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SUR 122

SUR 122. Genitourinary Surgery. Genitourinary System. Terminology Anatomy & Physiology Pathology Diagnostic & Pre-operative Testing Anesthesia & Medications Basic Instrumentation, Supplies, & Equipment Incision Site Options Positioning, Prep, & Draping

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SUR 122

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  1. SUR 122 Genitourinary Surgery

  2. Genitourinary System • Terminology • Anatomy & Physiology • Pathology • Diagnostic & Pre-operative Testing • Anesthesia & Medications • Basic Instrumentation, Supplies, & Equipment • Incision Site Options • Positioning, Prep, & Draping • Dressings, Drains, & Post-operative Care

  3. Terminology • BPH – nonmalignant enlargement of prostate common with age • Dialysis - waste product removal from the blood of a patient in renal failure • Enucleate – remove without cutting into • Epispadias – urethra terminates at base of penis or above clitoris (congenital) • Gerota’s capsule – perirenal fascia that holds kidney in place • Impotence – inability to achieve erection • Hematuria – blood in the urine • Hilum- everything enters and leaves kidneys through this notch • Ptosis – drooping of an organ or part • Trigone – triangle-like space a bladder base

  4. Terminology • Hydrocele – fluid filled sac in the scrotum • Hypospadias – urethra opens on ventral surface of penis, perineum, or inside the vagina (congenital) • Paraphimosis – retraction of prepuce results in painful swelling of glans • Phimosis – uncircumcised male prepuce won’t retract from glans • Wilm’s tumor - malignant neoplasm of a kidney in children 3-4yrs.

  5. Anatomy video • http://www.youtube.com/watch?v=xYTjvqzyd9k

  6. Male Reproductive System • Large part external to body cavity • Scrotum=pouch of skin that contains testis • Testis are both endocrine & exocrine glands • Exocrine=secrete sperm via ducts • Endocrine glands produce testosterone

  7. Male Reproductive System • Testis • Lobules with 3 cell types: • Seminiferous tubulesinvolved in spermatogenesis • Interstitial cells (cells of Leydig)produce testosterone • Seratoli cellsprovide nutrients for sperm

  8. Male Reproductive System • Sperm • Male produces 300 million sperm per day=120million per ml • Less than 20 million per ml considered sterile

  9. Sperm (3 parts) 1. Head a. Acrosome contains chemical hyaluronidase which is an enzyme that breaks down hyaluronic acid (found in loose connective tissue) that allows sperm to penetrate the eggb. Nucleus (haploid) contains 23 chromosomes (when unites with egg also 23 chromosomes, chromosome total becomes 46) Midpiece extension that contains large amt of mitochondria (ATP) Flagellatail composed of a protein that allows for movement generated by ATP Male Reproductive System 1N

  10. Male Hormones 1. FSH • Tells interstitial cells to produce testosterone and sperm in testis 2. LH • Tells interstitial cells to develop and secrete testosterone 3. Testosterone • Stimulates development, growth and maintenance of male reproductive system including sex characteristics, maturation of sperm, and skeletal muscle development

  11. Ducts 1. Epididymis • Series of ducts or channels that communicate with the testis • Store sperm • Area for sperm maturation • Ciliated columnar cells secrete 2. Vas Deferens • Loops up over bladder • Transports sperm • Ciliated columnar cells and smooth muscle (peristalsis) move sperm 3. Ejaculatory duct • Vas deferens merge into this posterior to bladder which merges with the urethra (runs through the prostate)

  12. Male Reproductive SystemSummation • Testis are located in the scrotum • Testes produce sperm and testosterone • Contain lobules containing seminiferous tubules where sperm arise • Lobules lead to ducts in the epididymis • Epididymis leads to ductus deferens • Ductus deferens open into urethra • Testis suspended by spermatic cord • Spermatic cordgoes from inguinal ring to testis • Inguinal ring also contains ductus deferens, testicular vessels (arterial, venous, and lymphatic), and nerves

