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SUR 122 Genitourinary Surgery.

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Presentation on theme: "SUR 122 Genitourinary Surgery."— Presentation transcript:

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

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

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9 Male Reproductive System
Testis Lobules with 3 cell types: Seminiferous tubules involved in spermatogenesis Interstitial cells (cells of Leydig) produce testosterone Seratoli cells provide nutrients for sperm

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

13 Male Reproductive System
Midpiece extension that contains large amt of mitochondria (ATP) Flagella tail composed of a protein that allows for movement generated by ATP 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 egg b. Nucleus (haploid) contains 23 chromosomes (when unites with egg also 23 chromosomes, chromosome total becomes 46) 1N

14 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

15 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)

16 Male Reproductive System Summation
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 cord goes from inguinal ring to testis Inguinal ring also contains ductus deferens, testicular vessels (arterial, venous, and lymphatic), and nerves

17 Accessory Organs 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 Internal urinary sphincter tightens w/ejaculation to prevent mixing of urine w/sperm

18 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

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21 Genitourinary System Kidneys Adrenal glands Ureters Urinary Bladder
Urethra Prostate Gland (male)

22 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

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24 Nephron > 1 million per kidney 2 types: juxtamedullary and cortical
Each composed of capillary network: Renal corpuscle Renal tubule Drugs actually removed in loop of Henle

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

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

27 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

28 Renal Tubules Secretion
Substances move from blood into tubules (urine) Distal Collecting Tubule Collecting Tubule

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30 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

31 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

32 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) ADH antidiuretic hormone secreted by the pituitary gland, decreases amount of urine making distal and collecting tubules permeable to water=urine-decreasing hormone. Aldosterone is the decreasing urine hormone as it stimulates the tubules to reabsorb salts and water.

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

34 Phimosis Foreskin will not retract Congenital Geriatric
Can cause infection, pain Tx: circumcision

35 Hypospadias Epispadias
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

36 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 Can cause infertility

37 Testicular Torsion Spermatic cord is twisted Tx: Orchiopexy
Necrosis from obstructed blood flow

38 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

39 BPH Hypertrophy Normal part of aging > 50 yrs
Urethral narrowing can result Tx: Drug therapy ↓ prostate growth (medical) TURP (surgical) 90% TURP noninvasive RE-op likely. Only removing affecting tissue not removing entire gland itself

40 Prostate Cancer > 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

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

42 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

43 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

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

45 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)

46 Diabetic Neuropathy (sclerosis)
Uncontrolled diabetic Progressive disease>ESRD>dialysis

47 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

48 Hemodialysis 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

49 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

50 Pathology Affecting the Adrenal Glands
Cushing’s Syndrome Addison’s Disease Pheochromocytoma

51 Pathology of the Adrenal Glands
Cushing’s Syndrome Overproduction of cortisol Cortisol production: Pituitary gland which stimulates ACTH (adrenal cortical trophic hormone) which stimulates cortisol production Caused by: (80%) pituitary tumor or (20%) adrenal cortex tumor s/sx: HTN, central body obesity, hirsutism, osteoporosis, kidney stones, emotional instability, abnormal menses Tx: surgical removal of tumor

52 Pathology of the Adrenal Glands
Addison’s Disease (Adrenal Insufficiency) Hormones needed to maintain fluid and electrolyte balance, blood pressure, and a normal stress response are inhibited s/sx: weight loss, weakness, fatigue, GI disturbances, low BP, darkening of skin, hair loss, mood/behavior changes Tx: medical hormone replacement therapy

53 Pathology of the Adrenal Glands
Pheochromocytoma Overproduction of adrenaline Caused by tumor of the medulla Excessive adrenaline creates severe hypertension s/sx: HTN, severe headache, excessive sweating, tachycardia, palpitations, anxiety, tremors, epigastric pain, weight loss, heat intolerance Tx: surgical removal of tumor

