Urologic Surgery

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Urologic Surgery

• Jason P. Gilleran, MD
• Assistant Professor
• Department of Urology
• Director, Female Pelvic Medicine and
  Reconstructive Surgery

2
Overview

• Anatomy
• Indications
• Preop Evaluation
• Surgical Techniques
• Complications

• Prostate
• Kidney
• Adrenal
• Testis
• Penis
• Bladder
• Urethra
• Female Urology

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Prostate
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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

5
Prostate Cancer

• Evaluation Digital rectal exam, prostate
  specific antigen (PSA)
• Normal level lt4.0 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.

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BPH Surgery

• Transurethral resection of prostate (TURP)
• Transurethral incision of prostate (TUIP)
• Laser ablation/enucleation
• Holmium
• PKP (Green Light)
• Microwave therapy/needle ablation

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TUIP
TURP
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Complications

• Hematuria
• Bladder neck contracture/stricture
• Retrograde ejaculation
• Total incontinence

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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

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Radical Prostatectomy Anatomy
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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)

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Artificial Urinary Sphincter
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Male Transobturator Sling(AdVance)
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Kidney, Adrenal
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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

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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)

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• Surgical Approaches
• Anterior subcostal
• Flank
• Laparoscopic (with or without hand-assisted)

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MRI of Large Right Renal Mass
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Partial Nephrectomy

• Exophytic lesions
• Accessible masses lt 4 cm
• Solitary kidney or high-risk for ESRD
• Diabetes, hypertension
• Genetic Diseases
• Von Hippel Lindau (VHL)

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Exophytic Masses
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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)

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Pyelonephritis

• Perinephric Abscess
• Emphysematous pyelonephritis
• Xanthogranulomatous pyelonephritis

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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

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Renal Calculus Treatment

• Extracorporeal shock-wave lithotripsy (ESWL)
• Ureteroscopy, laser lithotripsy
• Percutaneous nephrostolithotomy
• Open stone extraction (rare)

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• 8.5 Fr ureteroscope
• Nephroscope
• Holmium laser (200, 360 m)

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Complications

• Urosepsis
• Ureteral stricture
• Ureteral avulsion
• Renal AVM
• Hydrothorax / pneumothorax
• Bowel injury

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Bladder Calculi

• Urinary stasis, foreign body, mucus
• BPH, neurogenic bladder
• Calcium phosphate
• Cystolitholapaxy, remove underlying obstruction
  (in men with BPH)

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Adrenal Anatomy

• Embryologically unrelated to kidneys
  (neuroectoderm origin)
• Three zones
• Glomerulosa (mineralocorticoids aldosterone)
• Fasciculata (glucocorticoids cortisol)
• Reticularis (sex steroids)

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Adrenal Mass

• Often found incidentally
• Most common mass adenoma
• Functional studies, MRI
• Serum cortisol, metanephrines, aldosterone (if
  hypokalemic or hypertensive)
• Pheochromocytoma
• Adrenal carcinoma
• Myelolipoma

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Laparoscopic Adrenalectomy
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Scrotum, Testis
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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

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Scrotal/Testis Anatomy
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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

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Testicular Trauma

• Scrotal ultrasound
• Hematocele
• Scrotal rupture requires exploration and repair
  if presents lt 72 hrs from injury
• High degree of clinical suspicion

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Hydrocelectomy
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Varicocelectomy

• Bag of worms on standing, Valsalva examination
• Infertility
• Scrotal pain, thrombosis
• 95 on left (right sided varicocele should prompt
  abdominal imaging study)

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Varicocelectomy

• Scrotal
• Inguinal
• Retroperitoneal
• Loupes
• Operating microscope
• Doppler

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Bladder
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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

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TURBT

• Risks
• Perforation
• Sepsis
• Ureteral obstruction
• Adjuvant Treatment
• Mitomycin C
• BCG
• Thiotepa

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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

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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

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Male Cystoprostatectomy
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Urinary Diversion Techniques

• Incontinent Diversion
• Ileal conduit (most common)
• Continent Diversion
• Renal function
• Favorable disease
• Motivated patient

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Ileal Conduit
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Complications

• Bowel obstruction, fistula, abscess
• Chronic Diarrhea
• Renal insufficiency
• Ureterointestinal anastomotic stricture
• Metabolic abnormalities

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Penis, Urethra
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Penile/Urethral Anatomy
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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

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Urethral Trauma
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Urethroplasty

• Ideal for dense strictures that failed
  urethrotomy (DVIU)
• Bulbar strictures lt 2 cm best for end-to-end
  primary anastomosis
• Buccal graft interposition
• Penile skin onlay flap

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Complications

• Recurrent stricture
• Fistula, urethral phlegmon
• Salivary duct injury if harvesting buccal graft
• Positioning complications (DVT, leg pain,
  rhabdomyolysis)

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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

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Inguinal Lymph Node Dissection

• Presence of persistent palpable lymphadenopathy
  after penectomy and antibiotics
• Staging and therapeutic
• Complications skin breakdown, lymphedema, seroma

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Penile Fracture

• Eggplant deformity
• Patient hears a pop followed by immediate
  detumescence
• Contained within Colles fascia

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Peyronies Disease

• Originally described in 18th century France
• Penile curvature (dorsal most common) with
  palpable plaque
• Spontaneous regression possible
• Medical therapy of little use

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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

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Penile Prosthetic Surgery
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Complications

• Urethral injury
• Corporal cross-over or perforation
• Erosion
• Infection
• Mechanical Failure

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Female Urology
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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

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Abdominal MSCIntraoperative View
Peritoneal Edge
Mesh
Bladder
Sigmoid
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Urinary Incontinence

• Stress incontinence
• Urge incontinence
• Mixed incontinence
• Functional overflow incontinence

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Suburethral Sling

• Indicated for moderate-to-severe stress
  incontinence
• Urethral hypermobility
• Polypropylene mesh
• Sphincteric incompetence
• Bladder neck, autologous fascia

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Complications

• Obstruction and voiding dysfunction (3-5)
• Urethral erosion, vaginal extrusion (1)
• De novo urge incontinence (?10)
• Bladder, urethral injury, fistula
• Thigh abscess

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Sacral Neuromodulator

• Refractory urge incontinence, urgency/frequency,
  urinary retention
• S3 nerve root
• Quadripolar lead
• IPG

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Urethral Diverticulum

• Three Ds dysuria, dyspareunia, postvoid
  dribbling
• Palpable urethral mass, UTIs
• More common in African-American women
• Diagnose on cystoscopy /- VCUG, pelvic MRI

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Summary

• Wide variety of disease processes
• Non-invasive and pharmacologic approaches
• Surgical options include open, endoscopic,
  minimally invasive