stone surgery
- •Kidney stones: medical therapy (dissolution therapy)
- •Ureteric stones: presentation
- •Ureteric stones: diagnostic radiological imaging
- •Ureteric stones: acute management
- •Ureteric stones: indications for intervention to relieve obstruction and/or remove the stone
- •Ureteric stone treatment
- •Treatment options for ureteric stones
- •Prevention of calcium oxalate stone formation
- •Bladder stones
- •Management of ureteric stones in pregnancy
- •Hydronephrosis
- •Management of ureteric strictures (other than UPJ obstruction)
- •Pathophysiology of urinary tract obstruction
- •Ureter innervation
- •10 Trauma to the urinary tract and other urological emergencies
- •Renal trauma: clinical and radiological assessment
- •Renal trauma: treatment
- •Ureteral injuries: mechanisms and diagnosis
- •Ureteral injuries: management
- •Bladder and urethral injuries associated with pelvic fractures
- •Bladder injuries
- •Posterior urethral injuries in males and urethral injuries in females
- •Anterior urethral injuries
- •Testicular injuries
- •Penile injuries
- •Torsion of the testis and testicular appendages
- •Paraphimosis
- •Malignant ureteral obstruction
- •Spinal cord and cauda equina compression
- •11 Infertility
- •Male reproductive physiology
- •Etiology and evaluation of male infertility
- •Lab investigation of male infertility
- •Oligospermia and azoospermia
- •Varicocele
- •Treatment options for male factor infertility
- •12 Disorders of erectile function, ejaculation, and seminal vesicles
- •Physiology of erection and ejaculation
- •Impotence: evaluation
- •Impotence: treatment
- •Retrograde ejaculation
- •Peyronie’s disease
- •Priapism
- •13 Neuropathic bladder
- •Innervation of the lower urinary tract (LUT)
- •Physiology of urine storage and micturition
- •Bladder and sphincter behavior in the patient with neurological disease
- •The neuropathic lower urinary tract: clinical consequences of storage and emptying problems
- •Bladder management techniques for the neuropathic patient
- •Catheters and sheaths and the neuropathic patient
- •Management of incontinence in the neuropathic patient
- •Management of recurrent urinary tract infections (UTIs) in the neuropathic patient
- •Management of hydronephrosis in the neuropathic patient
- •Bladder dysfunction in multiple sclerosis, in Parkinson disease, after stroke, and in other neurological disease
- •Neuromodulation in lower urinary tract dysfunction
- •14 Urological problems in pregnancy
- •Physiological and anatomical changes in the urinary tract
- •Urinary tract infection (UTI)
- •Hydronephrosis
- •15 Pediatric urology
- •Embryology: urinary tract
- •Undescended testes
- •Urinary tract infection (UTI)
- •Ectopic ureter
- •Ureterocele
- •Ureteropelvic junction (UPJ) obstruction
- •Hypospadias
- •Normal sexual differentiation
- •Abnormal sexual differentiation
- •Cystic kidney disease
- •Exstrophy
- •Epispadias
- •Posterior urethral valves
- •Non-neurogenic voiding dysfunction
- •Nocturnal enuresis
- •16 Urological surgery and equipment
- •Preparation of the patient for urological surgery
- •Antibiotic prophylaxis in urological surgery
- •Complications of surgery in general: DVT and PE
- •Fluid balance and management of shock in the surgical patient
- •Patient safety in the operating room
- •Transurethral resection (TUR) syndrome
- •Catheters and drains in urological surgery
- •Guide wires
- •JJ stents
- •Lasers in urological surgery
- •Diathermy
- •Sterilization of urological equipment
- •Telescopes and light sources in urological endoscopy
- •Consent: general principles
- •Cystoscopy
- •Transurethral resection of the prostate (TURP)
- •Transurethral resection of bladder tumor (TURBT)
- •Optical urethrotomy
- •Circumcision
- •Hydrocele and epididymal cyst removal
- •Nesbit procedure
- •Vasectomy and vasovasostomy
- •Orchiectomy
- •Urological incisions
- •JJ stent insertion
- •Nephrectomy and nephroureterectomy
- •Radical prostatectomy
- •Radical cystectomy
- •Ileal conduit
- •Percutaneous nephrolithotomy (PCNL)
- •Ureteroscopes and ureteroscopy
- •Pyeloplasty
- •Laparoscopic surgery
- •Endoscopic cystolitholapaxy and (open) cystolithotomy
- •Scrotal exploration for torsion and orchiopexy
- •17 Basic science of relevance to urological practice
- •Physiology of bladder and urethra
