Urology PPT RPN Student Copy 2023 PDF

Genitourinary Surgery S425: RPN PERIOPERATIVE PROGRAM Learning Outcomes Describe the genitourinary (GU) anatomy. Explain surgical interventions for GU surgeries, scrotal surgery, prostate surgery and kidney surgery. Compare and contrast procedural consideration for open and closed GU surger...

Genitourinary Surgery S425: RPN PERIOPERATIVE PROGRAM Learning Outcomes Describe the genitourinary (GU) anatomy. Explain surgical interventions for GU surgeries, scrotal surgery, prostate surgery and kidney surgery. Compare and contrast procedural consideration for open and closed GU surgeries. Anatomy Anatomy - Kidneys Located: Retroperitoneal Remove urea and liquid waste from blood Blood supply directly off the aorta → renal artery → drainage through the renal vein Highly vascular organ Right is smaller and positioned lower than the left due to liver placement Anatomy – Adrenal Glands Located on top of kidneys Endocrine gland Medulla secretes epinephrine (adrenaline) Cortex secretes steroids and hormones and is influenced by the pituitary gland Blood supply – arterial branches of inferior phrenic artery and renal arteries (aorta) Anatomy - Ureters Extend from the renal pelvis to the base of the bladder 25 – 30 cm long and 4 – 5mm in diameter (adult) Propels urine into the bladder through peristalsis  Anatomy - Bladder Located extraperitoneal Reservoir for urine until voiding occurs Blood Supply to the bladder is supplied by the superior and inferior vesical arteries, which arise from the ________________ The veins drain into the internal iliac vein. Urethra Male urethra - 20-25 cm long Female urethra - 4 cm long Female and Male Genitourinary Anatomy Anatomy - Prostate Gland Located at the base of bladder neck and surrounds the urethra Divided in 4 glandular regions Intracapsulated by “capsule” Blood supply – pudendal and inferior vesical arteries Male Reproductive Organs Pair Organs: Testes Epididymis Vas Deferens Cowper’s Glands Singular Organ: Penis Scrotum Perioperative Nursing Considerations Anesthesia: Positioning: Count: Blood Replacement: Irrigation Fluids: Sterile water vs. Nonelectolytic Solutions Instrumentation Basic laparotomy set Short and long instruments Prostate and bladder extras Kidney instruments Large abdominal retractor (i.e. Bookwalter) Foley catheter Cystoscope or Resectoscope Equipment Lasers: Holmium Yag, KTP Green light Laser Precautions: Signs on doors Goggles/glasses outside of room Goggles/glasses for patient and staff Fire safety: wet towels, basin of water Irrigation Fluids Type Purpose Normal Saline Observational interventions i.e. Cystoscopy Use with lasers i.e. Pyelolithotomy – stone in renal pelvis – use Laser Lithotripsy Sterile Water Use with monopolar cautery where little absorption is anticipated Non-electrolytic Medium: Use with monopolar cautery and where Sorbitol, Cystosol, Glycine high absorption into bloodstream is anticipated i.e. TURP using a resectoscope  Cystoscope A- Flexible B- Rigid Resectoscope Surgical Interventions Closed GU Surgery Open GU Surgery Cystoscopy (rigid or flexible) Prostatectomy Ureteroscopy (rigid or flexible) Cystectomy Laser Lithotripsy Pyelolithotomy Retrograde Pyelogram Pyelostomy TURP Nephrectomy TURBT Kidney Transplant Orchidopexy Cystoscopy Endoscopic examination of the lower urinary tract: urethra, bladder neck, bladder and lobes of prostate (male) Rigid scopes are most used Flexible cystoscopes used for patients with obstructive symptoms Anesthesia: Position: Scrub nurse?  B, From Tighe SM: lnstrum&nta!10n for the operating room. St Louis, 2007, Mosby. Fig. 14-21. A, Method of using coude-tipped bougie for passing stricture. B, Variety of urethral sounds (dilators). Retrograde Pyelogram May be done at the same time as cystoscopy Identify any blocks in kidneys or ureters Contrast dye injected through catheter in one or both ureters for visualization on X-ray Stent can be inserted for patency Ureter Stent and Placement Ureterscopy/Urethroscopy Endoscopic procedures to remove stones in the urethra, ureter or kidney Ureteroscope inserted through the urethra → bladder → up the ureter to the stone location Small stones can be snared with stone basket device and removed Large stones will be removed via Lithotripsy to break down into smaller pieces Pyelolithotomy Open procedure to remove a stone in