- •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
576 CHAPTER 16 Urological surgery and equipment
Complications of surgery in general: DVT and PE
While venous thromboembolism (VTE) is uncommon after urological surgery, it is considered the most important nonsurgical complication of major urological procedures. Following TURP, 0.1–0.2% of patients experience a pulmonary embolus (PE)1 and 1–5% of patients undergoing major urological surgery experience symptomatic VTE.2
The mortality of PE is on the order of 1%.3
Risk factors for DVT and PE
Increased risk for deep venous thromboembolism (DVT) and PE is with open (versus endoscopic) procedures, malignancy, and increasing age and depends on the duration of the procedure.
Categorization of VTE risk
American College of Chest Physicians (ACCP) Guidelines on prevention of venous thromboembolism2 categorize the risk of VTE are as follows:
•Low-risk patients—those <40 years undergoing minor surgery (surgery lasting <30 minutes) and with no additional risk factors. No specific measures to prevent DVT are required in such patients other than early mobilization. Increasing age and duration of surgery increases risk of VTE.
•High-risk patients—include those undergoing non-major surgery (surgery lasting >30 minutes) who are age >60 years
Prevention of DVT and PE
See Box 16.1.
Diagnosis of DVT
Signs of DVT are nonspecific (i.e., cellulitis and DVT share common signs—low-grade fever, calf swelling and tenderness). If you suspect a DVT, arrange for a Doppler ultrasound. If the ultrasound probe can compress the popliteal and femoral veins, there is no DVT; if it can’t, there is a DVT.
Diagnosis of PE
Small PEs may be asymptomatic.
Symptoms include breathlessness, pleuritic chest pain, and hemoptysis. Signs include tachycardia, tachypnea, raised jugular venous pressure
(JVP), hypotension, and pleural rubs pleural effusion.
1 Donat R, Mancey–Jones B (2002). Incidence of thromboembolism after transurethral resection of the prostate (TURP). Scan J Urol Nephrol 36:119–123.
2 Geerts WH, Heit JA, Clagett PG, et al. (2001). Prevention of venous thromboembolism. (American College of Chest Physicians [ACCP] Guidelines on prevention of venous thromboembolism) Chest 119:132S–175S.
3 Quinlan DJ, McQuillan A, Eikelboom JW (2004). Low molecular weight heparin compared with intravenous unfractionated heparin for treatment of pulmonary embolism. Ann Intern Med 140:175–183.
COMPLICATIONS OF SURGERY IN GENERAL: DVT AND PE 577
Tests
•CXR may be normal or show linear atelectasis, dilated pulmonary artery, and small pleural effusion.
•ECG may be normal or show tachycardia, right bundle branch block, and inverted T waves in V1–V4 (evidence of right ventricular strain). The classic SI, QIII, TIII pattern is rare.
•Arterial blood gases show low PO2 and low PCO2.
•Imaging: Computed tomography pulmonary angiogram (CTPA) has superior specificity and sensitivity compared with that of ventilationperfusion (VQ) radioisotope scan.
•Spiral CT: A negative CTPA rules out a PE with similar accuracy to a normal isotope lung scan or a negative pulmonary angiogram.
Treatment of established DVT
•Below-knee DVT: above-knee thromboembolic stockings (AK-TEDs), if no peripheral arterial disease (enquire for claudication and check pulses) + unfractionated heparin (UFH) 5000 u SC 12 hourly
•Above-knee DVT: start a low molecular-weight heparin (LMWH) and warfarin, and stop heparin when INR is between 2 and 3. Continue treatment for 6 weeks for postsurgical patients; it should be lifelong if there is an underlying cause (e.g., malignancy).
•LMWH
Treatment of established PE
Fixed-dose, subcutaneous (SC) LMWH seems to be as effective as adjust- ed-dose, intravenous (IV) UFH for the treatment of PE found in conjunction with a symptomatic DVT.3 Rates of hemorrhage are similar with both forms of heparin treatment.
Start warfarin at the same time and stop heparin when INR is 2–3. Continue warfarin for 3 months.
578 CHAPTER 16 Urological surgery and equipment
Box 16.1 Options for prevention of VTE
•Early mobilization.
•Above-knee thromboembolic stockings (AK-TEDs) (provide graduated, static compression of the calves, thereby reducing venous stasis). More effective than below-knee TEDS for DVT prevention.1
•Subcutaneous heparin (low-dose unfractionated heparin [LDUH] or low molecular weight heparin [LMWH]). In unfractionated preparations, heparin molecules are polymerized, with molecular
weights from 5000 to 30,000 daltons. LMWH is depolymerized, with a molecular weight of 4000–5000 daltons.
•Intermittent pneumatic calf compression (IPC) boots, which are placed around the calves, are intermittently inflated and deflated, thereby increasing the flow of blood in calf veins.2
•For patients undergoing major urological surgery (radical prostatectomy, cystectomy, nephrectomy), AK-TEDS with IPC intraoperatively, followed by SC heparin (LDUH or LMWH) should be used. For TURP, many urologists use a combination of AK-TEDS and IPCs; relatively few use SC heparin.3
1 Howard A, et al. (2004). Randomized clinical trial of low molecular weight heparin with thighlength or knee-length antiembolism stockings for patients undergoing surgery. BJS 91:842–847. 2 Soderdahl DW, Henderson SR, Hansberry KL (1997). A comparison of intermittent pneumatic compression of the calf and whole leg in preventing deep venous thrombosis in urological surgery. J Urol 157:1774–1776.
3 Golash A, Collins PW, Kynaston HG, Jenkins BJ (2002). Venous thromboembolic prophylaxis for transurethral prostatectomy: practice among British urologists. J Roy Soc Med 95:130–131.
Further reading
British Thoracic Society guidelines for management of suspected acute pulmonary embolism (2003) Thorax 58:1–14.
Kelly J, Rudd A, Lewis RR, Hunt BJ (2002). Plasma D-dimers in the diagnosis of venous thromboembolism. Arch Intern Med 162:747–756.
Kruip MJH, Slob MJ, Schijen JH, et al. (2002). Use of a clinical decision rule in combination with D-dimer concentration in diagnostic workup of patients with suspected pulmonary embolism. Arch Intern Med 162:1631–1635.
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