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Urologic Surgery

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Urologic Surgery Powered By Docstoc
					    Urologic Surgery

        Jason P. Gilleran, MD
          Assistant Professor
       Department of Urology
Director, Female Pelvic Medicine and
       Reconstructive Surgery
           Overview
Prostate         Anatomy
Kidney
Adrenal          Indications
Testis
Penis            Preop Evaluation
Bladder
Urethra          Surgical Techniques
Female Urology
                 Complications
Prostate
  Benign Prostatic Hyperplasia
            (BPH)
Presenting symptoms
– Early: Frequency, urgency, nocturia
– Late: Hesitancy, weak stream, urinary retention

Medical Therapy
– Alpha Blockers (Flomax, Uroxatral, Cardura)
– 5-a-reductase inhibitors (Proscar, Avodart)

Evaluation: Digital rectal exam (DRE),
uroflowmetry, post-void residual (PVR),
urodynamics in select cases
           Prostate Cancer
Evaluation: Digital rectal exam, prostate specific
antigen (PSA)
– Normal level <4.0 ng/dL, but other factors to consider


Staging: Localized (T1-2), locally advanced
(T3), metastatic (M1+)

Usually no presenting symptoms until late

Mean time to progression 8-13 yrs.
             BPH Surgery
Transurethral resection of prostate (TURP)

Transurethral incision of prostate (TUIP)

Laser ablation/enucleation
– Holmium
– PKP (“Green Light”)


Microwave therapy/needle ablation
                                TUIP
TURP   Wein: Walsh-Campbell Urology, 9th Edition, 2006
            Complications
Hematuria

Bladder neck contracture/stricture

Retrograde ejaculation

Total incontinence
    Prostate Cancer Treatment
Radiation
Hormonal Therapy, Watchful waiting

Radical Prostatectomy
– Open retropubic (Walsh) – (non) nerve-sparing
– Perineal (Paulson)
– Laparoscopic/Robotic-Assisted

Complications
–   Bleeding (dorsal venous complex)
–   Bladder neck contracture
–   Erectile dysfunction, incontinence
–   Rectal injury
Radical Prostatectomy Anatomy




            Wein: Walsh-Campbell Urology, 9th Edition, 2006
Post-Prostatectomy Incontinence
More than 80% resolve within 1 year

Treatment options
– Kegel exercises, imipramine
– Bulking agents
– Artificial urinary sphincter (AUS)
– Male transobturator sling (AdVance)
Artificial Urinary Sphincter




             Wein: Walsh-Campbell Urology, 9th Edition, 2006
Male Transobturator Sling
       (AdVance)




          Wein: Walsh-Campbell Urology, 9th Edition, 2006
Kidney, Adrenal
      Renal Cell Carcinoma
Classic presentation: mass, flank pain,
hematuria
Often found incidentally

Poor prognosis if metastatic
Renal vein/IVC involvement

Diagnosis usually by CT scan (no biopsy)
Other benign lesions
– AML, Oncocytoma, complex cyst
              Nephrectomy
Includes perihilar fat

Left renal vein
– Lumbar, gonadal, and adrenal veins


Right renal vein
– Direct drainage into IVC


Adrenalectomy if involved (and normal
contralateral adrenal gland)
                                                  •Surgical Approaches

                                                    •Anterior subcostal

                                                    •Flank

                                                    •Laparoscopic (with
                                                    or without hand-
                                                    assisted)




Wein: Walsh-Campbell Urology, 9th Edition, 2006
MRI of Large Right Renal Mass




            Wein: Walsh-Campbell Urology, 9th Edition, 2006
       Partial Nephrectomy
Exophytic lesions

Accessible masses < 4 cm

Solitary kidney or high-risk for ESRD
– Diabetes, hypertension


Genetic Diseases
– Von Hippel Lindau (VHL)
Exophytic Masses




      Wein: Walsh-Campbell Urology, 9th Edition, 2006
            Complications
Radical Nephrectomy
– Bowel injury (hepatic or splenic flexure)
– Splenic injury / splenectomy
– IVC, aortic injury


Partial Nephrectomy
– Urinoma / leak / fistula (stent and Foley)
– Bleeding (Floseel)
         Pyelonephritis
Perinephric Abscess