  13. Seminal vesicles Behind (posterior) bladder Secrete into ejaculatory duct 60% liquid portion of semen Prostate gland Donut shaped as urethra runs through it Secretes 30% liquid portion of semen directly into the urethra Bulbourethral (Cowper’s) glands 10% volume of semen (lubricates head) Neutralizes acidity of urethra Secrete directly into urethra Accessory Organs Internal urinary sphincter tightens w/ejaculation to prevent mixing of urine w/sperm

  14. Accessory Organs • Penis • 3 cylindrical tissue masses • Corpus cavernosum x 2 (upper) • Corpus spongiosum x1 (lower) • Urethra passes through corpus spongiosum • These three areas are surrounded by blood sinuses • Arteriole blood retention allows an erection • Post-ejaculation pressure is released

  15. Genitourinary System • Kidneys • Adrenal glands • Ureters • Urinary Bladder • Urethra • Prostate Gland (male)

  16. Kidneys • Location retroperitoneal • At T-12 to L-3 vertebral column • Encapsulated in perineal fat and fascia renalis capsule which hold them in position • Hilum medial area where renal artery and vein enter and exit • Left larger • Right lower due to liver location • Functional unit is the nephron: filtration, reabsorption, secretion

  17. Nephron • > 1 million per kidney • 2 types: juxtamedullary and cortical • Each composed of capillary network: • Renal corpuscle • Renal tubule

  18. Nephron • Renal Corpuscle: • Bowman’s Capsule • Glomerulus • Renal Tubule: • Proximal Convuluted Tubule • Loop of Henle • Distal Convuluted Tubule • Collecting Tubule

  19. Renal Corpuscle 1. Filtration • Bowman’s Capsule (glomerulus encased by) • Glomerulus (capillary network) • Water and substances filtered from blood

  20. Renal Tubules 2. Reabsorption • Substances move from renal tubules into capillaries (blood) surrounding the tubules • Prevents needed body substances from being lost in urine • Proximal convuluted tubule (origin in Bowman’s Capsule) • Loop of Henle • Distal Convuluted Tubule

  21. Renal Tubules • Secretion • Substances move from blood into tubules (urine) • Distal Collecting Tubule • Collecting Tubule

  22. Filtrate/Urine Pathway • Fluid once it leaves the blood and is in the nephron called filtrate, once leaves nephron is called urine • Nephron > papillary duct > minor and major calyces > renal pelvis > ureters

  23. Urinary Bladder • Holds average of 800ml • Three layers: Submucosa, Muscularis, Inner Tunica Mucosa • Muscularis called detrusor muscle • Internal sphincter = smooth muscle = involuntary control • External sphincter = skeletal muscle = voluntary control • Stretch receptors in bladder signal brain via micturation reflex • About 400ml, brain relaxes internal sphincter • This signals you it’s time to go… • Inner Tunica mucosa is rugae surface (allows for stretching) except in the trigone area which is a smooth surface

  24. Adrenal Glands • Suprarenal glands • Endocrine glands: contain cortex and medulla • Cortex: secretion of fluid and electrolyte balance controlling steroids and hormones (aldosterone and cortisol) • Medulla: produces, stores, & secretes epinephrine (adrenaline) & norepinephrine (noradrenalin)

  25. Pathology of the Male Reproductive System • Phimosis • Hypospadias/Epispadias • BPH • Cancer of the Prostate • Cryptorchidism • Testicular Torsion • Testicular Cancer • Trauma

  26. Phimosis • Foreskin will not retract • Congenital • Geriatric • Can cause infection, pain • Tx: circumcision

  27. Hypospadias Urethral opening under the penis or on the perineum Urethral opening inside the vagina Congenital Tx: Surgical repair Epispadias Urethral opening on top of the penis Urethral opening above the clitoris Congenital Tx: Surgical repair Hypospadias Epispadias

  28. Cryptorchidism • Failure of testes to descend into scrotum after 1 yr of age • Found in abdomen or groin • Often seen with inguinal hernia • Premature birth • Tx: HCG hormone therapy Orchiopexy Orchiectomy

