Principles of Surgery, Companion Handbook - page 40

Chapter 38 Urology

Principles of Surgery Companion Handbook

CHAPTER
38
UROLOGY

Anatomy
Diagnosis
 Physical Examination
 Urinalysis
 Genital Secretions
 Instrumentation
 Special Diagnostic Studies
Bladder Function and Disorders
 Neurogenic Bladder Dysfunction
Acute Infections
 Acute Staphylococcal Infections of the Kidney
 Perinephric Abscess
 Acute Papillary Necrosis
 Acute Urethritis
 Acute Bacterial Prostatitis
 Acute Epididymitis
Chronic Infections
 Chronic Bacterial Prostatitis
 Chronic Cystitis
 Chronic Epididymitis
 Chronic Pyelonephritis
 Urinary Tuberculosis
Urinary Calculi
Benign Prostatic Hyperplasia
Neoplasms
 Renal Tumors
 Carcinoma of the Renal Pelvis and Ureter
 Tumors of the Urinary Bladder
 Carcinoma of the Prostate
 Testicular Tumors
 Carcinoma of the Penis
Sexual Disorders
Genitourinary Tract Injuries
 Renal Injury
 Ureteral Trauma
 Bladder and Urethral Injury
 External Genitalia
Pediatric Urology
 Congenital Anomalies
 Testicular Neoplasms
 Torsion
 Varicocele
 Hydrocele and Hematocele
Operations on Genitourinary Organs
 Nephrectomy
 Cutaneous Ureteroileostomy (Ileal Conduit)
 Cystostomy, Cystolithotomy
 Prostatectomy
 Hydrocelectomy
 Inguinal Orchiectomy
 Orchiopexy
 Bilateral Vasectomy
 Vasovasostomy
 Laparoscopic Surgery

ANATOMY

Kidney The kidneys are paired organs that lie in the retroperitoneum, enveloped in Gerota's fascia and variable amounts of fat. Dorsally, the lower ribs, the quadratus lumborum, and the psoas muscle are in close proximity. Ventral relationships of the right kidney include adrenal, liver, colon, and ileum; those of the left kidney include adrenal, stomach, spleen, pancreas, colon, and ileum.

The renal arteries arise from the aorta, and approximately two-thirds of kidneys will have a single renal artery. The main renal artery divides into five major branches, which represent an end artery supplying a renal segment. Thus occlusion of the renal artery branches will cause infarction of the renal segment. The renal veins empty into the inferior vena cava. The renal lymphatics empty into the hilar trunks, and the capsular lymphatics empty into infradiaphragmatic periaortic nodes. The renal nerves contain vasomotor and pain fibers and receive their contributions from T4–T12 segments. The renal pelvis lies dorsal to the renal vessels and has transitional epithelium.

Ureter The ureters are muscular tubes that travel through the retroperitoneum and connect the renal pelvis to the bladder. The normal adult ureter is 28–30 cm long and about 5 mm in diameter. The ureter transmits urine from the renal pelvis to the bladder by active peristalsis. The blood supply of the ureters originates from the renal, aortic, iliac, mesenteric, gonadal, vasal, and vesical arteries. Pain fibers transmit stimuli to the T12–L2 segments. The ureter can be deviated medially in retroperitoneal fibrosis and laterally by retroperitoneal tumor or aortic aneurysm.

Bladder The urinary bladder is a muscular organ located in the bony pelvis. The blood supply originates from the superior, middle, and inferior branches of the hypogastric arteries. The lymphatics drain into the perivesical, hypogastric, and periaortic nodes. The autonomic nervous system enters via the sacral cord and the presacral and epigastric plexus.

Prostate and Seminal Vesicles The prostate encases the proximal urethra and is attached to the bladder neck and the symphysis pubis. Distally, the prostate sits on the pelvic diaphragm, which contains the voluntary urinary sphincter. The blood supply is derived from inferior vesical, middle hemorrhoidal, and internal pudendal arteries. The prostate receives secretory and motor (parasympathetic) innervation from S3 and S4 and vasomotor (sympathetic) fibers from the hypogastric plexus. The lymphatics drain into the obturator nodes and the external, internal, and common iliac nodes. The seminal vesicles are situated behind the bladder, lateral to the ampullae of the vasa deferentia.

Penis and the Urethra The penis is composed of two erectile bodies called corpora cavernosa and a single body through which the urethra travels called the corpus spongiosum. The latter terminates with the glans penis, which is also erectile. The urethra in the male is divided into pendulous, bulbous, membranous, and prostatic segments. The female urethra corresponds to the prostatic and membranous urethra in males.

Testis and Epididymis The testes are ovoid, firm organs that are found in the scrotum. They are covered by the tunica albuginea. The epididymis and the vascular pedicle lie posteriorly. The epididymis is a crescent-shaped structure located around the dorsal portion of the testis. The vas deferens is a tubular structure that originates from the inferior portion of the epididymis. The arterial blood supply of the testis originates from the aorta. The venous drainage of the left testis is into the left renal vein; the right testis blood drains into the inferior vena cava.

DIAGNOSIS

Gross Hematuria Any amount of gross blood in the urine warrants further evaluation. The common causes are inflammation, tumors, calculi, and trauma. In young patients gross hematuria is more likely to be the result of infection, whereas in older patients it is more likely to be the result of tumor or prostate disease. It also is important to determine if the hematuria is initial, terminal, or total. This may help to localize the exact site of the pathology.

Acute Postrenal Retention of Urine This term reflects an inability to empty the bladder. A variety of afflictions can cause this condition.

Benign prostatic hypertrophy is the most common cause of acute retention in men. There usually is a long-standing history of difficulty in voiding. In carcinoma of the prostate, the symptoms are more acute. Carcinoma of the prostate usually coexists with benign prostatic hypertrophy. In young males, prostatic inflammation may lead to acute urinary retention. This usually is a result of urethritis and/or prostatitis. Acute urinary retention also may be the result of a urethral stricture that occurs because of urethritis or trauma.

Neurogenic bladder dysfunction may lead to an increase in residual urine and to complete urinary retention. This may be the first indication of spinal cord disease. Other causes of neurogenic retention include trauma, pelvic surgery, general anesthesia, and drugs that influence the innervation of the bladder and the sphincter mechanism. Acute urinary retention in females usually is a result of neurogenic and psychogenic factors or urethral obstruction.

Incontinence True incontinence is a situation in which a patient is not aware of the loss of urine. Enuresis is nocturnal bed wetting, usually affecting children. Urgency occurs when the sensation of urination cannot be controlled before reaching a bathroom. Certain urinary cutaneous or urinary genital fistulas can lead to incontinence. Stress incontinence results from ineffective sphincter muscle tone. Overflow incontinence represents a small amount of urine leakage from a bladder carrying a large amount of residual urine.

Ureteral Colic This is related to a sudden increase in the hydrostatic pressure of the upper urinary tract. Typically, there is a sudden, increasing pain at the costovertebral angle. This may be associated with nausea or vomiting.

