- •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
632 CHAPTER 16 Urological surgery and equipment
Nephrectomy and nephroureterectomy
Indications
•Renal cell cancer
•Nonfunctioning kidney containing a staghorn calculus
•Persistent hemorrhage following renal trauma
Anesthesia
General anesthesia is used.
Postoperative care
Nephrectomy
Cardiovascular status and urine output should be carefully monitored in the immediate postoperative period. Hemorrhage from the renal pedicle or, for left-sided nephrectomy, the spleen, is rare, but will present with an increasing tachycardia, cool peripheries, falling urine output, and eventually a drop in blood pressure.
A drain is usually not left in place, but if it is, there may be excessive drainage of blood from the drain. However, do not be lulled into a false sense of security by the absence of drainage—this does not mean that hemorrhage is not occurring, as the drain may be blocked but hemorrhage may be ongoing.
For nephrectomy via a posterolateral (rib-based) incision, watch for pneumothorax. Arrange for a CXR on return from the recovery room. Arrange routine chest physiotherapy to reduce the risk of chest infection. Regular chest examination is important, looking specifically for pneumothorax and pleural effusion.
Mobilize the patient as quickly as possible, to reduce the risk of DVT and PE.
Nephroureterectomy
Where the ureter has been excised from the bladder, a urethral catheter is left in place at the end of the procedure, to allow the hole in the bladder to heal. This is usually removed 10–14 days after surgery.
Common postoperative complications and their management
•Hemorrhage—see above.
•Wound infection is rare. If superficial, treat with antibiotics. If an underlying collection of pus is suspected, open the wound to allow free drainage, and pack the wound daily.
•Pancreatic injury is rare, but would be indicated by excessive drainage of fluid from the drain, if present, which will have a high amylase level. If no drain is present, an abdominal collection will develop, which may be manifested by a prolonged ileus.
NEPHRECTOMY AND NEPHROURETERECTOMY 633
Procedure-specific consent form—recommended discussion of adverse events
Serious or frequently occurring complications of nephrectomy or nephroureterectomy
Simple nephrectomy Common
•Temporary insertion of a bladder catheter
•Occasional insertion of a wound drain
Occasional
•Bleeding requiring further surgery or transfusion
•Entry into lung requiring temporary insertion of a drainage tube
Rare
•Involvement or injury to nearby structures—blood vessels, spleen, lung, liver, pancreas, bowel, requiring further extensive surgery
•Infection, pain, or hernia of incision, requiring further treatment
•Anesthetic or cardiovascular problems, possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack)
Alternative therapy includes observation, laparoscopic approach.
Radical nephrectomy
Complications are as above plus the following:
•Occasional: need for further therapy for cancer
•Rare: may be an abnormality other than cancer on microscopic analysis
Alternative therapy includes observation, embolization, immunotherapy, and laparoscopic approach.
Nephroureterectomy
Complications are the same as those listed above.
634 CHAPTER 16 Urological surgery and equipment
Radical prostatectomy
Indications
This is performed for localized prostate cancer.
Anesthesia
General or regional anesthesia is required.
Postoperative care
Mobilize the patient as quickly as possible and continue subcutaneous heparin and use of AK-TEDS until discharge to reduce the risk of DVT and PE. Remove the drains when drainage is minimal.
If there is persistent leak of fluid from the drains, send a sample for urea and creatinine, and if it is urine, get a cystogram to determine the size of the leak at the vesicourethral junction.
Urethral catheters are left in situ after radical prostatectomy for a variable time depending on the surgeon who performs the operation. Some surgeons leave a catheter for 3 weeks and others for just 1 week.
Common postoperative complications and their management
Hemorrhage
This is managed in the usual way (transfusion; return to surgery when bleeding persists or when there is cardiovascular compromise).
Ureteric obstruction
This usually results from edema of the bladder, obstructing the ureteric orifices. Retrograde ureteric catheterization is rarely possible (this would require urethral catheter removal and it is difficult to see the ureteric orifices because of the edema).
Arrange for placement of percutaneous nephrostomies.
Lymphocele
Drain by radiologically assisted drain placement. If the lymphocele recurs after drain removal, create a window from the lymph collection into the peritoneal cavity so the lymph drains into the peritoneum from which it is absorbed.
Displaced catheter post radical prostatectomy
If the catheter falls out a week after surgery, the patient may well void successfully, and in this situation no further action need be taken. If, however, the catheter inadvertently falls out the day after surgery, gently attempt to replace it with a 12 Fr. catheter that has been well lubricated.
If this fails, pass a flexible cystoscope, under local anesthetic, into the bulbar urethra and attempt to pass a guide wire into the bladder, over which a catheter can then safely be passed. If this is not possible, another option is to hope that the patient voids spontaneously and does not leak urine at the site of the anastomosis.
An ascending urethrogram may provide reassurance that there is no leak of contrast and that the anastomosis is watertight. If there is a leak
RADICAL PROSTATECTOMY 635
or the patient is unable to void, a suprapubic catheter can be placed (percutaneously or under general anesthetic via an open cystostomy).
Fecal fistula
This is due to rectal injury, either recognized and repaired at the time of surgery and later breaking down, or not immediately recognized. Formal closure is often required.
Contracture at the vesicourethral anastomosis
Gentle dilatation may be tried. If the stricture recurs, instruct the patient in ISC, in an attempt to keep the stricture open. If this fails, a bladder neck incision may be tried.
Procedure-specific consent form—recommended discussion of adverse events
Serious or frequently occurring complications of radical prostatectomy
Common
•Temporary insertion of a bladder catheter and wound drain
•High chance of impotence due to unavoidable nerve damage
•No semen is produced during orgasm, causing infertility
Occasional
•Blood loss requiring transfusion or repeat surgery
•Urinary incontinence—temporary or permanent, requiring pads or further surgery
•Discovery that cancer cells are already outside the prostate, needing observation or further treatment at a later date if required, including radiotherapy or hormonal therapy
Rare
•Anesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack)
•Pain, infection, or hernia in area of incision
•Rectal injury, very rarely needing temporary colostomy
Alternative therapy includes watchful waiting, radiotherapy, brachytherapy, hormonal therapy, and perineal or laparoscopic removal.