SPECIAL SURGERY II Lecture Notes PDF

Course Title: SPECIAL SURGERY II Course code: PON 422 MRS F. A ADESINA Lesson two Continued Benign Prostatic Hyperplasia BPH is a clinical diagnosis describing urinary symptoms attributable to obstruction by the prostate, although some patients with BPH have minimally enlarge...

Course Title: SPECIAL SURGERY II Course code: PON 422 MRS F. A ADESINA Lesson two Continued Benign Prostatic Hyperplasia BPH is a clinical diagnosis describing urinary symptoms attributable to obstruction by the prostate, although some patients with BPH have minimally enlarged glands, and some with large prostates have no symptoms. The symptoms of BPH are: Urinary frequency, urgency, hesitancy, slow stream, and/or nocturia. These symptoms are not specific and may be caused by infection, urethral strictures, or neurologic dysfunction from diabetes, Parkinson’s disease, multiple sclerosis, stroke, or spinal cord injury. Besides voiding symptoms, Consequences of BPH include gross hematuria, infections due to incomplete emptying, bladder calculi, and urinary retention. Over time, incomplete emptying may lead to chronic bladder overdistension that can result in a defunctionalized bladder.  Medical treatment of BPH is usually the first step. α-Blockers act on α receptors in the smooth muscle of the prostate and decrease its tone. 5α -Reductase inhibitors, which block the conversion of testosterone to the more potent Z, shrink the prostate over several months. Both are used either singly or in combination as medical therapy for BPH. If medications are ineffective at alleviating urinary symptoms or other consequences of BPH, surgical intervention is indicated. 1 Transurethral resection of the prostate is the mainstay of endoscopic surgical BPH treatment. It is extremely effective at improving flow and decreasing residual urine. Complications are rare but include incontinence and excessive fluid absorption of the hypotonic irrigating solution used during resection, resulting in the transurethral resection syndrome.(TUR). It is due to hyponatremia and fluid overload, and although rare, can result in death. Mental status changes and pulmonary edema are managed by diuresis and sodium supplementation with hypertonic saline in severe cases. Because of these rare, but potentially dangerous side effects, laser or electrovaporization of the prostate has grown popular. It is associated with very limited fluid absorption, and saline can be used because there is no monopolar electrocautery. There also is less bleeding. Urinary outcomes appear to be similar to transurethral resection of the prostate. When the prostate is very enlarged (>100 g), endoscopic management is less effective and open surgical procedures can be used. PROSTACTECTOMY Simple retropubic prostatectomy is the enucleation of hypertrophic prostatic tissue through an incision in the anterior prostatic capsule by an extra vesical approach. The retro pubic approach offers excellent exposure of the prostatic bed and vesicle neck and readily controllable intraoperative and postoperative bleeding. A preoperative bowel preparation and antibiotic therapy are the standard of care for all open prostatectomy.  SUPRAPUBIC PROSTACTECTOMY Suprapubic (simple) prostatectomy involves enucleation of the majority of the prostate, but the capsule is left so there is minimal effect on continence and erectile function. The removal through a trans vesicle 2  approach of benign per urethral glandular tissue obstructing the outlet of the urinary tract. Suprapubic prostatectomy. The suprapubic approach for prostatectomy is limited almost exclusively to the removal of a large, benign, hypertrophied gland weighing more than 50 g -100g. Through a midline vertical incision above the symphysis pubis, the superior bladder wall is opened to expose the prostatic urethra. The prostatic lobes are enucleated with a finger that is inserted through an incision into the mucosa of the urethra. This procedure may be termed transvesicocapsular prostatectomy, because the prostatic capsule is approached through the bladder. Hemostatic agents are usually packed into the extremely vascular prostatic fossa to help control bleeding. Pressure from the Foley catheter balloon inserted after closure of the urethra also helps obtain hemostasis. A suprapubic cystostomy tube is inserted to facilitate urinary drainage from the bladder during the healing process. MACRO SURGERY Surgical step Positioning The perioperative Nurse assist with positioning of the patient in a slight trendelenburg positioning with the pelvis elevated and the leg slightly adducted. Draping Draping procedure depends on operating room policies but the following are suggested. The first towel with a cuff is placed under the scrotum below the retro pubic 3 incision site and secured with 2 non perforating towel clamp. INSTRUMENT A basic laparotomy set, bladder and prostatic instrument Jackson Pratt drains Water soluble lubricants Syringes (different sizes 2mls, 10mls,50mls) Urinary drainage system i.e. Foleys catheter and drainage bag Self retaining retractors. Urology retractors systems. Spinal, epidural general anesthesia MICRO SURGERY The Surgeon inserts a 20f or 22f Foley catheter with 30mls balloon into the urethra and through the bladder neck and infiltrate it , this is to facilitate the identification of the bladder. A transverse or midline lower abdominal incision is made through the skin and other layer of superficial fascia. The external and internal oblique muscle are at along the lines of original incision. Bleeding vessel are clamped, eletrocoagulated or ligated with fine absorbable ties.The rectus muscles are separated in the midlines and retracted laterally. After placing traction sutures, the surgeon opens the