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SUR 122. Genitourinary Surgery. Genitourinary System. Terminology Anatomy & Physiology Pathology Diagnostic & Pre-operative Testing Anesthesia & Medications Basic Instrumentation, Supplies, & Equipment Incision Site Options Positioning, Prep, & Draping

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Sur 122

SUR 122

Genitourinary

Surgery


Genitourinary system

Genitourinary System

  • Terminology

  • Anatomy & Physiology

  • Pathology

  • Diagnostic & Pre-operative Testing

  • Anesthesia & Medications

  • Basic Instrumentation, Supplies, & Equipment

  • Incision Site Options

  • Positioning, Prep, & Draping

  • Dressings, Drains, & Post-operative Care


Terminology

Terminology

  • BPH – nonmalignant enlargement of prostate common with age

  • Dialysis - waste product removal from the blood of a patient in renal failure

  • Enucleate – remove without cutting into

  • Epispadias – urethra terminates on the dorsal surface of penis (on top of) or above clitoris (congenital)

  • Gerota’s capsule – perirenal fascia that holds kidney in place

  • Impotence – inability to achieve erection

  • Hematuria – blood in the urine

  • Hilum- everything enters and leaves kidneys through this notch

  • Ptosis – drooping of an organ or part

  • Trigone – triangle-like space a bladder base


Terminology1

Terminology

  • Hydrocele – fluid filled sac in the scrotum

  • Hypospadias – urethra opens on ventral surface (underneath) of penis, perineum, or inside the vagina (congenital)

  • Paraphimosis – retraction of prepuce results in painful swelling of glans

  • Phimosis – uncircumcised male prepuce won’t retract from glans

  • Wilm’s tumor - malignant neoplasm of a kidney in children 3-4yrs.


Sur 122

  • Anatomy video

  • http://www.youtube.com/watch?v=xYTjvqzyd9k


Male reproductive system

Male Reproductive System

  • Large part external to body cavity

  • Scrotum=pouch of skin that contains testis

  • Testis are both endocrine & exocrine glands

  • Exocrine=secrete sperm via ducts

  • Endocrine glands produce testosterone


Male reproductive system1

Male Reproductive System

  • Testis

  • Lobules with 3 cell types:

  • Seminiferous tubulesinvolved in spermatogenesis

  • Interstitial cells (cells of Leydig)produce testosterone

  • Seratoli cellsprovide nutrients for sperm


Male reproductive system2

Male Reproductive System

  • Sperm

  • Male produces 300 million sperm per day=120million per ml

  • Less than 20 million per ml considered sterile


Male reproductive system3

Sperm (3 parts)

1. Head a. Acrosome contains chemical hyaluronidase which is an enzyme that breaks down hyaluronic acid (found in loose connective tissue) that allows sperm to penetrate the eggb. Nucleus (haploid) contains 23 chromosomes (when unites with egg also 23 chromosomes, chromosome total becomes 46)

Midpiece extension that contains large amt of mitochondria (ATP)

Flagellatail composed of a protein that allows for movement generated by ATP

Male Reproductive System

1N


Male hormones

Male Hormones

1. FSH

  • Tells interstitial cells to produce testosterone and sperm in testis

    2. LH

  • Tells interstitial cells to develop and secrete testosterone

    3. Testosterone

  • Stimulates development, growth and maintenance of male reproductive system including sex characteristics, maturation of sperm, and skeletal muscle development


Ducts

Ducts

1. Epididymis

  • Series of ducts or channels that communicate with the testis

  • Store sperm

  • Area for sperm maturation

  • Ciliated columnar cells secrete

    2. Vas Deferens

  • Loops up over bladder

  • Transports sperm

  • Ciliated columnar cells and smooth muscle (peristalsis) move sperm

    3. Ejaculatory duct

  • Vas deferens merge into this posterior to bladder which merges with the urethra (runs through the prostate)


Male reproductive system summation

Male Reproductive SystemSummation

  • Testis are located in the scrotum

  • Testes produce sperm and testosterone

  • Contain lobules containing seminiferous tubules where sperm arise

  • Lobules lead to ducts in the epididymis

  • Epididymis leads to ductus deferens

  • Ductus deferens open into urethra

  • Testis suspended by spermatic cord

  • Spermatic cordgoes from inguinal ring to testis

  • Inguinal ring also contains ductus deferens, testicular vessels (arterial, venous, and lymphatic), and nerves


