Handbook of Surgical Consent
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Cite
Antegrade image-guided nephrostomy/insertion of ureteric stent 286
Circumcision (foreskin of the penis) 288
Cystectomy (radical) 290
Cystolitholapaxy (transurethral) 294
Cystoscopy (flexible) 296
Cystoscopy (rigid)—diagnostic 298
Epididymal cyst excision 300
Extracorporeal shockwave lithotripsy 302
Frenuloplasty 304
Hydrocoele repair 305
Intravesical injection of botulinum toxin-A 307
Nephrectomy (simple/partial/radical/nephro-ureterectomy) 309
Optical internal urethrotomy 312
Orchidectomy (simple/sub-capsular/radical) ± insertion of silicone implant 315
Percutaneous nephrolithotomy 318
Preputial adhesiolysis 320
Prostatectomy (radical) 322
Retrograde pyelogram ± retrograde insertion of ureteric stent 325
Scrotal exploration for suspected torsion of testis 328
Suprapubic catheter insertion (cystoscopic/blind/ ultrasound guided) 330
Transrectal ultrasound ± guided biopsies of the prostate gland 333
Transurethral resection of bladder tumour 336
Transurethral resection of prostate gland/open prostatectomy (transperineal/Millen's) 338
Ureterorenoscopy (diagnostic/therapeutic) 342
Urethral dilation (cystoscopy—male/female) 345
Vasectomy 347
Antegrade image-guided nephrostomy/insertion of ureteric stent
Description
Antegrade nephrostomy insertion is a radiologically guided procedure, commonly performed under fluoroscopic and/or ultrasound guidance. A percutaneous tube is placed within the renal pelvis or calyceal system and acts as a conduit for urinary drainage in the presence of ureteric obstruction, antegrade instillation of contrast medium, or placement of an antegrade ureteric stent. The commonest emergency indication for placement of a nephrostomy is in the obstructed, infected kidney where the retrograde approach carries a theoretical risk of both increased pyelovenous pressures with bacterial translocation into the systemic circulation1 and placing a potentially septic and hypotensive patient under general anaesthesia. To facilitate this procedure safely, the INR clotting result required should be <1.5.
The procedure is either performed with the patient supine, lateral position or prone and local anaesthetic is administered through the tract site. The kidney is punctured under ultrasound or fluoroscopic guidance and contrast medium injected to fill the pelvicalyceal system. A guide-wire is introduced, over which a nephrostomy tube or antegrade stent may be placed.
Additional procedures that may become necessary
Pyelography
Antegrade ureteric stent placement at the time of nephrostomy insertion or as a separate procedure
Repeat procedure to remove the nephrostomy under fluoroscopic guidance
Percutaneous nephrolithotomy (PCNL)2
Benefits
Diagnostic: a descending pyelogram can identify the level of ureteric obstruction, filling defects and anomalies, allowing for a ‘road-map’ of the upper urinary tract for further treatment
Therapeutic: to provide a tract prior to PCNL, to dissolve renal calculi, to obtain direct access to the upper urinary tract for various endourological procedures including placement of a ureteric stent, deliver chemotherapeutic agents to the renal collecting system, provide prophylaxis after resection for local chemotherapy in patients with tumours of the renal pelvis, to act as a conduit for urinary drainage
Alternative procedures/conservative measures
Medical: systemic antibiotics until resolution of sepsis and then consider a retrograde approach, in rare circumstances haemofiltration may be required to stabilize patient prior to intervention
Surgical: for staghorn renal calculi, consider flexible ureteroscopy and stone fragmentation, for obstructed renal tract consider retrograde stent insertion, for palliative setting of ureteric obstruction, consider long-term retrograde ureteric stents/metal ureteric stents/ureteric diversion procedures ± re-implantation3,4
Serious/frequently occurring risks
Bleeding (including haematuria), infection (often a profound septic response can occur resulting in further intravenous antibiotic administration), post-procedure pain, urinoma, renal parenchymal injury, peri-renal haematoma formation, deterioration in renal function
Need for further procedure to resolve cause of obstruction
Dislodgement/blockage of nephrostomy
Need for further procedure to change nephrostomy or to internalize ureteric stent)
Blood transfusion necessary
None/group and save
Type of anaesthesia/sedation
Local anaesthesia
Regional/general anaesthesia (if nephrostomy tract is created prior to PCNL)
Follow-up/need for further procedure
Monitor patient until sepsis has resolved prior to internalization of ureteric stent
Consider definitive treatment for underlying cause of obstruction
May require exchange/removal of ureteric stent
References
Circumcision (foreskin of the penis)
Description
Circumcision of the male foreskin involves surgical removal of the fold of skin covering the glans penis. The procedure can be performed at any age, however, it is most commonly performed in infancy, childhood, and in middle age.
Many cultures have historically used circumcision as a rite of passage, a mark of cultural identity1 or for hygienic reasons. Medical indications for circumcision are limited to phimosis, paraphimosis, balanitis xerotica obliterans (BXO), recurrent balanitis, harvesting of tissue for hypo/epispadias repair or for tissue biopsy of adherent penile malignancy.
There are numerous techniques for performing a circumcision (e.g. cuff technique (Fig. 11.1), bipolar scissor circumcision) and the choice often depends on the surgeon. There are numerous devices that aid in this process (e.g. Plastibell circumcision device), and the foreskin is removed and often sent for histological examination. The wound may be closed with absorbable or non-absorbable sutures depending on the technique employed. The penis itself may become swollen postoperatively for up to 3 weeks and the wound may take 4–6 weeks to heal.2
Cuff technique for circumcision of foreskin of the penis.
Additional procedures that may become necessary
Frenuloplasty
Preputial adhesiolysis
Preputioplasty (if an underlying hypospadias is identified and the foreskin is to be preserved)3
Meatal dilatation meatotomy
Benefits
Diagnostic: BXO, biopsy of underlying penile malignancy
Therapeutic: phimosis, paraphimosis, BXO, posthitis
Reconstructive: tissue grafting in the repair of hypo/epispadias
Religious/cultural/hygiene4
Alternative procedures/conservative measures
Conservative: poor anaesthetic risk or in patients with long-term suprapubic catheter in place where urethral passage of urine is no longer an issue. General foreskin and penile hygiene. Gentle retraction of foreskin in cases of phimosis. Disadvantage: underlying pathology not addressed and recurrence common
Medical: antibiotics for recurrent balanitis. Disadvantage: underlying pathology not addressed and recurrence common
Surgical: frenuloplasty (for painful or bleeding frenulum during intercourse or retraction of foreskin), preputial adhesiolysis (for preputial adhesions limiting retraction of foreskin), dorsal slit (for acute non-retractile paraphimosis)
Serious/frequently occurring risks
Common: bleeding (which may necessitate reoperative intervention and ligation of frenular artery), pain, scar, prolonged wound healing/dressings, infection (local/systemic), persistence of absorbable sutures
Occasional: cosmetic dissatisfaction (requiring further procedure to remove excess skin at a later date), tender scar
Rare: identification of underlying malignancy requiring further intervention, urethral injury (resulting in urethrocutaneous fistula) on performing dorsal slit or ligating frenular artery, tattooing from dyed sutures, Fournier's gangrene4
Blood transfusion necessary
None
Type of anaesthesia/sedation
General anaesthesia
Very occasionally under spinal/epidural/local anaesthesia (without adrenaline/ephedrine) for those unfit for general anaesthesia
Local anaesthetic infiltration as a penile block (at base of penis) or circumferential ring block (around foreskin)
Follow-up/need for further procedure
None or review in outpatient clinic for review of wound and histology
If associated with underlying malignancy (penile/foreskin), further surgical intervention/systemic treatment may need initiating, necessitating referral to specialist urological services
References
Cystectomy (radical)
Description
Although most bladder malignancies are non-muscle invasive at diagnosis (75%), tumours which are muscle invasive, associated with diffuse carcinoma in situ (CIS), or do not respond to conventional transurethral resection or intravesical chemotherapy require special attention.
