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 Dressings, Drains, & Post-operative Care

Terminology 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

Terminology

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

http://www.youtube.com/watch?v=xYTjvqzyd9k

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 System

Testis Lobules with 3 cell types:

1. Seminiferous tubulesinvolved in spermatogenesis

2. Interstitial cells (cells of Leydig)produce testosterone

3. Seratoli cellsprovide nutrients for sperm

Male Reproductive System

Sperm Male produces 300 million sperm per

day=120million per ml Less than 20 million per ml considered sterile

Male Reproductive System

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)

2. Midpiece extension that contains large amt of mitochondria (ATP)

3. Flagellatail composed of a protein that allows for movement generated by ATP

1N

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

Ducts

1. Epididymis Series of ducts or channels that communicate with the testis Store sperm Area for sperm maturation Ciliated columnar cells secrete2. Vas Deferens Loops up over bladder Transports sperm Ciliated columnar cells and smooth muscle (peristalsis) move

sperm3. Ejaculatory duct Vas deferens merge into this posterior to bladder which merges

with the urethra (runs through the prostate)

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 cord goes from inguinal ring to testis Inguinal ring also contains ductus deferens, testicular

vessels (arterial, venous, and lymphatic), and nerves

Accessory Organs

1. Seminal vesicles Behind (posterior) bladder Secrete into ejaculatory duct 60% liquid portion of semen2. Prostate gland Donut shaped as urethra runs through it Secretes 30% liquid portion of semen directly into the urethra3. Bulbourethral (Cowper’s) glands 10% volume of semen (lubricates head) Neutralizes acidity of urethra Secrete directly into urethra

Internal urinary sphincter tightens w/ejaculation to prevent mixing of urine w/sperm

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 System

Kidneys Adrenal glands Ureters Urinary Bladder Urethra Prostate Gland (male)

Kidneys

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

Nephron

> 1 million per kidney 2 types: juxtamedullary and cortical Each composed of capillary network: Renal corpuscle Renal tubule

Nephron

Renal Corpuscle: Bowman’s Capsule Glomerulus Renal Tubule: Proximal Convuluted Tubule Loop of Henle Distal Convuluted Tubule Collecting Tubule

Renal Corpuscle

1. Filtration Bowman’s Capsule (glomerulus encased by) Glomerulus (capillary network) Water and substances filtered from blood

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 Tubules

3. Secretion Substances move from blood into tubules

(urine) Distal Collecting Tubule Collecting Tubule

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

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)

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)

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 (cortex)

Adrenal gland (cortex) Cortisol (hydrocortisone) Affects glucose metabolism Regulates metabolism of fats, carbohydrates,

proteins, fats, potassium Anti-inflammatory

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 (medulla)

Norepinephrine Increases blood pressure Decreases heart rate Constricts vessels (arterioles and venules)

Pathology of the Male Reproductive System Phimosis Hypospadias/Epispadias BPH Cancer of the Prostate Cryptorchidism Testicular Torsion Testicular Cancer Trauma

Phimosis

Foreskin will not retract Congenital Geriatric Can cause infection, pain Tx: circumcision

Hypospadias Epispadias

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

perineum Urethral opening inside the vagina Congenital Tx: Surgical repair

Epispadias Urethral opening on top of the penis (dorsal) Urethral opening above the clitoris Congenital Tx: Surgical repair

Cryptorchidism

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

Orchiopexy

Orchiectomy

Testicular Torsion

Spermatic cord is twisted Tx: Orchiopexy

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

BPH

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

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

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

ESWL

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

Cystoscopic / ureteroscopic / nephroscopic lithotomy

Direct extraction via Laser through Small Lithotripsy unit used through Percutaneous lithotomy Open lithotomy

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%

2. Autosomal recessive (rare/congenital) Children

3. Acquired (long term kidney problems)

Diabetic Neuropathy (sclerosis)

Uncontrolled diabetic Progressive disease>ESRD>dialysis

ESRD

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

Hemodialysis

Vascular access1. 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

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 Cushing’s Syndrome Addison’s Disease Pheochromocytoma

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 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 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 System

Reproductive Organs: Female

Pathology of Female Genitourinary and Reproductive System Benign Cysts Polyps (pedunculated lesion) Fistulas Dysplasia Leiomyoma/Myoma/Fibroid Fibroma

Malignant Vulvar Vaginal Cervical Uterine Ovarian

Other Endometriosis Cystocele Rectocele (posterior colporrhaphy) Enterocele Ectopic Pregnancy Incompetent Cervix (cerclage)

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

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

Anesthesia

General Spinal Epidural MAC with Local

Medications

Antibiotics Contrast Media (Hypaque) Dyes (Methylene Blue, Indigo Carmine) Diuretics

Instruments

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

Bridges (short and long) Cystoscopes: 12°, 30°, and 70°

Supplies

Ureteral sounds (dilators) Flexible endoscope and accessories Rigid endoscope instrumentation Resectoscope Ellik evacuator Toomey irrigator/syringe Accessories: light cord, camera, insufflation

tubing, irrigation fluid

Irrigations

1. Glycine TURP

2. Water Laser

3. NS Cystograms

Supplies Continued

Lubricant Foley catheter and drainage bag Alternative catheters (difficult insertion) Catheter guide (facilitates insertion) Urethral catheters Ureteral drainage bag(s)

Catheters

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

Equipment

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

Positioning

Lithotomy Supine Lateral Variations of Above

Prep

Area of Involvement Begin at incision site and work way out Prep genital area last May not do a prep if urethral approach

Draping

Laparotomy Universal Perineal Combination Laparotomy/Perineal Surgeon’s preference/approach Depends on position

Dressings

Abdominal: steri-strips, telfa, xeroflo,

4x4s, ABD (surgeon’s preference) Vaginal packing Peri-pad Net panties

Drains

JP Snyder Hemovac/Grenade Penrose Depends on location of surgical wound and

surgeon preference

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

Complications

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)

Summary

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