Autologous tissue used to create a structure or a replacement structure within the body. Used here to describe the creation of a bladder reservoir from bowel tissue that communicates with the urethra.

Retroperitoneal

Behind the peritoneal cavity.

Transurethral

Through the urethral canal.

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Anatomy and physiology of the urinary system

The urinary system provides the vital life-sustaining functions of extracting waste products from the bloodstream and excreting them from the body. Organs of this system include bilateral kidneys and ureters, the bladder, and the urethra (Fig. 35-1). An obstruction to blood flow in the renal arteries or any part of the urinary system can cause renal damage, which ultimately results in uremia (a biochemical imbalance) or renal failure if left undiagnosed and untreated. Vascular hypertension, tumors, infection, trauma, and other systemic or neurogenic disorders are of major concern to a urologist.⁹^,¹⁶

FIG. 35-1 Anatomy of the urinary tract. A, Male urinary tract. B, Female reproductive organs and urinary system. (B, *From Thibodeau GA, Patton KT:* Anatomy and physiology, *ed 5, St. Louis, 2007, Mosby.)*

Special features of urologic surgery

Urologic endoscopy

Cystoscopic diagnostic procedures and some conservative urologic procedures approached through the urethra are performed in a specially designed and equipped area that is often referred to as the cysto room or suite. This area may be located within the OR suite or in the urology clinic. X-ray control booths and developing units are located adjacent to or within the area. Because x-ray procedures are often performed, the walls and doors of the room should be lined with lead and personnel remaining in the room with the patient during x-rays or fluoroscopy should wear lead aprons. Patients should be protected with gonadal and thyroid shields whenever feasible.

To protect the welfare of the patients and personnel, all safety regulations apply in the cysto room as they do elsewhere in the OR suite. All lighted instruments and electrical equipment should be checked for proper function before and after each use. Excess fluid should not be permitted to accumulate on the floor.

Proper OR attire is worn by all personnel entering the room. Personal protective equipment such as eyewear and masks should be worn if there is a possibility of splash or aerosolization. Many urologists don a water-repellant apron before scrubbing. It is recommended that the urologist wear a sterile gown and sterile gloves. Procedures performed in the cysto room should be performed as in a sterile field to prevent introducing microorganisms into the patient. Adherence to the principles of aseptic technique should be practiced to prevent urinary tract infection.

Urologic bed

A urologic bed differs from the standard operating bed in that it provides an x-ray–compatible base, a drainage system, and lithotomy knee supports with safety belts (Fig. 35-4). Some urologic beds incorporate electrosurgical units (ESUs). Urologic radiographic studies use conventional x-rays, fluoroscopy and image intensification, and tomography. The imaging system is an integral part of the urologic bed. Some beds have a built-in automatic x-ray film-handling system, others have a film cassette holder, and others adapt to a C-arm.

The drainage system may have a drainage pan with tubing to drain port or single-use drainage bags. Under-knee/calf supports with gel pads and Velcro straps provide patient comfort in the lithotomy position (Fig. 35-5). Urologic beds are equipped with hydraulic or electric controls to adjust height and tilt. Some have tray attachments for the light source and auxiliary ESU, as well as hooks for irrigating solution bags.

FIG. 35-5 Knee crutch stirrup commonly used with urologic table.

Patient preparation for a cystoscopic examination

1. Unless the procedure will be performed with the patient under general or regional anesthesia, the patient may be encouraged to drink fluids before coming to the cysto room. Fluids ensure rapid collection of a urine specimen from the kidneys. Some tests require the ability to void for bladder strength studies or while contrast medium passes through the urinary system. Electromyographic (EMG) data may be gathered during the process.

2. Intraurethral procedures are often performed with topical agents or local infiltration anesthetics. The patient should be reassured that the procedure usually can be performed with only mild discomfort. Respect the patient’s modesty by providing appropriate drapes and keeping the cysto room door closed.

3. The patient is assisted into the lithotomy position with the knees resting in padded knee supports or stirrups. Gel pads behind the legs and knees help avoid undue pressure in popliteal spaces. Velcro straps are used to secure the patient’s legs. Some cystoscopic procedures are performed with the male patient in the supine position.