Radical cystectomy does provide a potentially curative option for these patients. The procedure is performed in a supine patient where a midline lower abdominal transperitoneal approach is used. The bladder is taken off is lateral pedicles and midline urachus, and in men, the prostate gland in its entirety is also removed. In women, the anterior pelvic compartment is also removed (anterior vaginal wall/uterus) and effectively an anterior pelvic exenteration performed. During the procedure, bilateral pelvic lymphadenectomy is also performed.
Ileal conduit urinary diversion: this is the most popular form of urinary diversion where a segment of ileum is isolated and the distal end brought out as a stoma. The ureters are anastomosed to the proximal end of the ileal segment
Continent urinary diversion: there are a number of techniques to create a neo-bladder avoiding the presence of a stoma and external urinary collection device. The principles involve manipulation of small or large bowel to re-create an orthotopic neo-bladder for urinary storage. This is anastomosed to the native urethra
Ureterosigmoidostomy urinary diversion: the oldest form of urinary diversion methods where the ureters are anatomized to the sigmoid colon. This technique is particularly useful in developing countries where the social stigma and community support in stoma care is poor or non-existent
(a) Perivesical space developed to mobilize bladder anteriorly. (b) Incision of endopelvic fascia and division of pubourethral and puboprostatic ligaments. (c) In females, division of the posterior fornix of the vagina. (d) Dissection around the dorsal venous complex of the prostate. (e) Ligation of the dorsal venous complex of the prostate. (f) Oversewing of dorsal venous complex and division of urethra.
Indications for radical cystectomy include:
Muscle-invasive bladder cancer without evidence of metastasis (or with low-volume, resectable locoregional metastases)
Superficial bladder tumours refractory to cystoscopic resection, intravesical chemotherapy or immunotherapy, bladder tumour not amenable to transurethral resection of bladder tumour (TURBT), or invasive tumour involving the prostatic urethra
G3pT1 tumour unresponsive to intravesical bacille Calmette Guérin (BCG) vaccine therapy
CIS refractory to intravesical immunotherapy or chemotherapy
Palliation for pain, bleeding, or urinary frequency
Primary adenocarcinoma, squamous cell carcinoma, or sarcoma
Rarely, radical cystoprostatectomy is indicated for salvage treatment for recurrent prostate cancer or intractable haematuria following primary therapy with radiation
The decision behind radical cystectomy is ideally made within a multidisciplinary setting, and the patient may be offered other treatment options to secure oncological control. This can include external beam radiotherapy, TURBT, or intravesical/systemic chemotherapy. Patients are counselled pre- and postoperatively with close liaison with cancer nurse specialists’ and stoma care nurses (if necessary) throughout their journey.
Additional procedures that may become necessary
Postoperative pelvic and abdominal drains
Urethrectomy (for anterior urethral disease)
Pelvic lymphadenopathy
Neo-adjuvant chemotherapy
Adjuvant chemo-radiotherapy
Alternative urinary diversion technique
Benefits
Diagnostic: allows histopathological grading and staging of disease where in certain circumstances upstaging of disease is seen
Therapeutic: the procedure is performed for curative intent and oncological control
Functional: continent diversion procedures in younger patients aim to restore functional ‘storage’ capacity
Alternative procedures/conservative measures
Conservative/palliative: in patients with poor anaesthetic risk or in patients with poor quality of life, palliative care may be the appropriate management plan
Chemotherapy: this may be in the form of systemic or intra-vesical chemotherapy either in the neoadjuvant or adjuvant setting
Radiotherapy: in patients with poor anaesthetic risk or who have poor survival outcomes on preoperative risk stratification may be appropriate for radiotherapy
Surgery: regular debulking TURBT in patients who are not suitable for cystectomy. Alternatively the approach used for cystectomy can vary to include laparoscopic and robot assisted radical cystectomy
Urinary diversion techniques: neo-bladder formation, ileal conduit, ureterosigmoidostomy, cutaneous ureterostomy
Serious/frequently occurring risks
General: need for reoperation (10%), bleeding requiring reoperation or blood transfusion, thromboembolic event, wound infection and sepsis requiring intravenous or oral antibiotics, wound dehiscence (10%), prolonged intestinal ileus or obstruction (10%), rectal injury (4%), cardio-respiratory event, long-term erectile dysfunction, death (perioperative period: 1%)
Specific: need for ureteric stent insertion, erectile dysfunction, dry orgasm where no semen is produced on ejaculation, need for self-catheterization if neo-bladder/conduit fails to empty effectively, need for urethrectomy, incontinence of urine, local cancer recurrence or distant metastases, incisional hernia, deteriorating renal function, rectal injury requiring colostomy, difficulty in females with intercourse due to painful shortened or narrowed vagina
Ileal conduit: prolonged ileus, urinary leak requiring percutaneous drain or defunctioning nephrostomy, uretero-ileal or enteral anastomotic leak, uretero-ileal anastomotic stricture, pyelonephritis and ascending urinary tract infections, skin excoriation, stomal prolapse or stenosis, metabolic dysfunction (hyperchloraemic acidosis, B12 deficiency), adenocarcinoma (5%—long-term risk in bowel mucosa)
Continent urinary diversion: urinary leak requiring percutaneous drainage or defunctioning nephrostomy, pelvic abscess formation, orthotopic neo-bladder and urinary tract calculus formation, catheterizing problems and stomal stenosis, urinary incontinence, nocturnal enuresis, pouch-ureteric reflux, ascending urinary tract infections, uretero-pouch anastomotic strictures, neo-bladder rupture (early/late), metabolic dysfunction (hyperchloraemic acidosis, B12 deficiency), adenocarcinoma (5%—long-term risk in bowel mucosa)
Ureterosigmoidostomy: frequent ascending urinary tract infections, long-term risk of deteriorating renal function, frequent diarrhoea and watery stools, malignant transformation of urothelium (adenocarcinomas)1
Blood transfusion necessary
Cross-match 2–6 units
Type of anaesthesia/sedation
General anaesthesia
Epidural anaesthesia often administered preoperatively as a method of postoperative pain control
Follow-up/need for further procedure
Patients will often spend the initial postoperative period on the ITU/HDU
Drains will need removal when output decreases
Stoma nurse follow-up/continence nurse follow-up/urology cancer nurse support
Outpatient follow-up with regular surveillance imaging and serum electrolyte review (serum creatinine, potassium, bicarbonate and vitamin B12)
Multidisciplinary team review of histopathological results from resected specimen to determine postoperative surveillance or treatment plan