Accessory organs

Seminal vesicles

Behind (posterior) bladder

Secrete into ejaculatory duct

60% liquid portion of semen

Prostate gland

Donut shaped as urethra runs through it

Secretes 30% liquid portion of semen directly into the urethra

Bulbourethral (Cowper’s) glands

10% volume of semen (lubricates head)

Neutralizes acidity of urethra

Secrete directly into urethra

Accessory Organs

Internal urinary sphincter

tightens w/ejaculation to

prevent mixing of urine

w/sperm


Accessory organs1

Accessory Organs

  • Penis

  • 3 cylindrical tissue masses

  • Corpus cavernosum x 2 (upper)

  • Corpus spongiosum x1 (lower)

  • Urethra passes through corpus spongiosum

  • These three areas are surrounded by blood sinuses

  • Arteriole blood retention allows an erection

  • Post-ejaculation pressure is released


Genitourinary system1

Genitourinary System

  • Kidneys

  • Adrenal glands

  • Ureters

  • Urinary Bladder

  • Urethra

  • Prostate Gland (male)


Kidneys

Kidneys

  • Location retroperitoneal

  • At T-12 to L-3 vertebral column

  • Encapsulated in perineal fat and fascia renalis capsule which hold them in position

  • Hilum medial area where renal artery and vein enter and exit

  • Left larger

  • Right lower due to liver location

  • Functional unit is the nephron: filtration, reabsorption, secretion


Nephron

Nephron

  • > 1 million per kidney

  • 2 types: juxtamedullary and cortical

  • Each composed of capillary network:

  • Renal corpuscle

  • Renal tubule


Nephron1

Nephron

  • Renal Corpuscle:

  • Bowman’s Capsule

  • Glomerulus

  • Renal Tubule:

  • Proximal Convuluted Tubule

  • Loop of Henle

  • Distal Convuluted Tubule

  • Collecting Tubule


Renal corpuscle

Renal Corpuscle

1. Filtration

  • Bowman’s Capsule (glomerulus encased by)

  • Glomerulus (capillary network)

  • Water and substances filtered from blood


Renal tubules

Renal Tubules

2. Reabsorption

  • Substances move from renal tubules into capillaries (blood) surrounding the tubules

  • Prevents needed body substances from being lost in urine

  • Proximal convuluted tubule (origin in Bowman’s Capsule)

  • Loop of Henle

  • Distal Convuluted Tubule


Renal tubules1

Renal Tubules

  • Secretion

  • Substances move from blood into tubules (urine)

  • Distal Collecting Tubule

  • Collecting Tubule


Filtrate urine pathway

Filtrate/Urine Pathway

  • Fluid once it leaves the blood and is in the nephron called filtrate, once leaves nephron is called urine

  • Nephron > papillary duct > minor and major calyces > renal pelvis > ureters


Urinary bladder

Urinary Bladder

  • Holds average of 800ml

  • Three layers: Submucosa, Muscularis, Inner Tunica Mucosa

  • Muscularis called detrusor muscle

  • Internal sphincter = smooth muscle = involuntary control

  • External sphincter = skeletal muscle = voluntary control

  • Stretch receptors in bladder signal brain via micturation reflex

  • About 400ml, brain relaxes internal sphincter

  • This signals you it’s time to go…

  • Inner Tunica mucosa is rugae surface (allows for stretching) except in the trigone area which is a smooth surface


Adrenal glands suprarenal

Adrenal Glands (Suprarenal)

  • Job to augment the Sympathetic Nervous System division of the Autonomic Nervous System

  • Endocrine glands: contain cortex and medulla

  • Cortex: secretion of fluid and electrolyte balance controlling steroids and hormones (aldosterone and cortisol)

  • Medulla: produces, stores, & secretes epinephrine (adrenaline) & norepinephrine (noradrenalin)


Adrenal gland cortex

Adrenal gland (cortex)

  • Aldosterone- decreases urine output as it stimulates renal tubules to reabsorb water and salts (sodium reabsorption)

  • Most active hormone

  • Indirectly regulates:

  • Electrolyte levels (bicarbonate, potassium, chloride)

  • Blood pressure

  • Blood volume

  • pH levels


Adrenal gland cortex1

Adrenal gland (cortex)

  • Adrenal gland (cortex)

