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Ovid: Oxford Handbook of Urology

Authors: Reynard, John; Brewster, Simon; Biers, Suzanne Title: Oxford Handbook of Urology, 1st Edition Copyright ©2006 Oxford University Press > Table of Contents > Chapter 17 – Urological surgery and equipment Chapter 17 Urological surgery and equipment P.556
Preparation of the patient for urological surgery Degree of preparation is related to the complexity of the procedure. Certain aspects of examination (pulse rate, blood pressure) and certain tests (haemoglobin, electrolytes, creatinine) are important not only to assess fitness for surgery, but also as a baseline against which changes in the post-operative period may be measured.

  • Assess cardiac status (angina, arrhythmias, previous MI, blood pressure, ECG, CXR). We assess respiratory function by pulmonary function tests (FVC, FEV1) for all major surgery and any surgery where the patient has symptoms of respiratory problems or a history of chronic airways disease (e.g. asthma).
  • Arrange an anaesthetic review where there is, for example, cardiac or respiratory comorbidity.
  • Culture urine, treat active (symptomatic) infection with an appropriate antibiotic starting a week before surgery, and give prophylactic antibiotics at the induction of anaesthesia.
  • Stop aspirin and non-steroidal anti-inflammatory drugs 10 days prior to surgery.
  • Obtain consent (see p.596).
  • Measure haemoglobin and serum creatinine and investigate and correct anaemia, electrolyte disturbance, and abnormal renal function. If blood loss is anticipated, group and save a sample of serum or cross-match several units of blood, the precise number depending on the speed with which your blood bank can deliver blood if needed. In our own unit our policy is:
TURBT Group and save
TURP Cross-match 2 units
Open prostatectomy Cross-match 2 units
Simple nephrectomy Cross-match 2 units
Radical nephrectomy Cross-match 4 units
Cystectomy Cross-match 4 units
Radical prostatectomy Cross-match 2 units
PCNL Cross-match 2 units
  • The patient may choose to store their own blood prior to the procedure.

Bowel preparation Indicated if bowel is to be used (ileal conduit, bladder reconstruction). Use a simple mechanical prep (Citramag® or Picolax®—magnesium salts),2 doses starting the morning before surgery, with clear fluid-only diet. P.557
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Antibiotic prophylaxis in urological surgery The precise antibiotic prophylaxis policy that you use will depend on your local microbiological flora. Your local microbiology department will provide regular advice and updates on which antibiotics should be used, both for prophylaxis and treatment. The policy shown below and in Table 17.1 is our own local policy. Culture urine before any procedure, and use specific prophylaxis (based on sensitivities) if culture positive. We avoid ciprofloxacin in inpatients because it is secreted onto the skin and causes MRSA colonization. For most purposes, nitrofurantoin provides equivalent cover without being secreted onto the skin. We do use ciprofloxacin if there is known Proteus infection (all Proteus species are resistant to nitrofurantoin). Patients with artificial heart valves Patients with heart murmurs and those with prosthetic heart valves: 1g of IV amoxycillin with 120mg of gentamicin should be given at induction of anaesthesia, with an additional dose of oral amoxycillin, 500mg 6h later (substituting vancomycin 1g for those who are penicillin allergic). Patients with joint replacements The advice is conflicting. AAOS/AUA advice Joint advice of the American Academy of Orthopaedic Surgeons (AAOS) and the American Urological Association (AUA)—antibiotic prophylaxis is not indicated for urological patients with pins, plates, or screws, nor for most patients with total joint replacements. It is recommended for all patients undergoing urological procedures, including TURP within two years of a prosthetic joint replacement, for those who are immunocompromised (e.g. rheumatoid patients, those with systemic lupus erythematosus, drug-induced immunosuppression including steroids), and for those with a history of previous joint infection, haemophilia, HIV infection, diabetes, and malignancy. Antibiotic regime: single dose of a quinolone, such as 500mg of ciprofloxacin, 1–2h pre-operatively + ampicillin 2g IV + gentamicin 1.5mg/kg 30–60 min pre-operatively (substituting vancomycin 1g IV for penicillin allergic patients). UK advice In the UK, a Working Party of the British Society for Antimicrobial Chemotherapy has stated that patients with prosthetic joint implants (including total hip replacements) do not require antibiotic prophylaxis and consider that it is unacceptable to expose patients to the adverse effects of antibiotics when there is no evidence that such prophylaxis is of any benefit. This advice is based on the rationale that joint infections P.559
are caused by skin organisms that get onto the prosthesis at the time of the operation and that the role of bacteraemia as a cause of seeding, outside the immediate post-operative period, has never been established. We use the same antibiotic prophylaxis as for patients without joint prostheses.

Table 17.1 Oxford urology procedure: specific antibiotic prophylaxis protocol for urological surgery
Procedure Antibiotic prophylaxis
Catheter removal Nitrofurantoin, 100mg PO 30 min before catheter removal
Change of male long-term catheter Gentamicin 1.5mg/kg IM or IV 20 min before*
Flexible cystoscopy or GA cystoscopy Nitrofurantoin 100mg PO 30–60 min before procedure
Transrectal prostatic biopsy Ciprofloxacin 500mg PO and metronidazole 400mg 20 min pre-biopsy and for 48h post-biopsy (ciprofloxacin 500mg bds, metronidazole 400mg tds)
ESWL 500mg oral ciprofloxacin 30 min before treatment (nitrofurantoin does not cover Proteus, a common ‘stone’ bacterium)
PCNL Cefuroxime 1.5g IV tds starting the day before, hrs before operation, and 3 doses post-op; gentamicin at induction
Ureteroscopy Gentamicin 1.5mg/kg IV at induction
Urogynaecological procedures (e.g. colposuspension) Cefuroxime 1.5g IV and metronidazole 500mg IV at induction of anaesthesia
TURPs and TURBTs — both for non-catheterized patients (i.e. elective TURP for LUTS) and patients with catheters (undergoing TURP for retention) Nitrofurantoin 100mg + IV gentamicin at induction (1.5mg/kg); nitrofurantoin 100mg PO 30 min before catheter removal
Radical prostatectomy 1.5g IV cefuroxime + 240mg IV gentamicin + 500mg IV metronidazole at induction; 240mg of gentamicin 24h post-op; 48h IV cefuroxime 750mg tds; ciprofloxacin PO 5 days
Cystectomy or other procedures involving the use of bowel (e.g. augmentation cystoplasty) 1.5g IV cefuroxime + 500mg IV metronidazole at induction; a further intraoperative dose of cefuroxime 750mg 2h after the first dose + further 2 doses of cefuroxime (750mg) and metronidazole (500mg) post-op
Artificial urinary sphincter insertion Vancomycin 1g 1.5h before leaving the ward (infuse over 100 min)** + 1.5mg IV cefuroxime + 3mg/kg IV gentamicin at induction; continue IV cefuroxime, gentamicin, and vancomycin (1g bds) for 48h
* Sepsis rate (necessitating admission to hospital) may be as high as 1% without antibiotic cover.
** OR teicoplanin if vancomycin allergic—400mg at induction and bds thereafter for a total of 48h; meropenem may be substituted for vancomycin in ‘vancomycin-free’ hospitals.
Note: cefuroxime has a short half-life. Whenever using cefuroxime, give a further dose 2h after the first dose. Further intra-operative top-up doses of vancomycin and gentamicin are not required as they have long half-lives.

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Complications of surgery in general: DVT and PE Venous thromboembolism (VTE) is uncommon after urological surgery, but it is considered the most important non-surgical complication of major urological procedures. Following TURP, 0.1–0.2% of patients experience a pulmonary embolus4 and 1–5% of patients undergoing major urological surgery experience symptomatic VTE.5 The mortality of PE is in the order of 1%.6 Risk factors for DVT and PE Increased risk: open (versus endoscopic) procedures, malignancy, increasing age, duration of procedure. Categorization of VTE risk American College of Chest Physicians (ACCP) Guidelines on prevention of venous thromboembolism5 and British Thromboembolic Risk Factors (THRIFT) Consensus Group7 categorize the risk of VTE:

  • Low-risk patients—those <40 undergoing minor surgery (surgery lasting <30 min) and no additional risk factors. No specific measures to prevent DVT are required in such patients other than early mobilization. Increasing age and duration of surgery increases risk of VTE.
  • High-risk patients—include those undergoing non-major surgery (surgery lasting >30 min) who are aged >60.

Prevention of DVT and PE See box. Diagnosis of DVT Signs of DVT are non-specific (i.e. cellulitis and DVT share common signs— low-grade fever, calf swelling and tenderness). If you suspect a DVT arrange a Doppler ultrasound. If the ultrasound probe can compress the popliteal and femoral veins, there is no DVT; if it can’t, there is a DVT. Diagnosis of PE Small PEs may be asymptomatic. Symptoms include breathlessness, pleuritic chest pain, haemoptysis. Signs: tachycardia, tachypnoea, raised JVP, hypotension, pleural rub, pleural effusion. P.563
Tests

  • CXR May be normal or show linear atelectasis, dilated pulmonary artery, oligaemia of affected segment, small pleural effusion.
  • ECG May be normal or show tachycardia, right bundle branch block, inverted T waves in V1–V4 (evidence of right ventricular strain). The ‘classic’ SI, QIII, TIII pattern is rare.
  • Arterial blood gases Low PO2 and low PCO2.
  • Imaging CTPA-CT pulmonary angiogram. Superior specificity and sensitivity when compared with ventilation-perfusion (VQ) radioisotope scan.
  • Spiral computed tomography A negative CT pulmonary angiogram (CTPA) rules out a PE with similar accuracy to a normal isotope lung scan or a negative pulmonary angiogram.

Treatment of established DVT

  • Below-knee DVT: above-knee thromboembolic stockings (AK-TEDs), if no peripheral arterial disease (enquire for claudication and check pulses) + unfractionated heparin 5000u SC 12 hourly.
  • Above-knee DVT: start a low molecular weight heparin and warfarin, and stop heparin when INR is between 2–3. Continue treatment for 6 weeks for post-surgical patient; lifelong if underlying cause (e.g. malignancy).
  • Low molecular weight heparin (LMWH).

Treatment of established PE Fixed dose, subcutaneous LMWH seems to be as effective as adjusted dose, intravenous unfractionated heparin for the treatment of PE found in conjunction with a symptomatic DVT.6 Rates of haemorrhage are similar with both forms of heparin treatment. Start warfarin at the same time and stop heparin when INR is 2–3. Continue warfarin for 3 months. Options for prevention of VTE

  • Early mobilization.
  • Above-knee thromboembolic stockings (AK-TEDs) (provide graduated, static compression of the calves, thereby reducing venous stasis). More effective than below-knee TEDS for DVT prevention.8
  • Subcutaneous heparin (low-dose unfractionated heparin—LDUH or low molecular weight heparin—LMWH). In unfractionated preparations, heparin molecules are polymerized—molecular weights from 5000–30,000 daltons. Low molecular weight heparin is depolymerized—molecular weight 4000–5000 daltons.
  • Intermittent pneumatic calf compression (IPC) boots, which are placed around the calves, are intermittently inflated and deflated, thereby increasing the flow of blood in calf veins.9

For patients undergoing major urological surgery (radical prostatectomy, cystectomy, nephrectomy), AK-TEDS with IPC intra-operatively, followed by SC heparin (LDUH or LMWH) should be used. For TURP, many urologists use a combination of AK-TEDS and IPCs; relatively few use SC heparin.10 P.564
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Fluid balance and the management of shock in the surgical patient Daily fluid requirement Can be calculated according to patient weight:

  • For the first 10kg: 100ml/kg per 24h (=1000ml)
  • For the next 10kg (i.e. from 10–20kg): 50ml/kg per 24h (=500ml)
  • For every kg above 20kg: 20ml/kg per 24h (=1000ml for a patient weighing 70kg).

Thus, for every 24h, a 70kg adult will require 1000ml for their first 10kg of weight, plus 500ml for their next 10kg of weight, and 1000ml for their last 50kg of weight = total 24-h fluid requirement, 2500ml. Daily sodium requirement is ~100mmol, and for potassium, ~70mmol. Thus, a standard 24-h fluid regimen is 2L of 5% dextrose + 1L of N. saline (equivalent to about 150mmol Na+), with 20mmol K+ for every litre of infused fluid. Fluid losses from drains or nasogastric aspirate are similar in composition to plasma and should be replaced principally with N. saline. Shock due to blood loss Inadequate organ perfusion and tissue oxygenation. The causes are hypovolaemia, cardiogenic, septic, anaphylactic, and neurogenic. The most common cause in the surgical patient is hypovolaemia due to blood and other fluid loss. Haemorrhage is an acute loss of circulating blood volume. Haemorrhagic shock may be classified as:

  • Class I: up to 750ml of blood loss (15% of blood volume); normal pulse rate (PR), respiratory rate (RR), blood pressure, urine output, and mental status
  • Class II: 750–1500ml (15–30% of blood volume); PR >100; decreased pulse pressure due to increased diastolic pressure; RR 20–30; urinary output 20–30ml/h
  • Class III: 1500–2000ml (30–40% of blood volume); PR >120; decreased blood pressure and pulse pressure due to decreased systolic pressure; RR 30–40; urine output 5–15ml/h; confusion
  • Class IV: >2000ml (>40% of blood volume); PR >140; decreased pulse pressure and blood pressure; RR >35; urine output <5ml/h; cold, clammy skin

Management

  • Remember ‘ABC’: 100% oxygen to improve tissue oxygenation.
  • ECG, cardiac monitor, pulse oximetry.
  • Insert two short and wide intravenous cannulae in the antecubital fossa (e.g. 16G). A central venous line may be required.
  • Infuse 1L of warm Hartmann’s solution or, if severe haemorrhage, then start a colloid instead (e.g. gelofusin). Aim for a urinary output of 0.5ml/kg/h and maintenance of blood pressure.
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  • Check FBC, coagulation screen, U&Es, and cardiac enzymes.
  • Cross-match 6 units of blood.
  • Arterial blood gases to assess oxygentation and pH.