Need for adjuvant chemo/radiotherapy in select cases
References
www.baus.org.uk (accessed 17 May
2011). www.baus.org.uk (accessed 17 May
2011). www.baus.org.uk (accessed 17 May
2011). www.baus.org.uk (accessed 17 May
2011).Cystolitholapaxy (transurethral)
Description
Bladder calculi are associated with urinary stasis secondary to benign prostatic enlargement and therefore commoner in men over the age of 50. In a subgroup of patients who have long-term urethral or suprapubic catheters in situ, up to 25% develop bladder calculi. These stones may be associated with infection (struvite) or no infection (uric acid) and tend to be visible on a plain kidney–ureter–bladder (KUB) X-ray. Rare causes of bladder stones in the absence of bladder outflow obstruction or in children should be investigated further with metabolic testing (hyperparathyroidism, malnutrition).1
The majority of bladder stones are small enough to be removed cystoscopically with the use of stone-crushing forceps, intravesical pneumatic or ultrasonic lithotripsy and recently lasers.2 As the formation of bladder calculi is associated with bladder outflow obstruction, the vast majority of patients will have this procedure combined with bladder outflow obstruction surgery. In rare circumstances when stone retrieval is difficult due to poor vision or size, then conversion to an open procedure may be needed (open cystolitholapaxy).
Additional procedures that may become necessary
Bladder neck incision/TURP/holmium laser enucleation of prostate (HoLEP)/photo-selective vaporization of the prostate (PVP) (bladder outflow surgery)
Open cystolitholapaxy
Bladder biopsies
Catheterization (urethral or suprapubic)
Benefits
Diagnostic: assessment of the size of prostate, assessment of bladder neck for outflow obstruction
Therapeutic: remove bladder calculi in isolation or combined with bladder outflow surgery, reduce risk of urinary tract infections, symptomatic improvement
Alternative procedures/conservative measures
Conservative: encourage fluid intake, and bladder emptying exercises (largely ineffective), monitor calculus if asymptomatic and patient high risk for surgery
Medical: A-blocker and 5-A-reductase inhibitors as medical treatment for bladder outflow obstruction may improve symptoms, but will not treat bladder calculus. Prophylactic antibiotics to prevent secondary infection. Stone dissolution therapy does not work particularly well with bladder calculi
Surgical: open cystolitholapaxy involves open surgery and the propensity to have further complications associated with intra-abdominal surgery, percutaneous (with the aid of a 30F sheath) and even laparoscopic cystolitholapaxy has been described with good outcomes
Serious/frequently occurring risks
Common: bleeding (haematuria), dysuria, painful passage of stone fragments, catheter-associated discomfort
Occasional: urinary tract infections requiring oral or intravenous antibiotics, recurrence, residual fragments necessitating further procedure, trauma to urethra and bladder causing haematuria
Rare: haematuria and clot retention necessitating further cystoscopy and washout, injury to urethra necessitating catheterization (up to 2 weeks), urethral stricture formation, perforation of the bladder and/or urethra necessitating catheterization or open surgical repair3
Blood transfusion necessary
None/group and save
Type of anaesthesia/sedation
Regional/general anaesthesia
Follow-up/need for further procedure
Routine outpatient follow-up with X-ray KUB, flow-rate (urine) on arrival (FROA) and residual volume (RV)
May need to return for bladder outflow surgery at later date
References
www.baus.org.uk (accessed 17 May
2011).Cystoscopy (flexible)
Description
This is a telescopic examination of the bladder with the use of a thin fibreoptic flexible telescope (Fig. 11.3). The procedure allows direct visualization of the urethra and bladder for diagnostic or follow-up purposes in an outpatient setting using local anaesthetic lubricating jelly. The flexible cystoscope is introduced into the urethra under sterile conditions, and although the procedure is principally diagnostic, biopsies, diathermy and laser can be undertaken due to the presence of a working channel. The flexible cystoscope has the ability to deflect 270°, and therefore the user is able to retrovert the scope and view the bladder neck.
Flexible cystoscope.
It is important that the urine of the patient is tested to ensure there is no evidence of active urinary tract infection, which precludes this examination (unless in certain circumstances where it is performed under antibiotic cover).
Indications for flexible cystoscopy include:
Visible haematuria
Persistent non visible haematuria
Irritative lower urinary tract symptoms (LUTS)
Recurrent urinary tract infections
Establish diagnosis of stricture
Assess transurethral size of prostate gland
Follow-up surveillance of patients with previously diagnosed and treated bladder cancer
Cystoscopic removal of ureteric stents
Cystoscopic insertion of urethral catheter/suprapubic catheter
Additional procedures that may become necessary
Biopsy of bladder mucosal lesion
Removal of ureteric stent
Urethral dilatation
Diathermy/laser ablation of bladder lesion
Photography of bladder or urethral lesion
Active bladder filling to measure FROA and post-void residual (PVR) volume
Insertion of urethral/suprapubic catheter
Benefits
Diagnostic: diagnostic and follow-up direct examination of bladder
Therapeutic: biopsy, removal of ureteric stent, diathermy/laser ablation of bladder lesion
Alternative procedures/conservative measures
Radiological: for patients who are unable to tolerate flexible cystoscopy due to poor mobility, contractures or the extremely frail and elderly patient, consider ultrasound KUB/CT urogram/contrast CT abdomen and pelvis (
the diagnostic yield of these investigations is poor for small lesions within the bladder)
Surgical: for patients unable to tolerate flexible cystoscopy (paediatric patients/pain) consider general anaesthesia/regional anaesthesia and rigid cystoscopy ± bladder biopsies
Serious/frequently occurring risks
Common: bleeding (haematuria), dysuria
Rare: haematuria and clot retention necessitating further cystoscopy and washout, need for catheterization (temporary), urethral stricture formation3
Blood transfusion necessary
None
Type of anaesthesia/sedation
Local anaesthetic lubricating gel
Follow-up/need for further procedure
Dependent on the indication and findings of cystoscopy
If a bladder tumour or a suspicious area is identified within the bladder, urgent follow-up with transurethral resection of bladder tumour or rigid cystoscopy and bladder biopsies may be required
References
www.baus.org.uk (accessed 17 May
2011).Cystoscopy (rigid)—diagnostic
Description
This is a telescopic examination of the bladder with the use of a rigid telescope. The procedure allows direct visualization of the urethra and bladder for diagnostic or therapeutic purposes. It is carried out under regional or general anaesthesia and will therefore require the patient to be admitted in a day-case/inpatient setting.
