Urology Surgery PDF

CABILDO, TIFFANY JANE B. CABILDO, TIFFANY JANE B. Urethral Stricture Infections (e.g., tuberculosis,...

CABILDO, TIFFANY JANE B. CABILDO, TIFFANY JANE B. Urethral Stricture Infections (e.g., tuberculosis, schistosomiasis) urethral stricture an area of scarring or fibrosis that causes concentric Malignancy (e.g., lymphoma, multiple myeloma, narrowing of the urethra, impeding the flow of urine as it drains sarcoma). from the bladder. Symptoms General abdominal discomfort or back pain Causes of urethral Trauma – 19% Flank pain due to ureteral obstruction stricture disease Iatrogenic – 33% Lower extremity edema due to vena caval compression Inflammatory causes - 15% Labs Normocytic anemia Idiopathic causes—33% Increased C-reactive protein or ESR Symptoms Incomplete emptying Classic radiological findings well-defined retroperitoneal soft tissue mass encasing the great Weak urinary stream vessels with medialization of the ureters. Urinary urgency/frequency used to monitor disease Contrast enhancement on CT scan Pain activity and assess magnetic resonance imaging (MRI) Urethra in men Cephalad to caudad response to treatment positron emission tomography (PET) scan Prostatic Notes Patients with symptomatic renal obstruction, renal Membranous insufficiency, or signs of infection should be Bulbous (the area between the pelvic floor and the decompressed with either ureteral stents or penoscrotal junction)à MOST COMMON SITE OF nephrostomy and monitored for postobstructive STRICTURE diuresis. Penile Biopsy To r/o malignancy Options to treat urethral Endoscopic and surgical reconstruction Steroid therapy remains the mainstay of medical treatment stricture disease Endoscopic treatments include a urethral dilation or stricture incision with a cystoscope Success rateà 30% GENITOURINARY TRAUMA Relation Approximately 10% of victims of abdominal trauma will have a urologic The success of repeat endoscopic treatments of a urethral stricture drops to 13%, injury It may also impact the: Surgical reconstitution referred to as a direct vision internal urethrotomy Kidneys Surgical reconstruction of Excisional the urethra, referred to as Ureters o involves resection of the strictured segment of the a urethroplasty urethra Bladder o direct anastomosis of the two healthy urethral Urethra ends. External genitalia o RESERVED FOR MEMBRANOUS STRICTURES Testicles AND SHORT BULBAR STRICTURES. Majority are blunt and penetrating injuries. Tissue substitution KIDNEYS o Involves augmenting a narrowed urethral lumen Preservation The prime goal of renal trauma management is _______ with free tissue grafts. Of renal function USUALLY NON-OPERATIVE o The most common tissue substitute is buccal (oral) mucosal graft. Grade the renal The first goal of renal trauma is to accurately ______ injury CT scan with IV The gold standard test to diagnose and stage a renal injury includes a Other Causes of Obstruction contrast, with _____ Retroperitoneal fibrosis rare cause of ureteric obstruction secondary to an inflammatory delayed images. (RPF) and fibrotic process of the retroperitoneal structures. CT- urogram delayed contrast imaging delineates the upper urinary tract Most are idiopathic collecting system Identifiable causes in the Periaortic inflammation due to aneurysms Criteria that would Gross hematuria remaining cases include Medications (e.g., methysergide, ergot derivatives, "- mandate renal Microscopic hematuria with hypotension blockers, phenacetin), imaging include 1 2  CABILDO, TIFFANY JANE B. CABILDO, TIFFANY JANE B. mechanisms increasing the prevalence of renal injury (sudden When stent placement is not feasible or when presentation is deceleration injuries, flank contusion, etc). delayed, Until formal repair can be safely done. Hemodynamically ureter can be ligated with subsequent nephrostomy tube placement. unstable px Ureteral repair can then be delayed until the patient is stable for surgery. Maneuvers used to bridge the bladder mobilization with ligation of the contralateral defect of ureteral length for bladder pedicles direct anastomosis to the psoas