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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 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
  • 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
  • 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.

Anatomy video

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


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

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


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)
  • 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
  • > 1 million per kidney
  • 2 types: juxtamedullary and cortical
  • Each composed of capillary network:
  • Renal corpuscle
  • Renal tubule
  • 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
  • Foreskin will not retract
  • Congenital
  • Geriatric
  • Can cause infection, pain
  • Tx: circumcision
hypospadias epispadias

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

Urethral opening inside the vagina


Tx: Surgical repair


Urethral opening on top of the penis (dorsal)

Urethral opening above the clitoris


Tx: Surgical repair

Hypospadias Epispadias
  • 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



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
  • 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
  • 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
  • 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
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

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


Polyps (pedunculated lesion)














Rectocele (posterior colporrhaphy)


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

  • General
  • Spinal
  • Epidural
  • MAC with Local
  • Antibiotics
  • Contrast Media (Hypaque)
  • Dyes (Methylene Blue, Indigo Carmine)
  • Diuretics
  • 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°
  • Ureteral sounds (dilators)
  • Flexible endoscope and accessories
  • Rigid endoscope instrumentation
  • Resectoscope
  • Ellik evacuator
  • Toomey irrigator/syringe
  • Accessories: light cord, camera, insufflation tubing, irrigation fluid
  • 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)
  • 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
  • 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
  • Lithotomy
  • Supine
  • Lateral
  • Variations of Above
  • Area of Involvement
  • Begin at incision site and work way out
  • Prep genital area last
  • May not do a prep if urethral approach
  • Laparotomy
  • Universal
  • Perineal
  • Combination Laparotomy/Perineal
  • Surgeon’s preference/approach
  • Depends on position
  • Abdominal: steri-strips, telfa, xeroflo,

4x4s, ABD (surgeon’s preference)

  • Vaginal packing
  • Peri-pad
  • Net panties
  • 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
  • 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)
  • 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