The rigid cystoscope is a rigid metal instrument introduced into the urethra under sterile conditions, and although the procedure is principally diagnostic, it is used as an adjunct or precursor to a therapeutic procedure (e.g. cystolithalopaxy/TURP/ureteric stent insertion). Biopsies, cystodiathermy and ureteric (JJ) stent insertion can be undertaken due to the presence of a working channel (and in certain cystoscopes, a deflecting bridge).
The rigid cystoscope has the ability to be fitted with telescopes of varying deflection angle (0/30/70/120°), and therefore the user is able to view the bladder neck, bladder trigone, or urethra accordingly. It is important that the urine is tested to ensure there is no evidence of active urinary tract infection, which precludes this examination (unless in certain circumstances where it is performed under antibiotic cover).
Indications for rigid cystoscopy1 include:
Visible haematuria
Persistent non-visible haematuria
Irritative LUTS
Recurrent urinary tract infections
Establish diagnosis of stricture
Assess size of prostate gland
Follow-up surveillance of patients with previously diagnosed and treated bladder cancer
Evacuation of bladder clot/bladder calculi
Cystoscopic insertion/removal of ureteric stents
Cystoscopic insertion of urethral catheter/suprapubic catheter
Additional procedures that may become necessary
Biopsy of bladder mucosal lesion
Insertion/removal of ureteric stent
Urethral dilatation
Optical urethrotomy
Bladder washout
Evacuation of bladder clot/bladder calculi
Diathermy/laser ablation of bladder lesion
Insertion of urethral/suprapubic catheter
Benefits
Diagnostic: diagnostic and follow-up examination of bladder
Therapeutic: for indications as listed
Alternative procedures/conservative measures
Radiological: for patients who are unable to tolerate a general or flexible cystoscopy due to poor mobility, contractures, and the extremely frail and elderly patient who is not fit for a general/regional anaesthesia, consider ultrasound KUB/CT urogram/contrast CT abdomen and pelvis (the sensitivities of these investigations are poor for small lesions within the bladder)
Surgical: for patients unable to tolerate rigid cystoscopy consider flexible cystoscopy
Serious/frequently occurring risks
Common: bleeding (haematuria), dysuria, temporary insertion of urethral catheter
Occasional: urinary tract infections requiring oral or intravenous antibiotics, trauma to urethra, prostate or bladder resulting in haematuria, diagnosis of bladder mucosal lesion/stone requiring treatment
Rare: haematuria and clot retention necessitating further cystoscopy and washout, need for catheterization (temporary), urethral stricture formation, perforation of urethra/bladder necessitating temporary catheter insertion or open procedure to repair defect in bladder
Blood transfusion necessary
None/group and save (depending on subsequent therapeutic procedure)
Type of anaesthesia/sedation
Regional/general anaesthesia (rarely, rigid cystoscopy can be performed under local anaesthetic lubrication in women)
Follow-up/need for further procedure
Dependent on the indication and findings of cystoscopy or therapeutic procedure
References
www.baus.org.uk (accessed 17 May
2011).Epididymal cyst excision
Description
An epididymal cyst is also known as a spermatocoele (when there are spermatozoa contained within the cystic fluid).1 These slow-growing cystic swellings are derived from the collecting tubules of the epididymis and are often asymptomatic. They lie within the scrotum, vary in size and are felt separately from (above and behind) the testis. They are often multiple cysts, bilateral and multiloculated. Transillumination is possible and characteristic of larger cysts. Some can cause testicular pain, become large and cause a dragging sensation, become infected, or there may be cyst haemorrhage resulting in pain. These cysts are commonly diagnosed on clinical findings, however prior to surgical intervention, it is prudent to confirm this diagnosis with ultrasound.
A midline or transverse scrotal incision is performed. The dartos and tunica vaginalis are opened and the testis is delivered into the wound. The testis is inspected, a hydrocoele is excluded or repaired, and the epididymis is isolated with the cyst. The cyst is ideally enucleated or separated off the epididymis taking care not to damage it. The testis is returned to the scrotum after haemostasis is secured and the wound closed in layers with absorbable sutures.
Additional procedures that may become necessary
Hydrocoele repair (Lord's/Jaboulay procedure)
Multiple epididymal cyst excision
Epididymectomy (in circumstances where multiple epididymal cysts obscure normal epididymal tissue)
Epididymal/testicular biopsy
Benefits
Diagnostic: histopathological confirmation of benign epididymal cyst can be performed after removal, removal of equivocal cystic swellings on examination or ultrasound scan for diagnosis
Therapeutic: alleviate pain (although this may persist despite removal), remove unsightly swelling, decrease dragging sensation, or prevent recurrent infections of cyst
Alternative procedures/conservative measures
Conservative: analgesia, scrotal support, monitor asymptomatic cyst if causing no symptoms
Surgical: aspiration of cyst (high recurrence rates, and risk of introducing sepsis into cyst), sclerotherapy of cysts,2 epididymectomy for recurrent cysts refractory to multiple surgical exploration and excision, however, there is a risk of sub-fertility (unilateral) and infertility (bilateral)
Serious/frequently occurring risks
Occasional: bleeding (scrotal haematoma resulting in either slow resorption or further procedure to evacuate clot), chronic scrotal or testicular pain (up to 5% cases), infection (wound/epididymo-orchitis necessitating antibiotic therapy), non-resolution of symptoms, recurrence of epididymal cysts
Rare: epididymal scarring/damage resulting in sub-fertility3
Blood transfusion necessary
None
Type of anaesthesia/sedation
Local/regional/general anaesthesia
Follow-up/need for further procedure
Scrotal support for up to one week
Warm sit down bath after 48h to soak and remove dressing
No follow-up required unless indicated
References
www.baus.org.uk (accessed 17 May
2011).Extracorporeal shockwave lithotripsy
Description
Extracorporeal shockwave lithotripsy (ESWL) is a non-invasive technique whereby externally focused shockwaves are targeted at renal calculi within the urinary tract allowing for stone fragmentation. The three principal methods of shockwave generation are electrohydraulic, electromagnetic, and piezoelectric energy. The effectiveness of ESWL is dependent on the size of the stone, location of stone (lower pole calculi and calculi within a calyceal diverticulum have worse outcomes), obesity, renal anatomy, and stone composition (cystine and calcium oxalate monohydrate are difficult stones to fragment).
