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CHAPTER 20

CHAPTER 20. Genitourinary Surgery. Objectives. After studying this chapter, you will be able to: Recognize the relevant anatomy of the genitourinary system Recognize the pathology that prompts genitourinary system surgical intervention and the related terminology

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CHAPTER 20

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  1. CHAPTER 20 Genitourinary Surgery

  2. Objectives • After studying this chapter, you will be able to: • Recognize the relevant anatomy of the genitourinary system • Recognize the pathology that prompts genitourinary system surgical intervention and the related terminology • Assess any special preoperative genitourinary diagnostic procedures/tests

  3. Objectives (cont’d.) • Assess any special preoperative genitourinary preparation procedures • Indicate the names and uses of genitourinary instruments, supplies, and specialty equipment • Determine the intraoperative preparation of the patient undergoing the genitourinary procedure • Summarize the steps of the genitourinary procedures

  4. Objectives (cont’d.) • Determine the purpose and expected outcomes of the genitourinary procedures • Assess the immediate postoperative care and possible complications of the genitourinary procedure • Recognize any specific variations related to the preoperative, intraoperative, and postoperative care of the genitourinary patient

  5. Introduction • Genitourinary (GU) surgery • Surgical subspecialty • Addresses a wide spectrum of diseases involving the male and female GU systems and the male reproductive system • Urologists • Medical professionals: specialize in urology • Diagnose, treat, and manage diseases ranging from GU malignancies and renal calculi to congenital GU defects

  6. Diagnostic Procedures and Tests • Disorders of the GU tract • Diagnosed through many standard procedures • History and physical • Detailed history • Routine testicular self-examination • Digital rectal examination for men over 40

  7. Laboratory Findings • Microscopic examination • Accurate method for determining blood and urine composition • Chemical reagent strips • Available for fast general results for some tests • Home/office test strips • Not highly accurate

  8. Laboratory Findings (cont’d.) • Hematology findings • Specific hematologic examinations will require a patient to comply with certain prerequisites • Refer to Tables 20-1 and 20-2 • Urinalysis • Most important laboratory examination used in diagnosing problems affecting the urinary tract • Refer to Tables 20-3 and 20-4

  9. Radiologic Findings • Regular X-rays, ultrasound, CT scan, and MRI • Important tools in diagnosing tumors and obstructions of the GU tract • KUB: kidney, ureters, and bladder • An AP (anterior-to-posterior [anteroposterior]) radiographic view of the urinary system

  10. Radiologic Findings (cont’d.) • IVU • Enhancement of the KUB • Involves injection of a contrast medium into the patient’s vein • Retrograde urogram • Serves same purpose as IVU • Contrast medium must be injected into the ureters with the use of a cystoscope

  11. Biopsy • Only accurate way to determine the presence of malignancy and the exact cell type • Tissue samples are obtained using percutaneous, endoscopic, and open methods

  12. Endoscopy • Allows for visualization of the affected structures • Tissue and fluid samples may be collected at the same time, and/or additional tests • Laparoscopic procedures may also be performed to diagnose and treat conditions of the GU system

  13. Instrumentation, Routine Equipment, and Supplies • Routine instrumentation, equipment, and supplies for GU surgery • Similar to those for general surgery with the exception of specialty items needed for kidney, ureter, and prostate surgery

  14. Instrumentation, Routine Equipment, and Supplies (cont’d.) • General • Laparotomy instrument set • Long instrumentation set • Self-retaining abdominal retractor • Mixter right angles • Potts scissors • Vascular instruments • Hemoclip appliers, various sizes • Bladder and prostate retractors

  15. Instrumentation, Routine Equipment, and Supplies (cont’d.) • Kidney • Pedicle clamps and stone/lithotomy forceps • Thoracic (rib resection) • Self-retaining rib retractor (Finochietto) • Alexander periosteotome • Doyen rib elevator and raspatory • Rib shears • Sauerbruch rongeur • Bailey rib contractor (approximator)

  16. Instrumentation, Routine Equipment, and Supplies (cont’d.) • Transurethral procedures • More complex and unique to GU surgery • Refer to Table 20-5 • Equipment • Cysto room: contains specialty equipment • GU procedures: similar to general surgery • Supplies • Depend on procedure

  17. Incisional Options • Inguinal incision • Often used to access the scrotal contents of an adult or child • Scrotal incisions • Performed to access the scrotal contents • Abdominal incisions • Refer to Chapter 14

  18. Incisional Options (cont’d.) • Gibson incision • Extraperitoneal abdominal approach • Designed for access to the lower portion of the ureter • Refer to Figure 20-7 • Flank incision • Provides direct access to the adrenal gland, kidney, and proximal ureter • May be subcostal, transcostal, or intercostal

  19. Incisional Options (cont’d.) • Lumbar incision • Provides limited exposure • Used for adrenalectomy, renal biopsy, or removal of a small low-lying kidney • May be done with the patient in lateral or prone position

  20. Kidney, Ureter, and Bladder Surgical Procedures • Several procedures are used • Wilms’ tumor excision • Nephrectomy • Partial or radical • Open simple nephrectomy • Laparoscopic simple nephrectomy • Kidney transplant

  21. Kidney, Ureter, and Bladder Surgical Procedures (cont’d.) • GU endoscopy • Ureteroscopy • Pyelolithotomy • Cystoscopy with overview of TURBT • Cystectomy • Partial or segmental • Radical cystectomy with ileal conduit—male patient surgical anatomy and pathology

  22. Procedures for Stress Incontinence Affecting Women • Objectives • Restore the posterior urethrovesical angle and elevate the bladder base • May have been distorted during childbirth or as the natural result of aging • Mild stress incontinence • May be reduced following an anterior colporrhaphy

  23. Procedures for Stress Incontinence Affecting Women (cont’d.) • Significant incontinent episodes • May be eliminated with suprapubic vesicourethral suspension (Marshall-Marchetti-Krantz [MMK] procedure) • Procedure: refer to text • Suburethral sling (pubovaginal sling) • May be recommended to women who have been unsuccessfully treated via surgical elevation and stabilization techniques

  24. Prostate Surgery • Prostatectomy • Surgical removal of all or part of the prostate • May be accomplished transurethrally or may require an open procedure • Procedures • Transurethral resection of the prostate (TURP) • Laparoscopic prostatectomy with robot • Suprapubic prostatectomy

  25. Prostate Surgery (cont’d.) • Percutaneous implantation of radioactive seeds in the prostate gland • Allows for a focused release of high doses of radiotherapy as compared to external radiotherapy • Due to the focused nature of the radiation release, adjacent organs are not affected • Procedure: refer to text

  26. Testicular Surgery • Large percentage of testicular surgical procedures are performed on pediatric patients • Adult males may undergo procedures as an adjunct • Procedures • Hydrocelectomy • Orchiopexy • Simple orchiectomy

  27. Penile Surgical Procedures • Performed to treat congenital defects, disorders, and cancer • Procedures • Circumcision • Hypospadias repair • Epispadias repair • Insertion of Inflatable penile prosthesis • Penectomy

  28. Summary • This chapter reviewed: • Anatomy of the GU system • The pathology that prompts GU system surgical intervention • GU diagnostic procedures and tests • GU instruments, supplies, and specialty equipment • GU surgical procedures

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