4. The drainage pan is pulled out of the lower break of the urologic bed after the patient’s legs have been positioned on knee supports and the foot of the bed has been lowered.

5. The pubic region, external genitalia, and perineum are mechanically and chemically cleansed with an antiseptic agent according to routine skin preparation procedure. Scrub soaps can be diluted with warmed sterile saline or water for the comfort of the patient.

6. Topical anesthetic agents are instilled into the urethra at the end of the prep procedure. A viscous liquid or jelly preparation of lidocaine hydrochloride, 1% or 2%, may be used. This medium remains in the urethra rather than flowing into the bladder.

a. For the female: The female urethra is most sensitive at the meatus. A small, sterile cotton-tipped applicator dipped into the anesthetic gel and placed in the meatus is sufficient anesthesia for local urethral procedures. The applicator is removed when the urologist is ready to introduce an instrument. Cone-shaped syringes are commercially available for intraurethral instillation of local lidocaine 2% jelly.

b. For the male: A disposable cylinder with an acorn tip can be used for intraurethral insertion. The agent is injected into the urethra, and the penis is compressed with a noncrushing spring-loaded penile clamp for a few minutes to retain the drug.

7. A sterile stainless steel filter screen is placed over the drainage pan. The patient is draped as for other perineal procedures in the lithotomy position. The urologist may need to have access to the rectum. The perineal sheet has two fenestrations: one exposes the genitalia, and the other fits over the screen on the drainage pan. A gauze filter is incorporated into this latter fenestration to capture resected tissue.

The urologist may prefer to wear a sterile disposable plastic apron over his or her gown. The apron is attached to the bed, which provides a sterile field from the urologic bed to the urologist’s shoulders. A receptor kit that attaches to the apron eliminates the need for the drainage pan. Tissue specimens are collected as irrigating fluid passes through a collecting basket.

Urologic endoscopes

Urologic endoscopic instruments and catheters are available in sizes to suit infants, children, and adults. The sizes of these instruments and catheters are measured on the French (Fr) scale: the diameter in millimeters (mm) multiplied by 3. The smallest ureteral catheter is 1 mm in diameter, or 3 Fr; the largest is 14 Fr.

Each type of procedure requires specific endoscopic equipment. All rigid urologic endoscopes have the same basic components, which are discussed in the following sections (Fig. 35-6).

FIG. 35-6 A, Rigid cystoscopy. B, Flexible cystoscopy.

Sheath

The hollow sheath, through which the urologic endoscope passes, may be concave, convex, or straight in configuration at the distal end (the end inserted into the urethra) (Fig. 35-7). The other end has a stopcock attachment for irrigation. Sheath sizes range from 11 Fr for infants to 30 Fr for adults. Space is provided within the sheath to accommodate instruments for work in the bladder or urethra. Other instruments and catheters can be inserted through the sheath into the ureters and/or kidneys for diagnostic or therapeutic procedures.

Obturator

The stainless steel obturator, which is inserted into the sheath, occludes the opening of the sheath and facilitates introduction into the urethra without trauma to the mucosal lining.

Telescope

Telescopes are complex precision optical systems; they are costly, delicate instruments that are handled gently at all times. Each telescope contains multiple finely ground optical lenses that relay the image from the distal end inside the bladder or urethra to the ocular (eyepiece) used by the urologist to view internal structures. Additional rod-shaped elements (i.e., field lenses) are located between each pair of relay lenses. Properly spaced throughout the length of the telescope, the lenses provide undistorted and clear vision at the desired angle and with some magnification. All telescopes are stainless steel and have a Bakelite ocular. Some telescopes have operating or working elements incorporated into them.

The optical systems provide several angles of vision (Fig. 35-8):

• Direct forward or 0-degree vision is useful for viewing the urethra and for use with the optical urethrotome (an instrument for sharp resection of tissue in the urethra).

• Right-angle or 30-degree vision is most suitable for viewing the entire bladder and insertion of ureteral catheters.

• Lateral, which deviates 70 degrees but includes an additional visual field at a right angle in the line of vision, is used for wide-angle viewing within the bladder.

• Foroblique, which is a forward vision with an oblique view somewhat in front of a right angle, is used to examine the urethra and for transurethral surgical procedures.

• Retrospective, which provides an approximate 55-degree angle of retrograde vision, is used to inspect the bladder neck.

