- •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
640 CHAPTER 16 Urological surgery and equipment
Ileal conduit
Indications
•For urinary diversion following radical cystectomy
•Intractable incontinence for which anti-incontinence surgery has failed or is not appropriate
Postoperative care and common postoperative complications and their management
Oliguria or anuria: Try a fluid challenge.
Wound infection: Treat with antibiotics and wound care. Open the superficial layers of the wound to release pus.
Wound dehiscence is rare. It requires resuturing in the operating room, under general anesthetic.
Ileus is common. It usually resolves spontaneously within a few days.
Small bowel obstruction
This occurs from herniation of small bowel through the mesenteric defect created at the junction between the two bowel ends. Continue nasogastric aspiration. The obstruction will usually resolve spontaneously.
Reoperation is occasionally required when the obstruction persists or there are signs of bowel ischemia.
Leakage from the intestinal anastomosis
This can lead to the following:
•Peritonitis—requiring reoperation and repair or refashioning of the anastomosis
•An enterocutaneous fistula—bowel contents leak from the intestine and through a fistulous track onto the skin. A low-volume leak (<500 mL/24 hr) will usually heal spontaneously. Normal (enteral) nutrition may be maintained until the fistula closes (which usually occurs within a matter of days or a few weeks). If high volume, spontaneous closure is less likely, and reoperation to close the fistula may be required.
Leakage from the ureteroileal junction
Leakage may be suspected because of a persistently high output of fluid from the drain. Test this for urea. Urine will have a higher urea and creatinine concentration than serum. If the fluid is lymph, the urea and creatinine concentration will be the same as that of serum.
Arrange for a loopogram. This will confirm the leak. Place a soft, small catheter (12 Fr) into the conduit to encourage antegrade flow of urine and assist healing of the ureteroileal anastomosis. If the leakage continues, arrange for bilateral nephrostomies to divert the flow of urine away from the area and encourage wound healing.
Occasionally, a ureteroileal leak will present as a urinoma (this causes a persistent ileus). Radiologically assisted drain insertion can result in a dramatic resolution of the ileus, with subsequent healing of the ureteroileal leak.
ILEAL CONDUIT 641
Hyperchloremic acidosis
This may be associated with obstruction of the stoma at its distal end or from infrequent emptying of the stoma back (leading to back-pressure on the conduit). Catheterize the stoma relieves the obstruction. In the long term, the conduit may have to be surgically shortened.
Acute pyelonephritis is due to the presence of reflux combined with bacteriuria.
Stomal stenosis
The distal (cutaneous) end of the stoma may become narrowed, usually as a result of ischemia to the distal part of the conduit. Revision surgery is required if this stenosis causes obstruction leading to recurrent UTIs or back-pressure on the kidneys.
Parastomal hernia formation
Hernias occur around the site through which the conduit passes, through the fascia of the anterior abdominal wall. Many hernias can be left alone. The indications for repairing a hernia are as follows:
•Bowel obstruction
•Pain
•Difficulty with applying the stoma bag (distortion of the skin around the stoma by the hernia can lead to frequent bag detachment).
Repair the hernia defect by placing mesh over the hernia site, via an incision sited as far as possible from the stoma itself, to reduce the risk of wound infection.
Procedure-specific consent form—recommended discussion of adverse events
Serious or frequently occurring complications of ileal conduit formation
Common
•Temporary drain, stents, or nasal tube
•Urinary infections, occasionally requiring antibiotics
Occasional
•Diarrhea due to shortened bowel
•Blood loss requiring transfusion or repeat surgery
•Infection or hernia of incision requiring further treatment
Rare
•Bowel and urine leakage from anastomosis requiring reoperation
•Scarring to bowel or ureters requiring operation in future
•Scarring, narrowing, or hernia formation around urine opening requiring revision
•Decreased renal function with time
Alternative treatment includes catheters, continent diversion of urine.
642 CHAPTER 16 Urological surgery and equipment
Percutaneous nephrolithotomy (PCNL)
Indications
•Stones >3 cm in diameter
•Stones that have failed ESWL and/or an attempt at flexible ureteroscopy and laser treatment
•Staghorn calculi
Preoperative preparation
•CT scan to assist planning the track position and to identify a retrorenal colon1
•Stop aspirin 10 days prior to surgery
•Culture urine (so appropriate antibiotic prophylaxis can be given)
•Cross-match 2 units of blood
•Start IV antibiotics the afternoon before surgery to reduce the chance of septicemia (many stones treated by PCNL are infection stones). If urine is culture negative, use 1.0 g IV ampicillin and IV gentamicin (1.5 mg/kg). Routine antibiotic prophylaxis also reduces the incidence of postoperative UTI.2
Postoperative management
Once the stone has been removed, a nephrostomy tube is left in situ for several days (Fig. 16.15). This drains urine in the postoperative period and tamponades bleeding from the track.