Obvious and excessive blood loss may be seen from drains, but drains can block, so assume there is covert bleeding if there is a tachycardia (and low blood pressure). If this regimen fails to stabilize pulse and blood pressure, return the patient to the operating room for exploratory surgery. P.568
Patient safety in the urology theatre It is a fundamental part of safe surgical practice to cross-check that the following have been done prior to starting an operation or procedure. The process of cross-checking should be done with another member of staff.

  • Patient identification. Confirm you are operating on the right patient by a process of ‘active’ identification (i.e. ask the patient their name, date of birth, and their address to confirm that you are talking to the correct patient).
  • Ensure you are doing the correct procedure and on the correct side by cross-checking with the notes and X-rays. For lateralized procedures (e.g. nephrectomy, PCNL) the correct side of the operation should be confirmed by cross-checking with the X-rays and with the X-ray report, as well as referring to the notes. Where it is possible for the sides of an IVU to be incorrectly labelled, this cannot happen with a CT scan, where the location of the liver (right side) and the spleen (left side) provide confirmation of what side is what.
  • Appropriate antibiotic prophylaxis has been given.
  • DVT prophylaxis has been administered (e.g. heparin, AK-TEDS, intermittent pneumatic compression boots).
  • Blood is available, if appropriate.
  • The patient is safely and securely positioned on the operating table— pressure points padded, not touching metal (to avoid diathermy burns), body straps securely in place.

Develop an approach to operating which involves members of your team. Listen to the opinions of staff who are junior to you. They may sometimes be able to identify errors which are not obvious to you. Cultivate the respect of the recovery room staff. They may express concern about a patient under their care—listen to their concerns, take them seriously, and, if all is well, reassure them. It does no harm for your patients or for your reputation to develop the habit of visiting every patient in the recovery room to check that all is well. You may be able to identify a problem before it has developed into a crisis and, at the very least, you will gain a reputation for being a caring surgeon. P.569
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Transurethral resection (TUR) syndrome Arises from the infusion of a large volume of hypotonic irrigating solution into the circulation during endoscopic procedures (e.g. TURP, TURBT, PCNL). Occurs in 0.5% of TURPs. Pathophysiology Biochemical, haemodynamic, and neurological disturbances occur:

  • Dilutional hyponatraemia is the most important—and serious—factor leading to the symptoms and signs. The serum sodium usually has to fall to <125mmol/l before the patient becomes unwell.
  • Hypertension—due to fluid overload.
  • Visual disturbances may be due to the fact that glycine is a neurotransmitter in the retina.

Diagnosis—symptoms, signs, and tests Confusion, nausea, vomiting, hypertension, bradycardia and visual disturbances, seizures. If the patient is awake (spinal anaesthesia) they may report visual disturbances (e.g. flashing lights). Preventing development of TUR syndrome and definitive treatment Use a continuous irrigating cystoscope (provides low-pressure irrigation), limit resection time, avoid aggressive resection near the capsule, and reduce the height of the irrigant solution.15 For prolonged procedures, where a greater degree of fluid absorption may occur, measure serum Na and give 20–40mg of intravenous frusemide to start off-loading the excess fluid that has been absorbed. If the serum sodium comes back as being normal, you will have done little harm by giving the frusemide, but if it comes back at <125mmol/l, you will have started treatment already and thereby may have prevented the development of severe TUR syndrome. Techniques for measuring fluid overload

  • Weighing machines can be added to the ordinary operating table.16
  • Adding a little alcohol to the irrigating fluid and constantly monitoring the expired air with a breathalyser17 allows an estimation of the volume of excess fluid which has been absorbed.

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Catheters and drains in urological surgery Catheters Made from latex or silastic (for patients with Latex allergy or for long-term use—better tolerated by the urethral mucosa). Types

  • Self-retaining (also known as a Foley, balloon, or 2-way catheter) (Fig. 17.1). An inflation channel can be used to inflate and deflate a balloon at the end of the catheter, which prevents the catheter from falling out.
  • 3-way catheter (also known as an irrigating catheter). Has a third channel (in addition to the balloon inflation and drainage channels) which allows fluid to be run into the bladder at the same time as it is drained from the bladder (Fig. 17.2).

Size The size of a catheter is denoted by its circumference in mm. This is known as the ‘French’ or ‘Charriere’ (hence Ch) gauge. Thus a 12Ch catheter has a circumference of 12mm. Uses

  • Relief of obstruction (e.g. BOO due to BPE causing urinary retention— use the smallest catheter that you can pass; usually a 12Ch or 14Ch is sufficient in an adult).
  • Irrigation of the bladder for clot retention (use a 20Ch or 22Ch 3-way catheter).
  • Drainage of urine to allow the bladder to heal if it has been opened (trauma or deliberately, as part of a surgical operation).
  • Prevention of ureteric reflux, maintenance of a low bladder pressure, where the ureter has been stented (post-pyeloplasty for PUJ obstruction).
  • To empty the bladder before an operation on the abdomen or pelvis (deflating the bladder gets it out of harms’ way).
  • Monitoring of urine output post-operatively or in the unwell patient.
  • For delivery of bladder instillations (e.g. intravesical chemotherapy or immunotherapy).
  • To allow identification of the bladder neck during surgery (e.g. radical prostatectomy, operations on or around the bladder neck).

Drains Principally indicated for prevention of accumulation of urine, blood, lymph, or other fluids. Particularly used after the urinary tract has been opened and closed by suture repair. A suture line takes some days to become completely watertight, and during this time urine leaks from the closure site. A drain prevents accumulation of urine (a urinoma), the very presence of which can cause an ileus, and if it becomes infected, an abscess can develop.

Fig. 17.1 A Foley catheter with the balloon inflated
Fig. 17.2 2- and 3-way catheters

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  • Tube drains (e.g. a Robinson’s drain) (Figs. 17.3 and 17.4). Provide passive drainage (i.e. no applied pressure). Used to drain suture lines at a site of repair or anastomosis of the urinary tract. Avoid placing the drain tip on the suture line, as this may prevent healing of the repair. Suture it to adjacent tissues to prevent it from being dislodged.
  • Suction drains (e.g. Hemovac®) (Figs. 17.5 and 17.6). Provide active drainage (i.e. air in the drainage bottle is evacuated, producing a -ve pressure when connected to the drain tube to encourage evacuation of fluid). Used for prevention of accumulation of blood (a haematoma) in superficial wounds. Avoid in proximity to a suture line in the urinary tract—the suctioning effect may encourage continued flow of urine out of the hole, discouraging healing.

As a general principle, drains should be brought out through a separate stab wound, rather than through the main wound, since the latter may result in bacterial contamination of the main wound with subsequent risk of infection. Secure the drain with a thick suture to prevent it inadvertently ‘falling out’.

Fig. 17.3 A Robinson’s (passive) drainage system
Fig. 17.4 Note the eyeholes of the Robinson’s catheter

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Failure to deflate catheter balloon for removal of a urethral catheter From time to time an inflated catheter balloon will not deflate when the time comes for removal of the catheter.

  • Try inflating the balloon with air or water—this can dislodge an obstruction.
  • Leave a 10ml syringe firmly inserted in the balloon channel and come back an hour or so later.
  • Try bursting the balloon by over-inflation.
  • Cut the end of the catheter off, proximal to the inflation valve—the valve may be ‘stuck’ and the water may drain out of the balloon.
  • In the female patient, introduce a needle alongside your finger into the vagina and burst the balloon by advancing the needle through the anterior vaginal and bladder wall.
  • In male patients, balloon deflation with a needle can also be done under ultrasound guidance. Fill the bladder with saline using a bladder syringe so that the needle can be introduced percutaneously and directed towards the balloon of the catheter under ultrasound control.
  • Pass a ureteroscope alongside the catheter and deflate the balloon with the rigid end of a guidewire or with a laser fibre (the end of which is sharp).
Fig. 17.5 A Redivac suction drain showing the drain tubing attached to the needle used for insertion and the suction bottle
Fig. 17.6 The eye holes at the tip of the suction drain

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Guidewires An essential tool for endourological procedures. Uses As a track over which catheters or instruments can be passed into the ureter, collecting system of the kidney (retrograde or antegrade), or the bladder. Types Many different types of guidewire are available. They are classified according to their size, tip design, rigidity, and surface coating. These specific properties determine their use. All are radio-opaque so X-ray screening can be used to determine their position. They come prepackaged in a coiled sheath to allow ease of handling and storage (Fig. 17.7). Size ‘Size’ refers to diameter measured in inches (length is usually around 150cm). Most common size are 0.035 inches (2.7Ch) and 0.038 inches (2.9Ch). Also available, 0.032 inches (2.5Ch). Tip design Shape of tip—straight or angle (Fig. 17.8). A straight tip is usually adequate for most uses. Occasionally, an angle tip is useful for negotiating an impacted stone or for placing the guidewire in a specific position. Similarly, a J-shaped tip can negotiate an impacted stone—the curved leading edge of this guidewire type can sometimes suddenly flick past the stone (in this situation a straight guidewire can inadvertently perforate the ureter, thereby creating a false passage). Surface coating Most standard guidewires are coated with polytetrafluoroethylene (PTFE) which has a low coefficient of friction, thus allowing easy passage of the guidewire through the ureter and of instruments over them. Some guidewires are coated with a polymer which when wet is very slippery (hydrophilic coating). In some cases, the entire length of the guidewire is so coated (e.g. Terumo Glidewire) and in others, just the tip (e.g. Sensor guidewire). The virtually friction-free surface of Glidewires makes them liable to slip out of the ureter, and they therefore make unreliable safety wires (they can be exchanged for a wire with greater friction via a ureteric catheter). If allowed to become dry, these wires have a high coefficient of friction, which makes them difficult to manipulate. Tip rigidity The tip of all guidewires, over at least 3cm, is soft and therefore flexible. This reduces—though does not completely remove—the risk of ureteric perforation.

Fig. 17.7 Guidewires come prepackaged in a sheath for ease of handling
Fig. 17.8 Examples of straight-tip and angled-tip guidewires

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Shaft rigidity Stiff guidewires are easier to manipulate than floppy ones and help to straighten a tortuous ureter (e.g. Amplatz Ultrastiff is particularly useful for this). Very malleable wires such as the Terumo Glidewire can be very useful for passing an impacted stone (for the same reason as J-tip wires). Some guidewires provide a combination of properties—a soft, floppy, hydrophilic-coated tip with the remainder of the guidewire being stiff (e.g. Sensor guidewire). P.580
Irrigating fluids and techniques of bladder washout Glycine is used for:

  • endoscopic surgery requiring application of diathermy

Normal saline is used for:

  • irrigation of bladder following TURP, TURBT
  • irrigation during ureteroscopy, PCNL

Blocked catheter post TURP and clot retention Avoiding catheter blockage following TURP—keep the catheter bag empty; ensure a sufficient supply of irrigant solution. The bladder will be painfully distended. Irrigant flow will have stopped. A small clot may have blocked the catheter or a chip of prostate may have stuck in the eye of the catheter. Attach a bladder syringe to the end of the catheter and pull back (Fig. 17.9). This may suck out the clot or chip of prostate and flow may restart. If it does not, draw some irrigant up into the syringe until it is about half-full and forcefully inject this fluid into the bladder. This may dislodge (and fragment) a clot which has stuck to the eye of the catheter. If the problem persists, change the catheter. You may see the obstructing chip of prostate on the end of the catheter as it is withdrawn. Blocked catheter post TURBT Use the same technique as for post-TURP catheter blockage, but avoid vigorous pressure on the syringe—the wall of the bladder will have been weakened at the site of tumour resection and it is possible to perforate the bladder, particularly in elderly women who have thin bladder walls. Blocked catheters following bladder augmentation or neobladder The suture line of the augmented bladder is weak, and over-vigorous bladder washouts can rupture the bladder.

Fig. 17.9 A bladder syringe—the tip is designed to fit onto a catheter

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JJ stents These are hollow tubes, with a coil at each end, which are inserted through the bladder (usually), into the ureter, and thence into the renal pelvis. They are designed to bypass a ureteric obstruction (e.g. due to a stone) or drain the kidney (e.g. post renal surgery). They have a coil at each end (hence the alternative name of ‘double pigtail’ stent—the coils have the configuration of a pig’s tail—or the less accurate name of J stent). These prevent migration downwards (out of the ureter) or upwards (into the ureter). They are therefore ‘self-retaining’. Made of polymers of variable strength and biodurability. Some stents have a hydrophilic coating which absorbs water and thereby makes them more slippery and easier to insert. Stents are impregnated with barium- or bismuth-containing metallic salts to make them radio-opaque, so that they can be visualized radiographically to ensure correct positioning. Types Classified by size and length. Common sizes are 6Ch or 7Ch (Fig. 17.10). Common lengths for adults are 22–28cm. Multi-length stents are of variable length, allowing them to accommodate to ureters of different length. Stent materials Polyurethane; silicone; C-flex; Silitek; Percuflex; biodegradable (experimental—obviates need for stent removal and eliminates possibility of the ‘forgotten stent’). Indications and uses

  • Relief of obstruction: from ureteric stones; benign (i.e. ischaemic)ureteric strictures; malignant ureteric strictures. The stent will relieve the pain caused by obstruction and reverse renal impairment if present.
  • Prevention of obstruction: post ureteroscopy.
  • ‘Passive’ dilatation of ureter prior to ureteroscopy.
  • To ensure antegrade flow of urine following surgery (e.g. pyeloplasty) or injury to ureter.
  • Following endopyelotomy (endopyelotomy stents have a tapered end from 14Ch to 7Ch, to keep the incised ureter ‘open’).
Fig. 17.10 A JJ stent

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Symptoms and complications of stents

  • Stent symptoms—common: suprapubic pain, LUTS (frequency, urgency—stent irritates trigone), haematuria, inability to work.
  • Urinary tract infection. Development of bacteriuria after stenting is common. In a small proportion sepsis can develop. In such cases consider placement of a urethral catheter to lower the pressure in the collecting system and prevent reflux of infected urine.
  • Incorrect placement. Too high (distal end of stent in ureter; subsequent stent removal requires ureteroscopy; can be technically difficult; percutaneous removal may be required). Too low (proximal end not in renal pelvis; stent may not therefore relieve obstruction).
  • Stent migration (up the ureter or down the ureter and into bladder).
  • Stent blockage. Catheters and stents become coated with a biofilm when in contact with urine (a protein matrix secreted by bacteria-colonizing stent). Calcium, magnesium, and phosphate salts become deposited. Biofilm build-up can lead to stent blockage or stone formation on the stent (Fig. 17.11).
  • The ‘forgotten stent’—rare, but potentially very serious as biofilm may become encrusted with stone, making removal technically very difficult. If proximal end only is encrusted, PCNL may be required to remove the stone and then the stent. If the entire stent is encrusted, open removal via several incisions in the ureter may be necessary.

