1. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 1

2. 2 CHAPTER 20 Genitourinary Surgery

3. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 3 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

4. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 4 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

5. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 5 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

6. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 6 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

7. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 7 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

8. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 8 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

9. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 9 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

10. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 10 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

11. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 11 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

12. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 12 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

13. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 13 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

14. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 14 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

15. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 15 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

16. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 16 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)

17. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 17 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

18. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 18 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

19. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 19 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

20. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 20 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

21. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 21 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

22. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 22 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

23. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 23 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

24. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 24 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

25. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 25 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

26. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 26 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

27. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 27 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

28. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 28 Penile Surgical Procedures Performed to treat congenital defects, disorders, and cancer Procedures –Circumcision –Hypospadias repair –Epispadias repair –Insertion of Inflatable penile prosthesis –Penectomy

29. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 29 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