ESWL is used for renal stones <2cm size (stone-free rate: 80% for stones <1cm, 60% for stones 1–2cm and 50% for stones >2cm) and ureteric stones <1cm in size.
The patient is given analgesia or sedation pre-procedure and occasionally oral antibiotics, they are positioned supine, prone or in the lateral position to focus the stone under fluoroscopic/ultrasound guidance. Treatment is commenced at low energy and increased throughout the treatment session.
Contraindications to treatment include:
Pregnancy
Uncorrected coagulopathy
Use of anticoagulation
Active urinary tract infection
Abdominal aortic aneurysm
It is key to remind the patient that more than one ESWL session may be required to achieve stone fragmentation.
Additional procedures that may become necessary
Pre-ESWL ureteric stent placement for larger calculi >1cm (to facilitate passage of stone fragments) and prevent a steinstrasse (‘stone street’ line of obstructing stone fragments in ureter)
Benefits
Therapeutic: achieve stone fragmentation (non-invasive method)
Alternative procedures/conservative measures
Conservative: stones can be managed conservatively if asymptomatic, not causing pain, are non-obstructing and not acting as a focus for recurrent urinary tract infections. Occasionally a ureteric stent is inserted in an emergency setting, which may allow passage of calculi up to 1cm in size (European Association of Urology (EAU) guidelines1) without the need for treatment
Medical: A-blocker (tamsulosin) to aid the passage of lower third ureteric calculi, medical stone dissolution therapy (primary treatment/in combination with ESWL) in patients with uric acid stones unfit for surgery or in whom ESWL is contraindicated
Surgical: rigid cystoscopy and ureteric stent insertion (to facilitate stone passage), rigid ureteroscopy and stone basketing/fragmentation (ureteric calculi), flexible ureteroscopy and stone fragmentation
Serious/frequently occurring risks
Common: haematuria (visible/non-visible), renal angle tenderness, renal colic (as stone fragments pass), urinary tract infection necessitating oral/intravenous antibiotics (infectious stones that cause a transient bacteriuria/bacteraemia)
Rare: acute renal impairment (those with a history of ischaemic heart disease, type 2 diabetes mellitus, pre-existing chronic kidney disease, solitary kidney), steinstrasse (‘stone street’ line of obstructing stone fragments in ureter), severe renal tract sepsis/pyonephrosis necessitating nephrostomy insertion4
Blood transfusion necessary
None
Type of anaesthesia/sedation
Oral/intramuscular analgesia/sedation/(general anaesthesia in children)
Follow-up/need for further procedure
Follow-up KUB X-ray to confirm position and size of stone
CT KUB to assess stone fragmentation
Outpatient clinic appointment as required
Metabolic stone risk factor analysis (serum uric acid/calcium/24h urinary collection) in recurrent stone formers
References
www.baus.org.uk (accessed 17 May
2011).Frenuloplasty
Description
An abnormally short ‘bow-stringing’ frenulum on the ventral aspect of the glans penis restricts normal retraction of the foreskin. The condition known as frenulum breve can result in difficult painful foreskin retraction, a bleeding frenulum, chronic frenular scarring, and painful intercourse. It can co-exist with phimosis in which case circumcision is the treatment of choice, however, in isolation, frenuloplasty may be sufficient to relieve symptoms.1
The frenulum is divided either with a scalpel or diathermy and occasionally a haemostatic suture or a running suture is placed when sufficient frenular release/laxity is achieved. Often a V-Y-plasty or Z-plasty is required to allow sufficient length. The wound is closed with absorbable sutures.
Additional procedures that may become necessary
Circumcision of foreskin of penis
Preputioplasty
Benefits
Therapeutic: to regain sufficient length to the frenulum to allow painless retraction of the foreskin
Alternative procedures/conservative measures
Conservative: observation and moisturizer use to aid retraction of foreskin during sexual intercourse. Gentle retraction of foreskin to limit of frenular stretch (poor results)
Surgical: circumcision is often the treatment of choice in patients who have associated phimosis or who have frenular contracture or scarring post-frenuloplasty
Serious/frequently occurring risks
Occasional: bleeding (classically from frenular artery and may require ligation), pain; scarring; infection necessitating antibiotic treatment, need for circumcision if suboptimal improvement in symptoms, persistent suture present (delayed reabsorption of suture requiring removal)
Rare: altered penile sensation, scar tissue tenderness which may persist, cosmetic dissatisfaction2
Blood transfusion necessary
None
Type of anaesthesia/sedation
Local anaesthesia
Follow-up/need for further procedure
Warm bath to loosen dressing over penis after 48h
Follow-up not required unless specifically indicated
References
www.baus.org.uk (accessed 17 May
2011).Hydrocoele repair
Description
A hydrocoele is an abnormal collection of fluid between the parietal and visceral layer of the tunica vaginalis. They vary in size and are usually painless unless associated with underlying painful testicular pathology. Clinical examination reveals a uni- or bilateral scrotal lump, which is smooth to touch with a palpable superior margin. The underlying testis is often difficult to palpate and it will transilluminate on shining a light from the side of the lesion.
Causes of hydrocoele formation are:
Primary: these idiopathic masses develop over a long period of time with no underlying testicular pathology
Secondary: infection (epididymo-orchitis/filariasis/tuberculosis/syphilis), trauma, tumour (underlying testicular malignancy)
Surgical treatment of a hydrocoele usually follows ultrasound confirmation of the diagnosis and sonographic examination of the underlying testis to exclude testicular malignancy. A midline raphe incision or a transverse scrotal incision is used and deepened dividing the dartos muscle and the tunica vaginalis. Fluid is then aspirated and the hydrocoele is usually repaired via one of the following techniques:1
Lord's plication technique is usually performed for smaller or medium hydrocoeles whereby the tunica vaginalis is plicated. Advantages include decreased bleeding, a smaller incision and decreased trauma to surrounding scrotal tissue.
Jaboulay eversion procedure is usually performed for larger hydrocoeles, and involves excision and eversion of the hydrocoele sac (Fig. 11.4).
Lord's procedure for hydrocoele repair: (a) A skin incision is made and the hydrocoele delivered into the wound; (b) the tunica vaginalis is opened and the hydrocoele fluid drained. The testis is then delivered and the tunica inverted; (c) the inverted tunica vaginalis is plicated along its length allowing it to concertina behind the testis. The testis is then replaced into the scrotum and the dartos muscle and skin closed.