hitch (tacking the bladder down to the bladder include the following ipsilateral psoas tendon) Boari flap with downward nephropexy Remaining options Trans-ureteroureterostomy (anastomosing the injured ureter to the contralateral ureter), Treatment Absolute indications for surgical or radiological intervention on renal Creation of an ileal ureter trauma include Renal auto transplantation to the pelvis. life-threatening hemorrhage BLADDER renal pedicle avulsion, or MECAHNISM Iatrogenic pulsatile/expanding retroperitoneal hematoma. Traumatic Indications for Gross hematuria Exploration bladder imaging pelvic fracture à 29% chance of bladder laceration penetrating renal trauma with a retroperitoneal hematoma include Observation initially In a hemodynamically stable patient with a renal injury, renal trauma Dx CT cystogram or a fluoroscopic cystogram isolated penetrating renal injuries bladder is filled with 300cc of contrast à Contrast may be visible at the sight of injury, within the - Conservative management entails bed rest and hemodynamic peritoneal monitoring. Space Complications Urinoma Two general Extraperitoneal and intraperitoneal injuries. Abscess formation categories of An intraperitoneal injury requires repair during the index Persistent urinary Placement of a ureteral stent or nephrostomy tube bladder injuries admission after the patient has been resuscitated. extravasation Delayà abdominal sepsis nephrectomy The most common surgery for renal surgery in modern times Ureters Extraperitoneal injuries à can generally be managed with Foley Note: There is no association between the magnitude of ureteral injury and catheter drainage alone. the degree of hematuria that is present. à operative repair complex injuries involving bone spicules from a pelvic fracture The definitive operative management of a ureteral injury depends on within the laceration and concurrent rectal or bladder the location and the extent of devitalization. lacerations, which increase the possibility of fistula formation Dx CT urogram, IVP, or a cystoscopy with a retrograde pyelogram Repeat cystography should be done 7 to 14 days later prior to Foley Iatrogenic Most common mechanism of injury removal to ensure that the laceration, or operative repair, has Gynecological, colorectal, and urological surgeries healed Initial management Ureteral stent placement Urethral Injuries Open repair if indicated – shortly after the injury Mechanism of injury Pelvic fracture associated injuries and straddle injuries. Nephrostomy tube placement Pelvic fractureà membranous urethra straddle injuriesà bulbar urethra 3 4  CABILDO, TIFFANY JANE B. CABILDO, TIFFANY JANE B. blood at the meatus The clinical hallmark of a urethral injury is _____ Px with BPH Dxà retrograde urethrogram (prior to attempted Foley catheter Coude (French for curved) catheter is helpful in negotiating placement) past the angulation in the prostatic urethra. bladder drainage The initial step in management of a urethral injury is ________to prevent urinoma formation and subsequent abscess formation External Genital Injuries Penile fractures excessive torqueing of the erect penis à rupture of the tunica albuginea S/S Immediate detumescence with subsequent development of a hematoma Dx Hx and PE à may warrant surgical exploration UTZ, MRI Smaller cathetersà useful for bypassing a urethral stricture. Notes Up to 10% of penile fractures are associated with urethral injuries. Catheter meets A urethral stricture should be suspected when the____ Blood at the meatus signifies the possibility of a coexisting urethral injury resistance closer to the meatus many strictures occur in the distal urethra, which is narrower Dx: evaluated with either a retrograde urethrogram or cystoscopy at than the proximal portion. the time of repair Txt BPH as a cause of AUR Scrotal trauma generally occurs from a blunt mechanism. a-blockers (tamsulosin) –(without a catheter) Injuries to the testis, epididymis, and spermatic cord may occur. finasteride and dutasteride (5 a-reductase inhibitors) have Testicular rupture fracture of the fascial