Commonly asked questions about stents Does urine pass though the centre of the stent? No, it passes around the outside of the stent. Reflux of urine occurs through the centre. Should I place a JJ stent after ureteroscopy? A stent should be placed if:

  • there has been ureteric injury (e.g. perforation—indicated by extravasation of contrast)
  • there are residual stones that might obstruct the ureter
  • the patient has had a ureteric stricture that required dilatation

Routine stenting after ureteroscopy for distal ureteric calculi is unnecessary.18 Many urologists will place a stent after ureteroscopy for proximal ureteric stones.

Fig. 17.11 An encrusted stent

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Do stents cause obstruction? In normal kidneys stents cause a significant and substantial increase in intra-renal pressure which persists for up to 3 weeks.19 (This can be prevented by placing a urethral catheter.) Do stents aid stone passage? Ureteric peristalsis requires coaptation of the wall of the ureter proximal to the bolus of urine to be transmitted down the length of the ureter. JJ stents paralyse ureteric peristalsis. In dogs, the amplitude of each peristaltic wave (measured by an intraluminal ureteric balloon) falls (from 50 to 15mmHg) and the frequency of ureteric peristalsis falls (from 11 to 3 waves per minute). Peristalsis takes several weeks to recover. 3mm ball bearings placed within a non-stented dog ureter take 7 days to pass, compared with 24 days in a stented ureter. Are stents able to relieve obstruction due to extrinsic compression of a ureter? Stents are less effective at relieving obstruction due to extrinsic obstruction by, for example, tumour or retroperitoneal obstruction.20 They are much more effective for relieving obstruction by an intrinsic problem (e.g. a stone). Placement of two stents may provide more effective drainage (figure-of-eight configuration may produce more space around the stents for drainage). For acute, ureteric stone obstruction with a fever, should I place a JJ stent or a nephrostomy? In theory, one might imagine that a nephrostomy is better than a JJ stent—can be done under local anaesthetic (JJ stent insertion may require a GA); it lowers the pressure in the renal pelvis to 0 or a negative value, whereas a JJ stent results in a persistently +ve pressure; less likely to be blocked by thick pus; allows easier subsequent imaging (contrast can be injected down the ureter—a nephrostogram—to determine if the stone has passed). In practice, both seem to be effective for relief of acute stone obstruction and associated infection.21 P.587
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Lasers in urological surgery Light amplification by stimulated emission of radiation. Photons are emitted when an atom is stimulated by an external energy source and, its electrons having been so excited, revert to their steady state. In a laser the light is coherent (all the photons are in phase with one another), collimated (the photons travel parallel to each other), and of the same wavelength (monochromatic). The light energy is thus ‘concentrated’, allowing delivery of high energy at a desired target. The holmium:YAG (yttrium aluminium garnet) laser is currently the principal urological laser. It has a wavelength of 2140nm and is highly absorbed by water and therefore by tissues which are composed mainly of water. The majority of the holmium laser energy is absorbed superficially, resulting in a superficial cutting or ablation effect. The depth of the thermal effect is no greater than 1mm. The holmium:YAG laser produces a cavitation bubble that generates only a weak shock wave as it expands and collapses. Holmium laser lithotripsy occurs primarily through a photothermal mechanism that causes stone vaporization. Uses

  • Laser lithotripsy (ureteric stones, small intrarenal stones, bladder stones)
  • Resection of the prostate (holmium laser prostatectomy)
  • Division of urethral strictures
  • Division of ureteric strictures, including PUJO
  • Ablation of small bladder, ureteric, and intrarenal TCCs

Advantages

  • The holmium laser energy is delivered via a laser fibre (Fig. 17.12) which is thin enough to allow its use down a flexible instrument, without affecting the deflection of that instrument, and can therefore gain access to otherwise inaccessible parts of the kidney.
  • Zone of thermal injury adjacent to the tip of the laser fibre is limited to no more than 1mm; the laser can safely be fired at a distance of 1mm from the wall of the ureter.
  • Can be used for all stone types.
  • Minimal stone migration effect because of minimal shock wave generation.

Disadvantages

  • High cost
  • Produces a dust cloud during stone fragmentation which temporarily obscures the view
  • Can irreparably damage endoscopes if inadvertently fired near or within the scope
  • Relatively slow stone fragmentation—the laser fibre must be ‘painted’ over the surface of the stone to vaporize it.
Fig. 17.12 Holmium laser fibre

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Diathermy Diathermy is the coagulation or cutting of tissues through heat. Monopolar diarthermy When an electric current passes between two contacts on the body there is an increase in temperature in the tissues through which the current flows. This increase in temperature depends on the volume of tissue through which the current passes, the resistance of the tissues, and the strength of the current. The stronger the current, the greater the rise in temperature. If one contact is made large, the heat is dissipated over a wide area and the rise of temperature is insignificant. This is the earth or neutral electrode and under this the rise in temperature is only 1 or 2°C. The working electrode or diathermy loop is thin so that the current density is maximal and, therefore, so is the heating effect. When a direct current is switched on or off, nerves are stimulated and muscles will twitch. If the switching on and off is rapid enough, there is the sustained contraction familiar to the physiology class as the ‘tetanic contraction’. If a high-frequency alternating current is used (300kHz to 5MHz), there is no time for the cell membranes of nerve or muscle to become depolarized, and nerves and muscles are not stimulated (they are stimulated at lower frequencies). The effect of the diathermy current on the tissues depends on the heat that is generated under the diathermy loop. At relatively low temperatures, coagulation and distortion of small blood vessels occurs. If the current is increased to raise the temperature further, water within cells vaporizes and the cells explode. This explosive vaporization literally cuts the tissues apart. Bipolar diarthermy Bipolar diathermy involves the passage of electrical current between two electrodes on the same handpiece. It is inherently safer than monopolar diathermy, since the current does not pass through the patient, and diathermy burns cannot therefore occur. Potential problems with diathermy The diathermy isn’t working

  • Do not increase the current
  • Check that the irrigating fluid is glycine (sodium chloride conducts electricity causing the diathermy to short-circuit)
  • Check that the diathermy plate is making good contact with the skin of the patient
  • Check that the lead is undamaged
  • Check that the resectoscope loop is securely fixed to the contact

Modern diathermy machines have warning circuits which sound an alarm when there is imperfect contact between the earth plate and the patient. Diathermy burns If current returns to earth through a small contact rather than the broad area of the earth pad, then the tissues through which the current passes will be heated just like those under the cutting loop. If the pad is making good contact, the current will find it easier to run to earth through the P.591
pad and no harm will arise, even when there is accidental contact with some metal object. The real danger arises when the diathermy pad is not making good contact with the patient. It may not be plugged in or its wire may be broken. Under these circumstances the current must find its way to earth somehow, and any contact may then become the site of a dangerous rise in temperature. Pacemakers and diathermy See box for diathermy problems and their prevention. Pacemakers and diathermy: problems and their prevention

  • Pacemaker inhibition. The high frequency of diathermy current may simulate the electrical activity of myocardial contraction so the pacemaker can be inhibited. If the patient is pacemaker-dependent, the heart may stop.
  • Phantom reprogramming. The diathermy current may also simulate the radiofrequency impulse by which the pacemaker can be reprogrammed to different settings. The pacemaker may then start to function in an entirely different mode.
  • The internal mechanism of the pacemaker may be damaged by the diathermy current if this is applied close to the pacemaker.
  • Ventricular fibrillation. If the diathermy current is channelled along the pacemaker lead, ventricular fibrillation may be induced.
  • Myocardial damage. Another potential effect of channelling of the diathermy current along the pacemaker lead is burning of the myocardium at the tip of the pacemaker lead. This can subsequently result in ineffective pacing.

It was formerly recommended that a magnet was placed over the pacemaker to overcome pacemaker inhibition and to make the pacemaker function at a fixed rate. This can, however, result in phantom reprogramming. For demand pacemakers, it is better to programme the pacemaker to a fixed rate (as opposed to demand pacing) for the duration of the operation. Consult the patient’s cardiologist for advice. Other precautions

  • The patient plate should be sited so that the current path does not go right through the pacemaker. Ensure that the indifferent plate is correctly applied, as an improper connection can cause grounding of the diathermy current through the ECG monitoring leads, and this can affect pacemaker function. The indifferent plate should be placed as close as possible to the prostate (e.g. over the thigh or buttock).
  • The diathermy machine should be placed well away from the pacemaker and should certainly not be used within 15cm of it.
  • The heartbeat should be continually monitored, and a defibrillator and external pacemaker should be at hand.
  • Try to use short bursts of diathermy at the lowest effective output.
  • Give antibiotic prophylaxis (as for patients with artificial heart valves).
  • Because the pacemaker-driven heart will not respond to fluid overload in the normal way, the resection should be as quick as possible, and fluid overload should be avoided.

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Sterilization of urological equipment Techniques for sterilization Autoclaving Modern cystoscopes and resectoscopes, including components such as light leads, are autoclavable. Standard autoclave regimens heat the instruments to 121°C for 15 min or 134°C for 3 min. Chemical sterilization This involves soaking instruments in an aqueous solution of chlorine dioxide (Tristel), an aldehyde-free chemical (there has been a move away from formaldehyde because of health and environmental concerns). Chlorine dioxide solutions kill bacteria, viruses (including HIV and hepatitis B and C), spores, and mycobacteria. Cameras cannot be autoclaved. Use a camera sleeve or sterilize camera between cases in solutions such as Tristel. Sterilization and prion diseases Variant CJD (vCJD) is a neurodegenerative disease caused by a prion protein (PrP). Other examples of neurodegenerative prion diseases include classic CJD, kuru, sheep scrapie, and bovine spongiform encephalopathy (BSE). Variant CJD and BSE are caused by the same prion strain and represent a classic example of cross-species transmission of a prion disease. There has been much recent concern about the potential for transmission of vCJD between patients via contaminated surgical instruments. Classic CJD may be transmitted by neurosurgical and other types of surgical instruments because normal hospital sterilization procedures do not completely inactivate prions.23 It is not possible at present to quantify the risks of transmission of prion diseases by surgical instruments. To date, iatrogenic CJD remains rare, with 267 cases having been reported worldwide up to 2000.24 The risk of transmission of CJD may be higher with procedures performed on organs containing lymphoreticular tissue, such as tonsillectomy and adenoidectomy, because vCJD targets these tissues and is found in high concentrations there. For this reason there was a move towards the use of disposable, once-only-use instruments for procedures such as tonsillectomy. However, these instruments have been associated with a higher post-operative haemorrhage rate25 and, as a consequence, ENT departments in the UK are no longer obliged to use disposable instruments. In the UK, the Advisory Committee on Dangerous Pathogens and Spongiform Encephalopathy26 provides advice on appropriate methods of cleaning and sterilization of surgical instruments. Prions are particularly resistant to conventional chemical (ethylene oxide, formaldehyde, and chlorine dioxide) and standard autoclave regimens, and dried blood or tissue remaining on an instrument could harbour prions that will not then be killed by the sterilization process. Once proteinaceous material such as blood or tissue has dried on an instrument, it is very difficult to P.593
subsequently be sure that the instrument has been sterilized. Sterilization should include:

  • Pre-sterilization cleaning. Initial low-temperature washing (<35°C) with detergents and an ultrasonic cleaning system removes and prevents coagulation of prion proteins—sonic cleaners essentially ‘shake’ attached material from the instrument.
  • Hot wash.
  • Air drying.
  • Thermal sterilization. Longer autoclave cycles at 134–137°C for at least 18 min (or 6 successive cycles with holding times of 3 min) or 1h at conventional autoclave temperatures may result in a substantial reduction in the level of contamination with prions.

The latest models of pre-sterilization cleaning devices—automated thermal washer disinfectors—perform all of these cleaning tasks within one unit. Enzymatic proteolytic inactivation methods are under development. P.594
Telescopes and light sources in urological endoscopy There are 3 types of modern urological telescopes—rigid, semi-rigid, and flexible. These endoscopes may be used for inspection of the urethra and bladder (cystoscourethroscopes—usually simply called cystoscopes), the ureter and collecting system of the kidney (ureteroscopes and ureterorenoscopes), and, via a percutaneous access track, the kidney (nephroscopes). The light sources and image transmission systems are based on the innovative work of Professor Harold Hopkins, from the University of Reading. The Hopkins rod-lens system The great advance in telescope design was the development of the rodlens telescope, which replaced the conventional system of glass lens with rods of glass, separated by thin air spaces which, essentially, were air lenses (Fig. 17.13). By changing the majority of the light transmission medium from air to glass, the quantity of light that could be transmitted was doubled. The rods of glass were also easier to handle during manufacture, and therefore their optical quality was greater. The angle of view of the telescope can be varied by placing a prism behind the objective lens. 0°, 12°, 30°* and 70° scopes are available. Lighting Modern endoscopes (urological and those used to image the gastrointestinal tract) use fibreoptic light bundles to transmit light to the organ being inspected. Each glass fibre is coated with glass of a different refractive index, so that light entering at one end is totally internally reflected and emerges at the other (Fig. 17.14). These fibreoptic bundles can also be used for image (as well as light) transmission, as long as the arrangement of the fibres at either end of the instrument is the same (coordinated fibre bundles are not required for simple light transmission). The fibre bundles are tightly bound together only at their end (for coordinated image transmission). In the middle, the bundles are not bound—this makes the instrument flexible (e.g. flexible cystoscope and flexible ureteroscope).