Additional procedures that may become necessary
Scrotal drain insertion
Scrotoplasty (plastic surgical technique to reduce the amount of redundant scrotal skin associated with large hydrocoeles)
Rare: need for testicular surgery/biopsy/orchidectomy if underlying tumour identified (if no preoperative ultrasound performed)
Benefits
Diagnostic: hydrocoele fluid or tunica can be examined histologically for evidence of tumour, filariasis infection, microscopy, and culture of fluid in cases of infection or for cytology
Therapeutic: remove hydrocoele, allow symptomatic relief, aid passage of urine (buried penis)
Alternative procedures/conservative measures
Conservative: analgesia, scrotal support, monitor asymptomatic hydrocoele if not causing symptoms
Surgical: aspiration of cyst (high recurrence rates, and risk of introducing sepsis into hydrocoele)
Serious/frequently occurring risks
Occasional: bleeding (scrotal haematoma resulting in either slow resorption, lump in scrotum or need for further procedure to evacuate clot), chronic scrotal or testicular pain (up to 5% cases), infection (wound/epididymo-orchitis necessitating antibiotic therapy), non-resolution of symptoms, recurrence of hydrocoele
Rare: need for further therapy for abnormal testicle (in cases where malignancy is suspected or diagnosed intraoperatively)2
Blood transfusion necessary
None
Type of anaesthesia/sedation
Local anaesthesia (with cord block for small hydrocoeles)/regional anaesthesia/general anaesthesia
Follow-up/need for further procedure
Scrotal support for up to one week
Warm sit down bath after 48h to soak and remove dressing
No follow-up required unless indicated
References
www.baus.org.uk (accessed 17 May
2011).Intravesical injection of botulinum toxin-A
Description
Overactive bladder (OAB) is a symptom complex that includes urgency with or without urge incontinence, nocturia, and frequency of urination. Classically OAB is associated with detrusor overactivity. The diagnosis is made from history, exclusion of other causes of bladder/prostate/urethral pathology (urinary tract infection/bladder outflow obstruction) and/or urodynamics investigation.1
Treatment classically involves behavioural modification and medical treatment of which anti-cholinergic drugs are the mainstay of treatment.
Intravesical botulinum toxin-A represents a new therapeutic modality in patients with urodynamics-proven detrusor overactivity in whom conventional therapy has failed.2,3 Its use has also been shown to be effective in patients with similar symptoms from a neuropathic bladder secondary to an underlying neuromuscular disorder. Its action is to inhibit acetylcholine release at the neuromuscular junction reducing muscle contractility. This not only potentially increases bladder capacity, but reduces urgency.
Botulinum toxin-A is injected directly into the bladder submucosa or detrusor muscle under rigid or flexible cystoscopic guidance.1 The bladder trigone is avoided3 and up to 20 aliquots of 1mL injections are administered. Effects of botulinum toxin-A last between 6 and 12 months, and repeat procedures may be necessary when the effects diminish (dosage can increase depending on response). In up to 5% cases, detrusor paralysis can result in significant bladder residual volumes, necessitating intermittent self-catheterization (ISC). This should be taught to all patients preoperatively.
Additional procedures that may become necessary
Hydro-distension of bladder
Bladder biopsies
Need to teach ISC
Benefits
Decrease symptoms of overactive bladder (particularly urge incontinence) resistant to medical therapy and behavioural modification advice
Alternative procedures/conservative measures
Conservative: dietary and fluid intake advice (modify fluid intake, avoiding stimulants, bladder training), pelvic floor exercises, biofeedback training, high-frequency electrical stimulation (stimulation and strengthening of pelvic floor musculature)
Medical: (up to 50% response rate) anticholinergic drugs (oxybutynin, solifenacin, terfenadine, tolterodine, trospium chloride), tricyclic antidepressants, desmopressin, baclofen
Surgical: neuromodulation, auto-augmentation (detrusor myomectomy—excision of detrusor muscle over dome of bladder), augmentation enterocystoplasty (clam ileocystoplasty—bi-valving of bladder with anastomosis of detubularized segment of ileum), conduit diversion (incontinent ileal conduit), sacral nerve stimulation (SNS)
Serious/frequently occurring risks
Cystoscopy
Common: bleeding (haematuria), dysuria, temporary insertion of urethral catheter
Occasional: urinary tract infections requiring oral or intravenous antibiotics, trauma to urethra, prostate or bladder resulting in haematuria, diagnosis of bladder mucosal lesion/stone requiring treatment
Rare: haematuria and clot retention necessitating further cystoscopy and washout, need for catheterization (temporary), urethral stricture formation, perforation of urethra/bladder necessitating temporary catheter insertion or open procedure to repair defect in bladder
Botulinum toxin-A
Need for repeat treatment, failure to improve symptoms, acute retention of urine, need for ISC, febrile illness, proximal myopathy, flu-like symptoms, (rare: swallowing/breathing difficulties/headache/diarrhoea)
Blood transfusion necessary
None
Type of anaesthesia/sedation
Local/general anaesthesia
Follow-up/need for further procedure
Follow-up in 6–12 weeks to assess response
Teach patients ISC as necessary pre- or postoperatively
Follow up patients in 6 months to assess response or need for re-injection/repeat procedure
References
Nephrectomy (simple/partial/radical/nephro-ureterectomy)
Description
This is the surgical removal of the kidney (simple), kidney and its surrounding Gerota's fascia (radical), part of the kidney (partial), or the kidney and ureter (nephroureterectomy). The latter three procedures are performed for renal cancer. The procedure can be performed both as an open or laparoscopic procedure and the kidney can be approached retroperitoneally with the patient in the lateral position, or transperitoneally with the patient supine with a slight tilt towards the operating surgeon.
Indications for nephrectomy include renal cell carcinoma (radical nephrectomy, partial nephrectomy), transitional cell carcinoma (TCC) of the renal collecting system or ureter (nephroureterectomy), a symptomatic non-functioning kidney with or without a staghorn calculus or persistent haemorrhage following renal trauma.
Radical nephrectomy may involve exploration of the renal vein or IVC to achieve tumour clearance from the associated vein. If significant tumour thrombus exists (particularly in the vena cava), it may be that cardiothoracic support is necessary with extracorporeal cardiopulmonary bypass.
Partial nephrectomy is a treatment option to preserve nephron function and is suitable in certain smaller peripheral tumours which may be exophytic in nature. If there is any concern where oncological control may be compromised, then a radical nephrectomy or other forms of nephron-sparing surgery (e.g. RFA, cryotherapy) should be performed as appropriate.
All patients prior to surgery should have their case discussed in a multidisciplinary team meeting with a surgeon, radiologist, oncologist, and histopathologist present.
Postoperatively a drain may be placed in situ, a chest X-ray performed and a catheter may be left in situ for 10–14 days (post-nephro-ureterectomy). Routine chest physiotherapy is essential with early mobilization to reduce respiratory and thromboembolic complications following surgery and must be emphasized to the patient preoperatively.
