- •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
612 CHAPTER 16 Urological surgery and equipment
Transurethral resection of the prostate (TURP)
Indications
•Bothersome LUTS that fail to respond to changes in lifestyle or medical therapy
•Recurrent acute urinary retention
•Renal impairment due to bladder outlet obstruction (high-pressure chronic urinary retention)
•Recurrent hematuria due to benign prostatic enlargement
•Bladder stones due to prostatic obstruction
Postoperative care
A three-way catheter is left in situ after the operation, through which irrigation fluid (normal saline) is run to dilute the blood so that a clot will not form to block the catheter. The rate of inflow of the saline is adjusted to keep the outflow a pale pink rosé color and, as a rule, the rate of inflow can be cut down after about 20 minutes. The irrigation is continued for 712–24 hours.
The catheter is removed the day after (second postoperative day) if the urine has cleared to a normal color (trial without catheter [TWOC] or trial of void [TOV]).
Common postoperative complications and their management
Blocked catheter post-TURP
This is common. The catheter may become blocked with clot or a prostatic chip that was inadvertently left in the bladder at the end of the operation.
•Apply a bladder syringe to the end of the catheter to try to dislodge the obstruction.
•If this fails, withdraw some irrigant into the syringe and flush the catheter.
•If this fails, change the catheter. The obstructing chip of prostate may be found stuck in one of the eyeholes of the catheter.
•Pass a new catheter, on an introducer.
If the bladder has been allowed to become so full of clot that a simple bladder washout is unable to evacuate it all, return the patient to the operating room for clot evacuation.
Hemorrhage
Minor bleeding after TURP is common and will stop spontaneously. A simple system to allow communication between staff is to describe the color of the urine draining through the catheter as the same as a rosé wine (minor hematuria), a dark red wine (moderate hematuria), or frank blood (bright red bleeding, suggesting serious hemorrhage).
TRANSURETHRAL RESECTION OF THE PROSTATE (TURP) 613
The rosé urine requires no action. Dark red urine should be managed by increasing the flow of irrigant and by applying gentle traction to the catheter (with the balloon inflated to 40–50 mL), thereby pulling it onto the bladder neck or into the prostatic fossa to tamponade bleeding for 20 minutes or so. This will usually result in the urine clearing.
An attempt at controlling heavier bleeding by these techniques may be tried, but at the same time you should make preparations to return the patient to the operating room because it is unlikely that bleeding of this degree will stop. The bleeding vessel(s), if seen, is controlled with diathermy.
If bleeding persists, open surgical control is required—the prostatic capsule is opened, the bleeding vessels sutured, and the prostatic bed packed. Postoperative bleeding requiring a return to the operating room occurs in ~0.5% of cases.1
Procedure-specific consent form—recommended discussion of adverse events
Serious or frequently occurring complications of TURP
•Temporary mild burning on passing urine, urinary frequency, hematuria
•Retrograde ejaculation in 75% of patients
•Failure of symptom resolution
•Permanent inability to achieve an erection adequate for sexual activity
•UTI requiring antibiotic therapy
•10% of patients require re-do surgery for recurrent prostatic obstruction
•Failure to pass urine after the postoperative catheter has been removed
•In ~10% of patients, prostate cancer is found on subsequent pathological examination of the resected tissue.
•Urethral stricture formation requiring subsequent treatment
•Incontinence (loss of urinary control)—may be temporary or permanent
•Absorption of irrigating fluid causing confusion and heart failure (TUR syndrome)
•Very rarely, perforation of the bladder requiring a temporary urinary catheter or open surgical repair
Alternative therapy
This includes observation, drugs, a catheter, stent, or open operation.
1 Ryan PC, et al. (1994). The effects of acute and chronic JJ stent placement on upper urinary tract motility and calculus transit. Br J Urol 74:434–439.