Fig. 17.13 (a) Diagram of conventional cystoscope. The glass lenses are held in place by metal spacers and separated by air spaces. (b) Rod-lens telescope with ‘lenses’ of air, separated by ‘spaces’ of glass, with no need for metal spacers. (Reproduced with permission from Blandy and Fowler 199627)
Fig. 17.14 Total internal reflection permits light to travel along a flexible glass fibre. (Reproduced with permission from Blandy and Fowler 199627)

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Consent: general principles Consent is required before you examine, treat, or care for a competent adult (a person aged 16 or more). Think of obtaining consent as a process rather than an event. In order to give consent a patient must understand the nature, purpose, and likely effects (outcomes, risks) of the treatment. From the information they receive, the patient must be able to weigh up the risks against benefits, and so arrive at an informed choice. They must not be coerced into making a decision (e.g. by the doctor in a hurry). Giving the patient time to reach a decision is a good way of avoiding any accusation that they were pressured into a decision. To reiterate—think of consent as a process rather than an event. Giving information How much information should you give? What options and risks should you mention? The adequacy of your consent will be judged against the Bolam test: ‘A doctor is not guilty of negligence if he acted in accordance with a practice accepted by a responsible body of medical men skilled in that particular art’. (That body of medical men must be a competent and reasonable body and the opinion expressed must have a logical basis—the Bolitho modification of the Bolam defence.) You have a duty to discuss the range of treatment options available (the alternatives) regardless of their cost, in a form the patient can understand, and the side-effects and risks that are relevant to the individual patient’s circumstances. A risk is defined as a material one (one that matters, one that is important) if a reasonable person in the patient’s circumstances, if warned of that risk, would attach significance to it (e.g. loss of the tip of a little finger may be of little long-term consequence to many people, but for the concert pianist it could be a disaster). Thus, the amount and type of information you give is different in every case. Remember, it can be argued that the consent was not valid because the amount of information you gave was not enough or was in a form the patient could not understand. Recording Remember, record the consent discussion in the notes. If you do not record what you said, you might as well not bother saying it. If a patient later claims that they were not told of a particular risk or outcome, it will be difficult to refute this if your notes do not record what you said. Writing ‘risks explained’ is inadequate. When cases do come to court, this is usually several years after the events in question. You will have forgotten precisely what you said to the patient and it will not take much effort on the part of a barrister to suggest that you might not have said everything that you thought you said! If you give a written information sheet, record that you have done so and put a copy of the version you gave in the notes. P.597
The consent form The consent form is designed to record the patient’s decision and, to some extent, the discussions that took place during the consent process (although the space available for recording the discussion, even on the new NHS consent form, is limited). It is not proof that the patient was properly informed—that valid consent was obtained. Avoid, if possible, technical abbreviations such as TURBT. A patient could reasonably claim not to have understood what this was. Try to avoid standing over the patient waiting for them to sign the form. It is a good practice to leave the form with them and to return after a few minutes—they will feel less pressured and can ask further questions if they wish. Children Children aged less than 16 may give consent as long as they fully understand what is involved in the proposed examination or treatment (a parent cannot override the competent child’s consent to treatment). However, a child cannot refuse consent to treatment (i.e. a parent can override a child’s refusal to consent—the parent can consent on the child’s behalf if the child refuses consent, though such situations are rare). P.598
Cystoscopy A basic skill of the urologist. Allows direct visual inspection of the urethra and bladder. Indications

  • haematuria
  • irritative LUTS (marked frequency and urgency) where intravesical pathology is suspected (e.g. carcinoma in situ, bladder stone)
  • for bladder biopsy
  • follow-up surveillance of patients with previously diagnosed and treated bladder cancer
  • retrograde insertion of ureteric stents and removal
  • cystoscopic removal of stones

Technique

  • Flexible cystoscopy—flexible cystosope is easily passed down the urethra and into the bladder following instillation of lubricant gel (with or without local anaesthetic). Principally diagnostic, but small biopsies can be taken with a flexible biopsy forceps, small tumours can be fulgurated (with a diathermy probe) or vaporized (with a laser fibre), and JJ stents can be inserted and removed using this type of cystoscope.
  • Rigid cystoscopy—rigid, metal instrument which can be passed under local anaesthetic in women (short urethra), but usually requires general anaesthetic. Preferred over flexible cystoscopy where deeper biopsies will be required or as an antecedent to TURBT or cystolitholapxy where it is anticipated that other pathology will be found (tumour, stone).

The flexible cystoscope uses fibreoptics for illumination and image transmission. It can be deflected through 270°. Common post-operative complications and their management Mild burning discomfort and haematuria are common after both flexible and rigid cystoscopy. It usually resolves within hours. BAUS procedure specific consent form—recommended discussion of adverse events Serious or frequently occurring complications of flexible cystoscopy Warn the patient that if the cystoscopy is being done because of haemturia, it is possible that a bladder cancer may be found, which may require further treatment. You should specifically seek consent for biopsy (removal of tissue if an abnormality is found). Common

  • Mild burning or bleeding on passing urine for a short period after operation
  • Biopsy of an abnormal area in the bladder may be required

Occasional

  • Infection of bladder requiring antibiotics

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Rare

  • Temporary insertion of a catheter
  • Delayed bleeding requiring removal of clots or further surgery
  • Injury to urethra causing delayed scar formation (a stricture)

Serious or frequently occurring complications of rigid cystoscopy

  • As for flexible cystoscopy
  • The use of heat (diathermy) may be required to cauterize biopsy sites
  • Very rarely, perforation of the bladder can occur requiring temporary insertion of a catheter or open surgical repair

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Transurethral resection of the prostate (TURP) Indications

  • Bothersome LUTS which fail to respond to changes in life style or medical therapy
  • Recurrent acute urinary retention
  • Renal impairment due to bladder outlet obstruction (high pressure chronic urinary retention)
  • Recurrent haematuria due to benign prostatic enlargement
  • Bladder stones due to prostatic obstruction

Post-operative care A 3-way catheter is left in situ after the operation, through which irrigation fluid (normal saline) is run to dilute the blood so that a clot will not form to block the catheter. The rate of inflow of the saline is adjusted to keep the outflow a pale pink rosé colour and, as a rule, the rate of inflow can be cut down after about 20 min. The irrigation is continued for ~12–24h. The catheter is removed the day after (2nd post-operative day) if the urine has cleared to a normal colour (trial without catheter— TWOC or trial of void—TOV). Common post-operative complications and their management Blocked catheter post TURP Common. The catheter may become blocked with clot or a prostatic ‘chip’ which was inadvertently left in the bladder at the end of the operation.

  • Apply a bladder syringe to the end of the catheter to try to dislodge the obstruction.
  • If this fails, withdraw some irrigant into the syringe and flush the catheter.
  • If this fails, change the catheter. The obstructing chip of prostate may be found stuck in one of the eyeholes of the catheter.
  • Pass a new catheter, on an introducer.

If the bladder has been allowed to become so full of clot that a simple bladder washout is unable to evacuate it all, return the patient to the theatre for clot evacuation. Haemorrhage Minor bleeding after TURP is common and will stop spontaneously. A simple system to allow communication between staff is to describe the colour of the urine draining through the catheter as the same as a rosé wine (minor haematuria), a dark red wine (moderate haematuria), or frank blood (bright red bleeding, suggesting serious haemorrhage). The rosé urine requires no action. Dark red urine should be managed by increasing the flow of irrigant and by applying gentle traction to the catheter (with the balloon inflated to 40–50ml), thereby pulling it onto the bladder neck or into the prostatic fossa to tamponade bleeding for 20 min or so. This will usually result in the urine clearing. An attempt at P.601
controlling heavier bleeding by these techniques may be tried, but at the same time you should make preparations to return the patient to theatre because it is unlikely that bleeding of this degree will stop. The bleeding vessel(s), if seen, is controlled with diathermy. If bleeding persists, open surgical control is required—the prostatic capsule is opened, the bleeding vessels sutured, and the prostatic bed packed. Post-operative bleeding requiring a return to theatre occurs in ~0.5% of cases.28 BAUS procedure specific consent form—recommended discussion of adverse events Serious or frequently occurring complications of TURP

  • Temporary mild burning on passing urine, urinary frequency, haematuria
  • Retrograde ejaculation in 75% of patients
  • Failure of symptom resolution
  • Permanent inability to achieve an erection adequate for sexual activity
  • UTI requiring antibiotic therapy
  • 10% of patients require re-do surgery for recurrent prostatic obstruction
  • Failure to pass urine after the post-operative catheter has been removed
  • In ~10% of patients prostate cancer is found on subsequent pathological examination of the resected tissue
  • Urethral stricture formation requiring subsequent treatment
  • Incontinence (loss of urinary control)—may be temporary or permanent
  • Absorption of irrigating fluid causing confusion and heart failure (TUR syndrome)
  • Very rarely, perforation of the bladder requiring a temporary urinary catheter or open surgical repair

Alternative therapy: observation, drugs, catheter, stent, open operation. P.602
Transurethral resection of bladder tumour (TURBT) Indications

  • Local control of non-muscle-invasive bladder cancer (i.e. stops bleeding tumours)
  • Staging of bladder cancer—to determine whether the cancer is non-muscle-invasive or muscle-invasive, so that subsequent treatment and appropriate follow-up can be arranged

Post-operative care A 2- or 3-way catheter is left in situ after the operation, depending on the size of the tumour and, therefore, on the likelihood that bleeding requiring irrigation will be required. As for TURP, normal saline is run through the catheter to dilute the blood so that a clot will not form to block the catheter. It is particularly important to avoid catheter blockage post TURBT, since this could lead to distension of the bladder already weakened by resection of a tumour. The period of irrigation is usually shorter than that required after TURP and for small tumours the catheter may be removed the day after the TURBT. For larger tumours, remove it 2 days later. Common operative and post-operative complications and their management Bladder perforation during TURBT Small perforations into the perivesical tissues (extraperitoneal) are not uncommon when resecting small tumours of the bladder and so long as you have secured good haemostasis and all the irrigating fluid is being recovered, no additional steps are required except that perhaps one should leave the catheter in for 4 rather than 2 days. Intraperitoneal perforations (through the wall of the bladder, through the peritoneum, and into the peritoneal cavity) are uncommon, but far more serious. Is it an extraperitoneal or intraperitoneal perforation? Establishing this can be difficult. Both can cause marked distension of the lower abdomen—an intraperitoneal perforation by allowing escape of irrigating solution directly into the abdominal cavity, and an extraperitoneal perforation by expanding the retroperitoneal space, with fluid then diffusing directly into the peritoneal cavity. The fact that a suspected intraperitoneal perforation was actually extraperitoneal becomes apparent only at laparotomy when no hole can be found in the peritoneum overlying the bladder (the peritoneum over the bladder is not breached in an extraperitoneal perforation). When there is no abdominal distension, the volume of extravasated fluid is likely to be low and, if the perforation is small, it is reasonable to manage the case conservatively. Achieve haemostasis and pass a catheter. Make frequent post-operative assessments of the patient’s vital signs and abdomen (worsening abdominal pain, distension, and tenderness suggest the need for laparotomy). P.603
Where there is marked abdominal distension, whether the perforation is extraperitoneal or intraperitoneal, explore the abdomen, principally to drain the large amount of fluid (which can compromise respiration in an elderly patient) by splinting the diaphragm, but also to check that loops of bowel adjacent to the site of perforation have not been injured at the same time. Failing to make the diagnosis of an intraperitoneal perforation, particularly if bowel has been injured, is a worse situation to be in than performing a laparotomy for a suspected intraperitoneal perforation but then finding that the perforation was ‘only’ extraperitoneal. Open bladder repair: Pfannenstiel incision or lower midline abdominal incision, open the bladder, evacuate the clot, control bleeding, and repair the hole. Open the peritoneum and inspect small and large bowel for perforations. Leave a urethral catheter and a drain in place. Blocked catheter post TURBT The catheter may become blocked with clot. Use the same technique for unblocking it as for TURP, but avoid vigorous washouts of the bladder because of the risk of bladder perforation. Haemorrhage Minor bleeding after TURBT is common and will stop spontaneously. The only ‘technique’ for controlling it is to ensure that an adequate flow of irrigant is maintained (to dilute the blood and thereby prevent clots from forming). If bleeding persists, return the patient to theatre for endoscopic control. TUR syndrome Uncommon after TURBT, unless the tumour is large and the resection therefore long. BAUS procedure specific consent form—recommended discussion of adverse events Serious or frequently occurring complications of TURBT Common complications

  • Mild burning on passing urine
  • Additional treatment (intravesical chemotherapy or immunotherapy) may be required to reduce the risk of future tumour recurrence
  • UTI
  • No guarantee of bladder cancer cure
  • Tumour recurrence is common

Rare complications

  • Delayed bleeding requiring removal of clots or further surgery
  • Damage to drainage tubes from kidney (ureters) requiring additional therapy
  • Development of a urethral stricture
  • Bladder perforation requiring a temporary urinary catheter or open surgical repair

Alternative treatment: open removal of bladder; chemotherapy, radiation. P.604
Optical urethrotomy Indications

  • Bulbar urethral stricture
  • Also used for penile urethral strictures

Anaesthesia Regional or general Post-operative care

  • Leave a catheter for 3–5 days (longer catheterization does not reduce long-term restricturing).
  • Consider ISC for 3–6 months, starting several times daily, reducing to once or twice a week towards the end of this period.