Light source

The light source is a fiberoptic bundle and may be an integral part of the sheath or the telescope. A cable connects the instrument to a fiberoptic light source.

Types of urologic endoscopes

Many different types of urologic endoscopes and accessories are used, including nephroscopes introduced into the kidney and cystoscopes introduced through the urethra into the bladder. Before instrumentation is placed on the sterile instrument table, the preferred type and size of the endoscope for the examination and/or treatment should be verified with the urologist. The endoscopes and accessories most commonly used in the cysto room are described in the following sections.

Brown-buerger cystoscope

The stainless steel sheaths of the Brown-Buerger cystoscope range in size from 14 to 26 Fr. Used most often in adults is the size 21 Fr with a right-angle examination telescope for routine inspection of the bladder. Size 24 or 26 Fr is used to accommodate larger instruments and catheters that cannot be used through size 21 Fr. The sheath contains the light carrier.

A Brown-Buerger cystoscope set usually consists of two sheaths—one concave and one convex, each with its own obturator—and two or three right-angle telescopes. Along with the basic examination telescope, the set may have a combination operating and double catheterizing telescope (i.e., a convertible telescope), or the operating and double catheterizing functions may be in separate telescopes. The convertible operating and catheterizing telescopes have a small, deflectable lever on the distal end to aid in directing ureteral catheters or flexible stone baskets into the ureters. All corresponding parts of each set must be the same French size.

Mccarthy panendoscope

The stainless steel sheaths of the McCarthy panendoscope range in size from 14 to 30 Fr. These are used most often with the Foroblique telescope for viewing the urethra. Other telescopes are available for bladder visualization. The telescopes are interchangeable with all sizes of sheaths. A bridge assembly is required to fit the telescope properly to the sheath. The light is supplied through the telescope.

Wappler cystourethroscope

The Wappler cystourethroscope combines the functions of the Brown-Buerger cystoscope and the McCarthy panendoscope. The stainless steel sheaths range in size from 17 to 24 Fr. The Foroblique and lateral telescopes, which also supply the light, are interchangeable with all sheaths. A visual obturator may be used to permit visualization and irrigation during the introduction of the sheath into the urethra.

Resectoscope

The resectoscope uses electric current to excise tissue from the bladder, urethra, or prostate (Fig. 35-9). Components of this instrument include the sheath, obturator, telescope, working element, and cutting electrode. The sheath, usually 24 to 28 Fr, is made of Bakelite or fiberglass to prevent a short circuit of the electric current. If the short beak post sheath is used with a wide-angle telescope, a Timberlake obturator is used to introduce the sheath into the urethra.

The working element of the resectoscope, which is inserted through the sheath, has a channel for the telescope and cutting electrode. The types of working elements differ by the method in which the cutting electrode moves:

• The Iglesias resectoscope uses a thumb control on a leaf spring–lock mechanism. The working element can be adapted for simultaneous irrigation and suction to control hydraulic pressure in the bladder.

• The Nesbit resectoscope uses a thumb control on a spring.

• The Baumrucker resectoscope uses finger control on a sliding mechanism.

• The Stern-McCarthy resectoscope uses a rack and pinion to move the loop forward and back. This requires two hands.

The cutting electrode is the most critical component of a resectoscope. Because it cuts and coagulates tissue, the electrode must be stabilized in the working element so it retracts properly into the sheath after each cut. The electrode has a cutting loop from which electric current is passed through tissue, an insulated fork, an insulated stem, and a contact that is inserted into the working element. Several loop sizes are available; the stem is usually color-coded by size. Loop size corresponds to the French size of the sheath. The electrode is malleable and therefore is checked before use to be certain the insulation is intact and the loop is not broken.

Electric current is applied only when the loop is engaged in tissue, and it is inactivated after a cut is completed. The sheath can be charred if electric current is maintained after the cutting loop has been retracted into it. Disposable loop electrodes are commercially available and are preferred for use by most urologists. Conductive lubricants may provide a pathway for electric current and therefore should never be used on the sheath. Cleanliness of the sheath and all other components is essential to proper function.