614 CHAPTER 16 Urological surgery and equipment
Transurethral resection of bladder tumor (TURBT)
Indications
•Local control of non-muscle-invasive bladder cancer (i.e., stops bleeding tumors)
•Staging of bladder cancer—to determine whether the cancer is nonmuscle invasive or muscle invasive, so that subsequent treatment and appropriate follow-up can be arranged
Postoperative care
A twoor three-way catheter is left in situ after the operation, depending on the size of the tumor and, therefore, on the likelihood that bleeding requiring irrigation will be required. As for TURP, normal saline is run through the catheter to dilute the blood so that a clot will not form to block the catheter. It is particularly important to avoid catheter blockage post-TURBT, since this could lead to distension of the bladder already weakened by resection of a tumor.
The period of irrigation is usually shorter than that required after TURP, and for small tumors the catheter may be removed the day after the TURBT. For larger tumors, remove it 2 days later.
Common operative and postoperative complications and their management
Bladder perforation during TURBT
Small perforations into the perivesical tissues (extraperitoneal) are not uncommon when resecting small tumors of the bladder. So long as you have secured good hemostasis and all the irrigating fluid is being recovered, no additional steps are required, except that perhaps one should leave the catheter in for 4 rather than 2 days.
Intraperitoneal perforations (through the wall of the bladder, through the peritoneum, and into the peritoneal cavity) are uncommon, but far more serious.
Is it an extraperitoneal or intraperitoneal perforation? Establishing this can be difficult. Both can cause marked distension of the lower abdo- men—an intraperitoneal perforation by allowing escape of irrigating solution directly into the abdominal cavity, and an extraperitoneal perforation by expanding the retroperitoneal space, with fluid then diffusing directly into the peritoneal cavity.
The fact that a suspected intraperitoneal perforation was actually extraperitoneal becomes apparent only at laparotomy when no hole can be found in the peritoneum overlying the bladder (the peritoneum over the bladder is not breached in an extraperitoneal perforation).
When there is no abdominal distension, the volume of extravasated fluid is likely to be low and, if the perforation is small, it is reasonable to manage the case conservatively. Achieve hemostasis and pass a catheter.
Make frequent postoperative assessments of the patient’s vital signs and abdomen (worsening abdominal pain, distension, and tenderness suggest the need for laparotomy).
TRANSURETHRAL RESECTION OF BLADDER TUMOR (TURBT) 615
Where there is marked abdominal distension, regardless of whether the perforation is extraperitoneal or intraperitoneal, explore the abdomen, principally to drain the large amount of fluid (which can compromise respiration in an elderly patient) by splinting the diaphragm, but also to check that loops of bowel adjacent to the site of perforation have not been injured at the same time.
Failing to make the diagnosis of an intraperitoneal perforation, particularly if bowel has been injured, is a worse situation than performing a laparotomy for a suspected intraperitoneal perforation but then finding that the perforation was “only” extraperitoneal.
Open bladder repair
Use a Pfannenstiel incision or lower midline abdominal incision, open the bladder, evacuate the clot, control bleeding, and repair the hole. Open the peritoneum and inspect the small and large bowel for perforations. Leave a urethral catheter and a drain in place.
Blocked catheter post-TURBT
The catheter may become blocked with clot. Use the same technique for unblocking it as for TURP, but avoid vigorous washouts of the bladder because of the risk of bladder perforation.
Hemorrhage
Minor bleeding after TURBT is common and will stop spontaneously. The only technique for controlling it is to ensure adequate flow of irrigant is maintained (to dilute the blood and thereby prevent clots from forming). If bleeding persists, return the patient to the OR for endoscopic control.
TUR syndrome
This is uncommon after TURBT, unless the tumor is large and the resection therefore long.
Procedure-specific consent form—recommended discussion of adverse events
Serious or frequently occurring complications of TURBT
Common complications
•Mild burning on passing urine
•Additional treatment (intravesical chemotherapy or immunotherapy) may be required to reduce the risk of future tumor recurrence.
•UTI
•No guarantee of bladder cancer cure
•Tumor recurrence is common.
Rare complications
• Delayed bleeding requiring removal of clots or further surgery
•Damage to drainage tubes from kidney (ureters) requiring additional therapy
•Development of a urethral stricture
•Bladder perforation requiring a temporary urinary catheter or open surgical repair
Alternative treatment includes open removal of bladder, chemotherapy, and radiation.