Common post-operative complications and their management

  • Septicaemia
  • Restricturing is the most common long-term problem occurring after optical urethrotomy

BAUS procedure specific consent form—recommended discussion of adverse events Common

  • Mild burning on passing urine for short periods of time after operation
  • Temporary insertion of a catheter
  • Need for self-catheterization to keep the narrowing from closing down again

Occasional

  • Infection of bladder, requiring antibiotics
  • Permission for telescopic removal/biopsy of bladder abnormality/stone if found
  • Recurrence of stricture necessitating further procedures or repeat incision

Rare

  • Decrease in quality of erections, requiring treatment

Alternative therapy: observation, urethral dilatation, open (non-telescopic) repair of stricture. P.605
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Circumcision Indications

  • Phimosis
  • Recurrent paraphimosis
  • Penile cancer confined to the foreskin
  • Lesions on the foreskin of uncertain histological nature

Anaesthesia Local or general Post-operative care A non-adhesive dressing may be applied to the end of the penis, but this is difficult to keep on for more than an hour or two and is unnecessary. Warn the patient that the penis may be bruised and swollen after the operation, but that this resolves spontaneously over a week or two. Common post-operative complications and their management You might think that circumcision is about as simple an operation as you can get, but it can cause both the patient (or in the case of little boys, their parents) and you considerable concern if the cosmetic result is not what was expected, or if ‘complications’ occur about which the patient was not warned. As with any procedure, it should be performed with care and with the potential complications always in mind so that steps can be taken to avoid these. If complications do occur, manage them appropriately. Haemorrhage Most frequently occurs from the frenular artery on the ventral surface of the penis. If local pressure does not stop the bleeding (and if it is from the frenular artery, it usually won’t), return the patient to theatre and, either under ring-block local anaesthesia or general anaesthetic, suture ligature the bleeding vessel. Be careful not to place the suture through the urethra! Necrosis of the skin of the shaft of the penis In most cases of suspected skin necrosis, there is none. Not infrequently, a crust of coagulated blood develops around the circumference of the penis after circumcision. As blood oxidizes it turns black and this appearance can be mistaken for necrosis of the end of the penis. Reassurance of the patient (and the referring doctor!) is all that is needed. If necrosis has occurred because, for example, adrenaline was used in the local anaesthetic, wait for the necrotic tissue to demarcate before assessing the extent of the problem. The penis has a superb blood supply and has remarkable healing characteristics. Separation of the skin of the coronal sulcus from the shaft skin If limited to a small area this will heal spontaneously. If a larger circumference of the wound has ‘dehisced’, resuture in theatre. Wound infection Rare. P.607
Urethrocutaneous fistula Due to haemostatic sutures (placed to control bleeding from the frenular) passing through the urethra; the wound later breaking down. Urethral damage Due to a stitch placed through the urethra as the frenular artery is suture ligatured. Excessive removal of skin Re-epithelialization can occur if the defect between the glans and the shaft skin is not too great. If the defect is too great, the end result will be a buried penis—the glans retracts towards the skin at the base of the penis. BAUS procedure specific consent form—recommended discussion of adverse events Serious or frequently occurring complications of circumcision

  • Bleeding of the wound occasionally needing a further procedure
  • Infection of incision requiring further treatment
  • Permanent altered sensation of the penis
  • Persistence of absorbable stitches after 3–4 weeks, requiring removal
  • Scar tenderness, rarely long-term
  • You may not be completely cosmetically satisfied
  • Occasional need for removal of excessive skin at a later date
  • Permission for biopsy of abnormal area of glans if malignancy a concern

Alternative therapy: drugs to relieve inflammation, leave uncircumcised. P.608
Hydrocele and epididymal cyst removal Hydrocele repair (removal) Indications Primary (idiopathic) hydrocele repair; not indicated for secondary hydrocele repair. Anaesthesia Local or general Techniques

  • Lord’s plication technique—for small- to medium-sized hydroceles (minimal interference with surrounding scrotal tissues, which minimizes risk of post-operative haematoma).
  • Jaboulay procedure—for large hydroceles. Excision of hydrocele sac.

Hydrocele aspiration Strict attention to asepsis is vital, since introduction of infection into a closed space could lead to abscess formation. Avoid superficial blood vessels (if you hit them, a large haematoma can result). Post-operative care Nothing specific Post-operative complications and their management

  • Scrotal swelling. Resolves spontaneously.
  • Haematoma formation. If it is large, surgical drainage is best performed, as spontaneous resolution may take many weeks. It can be difficult to identify the bleeding vessel. Leave a small drain to prevent re-accumulation of the haematoma.
  • Hydrocele recurrence.

Epididymal cyst removal (spermatocelectomy)

  • Avoid in young men who wish to maintain fertility, since epididymal obstruction can occur.
  • An alternative to surgical removal is aspiration, though recurrence is usual.

BAUS procedure specific consent form—recommended discussion of adverse events Hydrocele removal Occasional

  • Recurrence of fluid collection can occur
  • Collection of blood around the testes which resolves slowly or requires surgical removal
  • Possible infection of incision or testis requiring further treatment

Alternative therapy

  • Observation
  • Removal of fluid with a needle

P.609
Epididymal cyst removal Occasional

  • Recurrence of fluid collection can occur
  • Collection of blood around the testes which resolves slowly or requires surgical removal
  • Possible infection of incision or testis requiring further treatment.

Rare

  • Scarring can damage the epididymis causing subfertility

Alternative therapy Observation; removal of fluid with a needle. P.610
Nesbit’s procedure Penile straightening procedure for correcting penile curvature. Wait for at least 6 months after the patient has experienced no more pain, and wait for the penile curvature to stabilize (there is no point in repairing the curvature if it is still progressing). Indications Peyronie’s disease Anaesthesia Local or general Post-operative care Avoid intercourse for 2 months. Oedema can be managed with cold compresses. BAUS procedure specific consent form—recommended discussion of adverse events Serious or frequently occurring complications Common

  • Some shortening of the penis
  • Possible dissatisfaction with the cosmetic or functional result
  • Temporary swelling and bruising of the penis and scrotum

Occasional

  • Circumcision is sometimes required as part of the procedure
  • There is no guarantee of total correction of the bend
  • Bleeding or infection—may require further treatment

Rare

  • Impotence or difficulty maintaining an erection
  • Nerve injury with temporary or permanent numbness of penis

Alternative treatment Observation, drugs, other surgical procedures. P.611
P.612
Vasectomy and vasovasostomy Vasectomy This is the removal of a section of the vas deferens from each side with the aim of achieving infertility. Indications A method of birth control Anaesthesia Local or general Post-operative care and common post-operative complications and their management Post-operative haematoma can occur. If large, evacuation may be required. Infection can occur, but is usually superficial. Two semen samples are required, usually at 10 and 12 weeks post vasectomy, before unprotected intercourse can take place. Viable sperm can remain distal to the site of vasectomy (in the distal vas deferens or seminal vesicles) for some weeks after vasectomy, and even longer. Occasionally a persistently +ve semen analysis is an indication that the vas was not correctly identified at the time of surgery and has not been ligated (or, very rarely, that there were 2 vas deferens on one side). The potential for fertility remains in those with +ve semen analysis and re-exploration is indicated. Warn the patient that the vas deferens can later recanalize, thereby restoring fertility. Sperm granuloma—a hard, pea-sized lump in the region of the cut ends of the vas, forming as a result of an inflammatory response to sperm leaking out of the proximal cut end of the vas. It can be a cause of persistent pain, in which case it may have to be excised or evacuated and the vas cauterized or re-ligated. Vasovasostomy Vasectomy reversal Anaesthesia This tends to be done under general or spinal anaesthesia, as it takes far longer than a vasectomy. Post-operative care and common post-operative complications and their management Much the same as for vasectomy. The patient should avoid sexual intercourse for 2 weeks or so. P.613
Vasectomy: BAUS procedure specific consent form—recommended discussion of adverse events Serious or frequently occurring complications Common

  • Irreversible
  • Small amount of scrotal bruising
  • 2 semen samples are required before unprotected intercourse, both of which must show no spermatozoa

Occasional

  • Bleeding requiring further surgery or bruising

Rare

  • Inflammation or infection of testis or epididymis, requiring antibiotics
  • Rejoining of vas ends resulting in fertility and pregnancy (1 in 2000)
  • Chronic testicular pain (5%) or sperm granuloma

Alternative treatment Other forms of contraception (male or female) Vasovasostomy: BAUS procedure specific consent form—recommended discussion of adverse events Serious or frequently occurring complications Common

  • Small amount of scrotal bruising
  • No guarantee that sperm will return to semen
  • Sperm may return but pregnancy not always achieved
  • If storing sperm, check that appropriate forms have been filled out

Occasional

  • Bleeding requiring further surgery

Rare

  • Inflammation or infection of testes or epididymis, requiring antibiotics
  • Chronic testicular pain (5%) or sperm granuloma

Alternative therapy IVF, sperm aspiration, ICSI. P.614
Orchidectomy Indications Two types—radical orchidectomy and simple orchidectomy. Radical (inguinal) orchidectomy For excision of testicular cancer. This approach is used for 3 reasons:

  • To allow ligation of the testicular lymphatics as high as possible as they pass in the spermatic cord and through the internal inguinal ring, thereby removing any cancer cells which might have started to metastasize along the cord.
  • To allow cross clamping of the cord prior to manipulation of the testis which, theortetically at least, could promote dissemination of cancer cells along the lymphatics. (In reality, this probably doesn’t occur.)
  • To prevent the potential for dissemination of tumour cells into the lymphatics that drain the scrotal skin that could occur if a scrotal approach is used. These lympatics drain to inguinal nodes. Thus, direct spread of tumour to scrotal skin and ‘violation’ of another lymphatic field (the groin nodes) is avoided. Historically, this was important because the only adjuvant therapy for metastatic disease was radiotherapy. The morbidity of groin and scrotal irradiation was not inconsiderable (severe skin reactions to radiotherapy, irradiation of femoral artery and nerve).

Obtain serum markers before surgery (α-fetoprotein, βHCG, and lactic acid dehydrogenase—LDH) and get a CXR. Full staging CT scan wait till after surgery. If the contralateral testis has been removed or is small, offer sperm storage—there is usually time to do this. Warn the patient that, very occasionally, what appears clinically and on ultrasound to be a malignant testis tumour, turns out to be a benign tumour on subsequent histological examination. Simple orchidectomy For hormonal control of advanced prostate cancer. Done via a scrotal incision, with ligation and division of the cord and complete removal of the testis and epididymis. Alternatively, a subcapsular orchidectomy may be done, where the tunica of the testis is incised and the seminiferous tubules contained within are excised. There is the potential with this approach to leave a small number of Leydig cells which can continue to produce testosterone. Anaesthesia Local, regional, general. Few men will require or opt for local. Post-operative care and common post-operative complications and their management For both simple and radical orchidectomy: scrotal haematoma. Drain it if large or enlarging or if there are signs of infection (fever, discharge of pus from the wound). For radical orchidectomy: damage to the ilioinguinal nerve leading to an area of loss of sensation overlying the scrotum. P.615
Orchidectomy ± testicular implant: BAUS procedurespecific consent form—recommended discussion of adverse events Serious or frequently occurring complications Occasional

  • cancer, if found, may not be cured by orchidectomy alone
  • there may be a need for additional surgery, radiotherapy, or chemotherapy
  • loss of future fertility
  • biopsy of contralateral testis may be required if an abnormality is found (small testis or history of maldescent)

Rare

  • on pathological examination cancer may not be found, or the pathologic diagnosis may be uncertain
  • infection of incision may occur, requiring further treatment and possibly removal of implant if this has been inserted
  • pain requiring removal of implant
  • cosmetic expectation not always met
  • implant may lie higher in the scrotum than the normal testis did
  • a palpable stitch may be felt at one end of the implant
  • long-term risks of silicone implants are not known.

P.616
Urological incisions Midline, transperitoneal Indications Access to peritoneal cavity and pelvis for radical nephrectomy, cystectomy, reconstructive procedures, etc. Technique Divide skin, subcutaneous fat. Divide fascia in midline. Find the midline between the rectus muscles. Dissect the muscles free from the underlying peritoneum. Place 2 clips on either side of the midline, pinch between the two to ensure no bowel has been trapped, elevate the clips, and divide between them with a knife. Extend the incision in the peritoneum up and down, ensuring no bowel is in the way. Closure Use a non-absorbable (e.g. nylon) or very slowly absorbable (e.g. PDS) suture, using Jenkins rule to reduce risk of dehiscence (suture length 4× wound length). Specific complications Dehiscence (classically around day 10 post op and preceded by pink serous discharge, then sudden herniation of a bowel through incision). Lower midline, extraperitoneal Indications Access to pelvis (e.g. radical prostatectomy, colposuspension). Technique Divide skin, subcutaneous fat. Divide fascia in midline. Find the midline between the rectus muscles and dissect the muscles free from the underlying peritoneum. If you make a hole in it, repair the defect with vicryl. Divide the fascia posterior to the rectus muscles in the midline, so exposing the extravesical space. Closure As for midline, transperitoneal Pfannenstiel Indications Access to pelvis (e.g. colposuspension, open prostatectomy, open cystolithotomy). Technique Divide the skin 2cm above the pubis and the tissues down to the rectus sheath which is cut in an arc avoiding the inguinal canal. Apply clips to top flap (and afterwards the bottom flap) and use a combination of scissors and your fingers to separate the rectus muscle from the sheath. For maximum exposure you must elevate the anterior rectus sheath from the recti, cranially to just below the umbilicus and caudally to the pubis. Take care to diathermy a perforating branch of the inferior epigastric artery on each side. Apply 2 Babock’s forceps to the inferior belly of the rectus on either side of the midline. Elevate and cut in the midline, the lower part of the fascia (transversalis fascia) between the recti. Separate the recti in the midline (do not divide them). Closure Tack the divided transversalis fascia together and then close the transversely divided rectus sheath with vicryl. P.617
Supra-12th rib incision Indications Access to kidneys, renal pelvis, upper ureter. Technique Make the incision over the tip of the 12th rib through skin and subcutaneous fascia. Palpate the tip of the 12th rib. Make a 3cm cut with diathermy, through the muscle (latissimus dorsi) overlying the tip of the 12th rib so you come down onto the tip of the 12th rib, and then cut anterior to the tip of the 12th rib, down through external and internal oblique, transversus abdominis, to Gerota’s fascia and the perirenal fat. Sweep anteriorly with a finger to push the peritoneum and intraperitoneal organs out of harm’s way. Cut the muscles overlying the rib, cutting centrally along the length of the rib, in so doing avoiding the pleura. Cut with scissors along the top edge of the rib to free the intercostal muscle from the rib—beware the pleura! Insert a Gillie’s forceps between the pleura and the overlying intercostal muscle and divide the muscle fibres, so protecting the pleura. Dissect fibres of the diaphragm away from the inner surface of the 12th rib—as you do so the pleura will rise upwards with the detached diaphragmatic fibres, out of harm’s way. At the posterior end of the incision feel for the sharp edge of the costovertebral ligament. Insert heavy scissors, with the blades just open, on the top of the rib (to avoid the XIth intercostal nerve) and divide the costovertebral ligament. You should now be on top of Gerota’s fascia. Specific complications Damage to the pleura. If you make a hole in the pleura, repair it at the end of the operation. Pass a small bore catheter (e.g. Jacques) through the hole, close all the muscle layers, inflate the lung, and then, before closing the skin, remove the catheter. Complications common to all incisions Hernia, wound infection, chronic wound pain. P.618
JJ stent insertion Preparation Can be done under sedation or general anaesthetic. With sedation Oral ciprofloxacin 250mg; lignocaine gel for urethral anaesthesia and lubrication; sedoanalgesia (diazemuls 2.5–10mg IV, pethidine 50–100mg IV). Monitor pulse and oxygen saturation with a pulse oximeter. Technique A flexible cystoscope is passed into the bladder and rotated through 180°. This allows greater deviation of the end of the cystoscope and makes identification of the ureteric orifice easier. A 0.9mm hydrophilic guidewire (Terumo Corporation, Japan) is passed into the ureter under direct vision. The guidewire is manipulated into the renal pelvis using C-arm digital fluoroscopy. The cystoscope is placed close to the ureteric orifice and its position, relative to bony landmarks in the pelvis, is recorded by frame grabbing a fluoroscopic image. The flexible cystoscope is then removed and a 4Ch ureteric catheter is passed over the guidewire, into the renal pelvis. A small quantity of non-ionic contrast medium is injected into the renal collecting system, to outline its position and to dilate it. The Terumo guidewire is replaced with an ultra-stiff guidewire (Cook UK Ltd, Letchworth, UK) and the 4Ch ureteric catheter is removed. We use a variety of stent sizes depending on the patient’s size (6–8Ch, 20–26cm) (Boston Scientific Ltd, St Albans, UK). The stent is advanced to the renal pelvis under fluoroscopic control, checking that the lower end of the stent is not inadvertently pushed up the ureter by checking the position of the ureteric orifice on the previously frame-grabbed image. The guidewire is then removed. P.619
P.620
Nephrectomy and nephroureterectomy Indications