Endoscopic accessories

Ureteral catheters, bougies, filiforms and followers, stone baskets, and sounds are commonly used by urologist-endoscopists. Other accessories, such as retractable baskets and graspers, are used to remove tissue or calculi (stones).

Electrodes

In addition to the cutting loops used with the resectoscope, primarily for transurethral resection (TUR), other types of electrodes with tips of various shapes are used in the bladder. One type, referred to as a Bugbee, is inserted through the operating telescope of the Brown-Buerger cystoscope or Wappler cystourethroscope. The Bugbee is used mainly for fulguration of bladder tumors, coagulation of bladder vessels to control bleeding after biopsy, and ureteral meatotomy. More electric current is needed when working in solution (as in the bladder) than when working in air.

A spark-gap generator is commonly used for transurethral resection and fulguration. A spark-gap ESU requires high-voltage arcing, which is described as spray coagulation. Spark-gap generator use requires the patient to be grounded with a grounding pad. The power control settings on the ESU should be as low as possible. Recommended practices as suggested by the Association of periOperative Registered Nurses (AORN) for the use and care of electrosurgical equipment (e.g., return electrodes) apply also to urologic procedures. Additional information about electrosurgical units can be found in Chapter 20.

Lasers

Argon, neodymium:yttrium aluminum garnet (Nd:YAG), and holmium (Ho):YAG lasers can be adapted for use with urologic endoscopes. These are particularly useful for the ablation of hemangiomas and vascular tumors in the bladder and kidneys. The argon-pumped tunable dye laser is used for photodynamic therapy on solid bladder tumors. A flash lamp-pulsed dye laser will fragment a calculus in a ureter.

Lasers used through endoscopes require most of the same equipment as needed for standard urologic endoscopy. The bladder expansion medium can be either saline or water to create the working space because unlike with the ESU and electrodes, no ionic charge is emitted from the laser.

Irrigating equipment

Continuous irrigation of the bladder is necessary during cystoscopy (cysto) to do the following:

• Distend bladder walls to create a working space so the urologist can visualize them.

• Wash out blood, bits of resected tissue, or stone fragments to permit continuous visibility and collection of specimens.

A sterile, disposable, and closed irrigating system is used because it prevents airborne contamination of the solution. The tubing is Y shaped (Fig. 35-10). Two or more liters of sterile irrigating solution may be needed for a single examination. Disposable tandem sets may be used to connect several containers together. Tandem sets allow for a continuous flow and replacement of containers without interruption of flow.

Sterile disposable irrigating tubing is connected to the irrigating solution container before it is hung on a hook on the urologic bed, in the ceiling, or on a stand placed beside the bed. The solution container should be at a level 2½ feet (0.75 m) above the bed; a lower level decreases flow, and a higher level increases hydraulic pressure with consequent fluid absorption by the tissues of the patient. Tubing should be filled with solution before being attached to the sheath of the cystoscope or resectoscope. The plastic tubing from the container to the instrument is for individual patient use only and is discarded after use.

Sterile isosmotic irrigating solutions that are nonhemolytic and nonelectrolytic are generally preferred by most urologists. Sterile distilled water may be used for visualization procedures and during resection or fulguration of bladder tumors with an ESU. Water may hemolyze red blood cells if a sufficient amount enters the circulation through open blood vessels. As much as 3 to 6 L of solution may be absorbed during a transurethral prostatectomy.

Saline is contraindicated for use with a monopolar ESU because the minerals in saline act as a conductor and disperse the current when the ESU is used. Newer bipolar resectoscopes use saline irrigation without problems.

Isosmotic solutions of 1.5% glycine (an amino acid) or sorbitol (an inert sugar) premixed in distilled water are commercially available in 1.5- and 3-L containers.

Glycine solution is sometimes used for TUR with an ESU; however, it can cause serious complications in some patients. Overabsorption of glycine can occur during TUR, causing water intoxication with resultant hyponatremia and acid-base imbalance (acidosis). This process has been called transurethral resection syndrome and is hallmarked by dilutional hyponatremia.

During a cysto procedure, the flow of solution into the endoscope is controlled by the stopcock on the sheath where the tubing attaches. Rubber tips or sealing caps are used to seal other openings on the instrument to prevent solution from escaping during a procedure. The openings through which catheters or instruments are to be inserted are closed with rubber caps that have a central hole. The accessory can be inserted through this hole with the seal maintained. Silicone caps should be used instead of rubber caps if the patient or surgeon has a latex sensitivity.