coating of the testicle, called the tunica albuginea. been shown to reduce the incidence urinary retention by 50% blunt or penetrating mechanisms. o months to take effect o most beneficial in large prostates Dx: The most specific findings on ultrasonography are tapering of narcotics loss of testicular contour and treat constipation heterogeneous echotexture of parenchyma. Acute spinal cord compression High index of suspicion Postvoid residuals should be checked with a portable Exploration ultrasound device (bladder scanner) or by “straight” catheterization to determine the residual amount of urine left Txt Testicular salvage Orchiectomy after the patient tries to empty his or her bladder. EMERGENCIES Testicular Torsion Acute Urinary Retention Notes Most common in neonates and adolescents. May be observed in Men with BPH Most commonly occur in other age group Other causes Diabetic neuropathy Mechanism Twisting of the spermatic cord à blood supply in the tunica vaginalis Urethral stricture to the testes and epididymis is compromised à Ischemia to the Multiple sclerosis epididymis and the testis Parkinson’s disease Hospitalized px Newbornà extravaginal torsion opiates or anticholinergics. RF Undescended testis o CONSTIPATIONà SEà worsen urinary retention. Testicular tumor Acute spinal cord compression “bell-clapper” deformity—poor gubernacular fixation of the S/S PAIN testicles to the scrotal wall Untreated Renal failure Dx Clinical hx Txt placement of a urethral catheter as quickly as possible. Sudden onset of pain at a distinct point in time, with subsequent swelling. 5 6  CABILDO, TIFFANY JANE B. CABILDO, TIFFANY JANE B. Supplement: o related to penile or perineal trauma resulting in a Doppler ultrasound, cavernous artery–corporal body fistula o which typically shows decreased intratesticular blood o Painless flow relative to the contralateral testis. o Conservative management – observation o If not availableà exploration Wit prolonged erection The sustained decrease in arterial inflowà tissue hypoxia, acidosis, and edema and results in long-term fibrosis and impotence, and PE swollen sometimes frank necrosis. asymmetric scrotum RF Sickle cell disease or trait with a tender, high-riding testicle. Malignancy medications Children: lost cremasteric reflex Cocaine abuse Fournier’s Gangrene Certain antidepressants Fournier’s gangrene is a necrotizing fasciitis of the male genitalia and perineum that can Total parenteral nutrition be rapidly progressive and fatal if not treated promptly Blood work up To R/O blood dyscrasias or malignancy The often polymicrobial infection spreads along dartos, Management Rapid detumescence with the goal of preservation of future erectile Scarpa’s, and Colles’ fascia. function Mortality rate 67% Initial management can include systemic treatment of the underlying RF Perirectal abscesses disorder Diabetes Obesity Initial intervention Chronic alcoholism o Therapeutic aspiration or injection of S/s Scrotal pain sympathomimetics (phenylephrine). Inflammation § SEà Hypertension and Reflex bradycardia Necrosis Surgical shunt -- If phenylephrine fails Crepitus o Distal (corporoglanular) shunts (first to perform) Dx Clinical suspicion § Easiest CT – can assist in the diagnosis § Least complications o soft tissue air associated with fluid collections within o Winter shunts the deep fascia. § uses a large biopsy needle to create holes Txt To prevent further spread between the glans and corpora § if failsà an operative procedure can be surgical debridement performed to remove the distal tips from each broad spectrum antibiotics corpora (Al-Ghorab). Fecal diversion o Proximal shunts such as Grayhack (corporal- Colostomy à if there is damage to the EAS saphenous vein) or Quackel (proximal cavernosum Priapism spongiosum) shunts may be Priapism is a persistent erection for greater than 4 hours unrelated § required in refractory cases. to sexual stimulation. Dx Ischemic priapism Two types low-flow/ischemic priapism --- is a medical emergency. penile blood gas o PEà tender penis o hypoxic, acidotic blood § Rigid cavernosal bodies