Additional procedures that may become necessary
Urethral catheterization
Abdominal drain insertion
Conversion to open procedure (if laparoscopic)
Conversion to radical nephrectomy (if partial nephrectomy)
Need for future therapy/surveillance (flexible cystoscopy for TCC surveillance/surveillance CT scans)
Benefits
Diagnostic: remove offending pathology and provide histopathological diagnosis for staging and further treatment planning
Therapeutic: to improve symptoms, prevent further haemorrhage (traumatic/debulking tumour load), curative procedure in cancer surgery, cytoreductive nephrectomy in larger tumours
Alternative procedures/conservative measures
Conservative: patients with smaller tumours, <3cm in size, with regular surveillance CT/ultrasound scans to ensure no increase in size. The older patient with multiple comorbidities may not be suitable for surgical intervention and potentially can be managed conservatively
Radiological: segmental renal artery embolization
Nephron sparing surgery: radiofrequency ablation (CT guided), cryotherapy (laparoscopic), partial nephrectomy
Surgical: partial nephrectomy, radical nephrectomy
Oncological: molecular-targeted therapies (e.g. tyrosine kinase inhibitors), immunotherapy, radiotherapy
Serious/frequently occurring risks
Common: temporary insertion of urinary catheter, insertion of wound drain
Occasional: bleeding which may require further surgery or blood transfusion, infection of wound necessitating antibiotic therapy, inadvertent injury to diaphragm or opening of pleura necessitating insertion of intercostals drain, need for adjuvant therapy for cancer control, chronic pain at incision site, numbness and paraesthesia along incision, incisional hernia which may require further surgery, ileus (particularly if transperitoneal approach)
Rare: injury to adjacent visceral structures including blood vessels, spleen, liver, pancreas, lung or bowel, which requires further treatment or surgery, alternative diagnosis on histopathological diagnosis other than cancer, cerebrovascular event, cardiopulmonary event, thromboembolic event, ITU/HDU admission, death
Partial nephrectomy: need for radical nephrectomy, local recurrence, inadequate oncological clearance with need for further therapy
Nephroureterectomy: recurrence of disease elsewhere within the urinary tract, need for surveillance cystoscopy and upper tract imaging
Blood transfusion necessary
Group and save/cross-match 2–6 units depending on patient
Type of anaesthesia/sedation
General anaesthesia (with regional anaesthesia for postoperative pain relief)
Follow-up/need for further procedure
Removal of drain when volumes decrease
Remove of urinary catheter 10–14 days postoperatively from nephroureterectomy (to allow bladder wall healing)
Outpatient review with histology
Oncological follow-up
Surveillance CT/ultrasound/chest radiograph or cystoscopy for TCC
References
www.baus.org.uk (accessed 17 May
2011). www.baus.org.uk (accessed 17 May
2011). www.baus.org.uk (accessed 17 May
2011). www.baus.org.uk (accessed 17 May
2011). www.baus.org.uk (accessed 17 May
2011).Optical internal urethrotomy
Description
Stricturing disease of the urethra is a pathological process that involves fibrotic scar tissue formation within the tissues surrounding the urethra resulting in a narrowing of the lumen. Patients can present with decreased flow, incomplete bladder emptying, dysuria, haematuria, recurrent urinary tract infections and obstructive uropathy. Diagnosis is made with history, clinical examination (external urethral meatus), flow-rate studies, retrograde/antegrade urethrography, or urethroscopy.
Disease processes that cause urethral stricture formation include:
Infection (gonococcal urethritis)
Inflammation (BXO resulting in meatal or submeatal stenosis)
Trauma (pelvic fractures, urethral instrumentation including post-transurethral resection of the prostrate (TURP), cystoscopy, catheterization, post radical prostatectomy)
Optical urethrotomy is an endoscopic procedure whereby the urethral stricture is visualized and incised with a knife or laser. It is best suitable for short (<1.5cm) strictures with minimal peri-urethral fibrosis, or for first time stricture presentation in the younger patient. The urethra re-epithelializes following incision of the stricture. Often, a catheter is placed between 3 and 5 days following the procedure and a trial of voiding is performed as an outpatient. In certain circumstances (particularly patients with recurrent strictures, the younger patient,1 or a patient with a long segment stricture) ISC or referral for excision and re-anastomosis/urethroplasty (free-tissue transfer technique) is advised.
Additional procedures that may become necessary
Urethral catheterization
Suprapubic catheterization
Urethral dilatation (in certain circumstances dilatation with a urethral sound will sufficiently open a stricture—beware of false passage creation, and avoid causing urethral trauma that may convert a short stricture into a longer stricture in the long term)
Bladder biopsies
Need for future therapy (ISC/referral for urethroplasty)
Meatotomy/meatal dilatation (for distal meatal strictures where the urethra cannot be cannulated with the optical urethrotome)
Benefits
Diagnostic: diagnose underlying stricture, length of stricture and proximity to external urethral sphincter
Therapeutic: to improve symptoms associated with urethral stricture and prevent complications from bladder outflow obstruction
Alternative procedures/conservative measures
Conservative: manage patient conservatively with regular urine flow-rate examination, residual volume measurements, and monitor serum creatinine and evidence of upper tract dilatation on ultrasonography in the patient who wishes no further treatment and is asymptomatic. In patients who are able to perform ISC, this is an option to prevent further re-stricturing. It requires good hand–eye coordination and dexterity and may be difficult in the older patient
Medical: in patients with BXO and meatal stenosis may require topical steroid treatment to limit the progression of disease. If this fails, formal circumcision of the foreskin may be necessary
Surgical:
Urethral dilatation (beware of false passage creation/stricture progression/conversion of short stricture into longer segment stricture—restructure rates are higher if associated with bleeding)
Suprapubic catheter insertion (to avoid trauma to stricture or urethra, and to provide a conduit for antegrade and retrograde urethrography to plan future treatment
In males—Excision and primary reanastomosis of urethra
Tissue transfer procedure (urethroplasty with buccal or pedicled skin flap). The latter two techniques should be performed following adequate imaging of urethra in younger patients or in patients with recurrent stricture formation who do not wish to have repeat dilatation/urethrotomy procedures. These are often carried out in specialist centres that deliver a urethral reconstruction service. In these circumstances, a urethrogram is a useful adjunct in delineating stricture anatomy2
Serious/frequently occurring risks
Common: bleeding (haematuria), dysuria, temporary insertion of urethral catheter
Occasional: urinary tract infections requiring oral or intravenous antibiotics, trauma to urethra, prostate or bladder resulting in haematuria, recurrence of stricture, need to biopsy lesion in bladder, need for further therapy (including ISC, referral for specialist stricture treatment—urethroplasty/excision and anastomosis, need to insert suprapubic catheter