Emphysematous pyelonephritis

Xanthogranulomatous pyelonephritis
           Renal Calculi
Most common in 4th-6th decades of life
Etiology: Hypercalcemia, hypercalciuria,
hypocitraturia
Presenting symptoms: flank pain,
hematuria, nausea, vomiting, fever/chills
Calcium oxalate, calcium phosphate, uric
acid, cystine
  Renal Calculus Treatment
Extracorporeal shock-wave lithotripsy
(ESWL)

Ureteroscopy, laser lithotripsy

Percutaneous nephrostolithotomy

Open stone extraction (rare)
      •8.5 Fr ureteroscope

      •Nephroscope

      •Holmium laser (200, 360 m)



Wein: Walsh-Campbell Urology, 9th Edition, 2006
            Complications
Urosepsis

Ureteral stricture
Ureteral avulsion

Renal AVM
Hydrothorax / pneumothorax
Bowel injury
         Bladder Calculi
Urinary stasis, foreign body, mucus

BPH, neurogenic bladder

Calcium phosphate

Cystolitholapaxy, remove underlying
obstruction (in men with BPH)
        Adrenal Anatomy
Embryologically unrelated to kidneys
(neuroectoderm origin)
Three zones
– Glomerulosa (mineralocorticoids; aldosterone)
– Fasciculata (glucocorticoids; cortisol)
– Reticularis (sex steroids)
           Adrenal Mass
Often found incidentally
Most common mass: adenoma
Functional studies, MRI
– Serum cortisol, metanephrines, aldosterone (if
  hypokalemic or hypertensive)
Pheochromocytoma
Adrenal carcinoma
Myelolipoma
Laparoscopic Adrenalectomy




           Wein: Walsh-Campbell Urology, 9th Edition, 2006
Scrotum, Testis
        Testicular Cancer
Most common in men 18-35

Seminoma
Non-seminomatous germ cell tumor (NSGCT)

Presenting symptoms: painless mass or lump in
testis

Tumor Markers (b-HCG, AFP)
CT scan, CXR
Scrotal/Testis Anatomy




         Wein: Walsh-Campbell Urology, 9th Edition, 2006
       Testicular Torsion
Pediatric population (puberty most
common due to testicular growth and/or
“bell-clapper” deformity)
One of the few true surgical emergencies
in urology
Scrotal ultrasound documents no flow but
clinical exam alone may be sufficient
        Testicular Trauma
Scrotal ultrasound

Hematocele

Scrotal rupture requires exploration and
repair if presents < 72 hrs from injury

High degree of clinical suspicion
Hydrocelectomy
              Varicocelectomy

“Bag of worms” on standing, Valsalva
examination

Infertility

Scrotal pain, thrombosis

95% on left (right sided varicocele should
prompt abdominal imaging study)
Varicocelectomy

           Scrotal
           Inguinal
           Retroperitoneal

           Loupes
           Operating
           microscope
           Doppler
Bladder
  Superficial Bladder Cancer
Most common form of TCC (85%)

Risk factors: smoking, radiation, chemo, family hx,
exposure to paints, aniline dyes

Highly dependent on grade of tumor to dictate
management
– Low grade can be managed with fulguration
– High grade needs aggressive monitoring, intravesical therapy

Stage Ta (mucosa/submucosa only), T1 (lamina propria)

Carcinoma-in-situ (CIS): “flat cancer”
– Treated with intravesical therapy
– Bad player and many progress to invasive disease
TURBT
           Risks
            – Perforation
            – Sepsis
            – Ureteral obstruction
           Adjuvant Treatment
            – Mitomycin C
            – BCG
            – Thiotepa




 Wein: Walsh-Campbell Urology, 9th Edition, 2006
   Invasive Bladder Cancer

Stage T2 (detrusor muscle) or beyond (T3,
perivesical fat; T4, surrounding organs)

Best therapy: radical cystectomy,
extended pelvic lymph node dissection

Aggressive disease requires adjuvant
chemotherapy and/or radiation
       Radical Cystectomy
Bladder, perivesical fat, prostate (in men),
strip of anterior vagina, uterus/ovaries (in
women), distal ureteral stumps

Frozen section of ureters, urethra

Pelvic lymph node dissection from
common iliacs to obturator
Male Cystoprostatectomy




         Wein: Walsh-Campbell Urology, 9th Edition, 2006
Wein: Walsh-Campbell Urology, 9th Edition, 2006
Urinary Diversion Techniques
Incontinent Diversion
– Ileal conduit (most common)