Renal Pelvis Randal stone forceps may be used Lithotripsy may also be done laparoscopically Laser Lithotripsy Noninvasive procedure to treat large kidney stones X-ray guided Laser breaks down stones to small pieces that can be excreted Lasers: Ho:YAG (pulse dye) laser, Er: YAG, or Nd:YAG Normal saline used for continuous irrigation **Laser Precautions!!! Transurethral Resection of the Prostate (TURP) Surgical removal of part of the prostate gland (not the capsule) Relieve symptoms of enlarged prostate Benign prostatic tumours Benign Prostatic Hyperplasia (BPH-enlarged prostate) Procedure Considerations Endoscope passed into urethra and bladder to assess for tumors or stones Resectoscope is passed into urethra to prostate Cutting loop electrode cauterizes and resects tissue of prostate causing obstructive symptoms Pieces of prostate tissue are carried by irrigation fluid into bladder Flushed out through urethra catheter A non-electrolytic ionic medium is used with the monopolar cautery  Procedure Considerations Resectoscope = monopolar cautery Non-electrolytic solution = non-conductive for electrodes Monitor for hyponatremia and S&S of fluid overload Irrigation Fluid Overload If too much irrigation is absorbed – fluid overload and disruption of balance of electrolytes in the blood! →Hypervolemia and Hyponatremia S&S: Bradycardia, hypertension, respiratory changes, swelling If S&S occur – procedure stopped and cystogram is done to determine if there is a bladder perforation Resectoscope - TURP Green Light Laser U S E D FOR BP H – R E M OVA L OF P ROSTATE T I SSU E Transurethral Ureteropyeloscopy (TUR) TUR for Bladder Tumour (TURBT) Endoscopic examination of ureters and bladder Assess if bladder cancer and location/adjacent tissues Used for early-stage treatment Common symptom for bladder tumours = hematuria Goal: excise tumour of the bladder wall Procedure Considerations Resectoscope resects bladder tumour Tissue sent to pathology Lasers used to burn additional tissue where tumour was located Multiple nonresectable tumors = Cystectomy Resectoscope TURP and TURBT Similar to the gynae resectoscopes used for ablations Prostatectomy 1. Simple Retropubic 2. Suprapubic 3. Nerve Sparing Radical Retropubic Prostatectomy with Pelvic Lymphadenectomy Simple Retropubic Prostatectomy Retropubic approach – prostate is removed through an abdominal incision Excellent exposure of the prostate bed and vesicle neck Intraoperative bleeding is easily controlled Prostate gland is excised and capsule is closed (0 absorbable sutures) Drain If CBI is indicated, a 3-way Foley will be inserted and Normal Saline will be used Suprapubic Prostatectomy Transvesicle (low abdominal incision) approach to remove glandular tissue obstructing urinary tract Done to remove part of enlarged prostate gland (BPH) Make incision through bladder Access to repair any other bladder conditions Controlling bleeding is difficult Procedure Considerations Bladder and bladder neck are opened Prostate gland is removed Bladder neck is repaired and closed Bladder is closed **Absorbable sutures Drain 3-way Foley to irrigation to PACU; Suprapubic Catheter Nerve Sparing Radical Retropubic Prostatectomy with Pelvic Lymphadenectomy Organ-confined carcinoma of the prostate Remove: entire prostate gland, capsule and seminal vesicles Pelvic Lymph nodes may be removed for staging Important structures that affect erectile function are within surgical field “Nerve Sparing” – surgeon tries to prevent damage to these vessels and nerves If cancer is too advanced - the surgeon will close and adjunct therapy will be considered Radical Prostatectomy Vesicourethral Anastomosis: Urethra to Bladder 3-0 Polysorb Sutures Procedure Considerations Anesthesia: GA Position: Supine or slight lithotomy Instrumentation: Deep in pelvis! long instruments, hemoclips, louers, McDougal clamp Open procedure with lower midline incision Foley Catheter inserted sterile by surgeon once case has begun Laparoscopic Radical Prostate Prostatectomy and Robotic Assisted Prostatectomy are now being done Laparoscopic Prostatectomy Partially done laparoscopically for nonmalignant cases Laparoscopic dissection of lymph nodes → Open Prostatectomy Insufflation with Verres needle (internal pressure usually to 15 mm Hg) Replaced with 10mm Hasaan 5mm ports X3, trocar at McBurney point, left iliac and midline