o easiest to perform § Flaccid glans penis o and the lowest amount of complications o Dec venous outflow , persistent inflow à Paraphimosis increased intracorporal pressure and tumescence Affected Uncircumcised men o Essentially a compartment syndrome Hospitalized High-flow/traumatic priapism Impaired mental status o Rare Unable to respond to pain 7 8  CABILDO, TIFFANY JANE B. CABILDO, TIFFANY JANE B. Prolonged foreskin penile necrosis may occur due to ischemia. ID CIS retraction Staging CT/MRI management Penile blocks, pain medication, and sedation à then manual Chest radiographà mediastinum and thorax evaluation reduction (apply firm pressure to the edematous distal penis for Bone scanà if with bone pain several minutes) Inc ALP surgical intervention Fully assess depth of invasion Emphysematous Pyelonephritis Transurethral resection of bladder tumor (TURBT) should include Emphysematous life-threatening infection that results from complicated an examination under anesthesia (EUA) and Pyelonephritis pyelonephritis by gas-producing organisms. Sampling of the bladder muscular n Predominantly in DM px Extravesical tumor extension If there is presence of induration or a mass on EUA S/S Sepsis Restaging TURBT within 2 to 6 weeks is recommended in the patient with Ketoacidosis incomplete, under-sampled, or uncertain resection. Escherichia coli ____appears to be the most frequent organism responsible for this infection. Increased potential for distant metastases; management Supportive care Invasion into the lamina propria and certainly the muscular wall IV antibiotics notes: Recurrence rates of non–muscle-invasive bladder cancers are high, Relief of any urinary tract obstruction ranging from 50% to 70%. Nephrostomy tubeà allow drainage of purulent material TURBTà then Adjuvant therapy to reduce rates Nephrectomy à extensive involvement of the perirenal tissue. o Signs of sepsis Intravesical immunotherapy using bacillus Calmette-Guérin (BCG) also Third-generation _______________have been suggested as the initial antibiotic of provides a significant reduction in recurrence that is greater than 50% in cephalosporins choice and ___________avoided due to high rates of resistance this population Radical The most effective single-modality treatment for patients with fluoroquinolones cystectomy muscle-invasive bladder cancer, refractory high-risk non–muscle- invasive disease, and especially lymph node–negative disease with a reported 10-year recurrence-free survival of organ-confined lymph node– UROLOGIC MALIGNANCIES negative (M Slings anatomy of the urethra Implantation of an artificial urinary sphincter childbirth categories Urge incontinence Overflow incontinence is the involuntary loss of urine associated with an urge to void. Directed at the cause of obstruction BPH Stress leakage o Bladder drainage occurs with increases in intra-abdominal pressure, such as o Medications such as "-blockers or 5-" reductase coughing or sneezing, and may relate to loss of sphincteric inhibitors, or function, urethral hypermobility from pelvic floor laxity (often o Surgical removal of the obstructing gland related to parity), or following prostate surgery in men. Fistula Overflow incontinence Tension-free multilayer closure occurs in the setting of obstruction, with urine leakage Nonoverlapping suture lines occurring with movement causing overflow of urine from a tissue interposition distended bladder. 15 16  CABILDO, TIFFANY JANE B. CABILDO, TIFFANY JANE B. Erectile Dysfunction Half-life Erectile dysfunction is defined as the inability to achieve and maintain an erection Highest in tadalafil (ED) adequate for sexual intercourse The impact of lipids in foods Early symptom of cardiovascular disease due to endothelial Sildenafil and vardenafil must be taken on an empty stomach dysfunction. Mechanism of Sexual stimulation à nerve fibers à NOà +GC à inc cGMPà SE: HEADACHE, HEARTBURN, FACIAL FLUSHING, NASAL erection Smooth muscle relaxation within the corpora cavernosa à allowing CONGESTION, AND MYALGIAS blood to fill the lacunar spacesà Expanded tissue compresses the