Frequency This refers to voiding an excessive number of times, whereas polyuria refers to an excessive amount of voiding. Frequency may be related to reduction in bladder capacity or to reduction in the effective bladder capacity that is seen with high residual urine. Frequency also may be a symptom of psychological stress.

Nocturia This may be caused by excessive fluid intake, generalized restlessness, cardiac decompensation, diuretic intake, and prostatic hypertrophy.

Urgency This symptom is a result of bladder or bladder outlet inflammation.

Dysuria This is difficult or painful urination. It usually is described as a burning sensation. Severe pain at the termination of urination is called strangury. Hesitancy indicates delay in voiding after mental command. Intermittency is involuntary stopping or starting of the stream.

Urinary Stream Lack of force of the urinary stream may reflect obstructive uropathy.

Erectile and Ejaculatory Dysfunction The cause may be endocrinologic, vasculogenic, or neurogenic. Certain drugs can lead to erectile and ejaculatory disturbances. In some instances, the problem may be situational or psychogenic. When anatomic abnormalities are found, they can be corrected. When directly injected into the corpora cavernosa, certain pharmacologic agents such as papaverine can result in adequate erections. In selected patients, insertion of penile prosthesis may be indicated.

Physical Examination

Renal Areas The renal areas are first examined with the patient in the upright position. Attention should be paid to bulging or asymmetry of the costovertebral region. Gentle palpation of the costovertebral region is followed by sharp percussion. Palpation is performed by bimanual examination of the area below the rib cage.

Ureters Because of their location in the retroperitoneum, the ureters cannot be palpated.

Bladder The bladder is examined with the patient in the supine position, and when empty, it cannot be palpated. With high residual urine the bladder can present as a lower abdominal mass.

Penis The penis can be examined with the patient in the upright or supine position. If the patient is not circumcised, the foreskin should be retracted. The urethral meatus, foreskin, and glans should be examined.

Scrotum Examination of the scrotum is carried out in conjunction with examination of the penis. The use of a flashlight to transilluminate lesions may help in diagnosis.

Epididymitis Acute epididymitis is a result of retrograde infection from the prostate, urethra, or bladder. The scrotum is very tender; the overlying skin is red and erythematous. There may be a mass in the scrotum. Nonspecific chronic epididymitis represents an incompletely resolved acute epididymitis. There may be an indurated scrotal mass that can be tender. Tuberculous epididymitis is nontender, stony hard, and associated with an indurated vas deferens. A sterile or chemical epididymitis can occur with retrograde extravasation of urine into the epididymis secondary to abdominal strain.

Varicocele This is more common on the left side because the left spermatic vein drains into the left renal vein, which usually is higher. Characteristically, there is a “bag of worms” appearance to the scrotum. The acute onset of a varicocele after the age of 40 may be a result of an invasive kidney tumor. If the patient is being evaluated for infertility, the finding of a varicocele may be significant. These patients may have a low sperm count with reduced motility and change in the sperm morphology.

Hydrocele Primary hydrocele may be unilateral or bilateral, which represents fluid between the tunica vaginalis. It presents as a nontender, fluid-filled scrotal mass. Secondary hydrocele is the consequence of serous effusions in the vicinity of a disease process. Acute hydrocele may be a result of testicular tumor. A communicating hydrocele is present in a patient with a patent processus vaginalis.

Spermatocele This is a cyst of an efferent ductule of the rete testis. It is located at the head of the epididymis as a cystic mass.

Testis Tumor A nodule within the testis is a malignant tumor unless proved otherwise. These usually are firm and nontender. Ultrasound examination can help define the lesion. Prompt surgical management is indicated.

Mumps Orchitis This lesion occurs after acute parotitis. Marked testicular swelling without scrotal edema is noted.

Torsion of the Testis and Appendages Torsion of the testis refers to torsion of the spermatic cord. The patient presents with sudden onset of pain associated with scrotal swelling and edema. The testis is elevated in the scrotum and is very tender to palpation. The cremasteric reflex usually is absent. This may be confused with acute epididymitis; isotopic testicular scanning may aid diagnosis. Detorsion and bilateral orchidopexy should be performed as soon as possible. Appendix testis, which is an embryologic remnant above the testis, also can undergo torsion. It can be detected as a black dot on transillumination.

Prostate The prostate is examined transrectally by digital palpation or ultrasonography. This could be done with the patient in a lateral recumbent or standing flexed position. The normal prostate is two finger breadths wide with a sulcus in between two lobes. The consistency of the normal prostate and benign hypertrophy is similar to that of the thenar eminence. In contrast, carcinoma of the prostate feels stony hard. Crepitations are a result of prostatic calculi. Acute inflammation of the prostate is accompanied by tenderness or fluctuations that require gentle examination.

Female Urethra Pelvic examination of the female is necessary to evaluate the lower urinary tract. The presence of urethral lesions, cystocele, or urethrocele can be determined. A urethral diverticulum can be detected by expressing purulent material by pressure.

Urinalysis

Optimal urine collection from males is a fresh two-glass specimen and in females a catheterized collection. However, carefully obtained midstream urine in both sexes usually is satisfactory. The specimen should be examined while fresh.

Cloudy urine is not normal. This may be because of phosphaturia, which will clear with acetic acid. Certain foods and drugs can alter the color of urine. The degree and the origin of bleeding can be determined by gross inspection of urine. Screening examination includes tests for the presence of blood, albumin, sugar, acetone, and pH. With microscopic examination of the centrifuged urinary sediment, one can detect casts, crystals, epithelial cells, white blood cells, red blood cells, and bacteria. Cytologic examination of the exfoliated cells may help in detecting malignancy in the urinary tract. Flow cystometry may give additional information about malignancy.

Genital Secretions

Urethral Discharge The discharge is collected on a glass slide before the patient urinates. Gonococcal urethritis is diagnosed by the presence of gram-negative intracellular diplococci. A wet specimen is adequate for the diagnosis of Trichomonas infections. Noninfected secretions usually are whitish and opalescent; infected secretions are purulent.

Prostatic Secretions The specimen is obtained by gentle massage. Normal prostatic fluid contains 3–5 white blood cells per high-power field. In the presence of infection, secretions become granular and contain large amounts of white blood cells.

Semen Analysis The semen specimen should be obtained by masturbation. After 1 h, the semen will liquefy and should contain more than 20 million spermatozoa per milliliter, with 80 percent motility and 60 percent normal morphology.

Instrumentation

Insertion of any instrument into the urethra carries a risk of trauma, introduction of infection, sepsis, stricture formation, and exacerbation of the preexisting condition.

Cystourethroscopy This can be performed in the office with local anesthetics with either flexible or rigid instruments. Not only can very small lesions be detected but also small calculi, ureteral orifices, prostate size, urethral strictures or valves, and other lesions can be seen.

Ureteropyeloscopy The entire upper urinary tract can be visualized with flexible or rigid ureteroscopes. Certain procedures can be performed with these instruments.

