Surgical Technology: Genitourinary Surgery Chapter 23 PDF

Chapter 23 Genitourinary Surgery Copyright © 2005 by Elsevier Inc. All rights reserved. Important Terms and Definitions Review Terms and Definitions Listed at Beginning of Chapter Use Your Medical Dictionary If Necessary Copyright © 2005 b...

Chapter 23 Genitourinary Surgery Copyright © 2005 by Elsevier Inc. All rights reserved. Important Terms and Definitions Review Terms and Definitions Listed at Beginning of Chapter Use Your Medical Dictionary If Necessary Copyright © 2005 by Elsevier Inc. All rights reserved.  Introduction to Genitourinary Surgery Genitourinary (GU) Encompasses Surgery of the Internal GU System – Kidney – Adrenal Gland – Bladder – Prostate – Urethra – Accessory Structures of These Organs Copyright © 2005 by Elsevier Inc. All rights reserved.  Three Basic Approaches to the Genitourinary (GU) System – Transurethral – Laparoscopic – Open Copyright © 2005 by Elsevier Inc. All rights reserved.  Anatomy of the Genitourinary Tract Kidney Inner structure of the kidney (Modified from Herlihy B and Maebius NK: The human body in health and illness, ed 2, Philadelphia, 2003, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Adrenal Glands (From Seidel HM et al: Mosby’s guide to physical examination, ed 3, St. Louis, 1995, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Ureter Ureter, urinary bladder, and urethra (Modified from Applegate EJ: The anatomy and physiology learning system, ed 2, Philadelphia, 2000, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Urinary Bladder (From Rothrock JC: Alexander’s Care of the Patient in Surgery, ed 12, St. Louis, 2003, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Urethra – Emerges from Bladder at Trigone – Function Is to Convey Urine from Urinary Bladder to Outside the Body Copyright © 2005 by Elsevier Inc. All rights reserved.  The Female Reproductive System (From Rothrock JC: Alexander’s Care of the Patient in Surgery, ed 12, St. Louis, 2003, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  External Reproductive Organs of the Male Male reproductive organs (From Herlihy B and Maebius NK: The human body in health and illness, ed 2, Philadelphia, 2003, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Scrotum – Lies at Base of Penis – Protects the Testicles Copyright © 2005 by Elsevier Inc. All rights reserved.  Testicles – Suspended in Scrotum by Epididymis – Serve as Housing for Sperm – Manufacture Testosterone Copyright © 2005 by Elsevier Inc. All rights reserved.  Penis – Male Copulatory Organ – Highly Vascular Flaccid Except during Sexual Stimulation Copyright © 2005 by Elsevier Inc. All rights reserved.  Internal Reproductive Organs of the Male Male reproductive organs (From Herlihy B and Maebius NK: The human body in health and illness, ed 2, Philadelphia, 2003, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Prostate Gland – Musculoglandular Structure, Size of a Chestnut – Conical; Lies with Base Close to Bladder – Secretes Alkaline Fluid to Nourish and Give Mobility to Sperm Copyright © 2005 by Elsevier Inc. All rights reserved.  Bulbourethral glands – Also Called Cowper’s Glands – Secrete Mucus, Part of Fluid that Makes Up Semen (From Seidel HM et al: Mosby’s guide to physical examination, ed 3, St. Louis, 1999, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Vas Deferens – Is a Portion of the Path that the Seminal Fluid Travels – Continues Across Bladder and Ureter Meets opening of seminal vesicle and forms ejaculatory duct Copyright © 2005 by Elsevier Inc. All rights reserved.  Equipment GU Surgery Often Daunting to Learner – Many Types and Amounts of Equipment – Systematic Study of Equipment and Thorough Knowledge of Anatomy Enhances Learning Process Copyright © 2005 by Elsevier Inc. All rights reserved.  Electrosurgical Unit (ESU) Left to right, enlarged tips: – Cutting electrode with round wire – Cutting electrode with pointed end – Coagulating electrode with ball end Copyright © 2005 by Elsevier Inc. All rights reserved.  Microscope – Operative Microscope Is Used during Fine Reconstructive Surgery, Laser Ablation, and Vaporization of Lesions – Sterile Procedures Require That the Microscope Be Draped Copyright © 2005 by Elsevier Inc. All rights reserved.  