below umbilicus MIS instruments Bladder filling occurs through Foley to distend and show contours of the bladder Prostate is removed Bladder repaired Laparoscopic Assisted Robotic- Assisted Bladder Surgery Open or Transurethral approach Open – tumours, congenital defects, trauma Transurethral – Diagnostic testing Open bladder surgery position is supine with bolster under pelvis Trendelenburg tilt to allow exposure to pelvic organs Radical Cystectomy Female vs. Male Radical Cystectomy with Pelvic Lymphadenectomy and Ileal Conduit Total excision of the urinary bladder, adjacent structures, and pelvic lymph nodes Ureteric catheters are pre-placed Adjacent structures: Male: prostate gland, seminal vesicles and distal ureters Female: uterus, cervix, 1/3rd vagina, urethra, distal ureters Tumour has invaded muscular wall of bladder Lymph nodes – stage disease A new reservoir to act as bladder is created called: Ileal Conduit Ileal Conduit Most common urinary diversion Urine flow is diverted to an isolated loop of bowel (piece of Ileum) Reservoir to act as bladder Opening (stoma) to act as urethra Ascending colon re-connected to rest of Ileum via GIA stapler Ureters are transplanted into the piece of bowel Urine flows from Kidneys → Ureters → Ileal Conduit → Stoma Urine output not controlled → Ileostomy bag Ileal Conduit Procedure Considerations Anesthesia: Position: Count: Blood replacement: Specimen: Sutures: Kidney Surgery Surgical Positioning = Lateral (Right or Left) Common positioning for Nephrectomy 3 incisional approaches: Flank Lumbar Thoracoabdominal 11th or 12th rib may be removed for optimal exposure Radical nephrectomy (cancer)– kidney, perirenal fat, adrenal gland, Gerota capsule and para-aortic nodes Lateral Position Nephrectomy Open or Laparoscopic Blunt dissection until perirenal fat (Gerotas fascia) is identified Psoas muscle - landmark lies right underneath kidney and IVC and aorta Renal artery and vein dissected Ureter clamped and ligated with 0- absorbable suture Kidney is isolated, major vessels are clamped and ligated with silk ties and sutures Laparoscopic Nephrectomy Benign disease Longer surgical time then open approach Shorter recovery time and pain Transabdominal approach preferred Start supine for placement of trocars and then positioned lateral on bean bag Procedure Considerations Anesthesia: Position: Surgical Count: Instrumentation: Hemostasis: Renal artery and vein double clamped and triple ligated – non-absorbable Ureter double clamped and ligated – absorbable Ligaments/pedicles – absorbable Kidney Transplant Living-related or cadaveric donor kidney Transplant to recipient’s iliac fossa Restore renal function Indicated for patients with __________________ Procedure Considerations Living Donor – nephrectomy Usually family related Laparoscopic approach – common approach Two adjacent ORs The Left kidney is usually removed because the left renal vein is longer for anastomosis Right kidney (smaller) may be removed if there are anatomical considerations in donor Patient’s native kidneys are NOT removed unless cancerous! Extra table is required with a sterile set up for the kidney Basin of iced saline and University of Wisconsin solution compatible for preserving the kidney Anastomoses (Living or Cadaveric) Donor Renal artery → Recipient Internal Iliac artery Donor Renal vein → Recipient Iliac vein Donor Ureter → Recipient Bladder (Ureteroneocystostomy) Vascular, Double armed sutures for anastomosis (Prolene/Surgipro) Orchidopexy Surgery for undescended testicle Common pediatric population Repositioning of testicle into scrotal sac to normal anatomical position Orchidopexy Blood supply, vessels and ducts (vas deferens) are dissected and freed Hernia sac repaired Sutured with an anchor stitch (Silk) Holds testicle in place Testicular Torsion Adult or pediatric surgery Scrotal pain but cause is unknown Twisted spermatic cord Compromised blood supply = risk of losing testicle Emergency surgery!!!! Testicular Torsion References Rothrock, J. (2022). Alexander’s care of the Patient in Surgery (17th ed.) Mosby: Elsevier. Tighe, S. (2015). Instrumentation for the Operating Room (9th ed.) Mosby. ORNAC Standards 2023 Potter & Perry (2015). Canadian Fundamentals of Nursing (5th ed.) Jones and Bartlett AORN Perioperative Articles: Brightspace John Hopkins Medicine: Kidney Transplantation (2021)