Complications of PCNL and their management
Bleeding
Some bleeding is inevitable, but an amount severe enough to threaten life is uncommon. In most cases it is venous in origin and stops following placement of a nephrostomy tube (which compresses bleeding veins in the track).
If bleeding persists, clamp tube for 10 minutes. If bleeding continues despite this, order urgent angiography, looking for an arteriovenous fistula or pseudoaneurysm, both of which require selective renal artery embolization (required in 1% of PCNLs3) or open exposure of kidney to control bleeding by suture ligation, partial nephrectomy, or nephrectomy.
Septicemia
This occurs in 1–2% of cases. Incidence is reduced by prophylactic antibiotics. Track damage; it is essentially minimal. Cortical loss from track is estimated to be <0.2% of total renal cortex in animal studies.4
1 Hopper KD, Sherman JL, Williams MD, et al. (1987). The variable anteroposterior position of the retroperitoneal colon to the kidneys. Invest Radiol 22:298–302.
2 Inglis JA, Tolly DA (1988). Antibiotic prophylaxis at the time of percutaneous stone surgery. J Endourol 2:59–62.
3 Martin X (2000). Severe bleeding after nephrolithotomy: results of hyperselective embolisation. Eur Urol 37:136–139.
PERCUTANEOUS NEPHROLITHOTOMY (PCNL) 643
Figure 16.15 A Malecot catheter, which has wide drainage eyeholes and an extension at the distal end which passes down the ureter to prevent fragments of stone from passing down the ureter.
Colonic perforation
The colon is usually lateral or anterolateral to the kidney and is therefore not usually at risk of injury unless a very lateral approach is made. The colon is retrorenal in 2% of individuals (more commonly in thin females with little retroperitoneal fat1).
The perforation usually occurs in an extraperitoneal part of the colon and is managed by JJ stent placement and withdrawal of the nephrostomy tube into the lumen of the colon to encourage drainage of bowel contents away from that of the urine, thereby encouraging healing without development of a fistula between the bowel and kidney.
A radiological contrast study a week or so later confirms that the colon has healed and that there is no leak of contrast from the bowel into the renal collecting system.
Damage to the liver or spleen is very rare in the absence of splenomegaly or hepatomegaly.
4 Clayman J (1987). Percutaneous nephrostomy: assessment of renal damage associated with semirigid (24F) and balloon (36F) dilation. J Urol 138:203–206.
644 CHAPTER 16 Urological surgery and equipment
Damage to the lung and pleura leading to pneumomothorax or pleural effusion can occur with supra-12th rib puncture.
Nephrocutaneous fistula
When the nephrostomy tube is removed from the kidney, a few days after surgery, the 1 cm incision usually closes within 2 days or so.
Occasionally, urine continues to drain percutaneously for a few days and a small stoma bag must be worn. In most of these cases the urine leak will stop spontaneously, but if it fails to do so after a week or so, place a JJ stent to encourage antegrade drainage of urine.
Outcomes
For small stones, the stone-free rate after PCNL is on the order of 90–95%. For staghorn stones, the stone-free rate of PCNL, when combined with postoperative ESWL for residual stone fragments, is on the order of 80–85%.
Procedure-specific consent form—recommended discussion of adverse events
Serious or frequently occurring complications of PCNL
Common
•Temporary insertion of a bladder catheter and ureteric stent or kidney tube needing later removal
•Transient hematuria
•Transient temperature
Occasional
•More than one puncture site may be required
•No guarantee of removal of all stones and need for further operations
•Recurrence of stones
Rare
•Severe kidney bleeding requiring transfusion, embolization, or, at last resort, surgical removal of kidney
•Damage to lung, bowel, spleen, or liver requiring surgical intervention
•Kidney damage or infection needing further treatment
•Overabsorption of irrigating fluids into the blood system, causing strain on heart function
Alternative treatment includes external shock wave treatments, open surgical removal of stones, observation.
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