  29. Testicular Torsion • Spermatic cord is twisted • Tx: Orchiopexy

  30. Testicular Cancer • 20-40yrs • Infants with cryptorchidism higher risk • Embarrassment leads to non-treatment which allows progression of disease • Tx: Orchiectomy • Sperm may be stored • Testicular implants available for cosmetic purposes

  31. BPH • Hypertrophy • Normal part of aging • > 50 yrs • Urethral narrowing can result • Tx: Drug therapy ↓ prostate growth (medical) • TURP (surgical)

  32. > 50 yrs Asymptomatic in early stages of disease Symptom of blood in the urine, likely too late PSA (prostate specific antigen) Normal value <4ng/mL PSA laboratory test of choice by men over 50 for early detection Will be done if BPH detected on digital exam to r/o cancer ↑PSA f/u with biopsy Prostate Cancer

  33. Pathology of the Urinary System • Bladder Tumors • Urinary Calculi • Polycystic Kidney Disease • Diabetic Nephropathy • ESRD • Renal Cell Carcinoma • Congenital Nephroblastoma (Wilm’s Tumor)

  34. Urinary Calculi/Stones • Solid particles that form in one or both kidneys • May become lodged • Pass < 4mm stones 80% of the time • 50% recurrence rate • 3 types: • Calcium (75%) dietary imbalance/hyperparathyroidism • Magnesium ammonium phosphate (struvite) (15%) UTI • Uric Acid (6%) associated with gout • Cystine amino acid reabsorption failure

  35. ESWL • Extra-Corporeal Shock-Wave Lithotripsy • Renal Calculi • Historical: Done in large tub and patients were intubated and connected to the shock therapy unit • Present: Water-bed like unit under lower body. Stone lined up with C-arm machine/cross-sectioned + Stone hit with shock waves precisely • Avoid bone • Shocks gauged to match patient HR, otherwise patient can experience arrhythmias if shock wave exceed HR • Usually range from 120/min to 60 /min

  36. Other Methods of Stone Removal • Cystoscopic / ureteroscopic / nephroscopic lithotomy • Direct extraction via • Laser through • Small Lithotripsy unit used through • Percutaneous lithotomy • Open lithotomy

  37. Polycystic Kidney Disease • Multiple fluid filled cysts in parenchyma of kidney • One kidney could have thousands • Kidney could weigh up to 22lbs. • 3 Types: 1. Autosomal dominant (hereditary) • 30-50yrs • 90% • Autosomal recessive (rare/congenital) • Children • Acquired (long term kidney problems)

  38. Diabetic Neuropathy (sclerosis) • Uncontrolled diabetic • Progressive disease>ESRD>dialysis

  39. ESRD • Kidney failure • Final stage of many kidney diseases • Filtration system in kidney < 10% • 50% are diabetics • s/sx: ↓UO, ↑BUN and creatinine levels • Death imminent without method of waste and fluid removal • Tx: Hemodialysis and Peritoneal Dialysis

  40. Vascular access 1. Temporary Dual lumen catheter (Vas Cath) 2. Permanent PTFE loop graft Creation of AV fistula (cephalic and radial artery most common) Must mature, so will likely have Vas Cath placed 2 lumens: one for outflow and one for inflow Dialysis machine has 2 compartments: one for incoming blood and one for dialysate Between compartments is a semi-permeable membrane that filters like the kidney Excess wastes and fluids go into dialysate and are disposed of Important blood components and proteins return to body Hemodialysis

  41. Peritoneal Dialysis • Requires implantation of catheter into peritoneal cavity (ex. Tenchkoff) • Allows for infusion of dialysate which draws out waste and fluids • After proper amount of time, dialysate and fluid/wastes are drained into a bag • Peritoneum serves as filter

  42. Pathology Affecting the Adrenal Glands • Cushing’s Syndrome • Addison’s Disease • Pheochromocytoma

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