628 CHAPTER 16 Urological surgery and equipment
Urological incisions
Midline, transperitoneal
Indications
These include access to the peritoneal cavity and pelvis for radical nephrectomy, cystectomy, reconstructive procedures, etc.
Technique
Divide skin, subcutaneous fat. Divide fascia in midline. Find the midline between the rectus muscles. Dissect the muscles free from the underlying peritoneum. Place two clips on either side of the midline, and pinch between the two to ensure no bowel has been trapped. Elevate the clips, and divide between them with a knife. Extend the incision in the peritoneum up and down, ensuring no bowel is in the way.
Closure
Use a nonabsorbable (e.g., nylon) or very slowly absorbable (e.g., PDS) suture.
Specific complications
These include dehiscence (classically around day 10 postoperative and preceded by pink serous discharge, then sudden herniation of a bowel through incision).
Lower midline, extraperitoneal
Indications
Access to pelvis (e.g., radical prostatectomy, colposuspension) is needed.
Technique
Divide skin, subcutaneous fat. Divide fascia in midline. Find the midline between the rectus muscles and dissect the muscles free from the underlying peritoneum. If you make a hole in it, repair the defect with vicryl. Divide the fascia posterior to the rectus muscles in the midline, thus exposing the extravesical space.
Closure is as for midline, transperitoneal incisions.
Pfannenstiel
Indications
Access to pelvis (e.g., colposuspension, open prostatectomy, open cystolithotomy) is needed.
Technique
Divide the skin 2 cm above the pubis and the tissues down to the rectus sheath, which is cut in an arc, avoiding the inguinal canal. Apply clips to the top flap (and afterward, the bottom flap) and use a combination of scissors and your fingers to separate the rectus muscle from the sheath.
For maximum exposure you must elevate the anterior rectus sheath from the recti, cranially to just below the umbilicus and caudally to the pubis. Take care to diathermy a perforating branch of the inferior epigastric artery on each side.
UROLOGICAL INCISIONS 629
Apply two Babcock forceps to the inferior belly of the rectus on either side of the midline. Elevate and cut in the midline, the lower part of the fascia (transversalis fascia) between the recti. Separate the recti in the midline (do not divide them).
Closure
Tack the divided transversalis fascia together and then close the transversely divided rectus sheath with vicryl.
Supra-12th rib incision
Indications
Access to kidneys, renal pelvis, or upper ureter is needed.
Technique
Make the incision over the tip of the 12th rib through skin and subcutaneous fascia. Palpate the tip of the 12th rib. Make a 3 cm cut with diathermy, through the muscle (latissimus dorsi) overlying the tip of the 12th rib so you come down onto the tip of the 12th rib, and then cut anterior to the tip of the 12th rib, down through external and internal oblique, transversus abdominis, to Gerota’s fascia and the perirenal fat. Sweep anteriorly with a finger to push the peritoneum and intraperitoneal organs out of harm’s way.
Cut the muscles overlying the rib, cutting centrally along the length of the rib, in so doing avoiding the pleura. Cut with scissors along the top edge of the rib to free the intercostal muscle from the rib—watch out for the pleura! Insert a Gillies forceps between the pleura and overlying intercostal muscle and divide the muscle fibers, protecting the pleura.
Dissect fibers of the diaphragm away from the inner surface of the 12th rib—as you do so, the pleura will rise upward with the detached diaphragmatic fibers, out of harm’s way. At the posterior end of the incision feel for the sharp edge of the costovertebral ligament.
Insert heavy scissors, with the blades just open, on the top of the rib (to avoid the XIth intercostal nerve) and divide the costovertebral ligament. You should now be on top of Gerota’s fascia.
Specific complications
These include damage to the pleura. If you make a hole in the pleura, repair it at the end of the operation. Pass a small-bore catheter (e.g., Jacques) through the hole, close all the muscle layers, inflate the lung, and then, before closing the skin, remove the catheter.
Complications common to all incisions
These include hernia, wound infection, and chronic wound pain.
630 CHAPTER 16 Urological surgery and equipment
JJ stent insertion
Preparation
This can be done under sedation or general anesthetic.
With sedation
Use oral ciprofloxacin 250 mg; lidocaine gel for urethral anesthesia and lubrication; sedoanalgesia (diazepam 2.5–10 mg IV, meperidine 50–100 mg IV). Monitor pulse and oxygen saturation with a pulse oximeter.
Technique
A flexible cystoscope is passed into the bladder and rotated through 180°. This allows greater deviation of the end of the cystoscope and makes identification of the ureteric orifice easier.
A 0.9 mm hydrophilic guide wire (Terumo Corporation, Japan) is passed into the ureter under direct vision. The guide wire is manipulated into the renal pelvis using C-arm digital fluoroscopy.
The cystoscope is placed close to the ureteric orifice and its position, relative to bony landmarks in the pelvis, is recorded by frame grabbing a fluoroscopic image.
The flexible cystoscope is then removed and a 4 Fr ureteric catheter is passed over the guide wire, into the renal pelvis. A small quantity of non-ionic contrast medium is injected into the renal collecting system, to outline its position and to dilate it.
The Terumo guide wire is replaced with an ultra-stiff guide wire (Cook Spencer) and the 4 Fr ureteric catheter is removed. We use a variety of stent sizes depending on the patient’s size (6–8 Fr, 20–26 cm) (Boston Scientific).
The stent is advanced to the renal pelvis under fluoroscopic control, checking that the lower end of the stent is not inadvertently pushed up the ureter by checking the position of the ureteric orifice on the previously frame-grabbed image.
The guide wire is then removed.
Further reading
Hellawell GO, Cowan NC, Holt SJ, Mutch SJ (2002). A radiation perspective for treating loin pain in pregnancy by double-pigtail stents. Br J Urol Int 90:801–808.
McFarlane J, Cowan N, Holt S, Cowan M (2001). Outpatient ureteric procedures: a new method for retrograde ureteropyelography and ureteric stent placement. Br J Urol Int 87:172–176.
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