subtunical venules thereby trapping blood within the penis and Contraindicated in px taking nitrate containing medsà severe blocking venous outflow hypotension Phosphodiesterase type-5 hydrolyzes cGMP to reverse the process. There are multiple Vasculogenic, Neurogenic, Iatrogenic, and Psychologic, but often Second-line options for ED mechanisms leading it is Multifactorial Vacuum erection devices (VED to ED Intracavernosal injections (ICI) Vasculogenic ED o prostaglandin E1 [alprostadil], papaverine, and cardiovascular disease and endothelial dysfunctionà phentolamine) cavernosal artery insufficiency Intraurethral suppositories o Alprostadil in the form of a pellet which is then placed in Neurogenic ED the urethra and massaged for absorption Nerve injuries due to diseases (diabetes, Parkinson’s, multiple sclerosis, spinal cord injury) Third-line treatment of ED Surgery (radical prostatectomy, abdominoperineal resection, surgery placement of a penile prosthesis and other radical pelvic procedures) Iatrogenic ED PEDIATRIC UROLOGY Surgery Hypospadias Medications Hypospadias A condition which may be considered a form of incomplete maturation o Antihypertensives of the genitalia, is a common abnormality that occurs in 1 out of 250 to o Opiates 300 newborn boys. o Antiandrogens Urethral opening that is not at the tip of the glans o Psychotherapeutics Meatus on the mid to distal shaft or proximal glans-- 70% to 80% Psychogenic ED A lesser number will have more proximal openings, whether Reaction to stress and anxiety penoscrotal, scrotal, or perineal. Result of noradrenaline deficient ventral foreskin Release causing smooth muscle contraction and thereby Associated penile curvatureà chordee inhibiting erections. Note: no increased risk of renal or bladder anomalies. Treatment Lifestyle modification Urinary Tract Infections in Children Phosphodiesterase type-5 inhibitors (PDE5i) Children may have Vesicoureteral reflux sildenafil, tadalafil, vardenafil, and avanafil conditions such as Ureteropelvic junction obstruction Ureteroceles Note: They differ in time to peak concentration Or Ectopic ureters Lowest in avanafil, sildenafil, and vardenafil As causes of these infections. 17 18  CABILDO, TIFFANY JANE B. Dx infants less than 2 months of age with febrile infections should undergo both a renal US and voiding cystourethrography (VCUG) Children between 2 months and 2 years who have their first documented infection only need have a renal ultrasound performed. A VCUG is only needed if there are abnormalities detected on the ultrasound such as hydronephrosis, scarring, or other evidence of anatomic abnormality. All children with UTIs need to have a thorough assessment of daily bladder and bowel habit bowel dysfunction may be the most important factor in the development of UTIs. Prenatal Hydronephrosis Notes Antenatal imaging will show hydronephrosis in nearly 1% of all babies RELATED TO Vesicoureteral reflux Ureteropelvic junction obstruction Ectopic Ureter/ureteroceles, and Other upper tract abnormalities Dx baseline renal ultrasound VCUG or Lasix renal scans can then be done depending on the degree of dilation. Special bilateral hydronephrosis or hydronephrosis associated with a consideration solitary kidneyà oligohydramnios à pulmonary insufficiency. Boys with bilateral hydronephrosis and low amniotic fluid are at high risk for having posterior urethral valves (PUV). à 25% risk of developing ESRD Prenatal Placement of vesicoamniotic shunts intervention Cryptorchidism Cryptorchidism undescended testes (UDT) is a common condition occurring in 3% of full term and 30% of premature babies. Gonadotropins Stimulus for descent Untreated will lead to testis damage, and there is evidence that permanent changes cryptorchidism may occur by 3 years of age Management Surgical repair before 3 years SURGERY IS THE TREATMENT OF CHOICE; HORMONAL TREATMENT HAS NO ROLE May be in Prader-Willi, Eagle-Barrett, or other such complex multisystem syndrome. association with The consequences Infertility and – 50% if bilateral of untreated Malignant degeneration cryptorchidism 19