  • renal cell cancer
  • non-functioning kidney containing a staghorn calculus
  • persistent haemorrhage following renal trauma

Anaesthesia General Post-operative care Nephrectomy Cardiovascular status and urine output should be carefully monitored in the immediate post-operative period. Haemorrhage from the renal pedicle or, for left-sided nephrectomy, the spleen, is rare, but will present with an increasing tachycardia, cool peripheries, falling urine output, and eventually a drop in blood pressure. A drain is usually not left in place, but if it is there may be excessive drainage of blood from the drain. However, do not be lulled into a false sense of security by the absence of drainage—this does not mean that haemorrhage is not occurring, as the drain may be blocked but haemorrhage may be ongoing. For nephrectomy via a posterolateral (rib-based) incision, watch for pneumothorax. Arrange a CXR on return from the recovery room. Arrange routine chest physiotherapy to reduce the risk of chest infection. Regular chest examination is important, looking specifically for pneumothorax and pleural effusion. Mobilize the patient as quickly as possible, to reduce the risk of DVT and PE. Nephroureterectomy Where the ureter has been excised from the bladder, a urethral catheter is left in place at the end of the procedure, to allow the hole in the bladder to heal. This is usually removed 10–14 days after surgery. Common post-operative complications and their management

  • Haemorrhage—see above.
  • Wound infection—rare. If superficial, treat with antibiotics. If an underlying collection of pus is suspected, open the wound to allow free drainage, and pack the wound daily.
  • Pancreatic injury is rare, but would be indicated by excessive drainage of fluid from the drain, if present, which will have a high amylase level. If no drain is present, an abdominal collection will develop, which may be manifested by a prolonged ileus.

BAUS procedure specific consent form—recommended discussion of adverse events Serious or frequently occurring complications of nephrectomy/nephroureterectomy Simple nephrectomy Common

  • Temporary insertion of a bladder catheter
  • Occasional insertion of a wound drain

P.621
Occasional

  • Bleeding requiring further surgery or transfusion
  • Entry into lung requiring temporary insertion of a drainage tube

Rare

  • Involvement or injury to nearby structures—blood vessels, spleen, lung, liver, pancreas, bowel, requiring further extensive surgery
  • Infection, pain, or hernia of incision, requiring further treatment
  • Anaesthetic or cardiovascular problems, possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack)

Alternative therapy: observation, laparoscopic approach Radical nephrectomy As above plus: Occasional: need for further therapy for cancer Rare: may be an abnormality other than cancer on microscopic analysis Alternative therapy: observation, embolisation, immunotherapy, laparoscopic approach Nephroureterectomy As above. P.622
Radical prostatectomy Indications Localized prostate cancer Anaesthesia General or regional Post-operative care Mobilize as quickly as possible and continue subcutaneous heparin and AK-TEDS until discharge, to reduce the risk of DVT and PE. Remove the drains when drainage is minimal. If there is persistent leak of fluid from the drains, send a sample for urea and creatinine, and if it is urine, get a cystogram to determine the size of the leak at the vesicourethral junction. Urethral catheters are left in situ post radical prostatectomy for a variable time depending on the surgeon who performs the operation. Some surgeons leave a catheter for 3 weeks and others for just 1 week. Common post-operative complications and their management Haemorrhage Managed in the usual way (transfusion; return to theatre where bleeding persists or where there is cardiovascular compromise). Ureteric obstruction Usually results from oedema of the bladder, obstructing the ureteric orifices. Retrograde ureteric catheterization is rarely possible (this would require urethral catheter removal and it is difficult to see the ureteric orifices because of the oedema). Arrange placement of percutaneous nephrostomies. Lymphocele Drain by radiologically assisted drain placement. If the lymphocele recurs after drain removal, create a window from the lymph collection into the peritoneal cavity so the lymph drains into the peritoneum from which it is absorbed. Displaced catheter post radical prostatectomy If the catheter falls out a week after surgery, the patient may well void successfully, and in this situation no further action need be taken. If, however, the catheter inadvertently falls out the day after surgery, gently attempt to replace it with a 12Ch catheter which has been well lubricated. If this fails, pass a flexible cystoscope, under local anaesthetic, into the bulbar urethra and attempt to pass a guidewire into the bladder, over which a catheter can then safely be passed. If this is not possible, another option is to hope that the patient voids spontaneously and does not leak urine at the site of the anastomosis. An ascending urethrogram may provide reassurance that there is no leak of contrast and that the anastomosis is watertight. If there is a leak or the patient is unable to void, a suprapubic catheter can be placed (percutaneously or under general anaesthetic via an open cystostomy). P.623
Faecal fistula Due to rectal injury, either recognized and repaired at the time of surgery and later breaking down, or not immediately recognized. Formal closure is often required. Contracture at the vesicourethral anastomosis Gentle dilatation may be tried. If the stricture recurs, instruct the patient in ISC, in an attempt to keep the stricture open. If this fails, bladder neck incision may be tried. BAUS procedure specific consent form—recommended discussion of adverse events Serious or frequently occurring complications of radical prostatectomy Common

  • Temporary insertion of a bladder catheter and wound drain
  • High chance of impotence due to unavoidable nerve damage
  • No semen is produced during orgasm causing subfertility

Occasional

  • Blood loss requiring transfusion or repeat surgery
  • Urinary incontinence—temporary or permanent, requiring pads or further surgery
  • Discovery that cancer cells are already outside the prostate needing observation or further treatment at a later date if required including radiotherapy or hormonal therapy

Rare

  • Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack)
  • Pain, infection, or hernia in area of incision
  • Rectal injury, very rarely needing temporary colostomy

Alternative therapy Watchful waiting, radiotherapy, brachytherapy, hormonal therapy, and perineal or laparoscopic removal. P.624
Radical cystectomy Indications

  • Muscle-invasive bladder cancer
  • Adenocarcinoma of bladder (radioresistant)
  • Squamous carcinoma of bladder (relatively radioresistant)
  • Non-muscle-invasive TCC bladder which has failed to respond to intravesical chemotherapy or immunotherapy
  • Recurrent TCC bladder post radiotherapy

Combined with urethrectomy if:

  • multiple bladder tumours
  • involvement of bladder neck or prostatic urethra

Anaesthesia General Post-operative care and common post-operative complications and their management Monitor cardiovascular status, urine output, and respiratory status carefully in the first 48h. Routine chest physiotherapy is started early in the post-operative period to reduce the chance of chest infection. Mobilize the patient as early as possible to minimize the risk of DVT and PE. Drains are removed when they stop draining. Some surgeons prefer to leave them for a week or so, so that late leaks (urine, intestinal contents) will drain via the drain track and not cause peritonitis. Try to remove the nasogastric tube, if used, as soon as possible to assist respiration and reduce the risks of chest infection. The patient usually starts to resume their diet within a week or so. If the ileus is prolonged, start parenteral nutrition. Haemorrhage Persistent bleeding which fails to respond to transfusion should be managed by re-exploration. Wound dehiscence Requires resuturing under general anaesthetic. Ileus Common. Usually resolves spontaneously within a few days. Small bowel obstruction From herniation of small bowel through the mesenteric defect created at the junction between the two bowel ends. Continue nasogastric aspiration. The obstruction will usually resolve spontaneously. Re-operation is occasionally required where the obstruction persists or where there are signs of bowel ischaemia. Leakage from the intestinal anastomosis Leading to:

  • Peritonitis—requiring re-operation and repair or refashioning of the anastomosis
  • An enterocutaneous fistula—bowel contents leak from the intestine and through a fistulous track onto the skin. If low-volume leak (<500ml/24h), will usually heal spontaneously. Normal (enteral) nutrition may be maintained until the fistula closes (which usually occurs within a matter of days or a few weeks). If high-volume, spontaneous closure is less likely and re-operation to close the fistula may be required.

P.625
Pelvic abscess Formal surgical (open) exploration of the pelvis is indicated with drainage of the abscess and careful inspection to see if the underlying cause is a rectal injury, in which case a defunctioning colostomy should be performed. Partial cystectomy Indications Primary, solitary bladder tumours at a site that allows 2cm of normal tissue around it to be removed in a bladder that will have adequate capacity and compliance after operation. There should be:

  • no prior history of bladder cancer
  • no carcinoma in situ
  • a solitary muscle-invasive tumour located well away from the ureteral orfices which includes 2cm of normal surrounding bladder

High-grade tumours should not be excluded if these criteria are met. The lesions most commonly amenable to partial cystectomy are G2 or G3 TCCs or adenocarcinomas located on the posterior wall or dome. Contraindications Associated carcinoma in situ; deeply invasive tumours; tumours at the bladder base (i.e. near the ureteric orifices). BAUS procedure specific consent form—recommended discussion of adverse events Serious or frequently occurring complications of radical cystectomy (See also consent for ileal conduit if this is the planned form of urinary diversion.) Common

  • Temporary insertion of a nasal tube, drain, and stent
  • High chance of impotence (lack of erections) due to unavoidable nerve damage
  • No semen is produced during orgasm (dry orgasm) causing subfertility
  • Blood loss requiring transfusion or repeat surgery
  • In women, pain or difficulty with sexual intercourse due to narrowing or shortening of vagina and need for removal of uterus and ovaries (causing premature menopause in those who have not reached menopause)

Occasional

  • Cancer may not be cured with surgery alone
  • Need to remove penile urinary pipe as part of procedure

Rare

  • Infection or hernia of incision, requiring further treatment
  • Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack)
  • Decreased renal function with time

P.626
Very rarely

  • Rectal injury, very rarely needing temporary colostomy
  • Diarrhoea due to shortened bowel, vitamin deficiency requiring treatment
  • Bowel and urine leak, requiring re-operation
  • Scarring of bowel or ureters, requiring operation in the future
  • Scarring, narrowing, or hernia formation around stomal opening, requiring revision

Alternative treatment Radiotherapy, neobladder formation rather than ileal conduit urinary diversion. Formation of neobladder with bowel Common: need to perform intermittent self-catheterization if bladder fails to empty. P.627
P.628
Ileal conduit Indications

  • For urinary diversion following radical cystectomy
  • Intractable incontinence for which anti-incontinence surgery has failed or is not appropriate

Post-operative care and common post-operative complications and their management Oliguria or anuria Try a fluid challenge. Wound infection Treat with antibiotics and wound care. Open the superficial layers of the wound to release pus. Wound dehiscence Rare. Requires resuturing in theatre under general anaesthetic. Ileus Common. Usually resolves spontaneously within a few days. Small bowel obstruction From herniation of small bowel through the mesenteric defect created at the junction between the two bowel ends. Continue nasogastric aspiration. The obstruction will usually resolve spontaneously. Re-operation is occasionally required where the obstruction persists or where there are signs of bowel ischaemia. Leakage from the intestinal anastomosis Leading to:

  • Peritonitis—requiring re-operation and repair or refashioning of the anastomosis
  • An enterocutaneous fistula—bowel contents leak from the intestine and through a fistulous track onto the skin. If low-volume leak (<500ml/24h), will usually heal spontaneously. Normal (enteral) nutrition may be maintained until the fistula closes (which usually occurs within a matter of days or a few weeks. If high-volume, spontaneous closure is less likely, and re-operation to close the fistula may be required.

Leakage from the ureteroileal junction May be suspected because of a persistently high output of fluid from the drain. Test this for urea. Urine will have a higher urea and creatinine concentration than serum. If the fluid is lymph, the urea and creatinine concentration will be the same as that of serum. Arrange a loopgram (conduitogram). This will confirm the leak. Place a soft, small catheter (12Ch) into the conduit to encourage antegrade flow of urine and assist healing of the ureteroileal anastomosis. If the leakage continues, arrange bilateral nephrostomies to divert the flow of urine away from the area and encourage wound healing. Occasionally, a ureteroileal leak will present as a urinoma (this causes a persistent ileus). Radiologically assisted drain insertion can result in a dramatic resolution of the ileus, with subsequent healing of the ureteroileal leak. P.629
Hyperchloraemic acidosis May be associated with obstruction of the stoma at its distal end or from infrequent emptying of the stoma back (leading to back pressure on the conduit). Catheterize the stoma—this relieves the obstruction. In the long term, the conduit may have to be surgically shortened. Acute pyelonephritis Due to the presence of reflux combined with bacteriuria. Stomal stenosis The distal (cutaneous) end of the stoma may become narrowed, usually as a result of ischaemia to the distal part of the conduit. Revision surgery is required if this stenosis causes obstruction leading to recurrent UTIs or back pressure on the kidneys. Parastomal hernia formation Around the site through which the conduit passes, through the fascia of the anterior abdominal wall. Many hernias can be left alone. The indications for repairing a hernia are:

  • bowel obstruction
  • pain
  • difficulty with applying the stoma bag (distortion of the skin around the stoma by the hernia can lead to frequent bag detachment).