Continent Diversion
– Renal function
– Favorable disease
– Motivated patient
                              Ileal Conduit




Wein: Walsh-Campbell Urology, 9th Edition, 2006
Wein: Walsh-Campbell Urology, 9th Edition, 2006
           Complications
Bowel obstruction, fistula, abscess
Chronic Diarrhea
Renal insufficiency
Ureterointestinal anastomotic stricture
Metabolic abnormalities
Penis, Urethra
Penile/Urethral Anatomy




             Wein: Walsh-Campbell Urology, 9th Edition, 2006
         Urethral Stricture

Common, most are small and short

Many fail dilation, direct-vision internal
urethrotomy (DVIU) and recur

Straddle injury, gonorrhea, idiopathic

Classified by length, location, etiology
             Urethroplasty
Ideal for dense strictures that failed urethrotomy
(DVIU)

Bulbar strictures < 2 cm best for end-to-end
primary anastomosis

Buccal graft interposition

Penile skin onlay flap
Wein: Walsh-Campbell Urology, 9th Edition, 2006
           Complications
Recurrent stricture

Fistula, urethral phlegmon

Salivary duct injury if harvesting buccal
graft

Positioning complications (DVT, leg pain,
rhabdomyolysis)
           Penile Cancer
Rare GU malignancy with wide spectrum of
presentation

Risk factors: uncircumcised, smoking

Presenting symptoms: phimosis, discharge,
palpable mass

Wide excision (2 cm margin) and urethral
preservation if possible
Wein: Walsh-Campbell Urology, 9th Edition, 2006
Inguinal Lymph Node Dissection
 Presence of persistent palpable
 lymphadenopathy after penectomy and
 antibiotics

 Staging and therapeutic

 Complications: skin breakdown,
 lymphedema, seroma
Wein: Walsh-Campbell Urology, 9th Edition, 2006
            Penile Fracture
“Eggplant deformity”

Patient hears a “pop”
followed by
immediate
detumescence

Contained within
Colles’ fascia

                        Wein: Walsh-Campbell Urology, 9th Edition, 2006
        Peyronie’s Disease
Originally described in 18th century
France

Penile curvature (dorsal most
common) with palpable plaque

Spontaneous regression possible

Medical therapy of little use
Erectile Dysfunction Surgery
Failed conservative management
– Oral agents (sildenafil, tadalafil, vardenafil)
– Vacuum erection device (VED)
– Intracavernosal injection tx (ICI)

Semi-rigid vs 2 or 3-piece inflatable penile
prosthesis (IPP)

Patient selection and counseling
Penile Prosthetic Surgery




          Wein: Walsh-Campbell Urology, 9th Edition, 2006
             Complications
Urethral injury

Corporal cross-over or perforation

Erosion

Infection

Mechanical Failure
Female Urology
  Pelvic Organ Prolapse (POP)
High rate of recurrence for
transvaginal pelvic organ
prolapse (POP) repairs
– 11% of women will undergo
  POP surgery by age 80
– Time to recurrence
  decreases with each repair
            Abdominal MSC
          Intraoperative View




           Bladder   Mesh   Peritoneal
Sigmoid
                            Edge
      Urinary Incontinence
Stress incontinence

Urge incontinence

Mixed incontinence

Functional overflow incontinence
        Suburethral Sling
Indicated for moderate-to-severe stress
incontinence

Urethral hypermobility
– Polypropylene mesh


Sphincteric incompetence
– Bladder neck, autologous fascia
Wein: Walsh-Campbell Urology, 9th Edition, 2006
             Complications
Obstruction and voiding dysfunction (3-5%)

Urethral erosion, vaginal extrusion (1%)

De novo urge incontinence (?10%)

Bladder, urethral injury, fistula

Thigh abscess
Sacral Neuromodulator

           Refractory urge
           incontinence,
           urgency/frequency,
           urinary retention
           S3 nerve root
           Quadripolar lead
           IPG
      Urethral Diverticulum
Three “D”s: dysuria, dyspareunia, postvoid
dribbling

Palpable urethral mass, UTIs

More common in African-American women

Diagnose on cystoscopy +/- VCUG, pelvic MRI
Wein: Walsh-Campbell Urology, 9th Edition, 2006
             Summary
Wide variety of disease processes

Non-invasive and pharmacologic
approaches

Surgical options include open, endoscopic,
minimally invasive