bladder at the dome with a scalpel. Liquid content are aspirated and the bladder incision is enlarged. The bladder is usually and manually explored for Calculi, Tumor, Diverticular. The surgeon manually enucleated the adenomatous tissue using the tip of the index finger, inserted through the vesicle neck into the prostrate Urethra. If difficulty is experienced with the enucleating, the surgeon assistant may place a finger into the rectum to elevate the prostrate gland. Aseptic technique is 4 maintained during nucleation with the use of a sterile second glove on the hand in the rectum. After enucleation attention is directed to maintain good homeostasis, by suture ligation of the vesicle neck at the 5 and 7o clock position. Other significant bleeding may also be ligated.A supra pubic catheter is placed into the bladder lumen through a small stab incision. A 22f or 24f 2 way or 3 way Foley catheter with 30mls balloon is inserted into the Urethra in place of the Original one and the catheter from falling or being pulled into the prostatic fossa. The surgeon closes the cystectomy incision with interrupted 20 absorbable suture A drain is left along the cystectomy incision exteriorized through a separate stab wound The muscle fascia and subcutaneous tissue are closed in layers and dressing is applied. To reduce clot formation and maintain catheter patency normal saline irrigation solution may be connected to the Foley catheter to provide continuous irrigation to the bladder. Continuous irrigation may be initiated during closure. 5  Transurethral Prostatectomy Transurethral resection, also referred to as Transurethral Resection of the Prostate (TURP), involves the removal of all or part of the glandular tissue within the prostatic capsule by electroresection through the urethra. A resectoscope, via cysto sheath, is introduced into the prostatic urethra. Using alternating currents from the Electro Surgical Unit (ESU) through the cutting loop electrode, the urologist resects tissue and coagulates bleeding vessels. The bladder is distended with solution to create a working space during resection. Non conducting and non hemolyzing, isosmotic glycine irrigating solution is commonly used; 10 to 12 L may be needed. (Normal Saline) Sterile water as an expansion medium can cause complications related to intravascular hemolysis. Care is taken not to permit the patient to absorb excessive amounts of solution through the prostatic venous sinuses or TUR syndrome may occur. This can cause dilutional hyponatremia less than 125 mEq/L. Glycine is a neurotransmitter inhibitor that is metabolized into glycolic acid and ammonium. Ammonia has been noted to be elevated during TUR syndrome. Risk factors include: Height of the solution bags (extremes of height increase the amount of pressure of the fluid as it enters the bladder) Deep resection (which allows for increased venous absorption of solution) Amount of tissue resected in excess of 45 g Duration of the procedure (risk increases when the 6 procedure exceeds 90 minutes) Signs of TUR syndrome include: Mental confusion Nausea and vomiting Hypertension followed by hypotension Symptoms of fluid overload and pulmonary edema Bradycardia and dysrhythmia Visual disturbances Seizures and twitching Coma Treatment of TUR syndrome includes: Administration of IV hypertonic saline Monitoring of serum sodium levels Diuretics Resected prostatic tissue is collected in an Ellik or other evacuator. After the surgical procedure, tissue fragments must be sent to the pathology department for analysis and weighing. The urologist may insert a three-way 30- or 50-mL Foley catheter for irrigation and hemostasis. The large inflated balloon compresses against the bladder neck fossa to form a tamponade to help control bleeding. Some urologists place the Foley catheter under direct tension by taping the catheter to the patient’s leg or abdomen to increase the tamponade effect for hemostasis. The third lumen provides a means for continuous postoperative irrigation to prevent the formation of clots in the bladder. Benign nodular hyperplasia of glands less than 50 g in size is the usual indication for TURP. This approach has the potential complications of impotence and urinary incontinence. The technique is one of the most difficult for a urologist to master. Although electroresection is used most commonly, transurethral incision of small prostate glands (less than 25 g), balloon dilation of the 7 prostate, laser surgery, and cryosurgery are other invasive techniques for treating BPH. TURP may be performed for the diagnosis or treatment of localized cancer.  Retropubic prostatectomy: In the retropubic approach, the prostate gland is exposed below the bladder neck through a vertical or transverse abdominal incision above the symphysis pubis. The bladder is not opened. The gland is removed through an incision in the prostatic capsule; this procedure is called a transcapsular prostatectomy. The periprostatic tissue, seminal vesicles, and vas ampullae also may be excised. This method is common for prostate glands larger than 50 g. Radical retropubic prostatectomy: A limited pelvic lymph node dissection is performed for carcinoma with no evidence of spread beyond the prostatic capsule. This radical procedure may be carried out as initial curative the the lymph nodes, one of two approaches may be used to totally remove the prostate: 1. Campbell technique: An incision is made at the bladder neck, and the urethra is transected. The prostate and periprostatic tissue are widely dissected anterograde from the bladder. The bladder neck is reconstructed for the vesicourethral anastomosis. The patient will be impotent, because the 8 nerves responsible for erection are transected. A penile prosthesis may be implanted. 