- •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
594 CHAPTER 16 Urological surgery and equipment
JJ stents
These are hollow tubes, with a coil at each end, which are inserted through the bladder (usually), into the ureter, and from there into the renal pelvis. They are designed to bypass a ureteric obstruction (e.g., due to a stone) or drain the kidney (e.g., after renal surgery). They have a coil at each end (hence the alternative name of “double pigtail” stent—the coils have the configuration of a pig’s tail—or the less accurate name of J stent).
JJ stents prevent migration downward (out of the ureter) or upward (into the ureter). They are therefore self-retaining.
They are made of polymers of variable strength and biodurability. Some stents have a hydrophilic coating that absorbs water and thereby makes them more slippery and easier to insert.
Stents are impregnated with bariumor bismuth-containing metallic salts to make them radio-opaque, so that they can be visualized radiographically to ensure correct positioning.
Types
Stents are classified by size and length. Common sizes are 6 Ch or 7 Ch (Fig. 16.10). Common lengths for adults are 22–28 cm. Multi-length stents are of variable length, allowing them to accommodate to ureters of different length.
Stent materials
These include polyurethane; silicone; C-flex; Silitek; Percuflex; and biodegradable material (the latter are experimental; they obviate the need for stent removal and eliminate the possibility of the “forgotten stent”).
Indications and uses
•Relief of obstruction from ureteric stones, benign (i.e., ischemic) ureteric strictures, or malignant ureteric strictures. The stent will relieve the pain caused by obstruction and reverse renal impairment if present.
•Prevention of obstruction post-ureteroscopy
•Passive dilatation of ureter prior to ureteroscopy
•To ensure antegrade flow of urine following surgery (e.g., pyeloplasty) or injury to ureter
•Following endopyelotomy (endopyelotomy stents have a tapered end from 14 Fr. to 7 Fr., to keep the incised ureter open)
Symptoms and complications of stents
•Stent symptoms that are common include suprapubic pain, LUTS (frequency, urgency—stent irritates trigone), hematuria, and inability to work.
•Urinary tract infection. Development of bacteriuria after stenting is common. In a small proportion of patients sepsis can develop. In such cases, consider placement of a urethral catheter to lower the pressure in the collecting system and prevent reflux of infected urine.
•Incorrect placement: too high (distal end of stent in ureter; subsequent stent removal requires ureteroscopy; can be technically difficult;
JJ STENTS 595
Figure 16.10 A JJ stent.
percutaneous removal may be required), or too low (proximal end not in renal pelvis; stent may not therefore relieve obstruction)
•Stent migration (up the ureter or down the ureter and into bladder)
•Stent blockage. Catheters and stents become coated with a biofilm when in contact with urine (a protein matrix secreted by bacteriacolonizing stent). Calcium, magnesium, and phosphate salts become deposited. Biofilm buildup can lead to stent blockage or stone formation on the stent (Fig. 16.11).
•The “forgotten stent is rare, but potentially very serious, as biofilm may become encrusted with stone, making removal technically very difficult. If the proximal end only is encrusted, PCNL may be required to remove the stone and then the stent. In some cases a combination of PCNL, ESWL, and ureteroscopy may be used. If the entire stent is encrusted, open removal via several incisions in the ureter may be necessary.
Commonly asked questions about stents
Does urine pass though the center of the stent?
No, it passes around the outside of the stent. Reflux of urine occurs through the center.
Should I place a JJ stent after ureteroscopy?
A stent should be placed if the following occur:
•There has been ureteric injury (e.g., perforation—indicated by extravasation of contrast)
•There are residual stones that might obstruct the ureter
•The patient has had a ureteric stricture that required dilatation
Routine stenting after ureteroscopy for distal ureteric calculi is unnecessary.1 Many urologists will place a stent after ureteroscopy for proximal ureteric stones.
1 Srivastava A, et al. (2003). Routine stenting after ureteroscopy for distal ureteral calculi is unnecessary: results of a randomized controlled trial. J Endourol 17:871–874.
596 CHAPTER 16 Urological surgery and equipment
Figure 16.11 An encrusted stent.
Do stents cause obstruction?
In normal kidneys, stents cause a significant and substantial increase in intrarenal pressure that persists for up to 3 weeks.1 (This can be prevented by placing a urethral catheter.)
Do stents aid stone passage?
Ureteric peristalsis requires coaptation of the wall of the ureter proximal to the bolus of urine to be transmitted down the length of the ureter. JJ stents paralyze ureteric peristalsis. In dogs, the amplitude of each peristaltic wave (measured by an intraluminal ureteric balloon) falls (from 50 to 15 mmHg) and the frequency of ureteric peristalsis falls (from 11 to 3 waves per minute).
Peristalsis takes several weeks to recover; 3 mm ball bearings placed within a nonstented dog ureter take 7 days to pass, compared with 24 days in a stented ureter.
Are stents able to relieve obstruction due to extrinsic compression of a ureter?
Stents are less effective at relieving obstruction due to extrinsic obstruction by, for example, tumor or retroperitoneal obstruction.2 They are
1 Ramsay JW, et al. (1985). The effects of double J stenting on obstructed ureters. An experimental and clinical study. Br J Urol 57:630–634.
2 Docimo SG. (1989). High failure rate of indwelling ureteral stents in patients with extrinsic obstruction: experience at two institutions. J Urol 142:277–279.
JJ STENTS 597
much more effective for relieving obstruction by an intrinsic problem (e.g., a stone).
Placement of two stents may provide more effective drainage (figure- of-eight configuration may produce more space around the stents for drainage).
For acute, ureteric stone obstruction with a fever, should I place a JJ stent or a nephrostomy?
In theory, one might imagine that a nephrostomy is better than a JJ stent—it can be done under local anesthetic (JJ stent insertion may require a general anesthetic) and it lowers the pressure in the renal pelvis to 0 or a negative value. A JJ stent, by contrast, results in a persistently positive pressure, is less likely to be blocked by thick pus, and allows easier subsequent imaging (contrast can be injected down the ureter—a nephrostogram—to determine if the stone has passed).
In practice, both seem to be effective for relief of acute stone obstruction and associated infection.3,4
3 Pearle MS, et al. (1998). Optimal method of urgent decompression of the collecting system for obstruction and infection due to ureteral calculi. J Urol 160:1260–1264.
4 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.