Therapeutic Instrumentation An indwelling catheter allows temporary relief of obstruction. If the catheter is left in for over 3 days, there is associated infection. Bladder drainage also can be obtained with suprapubic tap and insertion of a polyethylene tube. Drainage of an obstructed upper urinary tract can be accomplished by percutaneous nephrostomy tube or a retrograde ureteral catheter placement.

Therapeutic instrumentation may be applied in the endoscopic removal of calculi or foreign bodies, biopsy or excision of tumors, drainage of prostatic abscesses, dilatation or incision of urethral strictures or valves, and transurethral removal of prostatic obstruction.

Special Diagnostic Studies

Excretory Urography Certain intravenously administered organic molecules are excreted and concentrated by the kidneys. When they are rendered opaque by iodinization, renal parenchyma and the collecting system can be visualized radiographically. Because these agents are hyperosmotic, they can lead to diuresis and dehydration. These agents also can cause severe allergic reactions.

The adult male kidney is about 13 by 6.2 cm on pyelography. The female kidney is approximately 5 mm smaller. The right kidney is about a half vertebral body lower than the left. The longitudinal axis of the kidneys follows the lateral margin of the psoas muscle, and any deviation may indicate a pathologic condition. The calyces and the infundibulae should be delicate. The pelvis and the ureter should be smooth without redundancy.

Nephrotomography A more detailed visualization of the kidney is obtained by taking slices posteriorly and advancing anteriorly.

Retrograde Pyelourethrography This is indicated to further evaluate the pyelocalyceal system. This study requires cystoscopy, insertion of ureteral catheters, and injection of contrast material.

Antegrade Pyelography Percutaneous insertion of a small catheter into the pelvocalyceal system may be both therapeutic and diagnostic. An infected and obstructed kidney can be drained, whereas injection of contrast material allows the collecting system to be visualized. After percutaneous access to the kidney, stones can be fragmented (nephrolithotripsy), strictures dilated or incised, and lesions biopsied using nephroscopes.

Renal Arteriography Transfemoral renal arteriography is useful in the evaluation of renal vascular hypertension and therapeutic dilatation of narrow arteries (angioplasty). This also is useful in evaluating renal masses and renal vascular anatomy.

Digital Subtraction Angiography After intravenous or intraarterial injection of contrast material, a computerized subtraction system provides clear visualization of the renal vasculature.

Vena Cavography The inferior vena cava can be visualized by injection of contrast material through a catheter placed from the femoral vein. This is especially helpful in evaluating renal or testicular neoplasms.

Lymphangiography Pedal lymphangiography may provide information regarding lymph node involvement in certain genitourinary cancers.

Renography and Renal Perfusion Scan The iodine-131 (131I) hippurate renogram provides information regarding function and drainage of the kidneys. The use of different isotopes may provide additional information about renal perfusion, drainage, morphology, and differential renal function.

Ultrasound Using this noninvasive test, cystic renal lesions can be differentiated from solid lesions. Hydronephrosis also can be determined with this technique. Transrectal ultrasound also can aid in the detection of prostate cancer. Using ultrasound as a guide, biopsies and cyst aspirations can be performed.

Computed Tomography (CT) This is one of the most useful and accurate means of evaluating intraabdominal pathology, and in some instances it has replaced other tests. It can be performed with or without contrast material. Along with detailed anatomy, the extent and size of the tumors can be detected.

Cystometrics, Urethral Pressure Profiles, and Sphincter Electromyography These studies are useful in evaluating micturition dysfunction resulting from a variety of clinical problems.

Percutaneous Renal Cyst Puncture Aspiration of fluid from a renal mass may aid in differentiation of cysts from tumor.

Biochemical and Radioimmunoassay (RIA) Evaluation of renal function, hypertension, electrolyte disturbances, calculus disease, impotence, and genitourinary neoplasms requires the use of biochemistry and radioimmunoassay.

BLADDER FUNCTION AND DISORDERS

Physiology of Micturition Gradual bladder filling under normal circumstances is accompanied by a voiding reflex at a certain volume. This can be inhibited by cortical centers. If the conditions are socially acceptable, voiding results by contraction of the detrusor and relaxation of the sphincter. In patients with bladder outlet obstruction, the pressure required to empty the bladder exceeds normal, and detrusor hypertrophy ensues. In long-standing obstruction, muscle fibers may decompensate and result in atonia, which can be accompanied by high residual urine.

Bladder Innervation Sensations are mediated by sensory fibers accompanying the sympathetic and parasympathetic nerves. They arise from T9–L2 segments of the spinal cord. Motor pathways originate in the S2–S4 segments and reach the bladder via the pelvic nerves. Parasympathetics are responsible for reflex contractions of the detrusor. The external sphincter is innervated with motor nerves from the S2–S4 segments via the pudendal nerve. Sympathetic nerves have an important role in detrusor function and outlet resistance.

Motor pathways can be evaluated by bulbocavernosus reflex. Cystometry is the best method for evaluating motor function. This is performed by installation of either gas or water at a certain rate into the bladder and recording pressure changes. Intravesicle pressure rarely exceeds 20 cmH2O.

Neurogenic Bladder Dysfunction

Uninhibited Neurogenic Bladder This condition presents as urgent voiding that is without voluntary control. Cerebral vascular accidents and multiple sclerosis are classic causes. Treatment is with parasympatholytic drugs.

Reflex (Automatic) Neurogenic Bladder A well-functioning reflex bladder results if the spinal cord is transected. The lesion must be between T7 and C7. With rehabilitation, the bladder can provide adequate emptying.

Centrally Denervated Neurogenic Bladder This dysfunction is the result of lesions involving the sacral segments of the cauda equina. Meningomyelocele or occult spina bifida are the most frequent lesions. The symptoms are overflow incontinence with high residual urine and infections. Surgical therapy is directed toward facilitating bladder emptying. When bladder rehabilitation is unsuccessful, clean intermittent catheterization may be used. Cholinergic drugs may enhance detrusor tone, whereas sympatholytic agents can decrease urethral resistance.

Sensory Paralytic Bladder This results from sensory loss of bladder innervation such as from tabes dorsalis or cord degeneration. The patient is unable to sense bladder filling, which results in overflow incontinence. Treatment is similar to that for the conditions described above.

Motor Paralytic Bladder Dysfunction may be seen with poliomyelitis or infectious polyneuritis. Loss of motor activity results in a large capacity bladder. This may be reversible depending on the disease process.

Bladder drainage is required in the immediate posttrauma stage. This can be done with either indwelling catheters or intermittent catheterization. Chronic indwelling bladder catheterization is almost always accompanied by bacterial colonization. The specific complications of catheter drainage include acute cystitis and pyelonephritis, acute epididymitis, urethral abscess and fistula formation, and bladder or kidney stones. A regimen of intermittent catheterization should be used as soon as possible in these patients.