Repair the hernia defect by placing mesh over the hernia site, via an incision sited as far as possible from the stoma itself, so as to reduce the risk of wound infection. BAUS procedure specific consent form—recommended discussion of adverse events Serious or frequently occurring complications of ileal conduit formation Common

  • Temporary drain, stents, or nasal tube
  • Urinary infections, occasionally requiring antibiotics

Occasional

  • Diarrhoea due to shortened bowel
  • Blood loss requiring transfusion or repeat surgery
  • Infection or hernia of incision requiring further treatment

Rare

  • Bowel and urine leakage from anastomosis requiring re-operation
  • Scarring to bowel or ureters requiring operation in future
  • Scarring, narrowing, or hernia formation around urine opening requiring revision
  • Decreased renal function with time

Alternative treatment Catheters, continent diversion of urine. P.630
Percutaneous nephrolithotomy (PCNL) Indications

  • Stones >3cm in diameter
  • Stones that have failed ESWL and/or an attempt at flexible ureteroscopy and laser treatment
  • Staghorn calculi

Pre-operative preparation

  • CT scan to assist planning the track position and to identify a retrorenal colon31
  • Stop aspirin 10 days prior to surgery
  • Culture urine (so appropriate antibiotic prophylaxis can be given)
  • Cross-match 2 units of blood
  • Start IV antibiotics the afternoon before surgery to reduce the chance of septicaemia (many of the stones treated by PCNL are infection stones). If urine is culture -ve, use 1.5g IV cefuroxime TDS and once daily IV gentamicin (3mg/kg). Routine antibiotic prophylaxis also reduces the incidence of post-OP UTI.32

Post-operative management Once the stone has been removed, a nephrostomy tube is left in situ for several days (Fig. 17.15). This drains urine in the post-operative period and tamponades bleeding from the track. Complications of PCNL and their management Bleeding Some bleeding is inevitable, but that severe enough to threaten life is uncommon. In most cases it is venous in origin and stops following placement of a nephrostomy tube (which compresses bleeding veins in the track). If bleeding persists, clamp the tube for 10 min. If bleeding continues despite this, arrange urgent angiography, looking for an arteriovenous fistula or pseudoaneurysm, both of which will require selective renal artery embolization (required in 1% of PCNLs33) or open exposure of kidney to control bleeding by suture ligation, partial nephrectomy, or nephrectomy. Septicaemia Occurs in 1–2% of cases. Incidence is reduced by prophylactic antibiotics. Track damage. Essentially minimal. Cortical loss from track is estimated to be <0.2% of total renal cortex in animal studies.34 Colonic perforation The colon is usually lateral or anterolateral to the kidney and is therefore not usually at risk of injury unless a very lateral approach is made. The colon is retrorenal in 2% of individuals (more commonly in thin females with little retroperitoneal fat31). The perforation usually occurs in an extraperitoneal part of the colon, and is managed by JJ stent placement and withdrawal of the nephrostomy tube into the lumen of the colon to encourage drainage of bowel contents away from that of the urine, P.631
thereby encouraging healing without development of a fistula between bowel and kidney. A radiological contrast study a week or so later confirms that the colon has healed and that there is no leak of contrast from the bowel into the renal collecting system.

Fig. 17.15 A Malecot catheter, which has wide drainage eyeholes and an extension at the distal end which passes down the ureter to prevent fragments of stone from passing down the ureter

P.632
Damage to the liver or spleen Very rare in the absence of splenomegaly or hepatomegaly. Damage to the lung and pleura leading to pneumomothorax or pleural effusion Can occur with supra-12th rib puncture. Nephrocutaneous fistula When the nephrostomy tube is removed from the kidney, a few days after surgery, the 1cm incision usually closes within 2 or so. Occasionally, urine continues to drain percutaneously for a few days and a small ‘stoma’ bag must be worn. In the majority of such cases the urine leak will stop spontaneously, but if it fails to do so after a week or so, place a JJ stent to encourage antegrade drainage of urine. Outcomes For small stones, the stone-free rate after PCNL is in the order of 90–95%. For staghorn stones, the stone-free rate of PCNL, when combined with post-op ESWL for residual stone fragments, is in the order of 80–85%. BAUS procedure specific consent form—recommended discussion of adverse events Serious or frequently occurring complications of PCNL Common

  • Temporary insertion of a bladder catheter and ureteric stent/kidney tube needing later removal
  • Transient haematuria
  • Transient temperature

Occasional

  • More than one puncture site may be required
  • No guarantee of removal of all stones and need for further operations
  • Recurrence of stones

Rare

  • Severe kidney bleeding requiring transfusion, embolization, or, at last resort, surgical removal of kidney
  • Damage to lung, bowel, spleen, liver requiring surgical intervention
  • Kidney damage or infection needing further treatment
  • Over absorption of irrigating fluids into blood system causing strain on heart function

Alternative treatment External shock wave treatments, open surgical removal of stones, observation. P.633
P.634
Ureteroscopes and ureteroscopy The instruments Two types of ureteroscope in common use—the semi-rigid ureteroscope and the flexible ureteroscope. Semi-rigid ureteroscopes Have high-density fibre-optic bundles for light (‘non-coherently’ arranged) and image transmission (‘coherently’ arranged to maintain image quality). For equivalent light and image transmission using glass rod lenses, thicker lenses are required than with fibre-optic bundles. As a consequence, semi-rigid ureterosocpes can be made smaller, while maintaining the size of the instrument channel. In addition, the instrument can be bent by several degrees without the image being distorted. The working tip of most current models is in the order of 7 to 8Ch, with the proximal end of the scope being in the order of 11 to 12Ch. There is usually at least one working channel of at least 3.4Ch. Flexible ureteroscopes The fibre-optic bundles in flexible ureteroscopes are the same as those in semi-rigid scopes, only of smaller diameter. Thus, image quality and light transmission are not as good as with semi-rigid scopes, but are usually adequate. The working tip of most current models is in the order of 7 to 8Ch, with the proximal end of the scope being in the order of 9 to 10Ch. There is usually at least one working channel of at least 3.6Ch. The great advantage of the flexible ureteroscope over the semi-rigid variety is the ability to perform controlled deflection of the end of the scope (active deflection). Behind the actively deflecting tip of the scope is a segment of the scope which is more flexible than the rest of the shaft. This section is able to undergo passive deflection—when the tip is fully actively deflected, by advancing the scope further, this flexible segment allows even more deflection. Flexible ureteroscopes have recently been developed which have two actively deflecting segments. Flexible ureteroscopes are intrinsically more intricate and are therefore less durable than semi-rigid scopes. Ureteroscopic irrigation systems Normal saline is used (high-pressure irrigation with glycine or water would lead to fluid absorption from pyelolymphatic or venous backflow). Irrigation by gravity pressurization alone (the fluid bag suspended above the patient without any applied pressure) will produce flow that is inadequate for visualization because the long, fine-bore irrigation channels of modern ureteroscopes are inherently high-resistance. Several methods are available—hand-inflated pressure bags, foot pumps, and hand-operated syringe pumps. Whatever system is chosen, use the minimal flow required to allow a safe view so as to avoid flushing the stone out of the ureter and into the the kidney, from where you may not be able to retrive it. P.635
Ureteric dilatation Some surgeons do, others don’t. Those who don’t argue that dilatation is unnecessary in the era of modern, small-calibre ureteroscopes. Those who do cite a higher chance of being able to pass the ureteroscope all the way up to the kidney. Ureteric dilatation may be helpful where multiple passes of the ureteroscope up and down the ureter are going to be required for stone removal (alternatively, use a ureteric access sheath). Some surgeons prefer to place two guidewires into the ureter, one to pass the ureteroscope over (‘railroading’) and the other to act as a safety wire, so that access to the kidney is always possible if difficulties are encountered. The second guidewire is most easily placed via a dual lumen catheter which has a second channel, through which the second guidewire can be easily passed into the ureter, without requiring repeat cystoscopy. This dual lumen catheter has the added function of gently dilating the ureteric orifice to about 10Ch. There is probably no long-term harm done to the ureter as a consequence of dilatation.35 Ureteric access sheaths, which have outer diameters from 10 to 14Ch, may facilitate access to the ureter and are particularly useful if it is anticipated that the ureteroscope will have to be passed up and down the ureter on multiple occasions (to retrieve fragments of stone). In addition, they facilitate the outflow of irrigant fluid from the pelvis or the kidney, thereby maintaining the field of view and decreasing intra-renal pressures. Patient position The patient is positioned as flat as possible on the operating table to ‘iron out’ the natural curves of the ureter. A cystoscopy is performed with either a flexible or rigid instrument. A retrograde ureterogram can be done to outline pelvicalyceal anatomy. A guidewire is then passed into the renal pelvis. We use a Sensor guidewire (Microvasive, Boston Scientific) which has a 3cm long floppy, hydrophilic tip which can usually easily be negotiated up the ureter. The remaining length of the wire is rigid and covered in a smooth PTFE. Both properties aid passage of the ureteroscope. Technique of flexible ureteroscopy and laser treatment for intra-renal stones Flexible ureteroscopy and laser treatment can be performed with topical urethral local anaesthesia and sedation. However, trying to fragment a moving stone with the laser can be difficult and ideally, therefore, ureteroscopy is most easily done under general anaesthesia with endotracheal intubation (rather than a laryngeal mask) to allow short periods of suspension of respiration and so stop movement of the kidney and its contained stone. Empty the bladder to prevent ‘coiling’ of the scope in the bladder. Pass the scope over a guidewire. This requires two people—the surgeon holds the shaft of the scope and the assistant applies tension to the guidewire to fix the latter in position without pulling it down. This allows P.636
the scope to progress easily up the ureter. The assistant also ensures that acute angulation of the scope where the handle meets the shaft does not occur. The flexible ureteroscope should slide easily up the ureter and into the renal pelvis. With modern active secondary deflection ureteroscopes, access to most, if not all, parts of the renal collecting system is possible. Laser lithotripsy The main draw back of laser lithotripsy is the dust-cloud effect that occurs as the stone is fragmented. This temporarily obscures the view and must be washed away before the laser can safely be re-applied. To stent or not to stent after ureteroscopy JJ stent insertion does not increase stone-free rates and is therefore not required in ‘routine’ cases. A stent should be placed if:

  • there has been ureteric injury (e.g. perforation—indicated by extravasation of contrast)
  • there are residual stones that might obstruct the ureter
  • the patient has had a ureteric stricture that required dilatation
  • solitary kidneys

Routine stenting after ureteroscopy for distal ureteric calculi is unnecessary.36 Many urologists will place a stent after ureteroscopy for proximal ureteric stones. Complications of ureteroscopy Septicaemia; ureteric perforation requiring either a JJ stent or very occasionally a nephrostomy tube where JJ stent placement is not possible; ureteric stricture (<1%). BAUS procedure specific consent form—recommended discussion of adverse events Serious or frequently occurring complications of ureteroscopy for treatment of ureteric stones Common

  • Mild burning or bleeding on passing urine for a short period after the operation
  • Temporary insertion of a bladder catheter may be required
  • Insertion of a stent may be required with a further procedure to remove it
  • Urinary infections occasionally requiring antibiotics

Occasional

  • Inability to get stone or movement of stone back into kidney where it is not retrievable
  • Kidney damage or infection requiring further treatment
  • Failure to pass scope if ureter is narrow
  • Recurrence of stones

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Rare

  • Damage to ureter with need for open operation or placement of a nephrostomy tube into the kidney

Alternative treatment Open surgery, shock wave therapy, or observation to allow spontaneous passage. P.638
Pyeloplasty Indications PUJ obstruction Anaesthesia General Post-operative care A JJ stent, bladder catheter, and a drain are left in situ. The bladder catheter serves to prevent reflux of urine up the ureter, which can lead to increased leakage of urine from the anastomosis site (reflux occurs because of the presence of the JJ stent). The drain is removed when the drain output is minimal. The stent is left in position for ~6 weeks. Common post-operative complications and their management Haemorrhage Usually arising from the nephrostomy track (if a nephrostomy tube has been left in place—some surgeons leave a JJ stent and a perinephric drain, with no nephrostomy). Clamp the nephrostomy tube, in an attempt to tamponade the bleeding. If the bleeding continues, consider angiography and embolisation of the bleeding vessel if seen, or exploration. Urinary leak This can occur within the first day or so. If a urethral catheter has not been left in place, catheterize the patient, to minimize bladder pressure and therefore the chance of reflux, which might be responsible for the leak. If the drainage persists for more than a few days, shorten the drain—if it is in contact with the suture line of the anastomosis it can keep the anastomosis open, rather than letting it heal. If the leak continues, identify the site of the leak by either a nephrostogram (if a nephrostomy has been left in situ) or a cystogram (if a JJ stent is in place—contrast may reflux up the ureter and identify the site of leakge) or an IVU. Some form of additional drainage may help ‘dry up’ the leak (a JJ stent if only a nephrostomy has been left in situ, or a nephrostomy if one is not already in place). Obstruction at PUJ This is uncommon, and if it occurs it is usually detected once all the tubes have been removed and a follow-up renogram has been done. If the patient had symptomatic PUJO, but remains asymptomatic, then no further treatment may be necessary. If they develop recurrent flank pain, re-operation may be necessary. Acute pyelonephritis Manage with antibiotics. BAUS procedure specific consent form—recommended discussion of adverse events Serious or frequently occurring complications of pyeloplasty Common

  • Temporary insertion of a bladder catheter and wound drain
  • Further procedure to remove ureteric stent, usually a local anaesthetic

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Occasional

  • Bleeding requiring further surgery or transfusion

Rare

  • Recurrent kidney or bladder infections
  • Recurrence can occur, needing further surgery

Very rarely

  • Entry into lung cavity requiring insertion of temporary drainage tube
  • Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack)
  • Need to remove kidney at a later time because of damage caused by recurrent obstruction
  • Infection, pain, or hernia of incision requiring further treatment