- •Renal anatomy: renal blood flow and renal function
- •Renal physiology: regulation of water balance
- •Renal physiology: regulation of sodium and potassium excretion
- •Renal physiology: acid–base balance
- •18 Urological eponyms
- •Index
Chapter 16 |
571 |
|
|
Urological surgery and equipment
Preparation of the patient for urological surgery 572 Antibiotic prophylaxis in urological surgery 574 Complications of surgery in general: DVT and PE 576 Fluid balance and management of shock in the surgical
patient 580
Patient safety in the operating room 582 Transurethral resection (TUR) syndrome 583 Catheters and drains in urological surgery 584 Guide wires 590
Irrigating fluids and techniques of bladder washout 592 JJ stents 594
Lasers in urological surgery 598 Diathermy 600
Sterilization of urological equipment 604
Telescopes and light sources in urological endoscopy 606 Consent: general principles 608
Cystoscopy 610
Transurethral resection of the prostate (TURP) 612 Transurethral resection of bladder tumor (TURBT) 614 Optical urethrotomy 616
Circumcision 618
Hydrocele and epididymal cyst removal 620 Nesbit procedure 622
Vasectomy and vasovasostomy 624 Orchiectomy 626
Urological incisions 628 JJ stent insertion 630
Nephrectomy and nephroureterectomy 632 Radical prostatectomy 634
Radical cystectomy 636 Ileal conduit 640
Percutaneous nephrolithotomy (PCNL) 642 Ureteroscopes and ureteroscopy 646 Pyeloplasty 650
Laparoscopic surgery 652
Endoscopic cystolitholapaxy and (open) cystolithotomy 654 Scrotal exploration for torsion and orchiopexy 656
572 CHAPTER 16 Urological surgery and equipment
Preparation of the patient for urological surgery
The degree of preparation is related to the complexity of the procedure. Certain aspects of examination (pulse rate, blood pressure) and certain tests (hemoglobin, electrolytes, and creatinine) are important not only to assess fitness for surgery but also as a baseline against which changes in the postoperative period may be measured.
•Assess cardiac status (angina, arrhythmias, previous myocardial infarction [MI], blood pressure, electrocardiogram [ECG], chest X-ray [CXR]). We assess respiratory function by pulmonary function tests (forced vital capacity [FVC], forced expiratory volume in 1 second
[FEV1]) for all major surgery and for any surgery where the patient has symptoms of respiratory problems or a history of chronic airways disease (e.g., asthma).
•Arrange an anesthetic review when there is, for example, cardiac or respiratory comorbidity.
•Culture urine, treat active (symptomatic) infection with an appropriate antibiotic starting a week before surgery, and give prophylactic antibiotics at the induction of anesthesia.
•Stop aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) 10 days prior to surgery.
•Obtain consent (see p. 608).
•Measure hemoglobin and serum creatinine and investigate and correct anemia, electrolyte disturbance, and abnormal renal function. If blood loss is anticipated, group and save a sample of serum or cross-match several units of blood, the precise number depending on the speed with which your blood bank can deliver blood if needed. Recommendations on blood products are as follows:
TURBT |
Type and hold |
TURP |
Cross-match 2 units |
Open prostatectomy |
Cross-match 2 units |
Simple nephrectomy |
Cross-match 2 units |
Radical nephrectomy |
Cross-match 4 units |
Cystectomy |
Cross-match 4 units |
Radical prostatectomy |
Cross-match 2 units |
PCNL |
Cross-match 2 units |
|
|
• The patient may choose to store his or her own blood prior to the procedure.
Bowel preparation
This is indicated if bowel is to be used (ileal conduit, bladder reconstruction). Use a mechanical prep (Fleets phosphasoda or polyethelen glycol 3350) and antimicrobial prep (neomycin and erythromycin base), starting at noon the day before surgery, with a clear fluid-only diet for the rest of the day.
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574 CHAPTER 16 Urological surgery and equipment
Antibiotic prophylaxis in urological surgery
The precise antibiotic prophylaxis policy that you use will depend on your local microbiological flora. Your local microbiology department will provide regular advice and updates on which antibiotics should be used, both for prophylaxis and treatment. The policy shown below and in Table 16.1 is just a recommendation.