Laser – Nd:YAG – CO2 – Tunable dye – Argon lasers Copyright © 2005 by Elsevier Inc. All rights reserved.  Radiography The cystoscopy or urology table (From Nagle GM: Genitourinary surgery: perioperative nursing series, St Louis, 1997, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Video Camera Rigid cystourethroscope (From Nagle GM: Genitourinary surgery: perioperative nursing series, St Louis, 1997, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Video Camera, continued Left to right: cystoscope, 30 degree cystoscope, 70 degree fiberoptic cable (From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Catheters Urinary catheters A. Conical-tip urethral catheters B. Robinson urethral catheter C. Whistle-tip urethral catheter D. Coudé hollow olive-tip catheter E. Malecot self-retaining, four-wing urethral catheter F. Malecot self-retaining, two-wing catheter G. Pezzer self-retaining drain, open-end head, used for cystotomy drainage H. Foley-type balloon catheter I. Foley-type, three-way balloon catheter (Modified from Walsh PC, Retik AB, Vaughan ED, et al: Campbell's urology, ed 8, Philadelphia, 2002, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Catheters, continued – In-Dwelling Urinary Catheters Most hospitals use prepackaged one-time-use catheters Catheter is hollow tube of flexible synthetic material Variety may be used during GU procedures Copyright © 2005 by Elsevier Inc. All rights reserved.  Catheters, continued – Ureteral Catheters Ureteral stent with tether (A from Nagle GM: Genitourinary surgery: perioperative nursing series, St Louis, 1997, Mosby; B from Walsh PC, Retik AB, Vaughan ED, et al: Campbell's urology, ed 8, Philadelphia, 2002, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Ureteral Catheters, continued Ureteral catheters A A. Round-tip B. Olive-tip B C. Spiral-tip D. Conical- or C "bulb-" tip D (A from Nagle GM: Genitourinary surgery: perioperative nursing series, St Louis, 1997, Mosby; B from Walsh PC, Retik AB, Vaughan ED, et al: Campbell's urology, ed 8, Philadelphia, 2002, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Urethral Catheters Foley three-way balloon catheter (Modified from Walsh PC, Retik AB, Vaughan ED, et al: Campbell's urology, ed 8, Philadelphia, 2002, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Instruments Left to right Four westphal hemostatic forceps Six hemostatic tonsil forceps Two adson hemostatic forceps, fine curved Mayo (guyon) kidney clamp Two herrick kidney clamps Two satinsky (vena cava) clamps Six hemostatic tonsil forceps, 9 1/2 inch Two hemostatic tonsil forceps, 10 1/2 inch Two babcock tissue forceps, extra long Four mixter hemostatic forceps, 101/2 inch, fine tip Two ayer needle holders, extra long Two heaney needle holders, long Four randall stone forceps: – Full curve – 3/4 curve – 1/2 curve – 1/4 curve (From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Specialized GU Instruments Pedicle clamp Copyright © 2005 by Elsevier Inc. All rights reserved.  Special Sutures – Nonabsorbable Sutures Can Cause Formation of Stones For That Reason Absorbable Sutures Are Used Chromic gut Dexon Vicryl Copyright © 2005 by Elsevier Inc. All rights reserved.  Cystoscopic Procedures Psychological Considerations – Embarrassing Position – Very Little Privacy – Apprehension about Procedure – Cold Operating Room – Unfamiliar Surroundings Special Population of Patients Who Need Extra Care Copyright © 2005 by Elsevier Inc. All rights reserved.  The Cystoscopy “Cysto” Room – Cystoscopic Procedures Take Place in Specialized Cystoscopy (Cysto) Room – Patient Is Placed on Specialized Cysto Procedures Table – Table Is Designed for Use of X-rays Intraoperatively and for Fluid Control Copyright © 2005 by Elsevier Inc. All rights reserved.  Positioning Simple nephrectomy (Adapted from Hinman F Jr: Atlas of urologic surgery, ed 2, Philadelphia, 1998, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Electrosurgical Grounding and Settings Left to right, enlarged tips: Cutting electrode with round wire Cutting electrode with pointed end Coagulating electrode with ball end (From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Duties of the Cystoscopic Assistant – Before the Procedure – During a Cystoscopic Procedure – Following a Cystoscopic Procedure Copyright © 2005 by Elsevier Inc. All rights reserved.  