Rehabilitation of the Bladder During the first months after trauma, attention is directed to prevention of infection. After stabilization of the spine, the patient can resume the upright position and begin rehabilitation. The patient's bladder function is assessed with a thorough urodynamic evaluation, and every attempt is made to remove any indwelling catheters. Cholinergic agents can be tried at this time. Clean self-intermittent catheterization also may be instituted. It may be necessary to reinsert an indwelling catheter and to reevaluate at a later date. Certain patients may require antibacterial suppressive therapy.

ACUTE INFECTIONS

Pathogenesis The most common entry site for urinary tract infections (UTIs) is the urethra. When there is obstruction, inflammation, or ulceration in the urinary tract, the defense mechanism is inadequate. Most UTIs occur in females because of the short urethra. In older age groups, the incidence of UTIs increases in males. Recurrent UTIs in children are most likely associated with congenital malformations of the urinary tract. UTIs also can result from hematogenous spread.

Bacteriology The most common urinary pathogen is Escherichia coli. Other common pathogens include Proteus, Klebsiella, the enterococci, and Pseudomonas.

Treatment The kidneys enhance the efficacy of certain antibacterial agents by increasing their concentration in the urine. Drug selection is facilitated by culture and sensitivities. Drugs that are rapidly excreted by the kidneys are preferred in the treatment of uncomplicated lower UTIs. Patients with acute pyelonephritis or urinary sepsis are treated with drugs that yield high blood and tissue concentrations. These patients usually require parenteral combination therapy for an extended period of time.

UTI is sometimes a result of anatomic abnormality. Upper UTIs may need additional evaluation after treatment of the infection. These patients also are at risk for recurrence, and close follow-up is mandatory. Occasionally, long-term, low-dose suppressive therapy is required.

Gram-Negative Bacteremia This syndrome is considered a urologic disease because the source usually is from the urinary tract. Bacteremia can result from instrumentation. The patients show signs of sepsis with hemodynamic alterations. Bacteria can be resistant to common antibiotics.

Acute Staphylococcal Infections of the Kidney

Staphylococcal pyelonephritis or abscess is of hematogenous origin and usually results from metastatic infection. The patients usually are very ill, with fever, flank pain, frequency, and dysuria. Complications include renal carbuncle or perinephric abscess. Treatment consists of parenteral antibiotic therapy.

Perinephric Abscess

This usually occurs after perforation of renal infection or abscess into the perinephric space. The patient presents with high fever and rigid abdomen. Radiographs reveal an absent psoas shadow and concavity of the spine to the site of the lesion. Treatment requires drainage and long-term antibiotics.

Acute Papillary Necrosis

Necrosis of renal papillae occurs in patients with diabetes, sickle cell disease, tuberculosis, and excessive ingestion of phenacetin. Along with symptoms of infection, renal colic may be seen. Diagnosis is made on intravenous pyelogram by demonstrating sloughed renal papillae. Treatment is conservative unless there is obstruction.

Acute Urethritis

Acute urethritis usually is venereal in origin. Most common organisms include gonorrhea, Ureaplasm urealyticum, Chlamydia, and Trichomonas vaginalis. Diagnosis is established by Gram's stain of the discharge and appropriate cultures. Gonorrhea is a common venereal disease that presents with symptoms of acute urethritis. Diagnosis can be made with identification of intracellular gram-negative diplococci. Unless resistant, they are best treated with penicillin-type drugs. Nonspecific urethritis is the more common venereal disease in males. C. trachomatis and U. urealyticum are the usual organisms. These can be treated with tetracyclines, whereas Trichomonas infections are treated with metronidazol (Flagyl).

Acute Bacterial Prostatitis

This usually is caused by the same organism that produces urinary tract infections. Infection usually is ascending from the urethra and the prostatic ducts. Symptoms consist of perineal pain, dysuria, and frequency attended by fever, chills, and malaise. Liquefaction necrosis may lead to abscess formation. Parenteral antibiotics should be instituted pending appropriate cultures. Rectal examination should be performed gently and reveals a warm, tender prostate. Persistence of the symptoms suggests an abscess that requires drainage.

Acute Epididymitis

This is characterized by rapid swelling of the epididymis and testis along with pain. UTI is usually present with associated symptoms. It may be difficult to identify the pathogen if UTI is not present. The differential diagnosis includes acute torsion of the spermatic cord. Radioisotope and scrotal ultrasound may aid in diagnosis. Treatment consists of symptomatic measures such as scrotal elevation and broad-spectrum antibiotics. Abscess formation may occur and may require surgical drainage. Traumatic epididymitis can be seen after strain in lifting or scrotal trauma. Antibiotics usually are administered because infection cannot be ruled out.

CHRONIC INFECTIONS

Chronic Bacterial Prostatitis

Chronic bacterial prostatitis is characterized by recurrent UTIs, low back and perineal discomfort, urinary frequency, and dysuria. The duration of the symptoms can be variable; recurrence is common. Expressed prostatic secretions reveal many white blood cells, although the prostate usually is nontender. Most of the drugs that are effective in UTI are unable to penetrate the prostate. Trimethoprim, tetracyclines, carbenicillin, and quinolones seem to be effective. In nonbacterial prostatitis, although symptoms and findings are the same, cultures usually are sterile. Therapy in these cases usually is empirical and often unsuccessful.

Chronic Cystitis

Chronic cystitis can be the end result of recurrent bacterial cystitis. Infiltration of the bladder with the inflammatory process can impair detrusor function. There are often predisposing factors such as tumors, stones, or indwelling catheters. Irritating voiding symptoms usually are present. Diagnostic workup is directed toward identifying the predisposing factors. Chronic antibacterial therapy often is required.

Interstitial cystitis is a form of abacterial cystitis usually seen in females in their later years. The cause is unknown, and the symptoms are that of cystitis. This must be differentiated from tuberculous cystitis and carcinoma in situ of the bladder. Treatment is very difficult. Periodic instillations of dimethyl sulfoxide (DMSO) may relieve symptoms. Agents that repleate the glycosaminoglycan layer in the bladder such as Elmiron also can be effective.

Chronic Epididymitis

This is characterized by persistent induration of the epididymis. The epididymis is minimally tender, and there usually is a history of acute epididymitis. Ultrasound examination may aid in the differential diagnosis. Treatment consists of empirical antibacterial therapy.

Chronic Pyelonephritis

Histologically, this represents a nonspecific inflammation with fibrosis and scarring. Radiologic findings include loss of parenchyma, calyceal blunting, and cortical scars. Treatment usually is directed at correcting the predisposing factors and antibacterial therapy.

Urinary Tuberculosis

Renal tuberculosis is the result of hematogenous spread from other lesions. This infection usually is cortical and bilateral and becomes symptomatic when it ulcerates into the collecting system. Symptoms are similar to those of cystitis. There is abacterial pyuria on Gram stain. Special cultures reveal Mycobacterium tuberculosis. Radiographic findings include calcification of caseous abscess, ulceration, and stenosis of the collecting system. Therapy usually is medical with combinations of isoniazid (INH), ethambutol, rifampin, and pyridoxine.

Genital tuberculosis may accompany renal tuberculosis or may exist alone as a result of hematogenous spread. The epididymis is the most frequent site of infection.