  • Cortisol (hydrocortisone)

  • Affects glucose metabolism

  • Regulates metabolism of fats, carbohydrates, proteins, fats, potassium

  • Anti-inflammatory


Adrenal gland medulla

Adrenal gland (medulla)

  • Adrenalin (epinephrine)

  • Constricts visceral vessels

  • Dilates skeletal muscles

  • Dilates bronchiole musculature

  • Increases glucose production

  • Decreases GI activity

  • Increases heart rate


Adrenal gland medulla1

Adrenal gland (medulla)

  • Norepinephrine

  • Increases blood pressure

  • Decreases heart rate

  • Constricts vessels (arterioles and venules)


Pathology of the male reproductive system

Pathology of the Male Reproductive System

  • Phimosis

  • Hypospadias/Epispadias

  • BPH

  • Cancer of the Prostate

  • Cryptorchidism

  • Testicular Torsion

  • Testicular Cancer

  • Trauma


Phimosis

Phimosis

  • Foreskin will not retract

  • Congenital

  • Geriatric

  • Can cause infection, pain

  • Tx: circumcision


Hypospadias epispadias

Hypospadias

Urethral opening under the penis (ventral) or on the perineum

Urethral opening inside the vagina

Congenital

Tx: Surgical repair

Epispadias

Urethral opening on top of the penis (dorsal)

Urethral opening above the clitoris

Congenital

Tx: Surgical repair

Hypospadias Epispadias


Cryptorchidism

Cryptorchidism

  • Failure of testes to descend into scrotum after 1 yr of age

  • Found in abdomen or groin

  • Often seen with inguinal hernia

  • Premature birth

  • Tx: HCG hormone therapy

    Orchiopexy

    Orchiectomy


Testicular torsion

Testicular Torsion

  • Spermatic cord is twisted

  • Tx: Orchiopexy


Testicular cancer

Testicular Cancer

  • 20-40yrs

  • Infants with cryptorchidism higher risk

  • Embarrassment leads to non-treatment which allows progression of disease

  • Tx: Orchiectomy

  • Sperm may be stored

  • Testicular implants available for cosmetic purposes


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BPH

  • Hypertrophy

  • Normal part of aging

  • > 50 yrs

  • Urethral narrowing can result

  • Tx: Drug therapy ↓ prostate growth (medical)

  • TURP (surgical)


Prostate cancer

> 50 yrs

Asymptomatic in early stages of disease

Symptom of blood in the urine, likely too late

PSA (prostate specific antigen)

Normal value <4ng/mL

PSA laboratory test of choice by men over 50 for early detection

Will be done if BPH detected on digital exam to r/o cancer

↑PSA f/u with biopsy

Prostate Cancer


Pathology of the urinary system

Pathology of the Urinary System

  • Bladder Tumors

  • Urinary Calculi

  • Polycystic Kidney Disease

  • Diabetic Nephropathy

  • ESRD

  • Renal Cell Carcinoma

  • Congenital Nephroblastoma (Wilm’s Tumor)


Urinary calculi stones

Urinary Calculi/Stones

  • Solid particles that form in one or both kidneys

  • May become lodged

  • Pass < 4mm stones 80% of the time

  • 50% recurrence rate

  • 3 types:

  • Calcium (75%) dietary imbalance/hyperparathyroidism

  • Magnesium ammonium phosphate (struvite) (15%) UTI

  • Uric Acid (6%) associated with gout

  • Cystine amino acid reabsorption failure


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ESWL

  • Extra-Corporeal Shock-Wave Lithotripsy

  • Renal Calculi

  • Historical: Done in large tub and patients were intubated and connected to the shock therapy unit

  • Present: Water-bed like unit under lower body. Stone lined up with C-arm machine/cross-sectioned + Stone hit with shock waves precisely

  • Avoid bone

  • Shocks gauged to match patient HR, otherwise patient can experience arrhythmias if shock wave exceed HR

  • Usually range from 120/min to 60 /min


Other methods of stone removal

Other Methods of Stone Removal

  • Cystoscopic / ureteroscopic / nephroscopic lithotomy

  • Direct extraction via

  • Laser through

  • Small Lithotripsy unit used through

  • Percutaneous lithotomy

  • Open lithotomy


Polycystic kidney disease

Polycystic Kidney Disease

  • Multiple fluid filled cysts in parenchyma of kidney

  • One kidney could have thousands

  • Kidney could weigh up to 22lbs.