2. Walsh technique. The prostate is resected retrograde beginning at the urethra, working back to the bladder neck. Dissection is carried out close to the prostatic capsule to preserve the neurovascular bundle and thus maintain potency. The vesicourethral anastomosis is completed. Nerve-sparing procedures have been developed to preserve sexual potency. A device referred to as a CaverMap by UroMed Corporation (Suwanee, GA) can be used during the open prostatectomy procedure to locate nerves that control erection. A sensor band is placed around the penis, and a handheld device with a nervestimulating probe is used to sense nerve impulses responsible for causing erection. Studies performed by the American Urological Association show that between 40% and 70% of radical prostatectomy patients experienced erectile dysfunction of varying degrees after the surgery. Some patients are unable to achieve erection until after 18 months postoperatively. The CaverMap helps to locate the nerves but does not ensure the ability to achieve erection postoperatively.  Perineal prostatectomy: The perineum affords the most direct open surgical approach to the prostate through a relatively avascular field. With the patient in an extreme lithotomy position, the perineum is incised between the scrotum and the anal sphincter. The rectum is dissected from the posterior surface of the prostate, or dissection may be carried out between the external anal sphincter and the rectum. The perineal approach may be used to enucleate the prostate gland from its capsule or for radical cystoprostatectomy. This latter procedure includes removal of the entire prostate gland, its capsule, the seminal vesicles, and a portion of the 9  bladder. The classic radical perineal prostatectomy with pelvic lymph node dissection may be the surgical procedure of choice to reduce the morbidity of prostatic carcinoma. Urinary incontinence and impotence are common outcomes with this procedure. Laparoscopic methods can be used to sample intraabdominal lymph nodes.  Robotic-assisted prostatectomy: The robotic-assisted laparoscopic approach used is dependent on the method used to dissect the seminal vesicles and the vas deferens away from rectum. Enucleation of the prostate is facilitated by traction on the Foley catheter.  Urethral Stricture: The voiding symptoms of urethral stricture are very similar to BPH. Strictures may result from scarring due to infectious urethritis, prior instrumentation, trauma, or cancer. Urethral carcinoma is very rare, particularly in males, so most strictures are due to benign causes. Diagnosis is by retrograde urethrogram or cystoscopy. They may be treated with dilation or transurethral incision, but they have a tendency to recur after treatment. Open surgical excision is preferred for long or recalcitrant strictures, and long-term success rates are excellent.  URETHROPLASTY This is an open surgical reconstruction or replacement of the urethra that has been narrowed by scar tissue and sponge in fibrosis(urethral stricture). Urethroplasty is the gold standard for urethral reconstruction with the best most durable results. INDICATION FOR URETHROPLASTY Stricture Fracture 10  Narrowed Segments (congenital)Inflammatory or traumatic in origin Urethral grafts are generally required and may include free skin grafts, vascular flaps. There are many conditions of those procedures and in all of them some type of temporary diversions may used depending on the location and severity of the conditions. Post operative patients complain of symptoms like urinary tract infection. Technique of diagnosing includes  Urodynamics, voiding pressure above and below the site of obstruction.  Urinary flow cytometry  Intravenous urography to rule out upper tract lesion The length and density of the diseased urethra is determined to plan the appropriate reconstruction procedure. NOTES FOR URETHROPLASTHY Treat urinary tract infection before surgery. Definitive surgery should not be done 10-12 hours after the use of diagnostic instrument to allow the inflammatory reaction to subside Urethroplasty has 2 stages of the procedure  HORSTON DIVINE URETHROPLASTY  JOHNSON URETHROPLASTY URETHROPLASTY FISTULA REPAIR (VAGINA APPROACH) This is an abnormal passageway between the Urethra and the vagina. It results in urinary incontinence as urine continually leaves the vagina. It can occur as an obstetrical complication, catheter insertion injury or a surgical injury i.e. damage to the anterior wall and bladder radiation therapy or parturition 11 Surgical Step The patient is positioned in lithotomy position to safely raise and lower the patient simultaneously to prevent injury The basic vaginal instrument set is required with additional of Kelly fistula scissors, dressing forceps, probes, skin hooks, frazier sunction tips, urethral catheter and sterile water for irrigation. Prepping and draping done according to unit and institutional policy. After traction sutures are placed around the fistulous tract, the surgeon grasp the tissue with Allis –Adair forceps and plain tissue forceps. The surgeon excise scar tissue around the fistula, locates the cleavage between the bladder and vagina and mobilises the flap using scissors, forceps and gauze sponges. The bladder mucosa is averted towards the interior of the bladder with interrupted sutures, the sutures are passed through the muscularis of the bladder down to the mucosa. A second layer of inverting sutures is placed in the bladder and tied thereby completely inverting the bladder mucosa toward the interior. The surgeon closes the vaginal wall with interrupted sutures in a direction opposite the closure of the bladder wall. The bladder is distended with sterile saline to determine any leaks. An indwelling urinary catheter is inserted. 12