54 Genitourinary System Reproductive Organs: Female

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56 Pathology of Female Genitourinary and Reproductive System
Benign Cysts Polyps (pedunculated lesion) Fistulas Dysplasia Leiomyoma/Myoma/Fibroid Fibroma Malignant Vulvar Vaginal Cervical Uterine Ovarian Other Endometriosis Cystocele Rectocele (posterior colporrhaphy) Enterocele Ectopic Pregnancy Incompetent Cervix (cerclage) Cystocele=herniation of bladder into vagina, Rectocele=herniation of rectum into vagina; Enterocele=herniation of cul-de-sac of Douglas/includes loops of intestines into vagina; myoma=smooth muscle tumor;Fibroma=connective tissue tumor; Dysplasia=abnormal tissue growth

57 Pre-operative & Diagnostic Testing
H&P UA Hematology: CBC & HGB/HCT Blood Chemistry: Blood Urea Nitrogen and Creatinine KUB IVP Cystogram Urethrogram Cystoscopy CT MRI Biopsy

58 Incisional Approaches
Inguinal Scrotal Abdominal Thoracoabdominal pg. 603 Alexander’s Gibson pg. 755 Caruthers Flank pg. pg. 603 Alexander’s (more oblique) Lumbar pg. 603 Alexander’s (more vertical) *Provide best exposure Similar in location to McBurney but is lower and much longer/is oblique

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61 Anesthesia General Spinal Epidural MAC with Local

62 Medications Antibiotics Contrast Media (Hypaque)
Dyes (Methylene Blue, Indigo Carmine) Diuretics Prevent reabsorption of water and sodium by the kidneys. Are classified by where effect exerted in nephron.

63 Instruments Major Set Vascular Tray or CV Tray
Extra Long Instrument Set Self-Retaining Abdominal Retractor Chest Tray: Finochetti, periosteotome, Doyan, rib shears, rongeur, Bailey rib approximator Special: Mixters, Potts scissors, Vascular instruments, Bladder & Prostate retractors, Pedicle clamps, Stone/lithotomy forceps

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65 Other Cystoscope Components
Bridges (short and long) Cystoscopes: 12°, 30°, and 70°

66 Supplies Ureteral sounds (dilators) Flexible endoscope and accessories
Rigid endoscope instrumentation Resectoscope Ellik evacuator Toomey irrigator/syringe Accessories: light cord, camera, insufflation tubing, irrigation fluid See 714 Berry & Kohn’s

67 Irrigations Glycine TURP 2. Water Laser 3. NS Cystograms

68 Supplies Continued Lubricant Foley catheter and drainage bag
Alternative catheters (difficult insertion) Catheter guide (facilitates insertion) Urethral catheters Ureteral drainage bag(s)

69 Catheters Urethral Lumen Size range 8-30 French Ureteral
FYI: Divide French by 3 to get diameter of lumen in mm Ex: 12 French catheter divided by 3 = 4mm in diameter

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71 Equipment OR Table with Foot Drop (lithotomy) & Radiographic Capability Lead Aprons, Accessories Quick Access to X-ray Development Room IV Poles that will hold heavy fluid bags Sitting stool Multiple X-ray view boxes Video Tower (light source, camera box, insufflator) Cautery with bipolar capability

72 Positioning Lithotomy Supine Lateral Variations of Above

73 Prep Area of Involvement Begin at incision site and work way out
Prep genital area last May not do a prep if urethral approach

74 Draping Laparotomy Universal Perineal Combination Laparotomy/Perineal
Surgeon’s preference/approach Depends on position

75 Dressings Abdominal: steri-strips, telfa, xeroflo,
4x4s, ABD (surgeon’s preference) Vaginal packing Peri-pad Net panties

76 Drains JP Snyder Hemovac/Grenade Penrose
Depends on location of surgical wound and surgeon preference

77 Post-operative Care Discharge same day to 5 days hospitalization
Early ambulation TED hose Turn/cough/deep breath Drink plenty of fluids Avoid heavy lifting >10lbs. at least 6 weeks urine may be pink tinged to red/should clear in few days S/X Infection: incision red, warm, painful, purulent drainage S/SX UTI: fever, chills, hematuria, flank pain, sudden increase in urinary output

78 Complications Infection
Nicking ureters, bladder, urethra, reproductive organs Hemorrhage (major blood vessel proximity) Adhesions Sciatic nerve damage due to spinal placement Blood clot (thrombosis) DVT PE (pulmonary embolus)

79 Summary 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


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