URINARY CALCULI

The consequences of urinary calculi are responsible for many hospital admissions. Primary metabolic stones result from excessive excretion of insoluble substances such as uric acid or cystine. In hyperparathyroidism, increased calcium and phosphorus excretion may result in stone formation. Idiopathic hypercalciuria may be the result of increased intestinal absorption or a renal tubular defect that can lead to stone formation. Excessive absorption of oxalate can produce hyperoxaluria and result in urinary calculi. Secondary stones arise as a result of foreign bodies, obstruction, reflux, or prolonged recumbency. Infections with urea-splitting organisms result in ammonium–magnesium phosphate calculi.

Composition The calcium oxalate stones make up approximately 75 percent of calculi. Ammonium–magnesium phosphate is found with infected urine and accounts for approximately 15 percent of calculi. Uric acid stones constitute approximately 8 percent of all calculi. Cystine stones represent only 1 percent of stones.

Diagnosis Calculi within the ureter usually present with typical colic. Some stones can be asymptomatic, and urinalysis may be negative. Approximately 90 percent of the urinary calculi are radiopaque. Intravenous pyelography generally will diagnose the stone and reveal additional information about obstruction. Retrograde pyelography, ultrasound, and computed tomography (CT) may aid in the differential diagnosis.

Management (Fig. 38-1) Analgesics usually are necessary to relieve severe renal colic. Radiologic evaluation will assist in selecting treatment. About 93 percent of all ureteral calculi less than 4 mm in diameter will pass spontaneously. Those patients who are treated expectantly should have serial renal function evaluations.



FIGURE 38-1 Algorithm for the management of an acute stone event.



Indications and Methods for Removal The mere presence of a stone within the urinary tract does not warrant intervention. Extracorporeal shock-wave lithotripsy (ESWL) is currently the treatment of choice for most urinary stones. This procedure is noninvasive, and morbidity is low. A major disadvantage is the fate of the fragments after treatment. These may cause ureteral obstruction and colic. Stones within the urinary tract also can be approached by endoscopic techniques. A number of energy sources (holmium laser, electrohydraulic, and pneumatic) can be applied directly to the stones for their removal; with the combination of ureteroendoscopy, percutaneous nephrolithotripsy, and ESWL, the need for open surgical procedures has decreased significantly.

Open Surgery The techniques described above should be the initial approach to most urinary calculi. Surgical removal of staghorn calculi represents a clinical challenge. The open surgical approach is recommended by some authors. Occasionally, large bladder stones have to be removed by cystolithotomy. Certain urinary calculi can be dissolved by direct irrigation. Uric acid stones dissolve with alkalinization. Infection stones can be dissolved with Renacidin.

Radiologic Procedures By placing percutaneous nephrostomy tubes, obstruction can be relieved and an emergency situation may become more elective.

Prevention of Recurrence Stones usually recur, and most patients have a previous history of stones. Hydration is the single most important factor in preventing stone formation. Because some stones rapidly form at certain pH levels, this could be adjusted easily. UTIs should be treated. Regulation of diet is particularly important in some situations. A low-protein diet is useful in lowering uric acid levels excreted in the urine. A low-oxalate diet may be effective in preventing calcium oxalate stones. A low-calcium diet may be beneficial in eliminating calcium-containing stones. Urinary calcium can be decreased by hydrochlorthiazides or cellulose phosphate binders. Allopurinol may reduce the uric acid stone formation.

Hyperparathyroidism Most patients with hyperparathyroidism present with urinary calculi. Patients with recurrent urinary calculi should be investigated for increased serum calcium and alkaline phosphatase and decreased phosphorus levels. Serum parathormone level should be assayed. Treatment consists of surgical removal of parathyroid adenoma.

BENIGN PROSTATIC HYPERPLASIA

Benign prostatic hyperplasia (BPH) is a common disorder of the prostate gland. It is more common after the fifth decade of life and is due to benign enlargement of the prostate.

Clinical Manifestations Under the influence of testosterone and aging, the prostate increases in size and can cause obstruction to the outflow of the urinary stream. The onset of symptoms of “prostatism,” such as nocturia, urgency, and decreased force of urinary stream, is insidious. Acute urinary retention is the result of acute detrusor decompensation and usually is seen in patients with long-standing BPH. With digital rectal examination, an enlarged prostate with benign consistency usually can be palpated. A normal-sized gland does not exclude obstruction; cystoscopy is essential to inspect the urethra and the bladder. If radiographic techniques are used, increased bladder wall thickness, high bladder residual urine, and hydronephrosis may be noted. A serum creatinine determination should be obtained to assess kidney function. A thorough urinalysis should be performed to rule out infection. The best noninvasive test to evaluate men with prostatism is to measure their urine flow velocity.

Treatment (Fig. 38-2) Those patients with mild symptoms or enlarged prostates not causing symptoms should be managed by watchful waiting. Men who develop urinary retention, recurrent infections, bladder stones, or renal insufficiency should be treated surgically. For those men with significant prostatism, watchful waiting, medical therapy, and surgery should be presented as treatment options. There are two medical approaches to the treatment of BPH. Alpha-adrenergic receptor blockers relax prostatic smooth muscle, partially relieving the active part of the obstruction. These drugs improve symptoms and flow rates in a significant number of patients. The 5a-reductase inhibitor finasteride reduces intraprostatic dihydrotestosterone levels without lowering plasma testosterone levels. With this drug, prostate size can be reduced significantly; however, only one-third of the men notice improvement in their symptoms.



FIGURE 38-2 The decision diagram for the management of BPH recommended by the U.S. government's AHCPR BPH Guideline Panel.



Transurethral Prostatectomy This is performed by electroresection of the prostate through the urethra. Multiple pieces of the obstructing tissue are removed under direct vision. This procedure can be combined with endoscopic lithotripsy (crushing and removal of a bladder calculus). This technique also is applicable in carcinoma of the prostate that is not amenable to curative or palliative measures. Because of the excellent results obtained with transurethral resection of the prostate, open prostatectomy rarely is performed. The indications for open prostatectomy include large adenoma and associated bladder stone or tumor. Recently, minimally invasive techniques have been developed to relieve the obstruction. Transurethral microwave thermotherapy (TUMT), transurethral needle ablation of prostate (TUNA), and prostatic stents are being perfomed with increasing numbers.

Prognosis Over 90 percent of the patients have complete relief or improvement of their symptoms. Approximately 10–20 percent of the patients will have recurrent obstruction in 5 years.

NEOPLASMS

Renal Tumors

Incidence and Etiology Renal tumors account for 2 percent of all cancer deaths. Tumor probably arises from tubular cells. Etiology is unclear.

Pathology There are three major types of malignant tumors of the renal parenchyma. Granular cell carcinoma and tubular adenocarcinoma account for 60 percent. Wilms' tumor (adenomyosarcoma), which is commonly seen in children, accounts for 14 percent. These are followed by sarcomas and tumors of the collecting system.