Anesthesia – Local – Topical – Monitored Sedation – General Anesthetic – Spinal (Regional) Anesthetic Copyright © 2005 by Elsevier Inc. All rights reserved.  Patient Skin Prep – Using Aseptic Technique – Patient Is Prepped and Draped Procedure is same as for a standard perineal procedure Copyright © 2005 by Elsevier Inc. All rights reserved.  Irrigation – Sterile Saline Used for Most Procedures That Do Not Require ESU – Sorbitol or Glycine Used When Electrosurgery Required – Contrast Media May Be Added to Irrigation Fluid for Fluoroscopic Examination Copyright © 2005 by Elsevier Inc. All rights reserved.  The Rigid Cystourethroscope (From Nagle GM: Genitourinary surgery: perioperative nursing series, St Louis, 1997, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  The Rigid Cystourethroscope, continued Left to right: Cystoscope, 30 degree Cystoscope, 70 degree Fiberoptic cable (From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  The Rigid Cystourethroscope, continued – Fiberoptic light cable and source Light cable connects cystoscope to fiberoptic light source. Light sources used are same as those in other endoscopic procedures and include xenon and halide Cables are fiberoptic or liquid light As with all endoscopic equipment, light cords and camera cords should be handled carefully Copyright © 2005 by Elsevier Inc. All rights reserved.  The Rigid Cystourethroscope, continued – Sheath Left to right Obturator cystoscope sheath catheter deflecting mechanism with two instrument channels obturator for cystoscope two Storz short telescope bridges (From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 1999, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  The Rigid Cystourethroscope, continued – Obturator Metal rod with blunt, rounded tip Prevents end of sheath from abrading mucosal lining of urethra as it is inserted May be either straight or deflecting Copyright © 2005 by Elsevier Inc. All rights reserved.  The Flexible Cystourethroscope (From Nagle GM: Genitourinary surgery: perioperative nursing series, St Louis, 1997, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved. Cystoscopic Surgical Procedures Diagnostic Cystoscopy – Goal of Cystourethroscopy (Cystoscopy)—to Examine Inside of Urinary Bladder and Urethra for Evidence of Disease Copyright © 2005 by Elsevier Inc. All rights reserved.  Ureteral Dilation and Urethrotomy – Urethra Is Dilated to Relieve a Stricture Phillips filiforms and followers Graduated sounds Balloon dilators – Urethrotomy—Small Incision Made in Internal Urethra to Release Scar Tissue Copyright © 2005 by Elsevier Inc. All rights reserved.  Management of Bladder Calculi Using the Cystourethroscope – Bladder Calculi or Stones Are Removed Because of Pain or Urinary Blockage Copyright © 2005 by Elsevier Inc. All rights reserved.  Management of Bladder Calculi Using the Cystourethroscope, continued Lithotrite Specialized instrument that grasps and crushes the stone Copyright © 2005 by Elsevier Inc. All rights reserved.  Management of Bladder Calculi Using the Cystourethroscope, continued – Ellik Evacuator Top, left Mayo dissecting scissors, curved Bottom, left to right Crile hemostatic forceps, straight Crile hemostatic forceps, curved Five van buren urethral sounds, male, sizes 8 to 16 Right, top to bottom Two nonperforating towel forceps Ellik evacuator Copyright © 2005 by Elsevier Inc. All rights reserved.  Flexible Ureteroscopy Procedures Flexible ureteroscopes Copyright © 2005 by Elsevier Inc. All rights reserved.  Procedures – Tissue Biopsy Performed to determine if tissue specimen is benign or malignant Copyright © 2005 by Elsevier Inc. All rights reserved.  Procedures, continued – Tumor Removal Removal of neoplasm can be performed by fulguration or by using the holmium:YAG laser. Laser precautions must be observed Copyright © 2005 by Elsevier Inc. All rights reserved.  Procedures, continued – Pyeloplasty Strictures in ureter are relieved by fine electrosurgical or laser devices introduced through the endoscope Copyright © 2005 by Elsevier Inc. All rights reserved.  