The irrigating solution flows away from the instrument and into the drainage pan through the filter screen when the urologist needs to divert the flow. Solution drains from the pan, through the tubing, and into a collecting container that is emptied after each patient use. Some older cysto rooms have floor drains, which are a source of environmental contamination unless cleaned thoroughly. If large quantities of solution are used, the level of drainage into the container should be observed to prevent overflow onto the floor or around the foot pedal of the ESU, which can be an electrocution hazard.

Evacuators

Evacuators may be attached to the endoscope to irrigate the bladder and aspirate stone fragments, blood clots, or resected tissue. Stone or tissue fragments collected in the evacuator are retrieved and sent to the pathology laboratory. The two most commonly used types are the Ellik evacuator and the Toomey evacuator:

• Ellik evacuator. The Ellik evacuator is a double bowl-shaped glass or firm disposable plastic receptacle (Fig. 35-11). It contains a trap for fragments so they cannot be washed back into the sheath of the endoscope during irrigation with pressure on the compression-bulb attachment.

FIG. 35-11 Ellik evacuator for flushing prostate tissue from the bladder during transurethral resection of the prostate (TURP).

• Toomey evacuator. The Toomey evacuator is a syringe-type evacuator with a wide opening into the barrel (Fig. 35-12). It may be used with any endoscope sheath. A metal adapter permits its use with a catheter.

Care and preventive maintenance of urologic endoscopes

1. Sterilization is preferred, although high-level disinfection with 2% glutaraldehyde is commonly used. Endoscopes and reusable accessories must be free of debris and residue for sterilization and/or high-level disinfection techniques to be effective.

a. Disassemble all parts, and open all outlets.

b. Clean all parts in an appropriate liquid detergent solution. Clean the interior of sheaths and openings with a soft brush.

c. Rinse in clean water, and dry thoroughly.

d. Wipe lenses gently with a soft, dry cloth.

2. After cleaning, place endoscopes on a towel to drain. With air, blow-dry the lumens. Moisture in the channels can dilute chemical sterilants and, if ethylene oxide is used, will form ethylene glycol, which is toxic to tissues.

3. Check the function of all moving parts, the clarity of vision through telescopes, and the patency of channels through instruments and catheters.

4. Keep sets of sounds, bougies, and filiforms and followers together so the urologist has a complete range of sizes readily accessible.

5. Wrap items for sterilization after cleaning. Flexible instruments should be protected by a rigid container.

6. Clean and dry stone baskets before sterilizing by low-temperature sterilization methods, such as plasma vapor, peracetic acid, or ethylene oxide. Retractable stone baskets are sterilized in the open position.

7. The principles and methods of sterilization apply to urologic endoscopy equipment.

8. Endoscopic processors and sterilizers, such as the STERIS unit, are useful for sterilizing instrumentation between patient uses. The instrumentation is used immediately after processing and is not stored in the processing tray.

9. If sterilization between patient uses is not feasible, high-level disinfection may be the method of choice for processing urologic endoscopic instruments.

Surgical procedures of the genitourinary system

Most patients commonly seen by urologists are in the preadolescent or older age groups. Congenital and common pediatric problems are discussed in Chapter 8. This chapter focuses on adult problems, most of which occur in men older than 50 years who have prostatic disease and women who have urinary incontinence.

An open surgical procedure is performed only after conservative treatment fails or examination of the genitourinary (GU) tract confirms a condition that does not yield to treatment. Fortunately, most urologic conditions can be diagnosed and treated conservatively through a urologic endoscope and its accessories. Some laparoscopic procedures are performed to obtain lymph nodes for biopsy. When a congenital or acquired condition does not respond to conservative therapy, the urologist performs open surgical procedures to repair, revise, reconstruct, or remove organs.

Obstructive and neuromuscular disorders are common problems in the urinary tract. Renal calculous disease and tumors in the urinary tract are most commonly diagnosed in middle age. These conditions may cause obstruction and subsequent infection in the kidneys, ureter, or bladder.