Clinical Manifestations The classic triad of pain, mass, and hematuria is seen in fewer than half the patients. Hematuria is a late manifestation. Passage of blood clots can mimic renal stone colic. A mass can be palpated if the lesion is in the lower pole. Fever may be seen, which can be because of necrosis. Hypertension may be the result of compromised renal perfusion from tumor compression. Renal tumors can secrete excessive erythropoietin, which will result in erythrocytemia. Metastases involve the lung, bone, lymph nodes, liver, and skin.

Diagnosis Excretory urography is frequently diagnostic. Nephrotomography is helpful in differentiating cysts from tumors. Calcified cysts are more suggestive of tumor. Ultrasound also is very helpful in differentiating cyst from tumor. Renal arteriography is occasionally needed, and inferior vena cavography may be necessary to rule out tumor extension into the venous system. CT not only is diagnostic but also gives valuable information regarding the extent of the tumor. Magnetic resonance imaging (MRI) also can be diagnostic and may be more sensitive for showing venous extension.

Treatment Removal of the kidney with perinephric fat and lymph nodes offers the best chance of cure. Radiation therapy or chemotherapy generally is not effective. There have been some promising results with adaptive immunotherapy.

Prognosis This depends on the grade and extension of the tumor. The overall survival rate for renal tumors is about 50 percent at 5 years.

Carcinoma of the Renal Pelvis and Ureter

Tumors of the pelvocalyceal system usually are transitional cell types. Squamous cell carcinoma is rare and generally associated with chronic infection or calculous disease. Gross hematuria and colic are a common mode of presentation. Intravenous pyelography is diagnostic, showing the filling defect in the pelvis or the ureter. Cytology also is helpful in establishing the diagnosis. Treatment is by removing the kidney and the ureter.

Tumors of the Urinary Bladder

Incidence and Etiology This tumor is seen more commonly after the fifth decade of life. The usual lesion is transitional cell carcinoma, and it is more common in males. Papillary bladder tumors have been linked to certain chemicals, cigarette smoking, schistosomiasis, and bladder calculi.

Clinical Manifestations Gross or microhematuria is the initial sign in most patients. When the tumor is confined to the bladder, physical findings are minimal. The tumor can be visualized on excretory urography; however, cystoscopy and biopsy are confirmatory. Local extension and metastasis can occur. Bimanual examination may reveal fixed bladder in the pelvis. Urine cytology and flow cystometry are also helpful in the diagnosis.

Treatment and Prognosis Endoscopic resection is suitable for superficial lesions. Most tumors recur with superficial lesions; very few patients eventually will have invasive lesions. For locally invasive tumors, the best treatment is total cystectomy with urinary diversion. Definitive radiation therapy and combination chemotherapy may provide satisfactory results. Intravesicle administration of certain chemotherapeutic agents or bacille Calmette-Guérin (BCG) may reduce the recurrence rate of superficial lesions.

Carcinoma of the Prostate

Incidence and Etiology The cause of prostate cancer is not known; it is rare before age 50 and not seen in eunuchs. It is the second most common cancer in males in the United States.

Early Carcinoma This is the stage in which the carcinoma is localized to the gland. Prostatic-specific antigen (PSA) is a sensitive but not specific blood test for detecting prostatic carcinoma. More than 50 percent of the nodules palpated on rectal examination are positive for cancer on biopsy. Patients with localized cancer are best treated with prostatoseminalvesiculectomy. Careful dissection will preserve continence and sexual function. Ultrasound-guided transrectal biopsy is the most accurate diagnostic technique. On rectal examination, carcinoma usually feels rock hard; however, this could be seen in prostatitis, BPH, calculus, and bladder or rectal cancer extension. Bony metastasis can be evaluated with a bone scan. Serum acid phosphatase may be elevated in metastatic cancer. Histologically, prostatic malignant tumors are adenocarcinomas. Prognosis depends on the degree of differentiation and the stage of the disease.

Alternative treatment of early carcinoma is radiation therapy. Some centers report similar survival rates with surgery and radiation therapy and brachytherapy. Cure can be achieved only by total removal of the lesion. Patients who are not candidates for radiation therapy or surgery can be treated with antiandrogen therapy.

Advanced Carcinoma Patients can present with bladder outlet symptoms. Weight loss, extremity pain, gross hematuria, and lower extremity lymph edema can be seen. Rectal examination reveals a fixed, stony hard prostate. Acid and alkaline phosphatase and PSA are elevated. PSA also can be elevated in localized carcinoma. Treatment of symptomatic advanced carcinoma is with antiandrogen therapy. This could be done with bilateral orchiectomy, administration of estrogens, ketoconazole, flutamide, cyproterone acetate, amino glutethimide, and luteinizing hormone–releasing hormone (LHRH). Palliation is obtained in approximately 90 percent of the patients. Local radiation therapy for painful bone metastasis also is effective.

Testicular Tumors

Incidence and Etiology Testicular tumors account for 1 percent of cancers in the male. The average age at diagnosis is 30. They occur more frequently in undescended testes. Testicular cancer is infrequent in blacks.

Clinical Manifestations These patients usually present with a lump in their testis. The examination usually finds a firm, nontender, solid mass. These must be differentiated from hydroceles and epididymitis. Late symptoms of metastasis include weight loss, fatigue, lymph node enlargement, and ureteral obstruction.

Diagnosis and Treatment (Fig. 38-3) When a testicular tumor is suspected, an inguinal exploration is required. The testis, along with the spermatic chord, usually is removed, and a radical orchiectomy is performed. Before orchiectomy, human beta-chorionic gonadotropin (b-hCG) and alpha-fetoprotein (AFP) tumor marker levels should be obtained. Seminomas represent approximately 40 percent of malignant testis tumors, embryonal cell carcinomas and teratocarcinomas about 25 percent each, and teratomas 8 percent; choriocarcinoma is limited to approximately 1–2 percent. Benign tumors of the testis are very rare. Because seminomas usually are very radiosensitive, further operation usually is not indicated. Nonseminoma testicular tumors will require bilateral retroperitoneal lymph node resection for accurate staging of the disease. The use of combination chemotherapy has markedly increased the survival of these patients with advanced metastatic tumors. Survival depends on the cell type and the stage of the disease at the time of diagnosis.



FIGURE 38-3 Algorithm for the evaluation and management of testicular cancers.



Carcinoma of the Penis

Carcinoma of the penis develops in the squamous epithelium of the glans and foreskin and is almost eliminated by circumcision at infancy. This lesion is uncommon in the United States, and the average age of onset is over 60 years. Patients usually present with an ulcerated lesion on the penis, and the diagnosis is obtained by biopsy. Local excision and radiation therapy are associated with a 90 percent 5-year cure rate when there is no distant metastasis. When there is lymph node involvement, the 5-year survival is reduced to 30 percent.