Procedures, continued – Urethrotomy If urethrotomy (release of structure) is planned, optical urethrotome is inserted into stricture and blade incises scar tissue Copyright © 2005 by Elsevier Inc. All rights reserved.  Flexible Ureteroscopy Surgical Procedures Transurethral Resection of the Prostate (TURP) (From Rothrock JC: Alexander’s Care of the Patient in Surgery, ed 12, St. Louis, 2003, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Transurethral Resection of the Prostate (TURP), continued Left to right, enlarged tips: Cutting electrode with round wire Cutting electrode with pointed end Coagulating electrode with ball end (From Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Open Procedures of the External Genitalia Male reproductive organs (From Herlihy B and Maebius NK: The human body in health and illness, ed 2, Philadelphia, 2003, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Urethral Meatotomy – Procedure in which the external urethral meatus is enlarged with an incision Urethral Meatoplasty – The incisional enlargement and repair of the external meatus of the urethra Copyright © 2005 by Elsevier Inc. All rights reserved.  Circumcision in the Adult Dorsal skin is elevated and freed from the dartos fascia. Bleeders are fulgurated with an ESU or tied with 4-0 absorbable sutures (From Nagle GM: Genitourinary surgery: perioperative nursing series, St Louis, 1997, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Repair of Hypospadias Incisions are approximated, and the intervening strip of tunica albuginea and suture knots are buried Copyright © 2005 by Elsevier Inc. All rights reserved.  Repair of Hypospadias, continued – Meatal Opening in Hypospadias Photo of hypospadias (From Walsh PC, Retik AB, Vaughan ED, et al: Campbell's urology, ed 8, Philadelphia, 2002, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Repair of Epispadias Three-month-old male with complete epispadias (From Walsh PC, Retik AB, Vaughan ED, et al: Campbell's urology, ed 8, Philadelphia, 2002, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Repair of Bladder Exstrophy – Repair of Most Severe Form of Epispadias Anterior wall of the bladder, as well as the roof of the urethra, are absent or malformed Copyright © 2005 by Elsevier Inc. All rights reserved.  Orchidopexy – Surgical Correction of Undescended Testicle – Also Called Cryptorchidism Copyright © 2005 by Elsevier Inc. All rights reserved.  Vasectomy and Vasovasostomy (From Chabner D: The language of medicine, ed 6, Philadelphia, 2001, Saunders). Copyright © 2005 by Elsevier Inc. All rights reserved.  Varicocelectomy – High Ligation of Gonadal Veins of Testes To reduce venous backflow of blood into the venous plexus of the testes and to improve spermatogenesis Copyright © 2005 by Elsevier Inc. All rights reserved.  Hydrocelectomy (From Huether SE, McCance KL: Understanding Pathophysiology, ed 2, 2000, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Orchiectomy – Surgical removal of one or both testicles A transverse incision is made to expose both testes (From Nagle GM: Genitourinary surgery: perioperative nursing series, St Louis, 1997, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Orchiectomy, continued The testis and tunica vaginalis are displaced from the scrotum (From Nagle GM: Genitourinary surgery: perioperative nursing series, St Louis, 1997, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Insertion of Penile Implant Preparation of the reservoir Copyright © 2005 by Elsevier Inc. All rights reserved.  Insertion of Penile Implant, continued (From Rothrock JC: Alexander’s Care of the Patient in Surgery, ed 12, St. Louis, 2003, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Transabdominal Surgical Procedures Performed as Open or Laparoscopic Surgery – Techniques and Instruments used for Laparoscopic Procedures Follow Those of Abdominal Laparotomy Copyright © 2005 by Elsevier Inc. All rights reserved.  Pyelolithotomy Inner structure of the kidney (Modified from Herlihy B and Maebius NK: The human body in health and illness, ed 2, Philadelphia, 2003, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Pyelolithotomy, continued – Patient Positioning (From Brundage D: Renal disorders, St. Louis, 1992, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Simple Nephrectomy The pedicle is isolated by blunt dissection (Adapted from Hinman F Jr: Atlas of urologic surgery, ed 2, Philadelphia, 1998, Saunders.