Alternative therapy Observation, telescopic incision, dilation of area of narrowing, temporary placement of plastic tube through narrowing, laparoscopic repair. P.640
Laparoscopic surgery Virtually every urological procedure can be done laparoscopically. It is particularly suited to surgery in the retroperitoneum (nephrectomy for benign and malignant disease and for kidney donation at transplantation, pyeloplasty for PUJO), but is also suited to pelvic surgery (lymph node biopsy, radical prostatectomy). Reconstructive surgery requiring laparoscopic suturing and using bowel is technically very challenging, but is possible. Laparoscopic surgery offers the advantage over open surgery of:

  • Reduced post-operative pain
  • Smaller scars
  • Less disturbance of bowel function (less post-operative ileus)
  • Reduced recovery time and reduced hospital stay

Contraindications to laparoscopic surgery

  • Severe COPD (avoid use of CO2 for insufflation)
  • Uncorrectable coagulopathy
  • Intestinal obstruction
  • Abdominal wall infection
  • Massive haemoperitoneum
  • Generalized peritonitis
  • Suspected malignant ascites

Laparoscopic surgery is difficult or potentially hazardous in the morbidly obese (inadequate instrument length, decrease range of movement of instruments, higher pneumoperitoneum pressure required to lift the heavier anterior abdominal wall, excess intra-abdominal fat limiting the view); those with extensive previous abdominal or pelvic surgery (adhesions); previous peritonitis leading to adhesion formation; in those with organomegaly; in the presence of ascites; in pregnancy; in patients with a diaphragmatic hernia; in those with aneurysms. Potential complications unique to laparoscopic surgery Gas embolism (potentially fatal), hypercarbia (acidosis affecting cardiac function—e.g. arrhythmias), post-operative abdominal crepitus (subcutaneous emphysema), pneumothorax, pneomomediastinum, pneumopericardium, barotraumas. Bowel, vessel (aorta, common iliac vessels, IVC, anterior abdominal wall injury), and other viscus injury are not unique to laparoscopic surgery, but are a particular concern during port access. Perforation of small or large bowel is the most common trocar injury. Rarely, the bladder is perforated. Failure to progress with a laparoscopic approach, or vessel injury with uncontrollable haemorrhage requires conversion to an open approach. Post-operatively, bowel may become entrapped in the trocar sites, or there may be bleeding from the sheath site. An acute hydrocele can develop due to irrigation fluid accumulating in the scrotum. It resorbs spontaneously. Scrotal and abdominal wall bruising not uncommonly occurs. P.641
BAUS procedure specific consent forms For all laparoscopic procedures Common

  • Temporary shoulder tip pain
  • Temporary abdominal bloating
  • Temporary insertion of a bladder catheter and wound drain

Occasional

  • Infection, pain, or hernia of incision requiring further treatment

Rare

  • Bleeding requiring conversion to open surgery or transfusion
  • Entry into lung cavity requiring insertion of a temporary drainage tube

Very rarely

  • Recognized (and unrecognized) injury to organs or blood vessels requiring conversion to open surgery or deferred open surgery
  • Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack)

Laparoscopic pyeloplasty Common

  • Further procedure to remove ureteric stent, usually under local anaesthesia

Occasional

  • Recurrence can occur needing further surgery
  • Short-term success rates are similar to open surgery, but long-term results unknown

Very rarely

  • Need to remove kidney at a later time because of damage caused by recurrent obstruction

Alternative therapy Observation, telescopic incision, dilation of area of narrowing, temporary placement of a plastic tube through narrowing, conventional open surgical approach. Laparoscopic simple nephrectomy Occasional

  • Short-term success rates are similar to open surgery, but long-term results unknown

Alternative therapy Observation and conventional open surgical approach Laparoscopic radical nephrectomy Occasional

  • Short-term success rates are similar to open surgery, but long-term results unknown

Rare

  • A histological abnormality other than cancer may be found

Alternative therapy Observation, embolisation, chemotherapy, immunotherapy, conventional open surgical approach. P.642
Endoscopic cystolitholapxy and (open) cystolithotomy Indications

  • Endoscopic cystolitholapxy: generally indicated for stones <6cm in diameter
  • Open cystolithotomy: for stones >6cm in diameter; patients with urethral obstruction which precludes endoscopic access to bladder

Anaesthesia Regional or general Post-operative care A catheter is left in the bladder for a day or so, since haematuria is common, particularly after fragmentation of large stones. Irrigation may be required if the haematuria is heavy. Common post-operative complications and their management Haematuria requiring bladder washout or return to theatre is rare. Septicaemia Uncommon Bladder perforation Uncommon, but can occur with the use of stone ‘punches’ which grab the stone between powerful cutting jaws. Grasping the bladder wall in the jaws of the stone forceps or punch is easily done, and can cause perforation. BAUS procedure specific consent form—recommended discussion of adverse events Serious or frequently occurring complications of endoscopic cystolitholapxy Common

  • Mild burning or bleeding on passing urine for short periods after operation
  • Temporary insertion of a catheter

Occasional

  • Infection of bladder requiring antibiotics
  • Permission for removal/biopsy of bladder abnormality if found
  • Recurrence of stones or residual stone fragments

Rare

  • Delayed bleeding requiring removal of clots or further surgery
  • Injury to urethra causing delayed scar formation

Very rarely

  • Perforation of bladder requiring a temporary urinary catheter or return to theatre for open surgical repair

Alternative therapy Open surgery, observation. P.643
P.644
Scrotal exploration for torsion and orchidopexy Indications Suspected testicular torsion Technique A midline incision, since this allows access to both sides so that they may both be ‘fixed’ within the scrotum. Untwist the testis and place in a warm, saline-soaked swab for 10 min. If it remains black, remove it, having ligated the spermatic cord with a transfixion stitch of absorbable material. If it ‘pinks-up’, fix it. If uncertain about its viability, make a small cut with the tip of a scalpel. If the testis bleeds actively, it should be salvaged (close the small wound with an absorbable suture). If not, it is dead and should be removed. Whatever you do, fix the other side. Fixation technique Some surgeons fix the testis within the scrotum with suture material, inserted at 3 points (3-point fixation). Some use absorbable sutures and others, non-absorbable. Those who use the latter argue that absorbable sutures may disappear, exposing the patient to the risk of retorsion.38 Those who use absorbable sutures argue that the fibrous reaction around the absorbable sutures prevents retorsion and argue that the patient may be able to feel non-absorbable sutures, which can be uncomfortable. The sutures should pass through the tunica albuginea of the testis, and then through the parietal layer of the tunica vaginalis lining the inner surface of the scrotum. Others say the testis should be fixed within a dartos pouch,39 arguing that suture fixation breaches the blood–testis barrier, exposing both testes to the risk of sympathetic orchidopathia (an autoimmune reaction caused by development of antibodes against the testis). For dartos pouch fixation, open the tunica vaginalis, bring the testis out and untwist it. Develop a dartos pouch in the scrotum by holding the skin with forceps and dissecting with scissors between the skin and the underlying dartos muscle. Enlarge this space by inserting your two index fingers and pulling them apart. Place the testis in this pouch. Use a few absorbable sutures to attach the cord near the testis to the inside of the dartos pouch to prevent retorsion of the testes. The dartos may then be closed over the testis and the skin can be closed in a separate layer. Post-operative care and potential complications and their management As for all procedures involving scrotal exploration, a scrotal haematoma may result which may have to be surgically drained. BAUS procedure specific consent form—recommended discussion of adverse events Serious or frequently occurring complications of scrotal exploration Common

  • The testis may have to be removed if non-viable

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Occasional

  • You may be able to feel the stitch used to fix the testis
  • Blood collection around the testes which slowly resolves or requires surgical removal
  • Possible infection of incision or testis requiring further treatment

Rare

  • Loss of testicular size or atrophy in future if testis is saved
  • No guarantee of fertility

Alternative therapy Observation—risks loss of testis and autoimmune reaction leading to subfertility and loss of hormone production in remaining testis. References 1 British Medical Association and the Royal Pharmaceutical Society of Great Britain (September 2003) British National Formulary. 2 Hargreave TB, Botto B, Rikken GHJM, et al. (1993) European Collaborative Study of Antibiotic Prophylaxis for Transurethral Resection of the Prostate. Eur Urol 23:437–43. 3 The American Academy of Orthopaedic Surgeons (AAOS) and the American Urological Association (AUA) (2003) Advisory statement. J Urol 169:1796. 4 Donat R, Mancey-Jones B (2002) Incidence of thromboembolism after transurethral resection of the prostate (TURP). Scan J Urol Nephrol 36:119–23. 5 Geerts WH, Heit JA, Clagett PG, et al. (2001) Prevention of venous thromboembolism. (American College of Chest Physicians (ACCP) Guidelines on prevention of venous thromboembolism) Chest 119:132S-175S. 6 Quinlan DJ, McQuillan A, Eikelboom JW (2004) Low molecular weight heparin compared with intravenous unfractionated heparin for treatment of pulmonary embolism. Ann Intern Med 140:175–83. 7 Lowe GDO, Greer IA, Cooke TG, et al. (1992) Risk of and prophylaxis for venous thromboembolism in hospital patients. Thromboembolic Risk Factors (THRIFT) Consensus Group. BMJ 305:567–74. 8 Howard A, et al. (2004) Randomized clinical trial of low molecular weight heparin with thigh-length or knee-length antiembolism stockings for patients undergoing surgery. BJS 91:842–47. 9 Soderdahl DW, Henderson SR, Hansberry KL (1997) A comparison of intermittent pneumatic compression of the calf and whole leg in preventing deep venous thrombosis in urological surgery. J Urol 157:1774–76. 10 Golash A, Collins PW, Kynaston HG, Jenkins BJ (2002) Venous thromboembolic prophylaxis for transurethral prostatectomy: practice among British urologists. J Roy Soc Med 95:130–31. 11 British Thoracic Society guidelines for management of suspected acute pulmonary embolism (2003) Thorax 58:1–14. 12 Kelly J, Rudd A, Lewis RR, Hunt BJ (2002) Plasma D-dimers in the diagnosis of venous thromboembolism. Arch Intern Med 162:747–56. 13 Kruip MJH, Slob MJ, Schijen JH, et al. (2002) Use of a clinical decision rule in combination with D-dimer concentration in diagnostic workup of patients with suspected pulmonary embolism. Arch Intern Med 162:1631–35. 14 American College of Surgeons Committee on Trauma (1999) Advanced Trauma Life Support for Doctors—Student Course Manual, 6th Edition. 15 Madsen PO, Naber KG (1973) The importance of the pressure in the prostatic fossa and absorption of irrigating fluid during transurethral resection of the prostate. J Urol 109:446–52. 16 Coppinger SW, Lewis CA, Milroy EJG (1995) A method of measuring fluid balance during transurethral resection of the prostate. Br J Urol 76:66–72. 17 Hahn RG (1993) Ethanol monitoring of extravascular absorption of irrigating fluid. Br J Urol 72:766–69. 18 Srivastava A, et al. (2003) Routine stenting after ureteroscopy for distal ureteral calculi is unnecessary: results of a randomized controlled trial. J Endourol 17:871–74. 19 Ramsay JW, et al. (1985) The effects of double J stenting on obstructed ureters. An experimental and clinical study. Br J Urol 57:630–34. 20 Docimo SG. (1989) High failure rate of indwelling ureteral stents in patients with extrinsic obstruction: experience at two institutions. J Urol 142:277–79. 21 Pearle MS, et al. (1998) Optimal method of urgent decompression of the collecting system for obstruction and infection due to ureteral calculi. J Urol 160:1260–64. 22 Ryan PC, et al. (1994) The effects of acute and chronic JJ stent placement on upper urinary tract motility and calculus transit. Br J Urol 74:434–39. 23 Collinge J (1999) Variant Creutzfeldt-Jakob disease. Lancet 354:317–23. 24 Collins SJ, Lawson VA, Masters CL (2004) Transmissible spongiform encephalopathies. Lancet 363:51–61. 25 Nix P (2003) Prions and disposable surgical instruments. Int J Clin Pract 57:678–80. 26 The Advisory Committee on Dangerous Pathogens and Spongiform Encephalopathy (1998) Transmissible spongiform encephalopathy agents: safe working and the prevention of infection. London: HM Stationery Office. 27 Blandy J, Fowler C (1996) Urology. Blackwell Science, pp. 3–5. 28 Emberton M, et al. (1995) The National Prostatectomy Audit: the clinical management of patients during hospital admission. Br J Urol 75:301–16. 29 Hellawell GO, Cowan NC, Holt SJ, Mutch SJ (2002) A radiation perspective for treating loin pain in pregnancy by double-pigtail stents. Br J Urol Int 90:801–8. 30 McFarlane J, Cowan N, Holt S, Cowan M (2001) Outpatient ureteric procedures: a new method for retrograde ureteropyelography and ureteric stent placement. Br J Urol Int 87:172–76. 31 Hopper KD, Sherman JL, Williams MD, et al. (1987) The variable anteroposterior position of the retroperitoneal colon to the kidneys. Invest Radiol 22:298–302. 32 Inglis JA, Tolly DA (1988) Antibiotic prophylaxis at the time of percutaneous stone surgery. J Endourol 2:59–62. 33 Martin X (2000) Severe bleeding after nephrolithotomy: results of hyperselective embolisation. Eur Urol 37:136–39. 34 Clayman J (1987) Percutaneous nephrostomy: Assessment of renal damage associated with semi-rigid (24F) and balloon (36F) dilation. J Urol 138:203–6. 35 Garvin TJ, Clayman RV (1991) Balloon dilation of the ureter for ureteroscopy. J Urol 146:742–45. 36 Srivastava A, et al. (2003) Routine stenting after ureteroscopy for distal ureteral calculi is unnecessary: results of a randomized controlled trial. J Endourol 17:871 37 Harmon WJ, et al. (1997) Ureteroscopy: current practice and long-term complications. J Urol 157:28–32. 38 Kuntze JR (1985) Testicular torsion after orchidopexy. J Urol 134:1209–10. 39 Frank JD (2002) Fixation of the testis. Br J Urol Int 89:331–33.

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