SEXUAL DISORDERS

Priapsm Priapsm is defined as prolonged erection without sexual excitement. It results from vascular disorders in which blood is trapped by venous occlusion and cannot escape. The most common cause is injection of erection-producing agents by the patient. The treatment is the slow injection of a few millimeters of 1:1000 epinephrine directly into the corpora. If this fails, heparinized saline may be effective. In some instances, incision and drainage are required.

Impotence Impotence is defined as the inability to generate or maintain an erection. Erection can be enhanced by alpha-adrenergic blockers, which are now available and effective. Erection also can be produced by a vacuum tube device or the implantation of solid or inflatable penile prosthesis.

Infertility In evaluating infertility, both partners must be investigated. The man is responsible in about 20 percent of cases and a contributing factor in about 30 percent. Semen analysis is best taken 3 days after sexual abstinance. Patients are classified as azoospermic, oligospermic (<20 million sperm/mL), or normospermic.

Failure to ejaculate can be caused by drugs, an incompetent bladder neck, advanced atherosclerosis, or diabetes mellitus.

GENITOURINARY TRACT INJURIES

Renal Injury (Fig. 38-4)



FIGURE 38-4 Algorithm for the management of renal trauma. (From: Wessels H, McAninch JW: Update on upper urinary tract trauma. AUA Update Series, vol 15, 1996, with permission.)



Blunt renal trauma is more common than penetrating kidney trauma. Rapid deceleration such as the impact after a fall may result in renal vessel injury. Patients who suffer renal injury usually will have gross hematuria or microhematuria. Diagnosis of renal injury is confirmed by excretory urography or CT scan. Abdominal CT may be the single most important diagnostic test. It will give not only adequate visualization of the renal structures but also an idea about other intraabdominal organs. Patients with renal contusions and lacerations without extravasation of urine may be treated conservatively. When there is failure to visualize a kidney on a CT scan and arteriograph, or when there is significant extravasation, surgical treatment is considered. Every effort should be made to preserve renal parenchyma. In massive trauma to the kidney, nephrectomy may be a lifesaving procedure. Most cases of renal trauma can be treated conservatively.

Ureteral Trauma

Ureteral injuries occur mainly as a result of surgery. If the injury is recognized, direct repair over an indwelling stent can be performed. If it is not recognized, the patient may present with anuria, urinary fistula, or urinoma. The ureters also can be injured by penetrating objects such as bullets and knives. In this case, exploratory laparotomy and surgical repair usually are indicated.

Bladder and Urethral Injury

The full bladder is more vulnerable to trauma. Direct blows and penetrating injury by spicules of bone, stab wounds, and gunshot wounds may all result in rupture of the bladder. Direct blows usually cause intraperitoneal rupture; the penetrating injuries usually are extraperitoneal. Urine can be grossly bloody, and the patient may not be able to void. When there is suspicion of bladder trauma, a retrograde urethrogram and cystogram should be obtained. Blood at the meatus suggests urethral injury; retrograde urethrography should be done before any instrumentation of the urethra. Treatment of severe bladder trauma usually consists of surgical repair and cystostomy drainage. In most cases of bladder injury, conservative management without an operation may be satisfactory. This especially is true in extraperitoneal rupture of the bladder, in which catheter drainage may result in adequate healing. If the urethra is avulsed, this may be repaired at the time of repair of the bladder rupture. If the trauma is extensive and the patient's condition is poor, cystostomy under local anesthesia may be the procedure of choice, and this would allow second-stage repair.

External Genitalia

Penis Injury to the corpora cavernosa may result in extravasation of blood and urine within or outside of Buck's fascia. They may be caused by penetrating trauma or blunt trauma sustained during vigorous sexual intercourse. These injuries must be explored through a circumcising incision with degloving of the penis and repair of the corpora. Degloving injuries of the penis mandate surgical debridement and skin grafting. Traumatic penile amputation can be salvaged with microsurgical repair of the dorsal penile arteries and vein and selective skin grafting.

Scrotum Scrotal skin is elastic and can be mobilized to cover extensive defects. If the scrotal tissue is insufficient, the testes can be temporarily placed in thigh pockets.

Testes Ruptured testes may occur from either blunt or penetrating trauma, and in some cases debridement can be performed and the tunica albuginea closed. A completely shattered testes will require orchiectomy.

PEDIATRIC UROLOGY

The genitourinary system should be evaluated in all instances of “failure to thrive” syndrome, undiagnosed febrile illnesses, externally apparent congenital anomalies, and abdominal masses. Wilms' tumor of the kidney and neuroblastoma of the adrenal gland are the most common solid tumors in children.

Congenital Anomalies

Phimosis (Redundant Prepuce) Poor hygiene predisposes this condition to infection and carcinoma of the glans penis. Circumcision usually is recommended.

Urethral Meatal Stenosis This condition can be congenital or acquired in the male. It is easily detected by inspection, and treatment consists of meatotomy.

Urethral Valves These usually are seen in boys and produce variable changes because of obstruction. Diagnosis is established by voiding cystourethrography and endoscopy. Along with dilatation of the posterior urethra, hydroureteronephrosis is common. Endoscopic incision or fulguration of the valves usually is done early. In some cases, excessive dilatation may require a supravesical diversion such as a cutaneous vesicostomy.

Neurogenic Bladder This usually is the result of autonomic dysfunction accompanying meningomyelocele. The patient presents with overflow incontinence, infection, and impaired voiding. Diagnosis is established by cystourethrography and cystometry. Mild cases can be treated by bladder rehabilitation and preventing infections. Severe cases are treated by reducing residual urine with surgery or intermittent catheterization.

Ureterocele This is cystic dilatation of the intravesicle portion of the ureter. The ureteral orifice may or may not be stenotic. This may become large enough to obstruct the urethra. Diagnosis can be made with the cystogram phase of the intravenous pyelogram. The contrast-filled intravesicle mass is referred to as “cobra head” deformity. Treatment usually is surgical.

Vesicoureteral Reflux This may be associated with posterior urethral valves, “prune belly” syndrome, complete duplication of the collecting system, ectopic ureter, ectopic uretercele, neurogenic bladder, bladder neck obstruction, and bladder infections. In adults there are often no adverse effects of the reflux, and most cases can be managed without an operation by minimizing the amount of residual urine. Submucosal injection of polytetrafluoroethylene or collagen has been shown to eliminate vesicoureteral reflux. Reimplantation of the ureter into the bladder is required almost exclusively in young children.

Hydronephrosis This often is a result of a congenital obstruction at the ureteropelvic junction. This can result in significant dilatation and atrophy of the renal parenchyma. Children commonly present with a palpable abdominal mass. Intravenous pyelography and ultrasonography will establish the diagnosis. Pyeloplasty is the treatment of choice; however, nephrectomy may be required for poorly functioning kidneys.

Congenital Nonobstructive Renal Disease Congenital or neonatal glomerular disease usually is fatal. There are many forms of cystic disease of the kidney. In medullary cystic disease, collecting ducts are ectatic, whereas in polycystic disease, there is a failure of communication between tubules and glomeruli. Nonfunctioning multicystic disease may be a failure of development of the metanephric blastema. Detailed renal function studies and close follow-up are required.