  • 3 Types:

    1. Autosomal dominant (hereditary)

  • 30-50yrs

  • 90%

  • Autosomal recessive (rare/congenital)

  • Children

  • Acquired (long term kidney problems)


Diabetic neuropathy sclerosis

Diabetic Neuropathy (sclerosis)

  • Uncontrolled diabetic

  • Progressive disease>ESRD>dialysis


Sur 122

ESRD

  • Kidney failure

  • Final stage of many kidney diseases

  • Filtration system in kidney < 10%

  • 50% are diabetics

  • s/sx: ↓UO, ↑BUN and creatinine levels

  • Death imminent without method of waste and fluid removal

  • Tx: Hemodialysis and Peritoneal Dialysis


Hemodialysis

Vascular access

1. Temporary

Dual lumen catheter (Vas Cath)

2. Permanent

PTFE loop graft

Creation of AV fistula (cephalic and radial artery most common)

Must mature, so will likely have Vas Cath placed

2 lumens: one for outflow and one for inflow

Dialysis machine has 2 compartments: one for incoming blood and one for dialysate

Between compartments is a semi-permeable membrane that filters like the kidney

Excess wastes and fluids go into dialysate and are disposed of

Important blood components and proteins return to body

Hemodialysis


Peritoneal dialysis

Peritoneal Dialysis

  • Requires implantation of catheter into peritoneal cavity (ex. Tenckhoff)

  • Allows for infusion of dialysate which draws out waste and fluids

  • After proper amount of time, dialysate and fluid/wastes are drained into a bag

  • Peritoneum serves as filter


Pathology affecting the adrenal glands

Pathology Affecting the Adrenal Glands

  • Cushing’s Syndrome

  • Addison’s Disease

  • Pheochromocytoma


Pathology of the adrenal glands

Pathology of the Adrenal Glands

  • Cushing’s Syndrome

  • Overproduction of cortisol

  • Cortisol production:

  • Pituitary gland which stimulates ACTH (adrenal cortical trophic hormone) which stimulates cortisol production

  • Caused by: (80%) pituitary tumor or (20%) adrenal cortex tumor

  • s/sx: HTN, central body obesity, hirsutism, osteoporosis, kidney stones, emotional instability, abnormal menses

  • Tx: surgical removal of tumor


Pathology of the adrenal glands1

Pathology of the Adrenal Glands

  • Addison’s Disease (Adrenal Insufficiency)

  • Hormones needed to maintain fluid and electrolyte balance, blood pressure, and a normal stress response are inhibited

  • s/sx: weight loss, weakness, fatigue, GI disturbances, low BP, darkening of skin, hair loss, mood/behavior changes

  • Tx: medical hormone replacement therapy


Pathology of the adrenal glands2

Pathology of the Adrenal Glands

  • Pheochromocytoma

  • Overproduction of adrenaline

  • Caused by tumor of the medulla

  • Excessive adrenaline creates severe hypertension

  • s/sx: HTN, severe headache, excessive sweating, tachycardia, palpitations, anxiety, tremors, epigastric pain, weight loss, heat intolerance

  • Tx: surgical removal of tumor


Genitourinary system2

Genitourinary System

  • Reproductive Organs:

  • Female


Pathology of female genitourinary and reproductive system

Benign

Cysts

Polyps (pedunculated lesion)

Fistulas

Dysplasia

Leiomyoma/Myoma/Fibroid

Fibroma

Malignant

Vulvar

Vaginal

Cervical

Uterine

Ovarian

Other

Endometriosis

Cystocele

Rectocele (posterior colporrhaphy)

Enterocele

Ectopic Pregnancy

Incompetent Cervix (cerclage)

Pathology of Female Genitourinary and Reproductive System


Pre operative diagnostic testing

Pre-operative & Diagnostic Testing

  • H&P

  • UA

  • Hematology: CBC & HGB/HCT

  • Blood Chemistry: Blood Urea Nitrogen and Creatinine

  • KUB

  • IVP

  • Cystogram

  • Urethrogram

  • Cystoscopy

  • CT

  • MRI

  • Biopsy


Incisional approaches

Incisional Approaches

  • Inguinal

  • Scrotal

  • Abdominal

  • Thoracoabdominal pg. 603 Alexander’s

  • Gibson pg. 755 Caruthers

  • Flank pg. pg. 603 Alexander’s (more oblique)

