- •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
604 CHAPTER 16 Urological surgery and equipment
Sterilization of urological equipment
Techniques for sterilization
Autoclaving
Modern cystoscopes and resectoscopes, including components such as light leads, are autoclavable. Standard autoclave regimens heat the instruments to 121°C for 15 minutes or 134°C for 3 minutes.
Chemical sterilization
This involves soaking instruments in an aqueous solution of chlorine dioxide (Cidex), an aldehyde-free chemical (there has been a move away from formaldehyde because of health and environmental concerns). Chlorine dioxide solutions kill bacteria, viruses (including HIV and hepatitis B and C), spores, and mycobacteria.
Cameras cannot be autoclaved. Use a camera sleeve or sterilize the camera between cases.
Sterilization and prion diseases
Variant Creutzfeldt Jacob disease (vCJD) is a neurodegenerative disease caused by a prion protein (PrP). Other examples of neurodegenerative prion diseases include classic CJD, kuru, sheep scrapie, and bovine spongiform encephalopathy (BSE). Variant CJD and BSE are caused by the same prion strain and represent a classic example of cross-species transmission of a prion disease.
There has been much recent concern about the potential for transmission of vCJD between patients via contaminated surgical instruments. Classic CJD may be transmitted by neurosurgical and other types of surgical instruments because normal hospital sterilization procedures do not completely inactivate prions.1 It is not possible at present to quantify the risks of transmission of prion diseases by surgical instruments. To date, iatrogenic CJD remains rare, with 267 cases having been reported worldwide, up to the year 2000.2
The risk of transmission of CJD may be higher with procedures performed on organs containing lymphoreticular tissue, such as tonsillectomy and adenoidectomy, because vCJD targets these tissues and is found in high concentrations there. For this reason there was a move toward the use of disposable, once-only-use instruments for procedures such as tonsillectomy. However, these instruments have been associated with a higher postoperative hemorrhage rate.3
Prions are particularly resistant to conventional chemical (ethylene oxide, formaldehyde, and chlorine dioxide) and standard autoclave regimens, and dried blood or tissue remaining on an instrument could harbor prions that will not then be killed by the sterilization process. Once
1 Collinge J (1999). Variant Creutzfeldt-Jakob disease. Lancet 354:317–323.
2 Collins SJ, Lawson VA, Masters CL (2004). Transmissible spongiform encephalopathies. Lancet 363:51–61.
3 Nix P (2003). Prions and disposable surgical instruments. Int J Clin Pract 57:678–680.
STERILIZATION OF UROLOGICAL EQUIPMENT 605
proteinaceous material such as blood or tissue has dried on an instrument, it is very difficult to subsequently be sure that the instrument has been sterilized.4 Sterilization should include the following:
•Presterilization cleaning: Initial low-temperature washing (<35°C) with detergents and an ultrasonic cleaning system removes and prevents coagulation of prion proteins—sonic cleaners essentially shake attached material from the instrument.
•Hot wash
•Air drying
•Thermal sterilization: Longer autoclave cycles at 134–137°C for at least 18 minutes (or 6 successive cycles with holding times of 3 minutes) or 1 hour at conventional autoclave temperatures may result in a substantial reduction in the level of contamination with prions.
The latest models of presterilization cleaning devices—automated thermal washer disinfectors—perform all of these cleaning tasks within one unit.
Enzymatic proteolytic inactivation methods are under development.
4 The Advisory Committee on Dangerous Pathogens and Spongiform Encephalopathy (1998). Transmissible spongiform encephalopathy agents: safe working and the prevention of infection. London: HM Stationery Office.
606 CHAPTER 16 Urological surgery and equipment
Telescopes and light sources in urological endoscopy
There are three types of modern urological telescopes—rigid, semi-rigid, and flexible. These endoscopes may be used for inspection of the urethra and bladder (cystoscourethroscopes, usually simply called cystoscopes), the ureter and collecting system of the kidney (ureteroscopes and ureterorenoscopes), and, via a percutaneous access track, the kidney (nephroscopes).
The light sources and image transmission systems are based on the innovative work of Professor Harold Hopkins, University of Reading.
The Hopkins rod-lens system
The great advance in telescope design was the development of the rodlens telescope, which replaced the conventional system of glass lens with rods of glass, separated by thin air spaces that essentially were air lenses (Fig. 16.13). By changing the majority of the light transmission medium from air to glass, the quantity of light that could be transmitted was doubled. The rods of glass were also easier to handle during manufacture, and therefore their optical quality was greater.
The angle of view of the telescope can be varied by placing a prism behind the objective lens. 0°, 12°, 30° and 70° scopes are available.
Lighting
Modern endoscopes (urological and those used to image the gastrointestinal tract) use fiber-optic light bundles to transmit light to the organ being inspected. Each glass fiber is coated with glass of a different refractive index so that light entering at one end is totally internally reflected and emerges at the other end (Fig. 16.14).
These fiber-optic bundles can also be used for image (as well as light) transmission, as long as the arrangement of the fibers at either end of the instrument is the same (coordinated fiber bundles are not required for simple light transmission). The fiber bundles are tightly bound together only at their end (for coordinated image transmission). In the middle, the bundles are not bound—this makes the instrument flexible (e.g., flexible cystoscope and flexible ureteroscope).
TELESCOPES AND LIGHT SOURCES IN UROLOGICAL ENDOSCOPY 607
(a)
Glass Air
(b)
Glass Air
Figure 16.13 (a) Diagram of conventional cystoscope. The glass lenses are held in place by metal spacers and separated by air spaces. (b) Rod-lens telescope with “lenses” of air, separated by “spaces” of glass, with no need for metal spacers.
Reprinted with permission from Blandy J, Fowler C (1996) Urology. Wiley-Blackwell, pp. 3–5.
Figure 16.14 Total internal reflection permits light to travel along a flexible glass fiber. Reprinted with permission from Blandy J, Fowler C (1996) Urology. Wiley-Blackwell, pp. 3–5.