Cryptorchidism About 30 percent of premature males have an undescended testicle. The incidence in full-term males is 4 percent. Spontaneous descent occurs in most patients by 1 year of age. Bilateral cryptorchidism after 1 year should be treated initially with gonadotropins, resorting to operation in refractory cases. Unilateral cryptorchidism can be treated with surgery, repairing the associated indirect hernia at the time of orchiopexy. There is an association between cryptorchidism and testicular malignancy.

Hypospadias This is a fusion defect of the urethra. The anomaly consists of a dorsal hood (absent ventral foreskin), chordee (ventral curvature of the penis), and proximal location of the urethral opening. Hypospadias can be associated with abnormal urinary stream and infertility. Hypospadias with the urethral opening in the scrotum can be accompanied with bilateral undescended testicles; this must be differentiated from adrenogenital syndrome or pseudohermaphroditism. Treatment consists of surgical correction.

Epispadias This is associated with a dorsally cleft urethra, which is very rare.

Exstrophy of the Bladder In this anomaly, the bladder is part of the abdominal wall. Several procedures usually are required for total reconstruction.

Ectopic Ureteral Orifice This usually is associated with duplex ureters, and the ectopic orifice drains the upper collecting system. The condition is more common in females. When the opening is in the vagina, incontinence is the rule. Treatment is surgical.

Testicular Neoplasms

Embryonal carcinoma is the most common testicular tumor of children. Teratoma before puberty can be a benign tumor for which a high inguinal orchiectomy is curative. Conversely, teratoma after puberty should be managed as a teratocarcinoma. Gonadoblastoma usually occurs in patients with gonadal dysgenesis.

Torsion

Although torsion can occur at any age, it is more common before puberty. The isotope scan is helpful in making the diagnosis, but the scan should not delay surgical repair. At operation, the tunica vaginalis is opened, and the testicular necrosis is evaluated. A decision must be made as to whether to remove the testes. After detorting the cord, a bilateral orchiopexy should be performed.

Varicocele

This results from an incompetent valve or obstruction of the gonadal vein. There is an association between varicocele and subfertility. The indications for repair include size, persistent scrotal pain, growth, and subfertility.

Hydrocele and Hematocele

Hydrocele is an accumulation of clear fluid within the tunica vaginalis. It is repaired as an indirect inguinal hernia. The collection of blood within the tunica vaginalis can result from trauma or rupture of the tunica or testes. This is known as a hematocele and should be treated by aspiration or open drainage.

OPERATIONS ON GENITOURINARY ORGANS

Nephrectomy

Nephrectomy can be performed by a retroperitoneal flank approach or by a transabdominal anterior approach. The flank approach usually is preferred in the treatment of inflammatory disease, calculi, perinephric abscess, hydronephrosis, and renal cystic disease. Nephrectomy for renal carcinoma is performed through the transperitoneal approach, in which the vascular ligation is carried out early.

Cutaneous Ureteroileostomy (Ileal Conduit)

This is the most popular method of supravesicle urinary diversion. The major indication for this procedure is urinary diversion after removal of the bladder. The patient has an ileal conduit that is continuously draining urine to the skin and requires carrying drainage bags. Recently, there have been modifications of the conduit in which the stoma has been made into a continent drainage system. These selected patients have to catheterize their conduits. There also is research developing continent neobladders using small or large bowel segments. An ileal loop usually is constructed through a midline abdominal incision. The stoma is created before the creation of the conduit on the appropriate area of the abdomen. A segment of ileum then is mobilized, and the bowel is reanastomosed end to end. The ureters are anastomosed to the conduit at one end, and the conduit at the other end is brought out through the skin as a stoma.

Cystostomy, Cystolithotomy

The bladder usually is approached with a lower abdominal incision, and the detrusor muscle can be incised longitudinally. If stones are present, these are removed. Drainage can be provided by a large catheter. In the urinary tract it is important to use absorbable sutures such as chromic catgut. Introduction of any foreign bodies such as silk sutures will result in the formation of stones.

Prostatectomy

Transurethral Prostatectomy This is the most common operation to remove prostatic obstruction. This is done endoscopically using a resectoscope. Using electric current and a cutting loop, prostatic tissue is resected, and hemostasis is secured with electrocoagulation. A catheter is inserted and left in place for several days for hemostasis, after which it is removed and patient's voiding observed.

Suprapubic Prostatectomy This operation is performed through a cystotomy approach, as described previously. The adenoma is mobilized and enucleated using finger dissection. The surgical capsule of the prostate is left behind. Hemostasis is obtained, and a suprapubic tube as well as a urethral Foley catheter are left indwelling. The urethral catheter is removed in 5–7 days, and the patient is observed voiding.

This also is accomplished through an incision intraabdominally, but the bladder is not entered during this operation. An incision is made on the bladder neck, and the capsule of the prostate is incised. After this, the adenoma is exposed and dissected through the capsule of the prostate and removed. Hemostasis is established, and again, the capsule is closed with absorbable sutures. Adequate drainage of the urinary tract is established by a Foley catheter and a suprapubic tube.

Hydrocelectomy

A vertical scrotal incision is used; the hydrocele sac is approached and dissected. The sac is entered and fluid evacuated. The excess tunica is excised, and hemostasis is established. The layers are reapproximated with absorbable sutures. Hydrocelectomy in children is carried out through an inguinal incision. At this time, hernia repair usually is undertaken.

Inguinal Orchiectomy

This is performed when a testicular tumor is suspected. It provides access to the spermatic vessels before manipulation of the testis. The spermatic cord is identified and ligated. The spermatic cord and the testis are then removed and sent to pathology.

Orchiopexy

This is performed through an inguinal incision and permits mobilization of the spermatic cord and correction of the indirect hernia. The testis is then brought to the scrotum and placed in a Dartos pouch and fixed. No tension is placed on the spermatic cord.

Bilateral Vasectomy

This is a male sterilization procedure usually performed under local anesthesia in an outpatient setting. The vas deferens on each side of the scrotum are identified, and these are dissected, tied, and coagulated. A small portion of the vas is then sent to pathology for identification.

Vasovasostomy

This procedure is carried out on an in-hospital basis and can be done under local or general anesthesia. The incision is made in the scrotum on both sides of the vas. The granulomatous areas of the vas are excised until sperm is noted coming from the testicular portion of the vas. Using magnification with either surgical loops or a microscope, the anastomosis is performed in an end-to-end fashion.

Laparoscopic Surgery

Laparoscopic surgical techniques have been applied to urology. Pelvic lymphadenectomy, varicocelectomy, and nephrectomy have been performed. Living-donor nephrectomy has been performed with this approach. As the technology develops, it is believed that there will be more urologic applications.

For a more detailed discussion, see Pearle MS, McConnell JD, and Peters PC: Urology, chap. 38 in Principles of Surgery, 7th ed.

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Copyright © 1998 McGraw-Hill
Seymour I. Schwartz
Principles of Surgery Companion Handbook