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Kidney Transplant – Removal of Kidney from Living Donor or Cadaver – Implantation of Kidney to Surgical Patient – Performed for Acute or Chronic End-Stage Renal Failure Copyright © 2005 by Elsevier Inc. All rights reserved.  Kidney Transplant, continued – Technique to Retrieve a Kidney (From Rothrock JC: Alexander’s Care of the Patient in Surgery, ed 12, St. Louis, 2003, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Kidney Transplant, continued – Surgical Technique for Kidney Recipient (From Droller MJ: Surgical management of urologic disease, St. Louis, 1992, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Kidney Transplant, continued – Ideal tissue donor Young Free of drugs and alcohol History is known Tissue and blood type match the recipient’s Copyright © 2005 by Elsevier Inc. All rights reserved.  Adrenalectomy – Adrenal Diseases Often Life Threatening – Procedure Has Potential for Many Postoperative Metabolic Complications Copyright © 2005 by Elsevier Inc. All rights reserved.  Cystectomy Surgical specimen consisting of the bladder, distal ureters, prostate, seminal vesicles, and distal vas deferens is removed en bloc (From Nagle GM: Genitourinary surgery: perioperative nursing series, St Louis, 1997, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Ileal Conduit The ileal segment is opened (From Nagle GM: Genitourinary surgery: perioperative nursing series, St Louis, 1997, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Ureteral Reimplantation – Reconstructive Operations of Ureter Are Performed to Repair Forms of Renal Obstruction Avoids Subsequent Renal Failure – Causes of Renal Obstructions Congenital malformations Stasis Metabolic imbalances Copyright © 2005 by Elsevier Inc. All rights reserved.  Types of Prostatectomy – Prostatectomy Is Performed to Treat Benign Prostatic Hypertrophy and for Cancer of the Prostate Suprapubic prostatectomy Retropubic prostatectomy Perineal prostatectomy Transuretheral resection prostatectomy (TURP) Copyright © 2005 by Elsevier Inc. All rights reserved.  Suprapubic Prostatectomy (From Lewis SM, Collier IC, Heitkemper MM: Medical-surgical nursing: assessment and management of clinical problems, ed 4, St. Louis, 1996, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Enucleation of the Prostate The prostatic adenoma is removed (From Nagle GM: Genitourinary surgery: perioperative nursing series, St Louis, 1997, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Retropubic Prostatectomy – Patient Is Placed in Supine Position, Prepped, and Draped as for Suprapubic Prostatectomy – In This Approach, Bladder Is Not Entered for Access to Prostate Copyright © 2005 by Elsevier Inc. All rights reserved.  Perineal Prostatectomy (From Lewis SM, Collier IC, Heitkemper MM: Medical-surgical nursing: assessment and management of clinical problems, ed 4, St. Louis, 1996, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Perineal Prostatectomy, continued – TURP Pack (From Lewis SM, Collier IC, Heitkemper MM: Medical-surgical nursing: assessment and management of clinical problems, ed 4, St. Louis, 1996, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Suprapubic Cystostomy – Placement of Suprapubic Catheter into Bladder for Drainage More comfortable for patient than urethral catheter Copyright © 2005 by Elsevier Inc. All rights reserved.  Vesicourethral Suspension of the Bladder – Performed to Treat Urinary Stress Incontinence in the Female When caused by reduction in the angle at the urethrovesical junction Copyright © 2005 by Elsevier Inc. All rights reserved.  Vesicourethral Suspension (Marshall-Marchetti-Krantz) Procedure Suburethral sling Back table set-up for suburethral sling (From Nagle GM: Genitourinary surgery: perioperative nursing series, St Louis, 1997, Mosby.) Copyright © 2005 by Elsevier Inc. All rights reserved.  Suburethral Sling – Graft Strip of Fascia Lata or Synthetic Material Is Placed between Urethra and Anterior Vaginal Wall Copyright © 2005 by Elsevier Inc. All rights reserved.