Kidney

Definitive renal surgical procedures are justified for the management of renal neoplasms, large cystic lesions that compromise renal function and/or produce obstruction, inflammatory diseases that necessitate drainage, or renal vascular disease. Chronic degenerative disease or severe traumatic injury can produce irreparable damage to renal cells. Computed tomography (CT) and magnetic resonance imaging (MRI) identify the site, size, and extent of tumor involvement.

Ultrasonography and intravenous (IV) urograms differentiate among solid tumors, stones, and cystic disease. A radionuclide scan may indicate renal function; arteriograms and venograms indicate the extent of renal vascular disease.

The kidney is usually approached posteriorly with the patient in a lateral position (Fig. 35-13). The kidney rest is raised, and the bed is flexed until the flank muscles become tense. After the patient is secured in position, the bed is tilted in Trendelenburg’s position until the flank is horizontal to the floor. A flank incision is made parallel to and just below or over the eleventh or twelfth rib; the twelfth rib may be removed. The retroperitoneum is opened to expose the kidney.

FIG. 35-13 Surgical position for open kidney procedure.

The kidney can be approached anteriorly through a transverse, subcostal, or midline incision. A thoracoabdominal incision may be preferred in an obese patient or to reach a lesion in the upper pole of the kidney. These incisions, with the patient in the supine position, are often used for exposure of the aorta and vena cava for renovascular procedures. An anterior approach may be advantageous when prompt control of blood supply is important in renal trauma.

Nephrectomy

Removal of a lobe or the entire kidney is indicated when tumor, disease, or traumatic injury has resulted in the absence of renal function. The entire kidney can be removed during a laparoscopic procedure. The organ is dissected, fragmented, and aspirated; vascular pedicles are stapled. This alternative technique is used primarily for benign renal disease.

Partial nephrectomy or heminephrectomy.

Partial excision of the kidney may be sufficient when a lobe has been destroyed by localized disease or injury but the remainder of the kidney remains functional. The vascular supply to the segment to be removed must be identified, ligated, and divided. The parenchyma of the lobe is resected from the capsule by blunt dissection. The renal pelvis and remaining capsule are closed.

Radical nephrectomy.

In a radical nephrectomy, the renal vessels are dissected free, ligated, and divided. Prerenal fat and fascia are dissected to remove the kidney. The ureter is ligated and divided close to the bladder. The renal pedicle is ligated and divided, and the kidney is removed. Massive hemorrhage from the renal artery and veins is a potential complication, as is injury to adjacent structures (i.e., inferior vena cava, aorta, and duodenum on the right side or spleen on the left side).

A nephrectomy is performed in the OR on a living donor (unilateral) or a cadaver donor (bilateral) to procure the kidney(s) for transplantation. Meticulous dissection is necessary to free the kidney, its blood vessels, and the ureter with minimal trauma. The ureter is dissected free and transected while the renal blood supply remains intact to ensure adequate urinary output. A kidney from a living-related donor may last longer than a kidney from a cadaver. Living donor kidney can be obtained by hand-assisted laparoscopy (HALS).

The left kidney is most commonly used for living-related donor transplant because it is easier to access. The anatomy is more complex on the right side because of the renal vein structure and requires a longer surgical time, causing a longer scar. Studies are being conducted for right laparoscopic donor nephrectomy at the University of Alabama at Birmingham. Dr. Rizk El-Galley has developed a special angled clamp that permits HALS right nephrectomy by excising a cuff of vena cava with the renal vein for added length of the vessel.

Bilateral nephrectomy.

Removal of both kidneys may be indicated before transplantation in a patient maintained on chronic dialysis who has severe hypertension. If rejection is uncontrollable after kidney transplantation, the donor kidney may have to be explanted and the patient returned to chronic hemodialysis. This is less likely after transplantation from a live donor than from a cadaver.

Nephrostomy or pyelostomy

An incision through the renal parenchyma or into the renal pelvis may be necessary to establish temporary or permanent drainage when an obstruction prevents the flow of urine from the kidney (Fig. 35-14). A tube placed in the kidney exits through the skin. A cutaneous nephrostomy tube may be used to drain a kidney postoperatively during healing after renal reconstruction or revascularization. Silastic tubes placed internally through a cystoscope via the ureter eliminate the need for an open surgical procedure for a temporary urinary diversion.