Culture urine before any procedure, and use specific prophylaxis (based on sensitivities) if culture positive.
We avoid ciprofloxacin in inpatients because it is secreted onto the skin and causes methicillin-resistant Staphylococcus aureus (MRSA) colonization. For most purposes, nitrofurantoin provides equivalent coverage without being secreted onto the skin.
We do use ciprofloxacin if there is known Proteus infection (all Proteus species are resistant to nitrofurantoin).
Patients with artificial heart valves
Patients with heart murmurs and those with prosthetic heart valves should be given 1 g IV amoxycillin with 80 mg gentamycin at induction of anesthesia, with an additional dose of oral amoxycillin, 500 mg 6 hours later (substituting vancomycin 1 g for those who are penicillin allergic).
Patients with joint replacements
The advice is conflicting.
AAOS/AUA advice
Joint advice of the American Academy of Orthopedic Surgeons (AAOS) and the American Urological Association (AUA) is that antibiotic prophylaxis is not indicated for urological patients with pins, plates, or screws, nor for most patients with total joint replacements.
It is recommended for all patients undergoing urological procedures, including TURP, within 2 years of a prosthetic joint replacement, for those who are immunocompromised (e.g., rheumatoid patients, those with systemic lupus erythematosus [SLE], drug-induced immunosuppression, including steroids), and for those with a history of previous joint infection, hemophilia, HIV infection, diabetes, or malignancy.
Antibiotic regime
Give a single dose of a quinolone, such as 500 mg of ciprofloxacin, 1–2 hours preoperatively + ampicillin 2 g IV + gentamicin 1.5 mg/kg 30–60 minutes preoperatively (substituting vancomycin 1 g IV for penicillin-allergic patients).
ANTIBIOTIC PROPHYLAXIS IN UROLOGICAL SURGERY 575
Table 16.1 Oxford urology procedure: specific antibiotic prophylaxis protocol for urological surgery
Procedure |
Antibiotic prophylaxis |
Catheter removal |
Nitrofurantoin, 100 mg PO 30 min |
|
before catheter removal |
Change of male long-term catheter |
Gentamicin 1.5 mg/kg IM or IV 20 min |
|
before* |
Flexible cystoscopy or GA cystoscopy |
Nitrofurantoin 100 mg PO 30–60 min |
|
before procedure |
Transrectal prostatic biopsy |
Ciprofloxacin 500 mg PO 30 min |
|
pre-biopsy and for 48 hr post-biopsy |
|
(ciprofloxacin 500 mg bid) |
ESWL |
500 mg oral ciprofloxacin 30 min |
|
before treatment (nitrofurantoin does |
|
not cover Proteus, a common stone |
|
bacterium) |
PCNL |
Ampicillin 1 g + IV gentamicin |
|
at induction (1.5 mg/kg); |
|
before operation, and 2 doses |
|
postoperatively |
Ureteroscopy
Urogynecological procedures (e.g., colposuspension)
TURPs and TURBTs — both for non-catheterized patients (i.e., elective TURP for LUTS) and patients with catheters (undergoing TURP for retention)
Gentamycin 1.5 mg/kg IV at induction
Cefuroxime 1.5 g IV and metronidazole 500 mg IV at induction of anesthesia
Ampicillin 1 g + IV gentamicin at induction (1.5 mg/kg); nitrofurantoin 100 mg PO 30 min before catheter removal
Radical prostatectomy
Cystectomy or other procedures involving the use of bowel (e.g., augmentation cystoplasty)
Artificial urinary sphincter insertion
Ampicillin 1 g + IV gentamicin at induction (1.5 mg/kg); before operation
Ampicillin 1 g + IV gentamicin at induction (1.5 mg/kg); before operation
Vancomycin 1 g 1.5 hr before leaving the ward (infuse over 100 min) + 1.5 mg IV cefuroxime + 3 mg/kg IV gentamicin at induction; continue
IV cefuroxime, gentamicin, and vancomycin (1 g) for 48 hr
*Sepsis rate (necessitating admission to hospital) may be as high as 1% without antibiotic coverage.
Note: Cefuroxime has a short half-life. Whenever using cefuroxime, give a further dose 2 hours after the first dose. Further intraoperative top-up doses of vancomycin and gentamicin are not required as they have long half-lives.