  • Lumbar pg. 603 Alexander’s (more vertical)

    *Provide best exposure


Anesthesia

Anesthesia

  • General

  • Spinal

  • Epidural

  • MAC with Local


Medications

Medications

  • Antibiotics

  • Contrast Media (Hypaque)

  • Dyes (Methylene Blue, Indigo Carmine)

  • Diuretics


Instruments

Instruments

  • Major Set

  • Vascular Tray or CV Tray

  • Extra Long Instrument Set

  • Self-Retaining Abdominal Retractor

  • Chest Tray: Finochetti, periosteotome, Doyan, rib shears, rongeur, Bailey rib approximator

  • Special: Mixters, Potts scissors, Vascular instruments, Bladder & Prostate retractors,

    Pedicle clamps, Stone/lithotomy forceps


Other cystoscope components

Other Cystoscope Components

  • Bridges (short and long)

  • Cystoscopes: 12°, 30°, and 70°


Supplies

Supplies

  • Ureteral sounds (dilators)

  • Flexible endoscope and accessories

  • Rigid endoscope instrumentation

  • Resectoscope

  • Ellik evacuator

  • Toomey irrigator/syringe

  • Accessories: light cord, camera, insufflation tubing, irrigation fluid


Irrigations

Irrigations

  • Glycine

  • TURP

    2. Water

  • Laser

    3. NS

  • Cystograms


Supplies continued

Supplies Continued

  • Lubricant

  • Foley catheter and drainage bag

  • Alternative catheters (difficult insertion)

  • Catheter guide (facilitates insertion)

  • Urethral catheters

  • Ureteral drainage bag(s)


Catheters

Catheters

  • Urethral

  • Lumen Size range 8-30 French

  • Ureteral

  • Lumen Size range 3-14 French

  • FYI: Divide French by 3 to get diameter of lumen in mm

  • Ex: 12 French catheter divided by 3 = 4mm in diameter


Equipment

Equipment

  • OR Table with Foot Drop (lithotomy) & Radiographic Capability

  • Lead Aprons, Accessories

  • Quick Access to X-ray Development Room

  • IV Poles that will hold heavy fluid bags

  • Sitting stool

  • Multiple X-ray view boxes

  • Video Tower (light source, camera box, insufflator)

  • Cautery with bipolar capability


Positioning

Positioning

  • Lithotomy

  • Supine

  • Lateral

  • Variations of Above


Sur 122

Prep

  • Area of Involvement

  • Begin at incision site and work way out

  • Prep genital area last

  • May not do a prep if urethral approach


Draping

Draping

  • Laparotomy

  • Universal

  • Perineal

  • Combination Laparotomy/Perineal

  • Surgeon’s preference/approach

  • Depends on position


Dressings

Dressings

  • Abdominal: steri-strips, telfa, xeroflo,

    4x4s, ABD (surgeon’s preference)

  • Vaginal packing

  • Peri-pad

  • Net panties


Drains

Drains

  • JP

  • Snyder

  • Hemovac/Grenade

  • Penrose

  • Depends on location of surgical wound and surgeon preference


Post operative care

Post-operative Care

  • Discharge same day to 5 days hospitalization

  • Early ambulation

  • TED hose

  • Turn/cough/deep breath

  • Drink plenty of fluids

  • Avoid heavy lifting >10lbs. at least 6 weeks

  • urine may be pink tinged to red/should clear in few days

  • S/X Infection: incision red, warm, painful, purulent drainage

  • S/SX UTI: fever, chills, hematuria, flank pain, sudden increase in urinary output


Complications

Complications

  • Infection

  • Nicking ureters, bladder, urethra, reproductive organs

  • Hemorrhage (major blood vessel proximity)

  • Adhesions

  • Sciatic nerve damage due to spinal placement

  • Blood clot (thrombosis)

  • DVT

  • PE (pulmonary embolus)


Summary

Summary

  • Terminology

  • Anatomy & Physiology

  • Pathology

  • Diagnostic & Pre-operative Testing

  • Anesthesia & Medications

  • Basic Instrumentation, Supplies, & Equipment

  • Incision Site Options

  • Positioning, Prep, & Draping

  • Dressings, Drains, & Post-operative Care


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