Rare: haematuria and clot retention necessitating further cystoscopy and washout, failure of procedure due to complete urethral occlusion, false passage creation or perforation of urethra/bladder necessitating prolonged period of catheterization or conversion to open procedure to repair defect in bladder, erectile dysfunction, decreased continence (if stricture involves or lies adjacent to external urethral sphincter)1
Blood transfusion necessary
None/group and save
Type of anaesthesia/sedation
Regional or general anaesthesia
Follow-up/need for further procedure
Dependent on findings of stricture
If catheter inserted, trial without catheter can be scheduled between 24h and 5 days post optical urethrotomy
Review in outpatient clinic with flow rate assessment, RV, and symptomatic review
Referral to learn ISC
Referral for definitive surgical procedure for stricture
References
www.baus.org.uk (accessed 17 May
2011).Orchidectomy (simple/sub-capsular/radical) ± insertion of silicone implant
Description
Orchidectomy is performed for both testicular and non-testicular pathology. The approach used varies depending on the underlying disease process that requires attention. Unilateral or bilateral orchidectomy can be performed. Three approaches are commonly used to remove the testicle or testicular tissue:
Radical inguinal orchidectomy: this is the approach used for (suspected) testicular malignancy. An inguinal incision is used, the external oblique aponeurosis opened and the spermatic cord isolated and ligated. The testis is then mobilized from the scrotum via the superficial inguinal ring and removed. This technique allows ligation of the testicular lymphatics high up the spermatic cord. Cross-clamping of the cord early in the procedure avoids spread during testicular manipulation and avoids scrotal skin metastasis if a scrotal approach was used. Occasionally the opposite testis is biopsied if clinically small, abnormal on ultrasound or clinical examination or there is a history of maldescent. Patients should have a chest X-ray and serum tumour markers (B-human chorionic gonadotrophin (hCG), A-fetoprotein (AFP) and lactate dehydrogenase (LDH)) measured prior to radical orchidectomy. Their diagnosis should be correlated with findings on ultrasound1
Simple orchidectomy: this is performed via vertical or horizontal scrotal incision. The testis is delivered and a transfixion suture used to secure the cord on its removal. This approach is used for removing the testicle when cancer is not suspected (i.e. severe epididymo-orchitis with abscess formation, infarcted testis secondary to torsion, tuberculous orchitis, chronic testicular pain)
Subcapsular orchidectomy: this technique is used to achieve castrate levels of testosterone by removal of the functioning testicular tissue in an attempt to achieve hormonal control for advanced prostate cancer. It is performed via a midline scrotal approach and both testicles are treated. The tunica albuginea is opened, and the seminiferous tubules removed. The capsule is then closed with preservation of the epididymis and testicular appendages. Rapid drop in serum testosterone levels are expected to <0.2nmol/L within 8h of subcapsular orchidectomy
In cases where the patient requests a testicular implant, a silicone implant may be inserted and secured to the scrotum. This is contraindicated in the presence of active sepsis and great care must be taken in handling the implant to avoid contamination. Where bilateral orchidectomy is performed, or in the younger patient who is likely to require chemotherapy, hormone therapy and/or sperm banking with pre- and postoperative counselling may be required.
Additional procedures that may become necessary
Scrotal drain insertion
Need for further treatment (chemotherapy/radiotherapy)
Need for further investigations (staging CT scan)
Insertion of testicular prosthesis (generally avoid in the infected setting of infection or if chemotherapy/radiotherapy may be given)
Rare: need for further testicular surgery/biopsy/orchidectomy if underlying tumour identified during scrotal exploration
Benefits
Diagnostic: histopathological evaluation of testicular specimen and spermatic cord and allow future treatment planning
Therapeutic: remove diseased or symptomatic testicle
Alternative procedures/conservative measures
Conservative: benign conditions: analgesia, antibiotics, scrotal support, monitor asymptomatic or minimally symptomatic patients, serial radiological intervention to characterize lesions of the testis in unconvincing cases, no testicular prosthesis insertion
Medical: for treatment of advanced/metastatic prostate cancer—luteinizing hormone-releasing hormone agonists, oestrogens, antiandrogens, 5-A-reductase inhibitors
Surgical: testicular biopsy prior to formal orchidectomy
Serious/frequently occurring risks
Occasional: bleeding (scrotal haematoma resulting in either slow resorption, lump in scrotum, or need for further procedure to evacuate clot), chronic scrotal pain (up to 5% cases), infection (wound necessitating antibiotic therapy), non-resolution of symptoms, infertility/sub-fertility, if performed for malignancy the need for further therapy (chemo-radiation), the need to biopsy other testicle if small, abnormal, or history of maldescent of testis
Rare: unsuspected diagnosis on histopathological diagnosis of malignancy, need for further therapy for abnormal testicle (in cases where malignancy is suspected or diagnosed intraoperatively)
Insertion of testicular prosthesis: abnormal position or lie of implant (in particular may be high riding in warm weather), palpable suture (may be painful), imperfect cosmetic result, prosthesis infection and pyo-scrotum requiring drainage or/and removal of testicular implant, bleeding requiring implant removal, leakage of silicone-based fluid from implant within scrotum, unknown long-term effects of silicone-based implants2–4
Blood transfusion necessary
None/group and save
Type of anaesthesia/sedation
Local anaesthesia with cord block (regional anaesthesia/general anaesthesia
Follow-up/need for further procedure
Dependent on underlying indication for orchidectomy
No follow-up in benign cases unless patient requests testicular implant insertion
Prostate-specific antigen (PSA)/serial tumour markers/staging CT/chest radiograph in patients with malignancy
References
www.baus.org.uk (accessed 17 May
2011). www.baus.org.uk (accessed 17 May
2011). www.baus.org.uk (accessed 17 May
2011).Percutaneous nephrolithotomy
Description
Percutaneous nephrolithotomy (PCNL) is a percutaneous endoscopic technique that facilitates direct access into the kidney via a tract between the skin and the renal collecting system. It has been developed to remove upper urinary tract calculi that are not amenable to other treatment modalities (ESWL/flexible ureteroscopy and stone fragmentation).
Indications for PCNL include:
Stone size >2cm (symptomatic or associated with urinary tract sepsis)
Stones that have failed ESWL or retrograde flexible ureteroscopy and stone fragmentation
Stag-horn calculi
Symptomatic calculi located within a calyceal diverticulum
Initially the collecting system is filled via cystoscopic cannulation of the ureter and fluid instilled into the renal collecting system. The patient is then repositioned (traditionally in the prone position, however, recently increasing data are available for supine procedures) for PCNL and under ultrasound or fluoroscopic guidance, a renal calyx is punctured and a guide-wire threaded into the collecting system. Serial dilators are passed over the guide-wire to create a tract through which a nephroscope is advanced, and fragmentation of the renal calculus is performed with laser or ultrasonic lithotripsy. A nephrostomy tube is placed post-procedure and occasionally a ureteric stent is placed. More recently, ‘tubeless’ PCNL has been practised.
Outcomes are good for small stones (90–95% stone clearance), staghorn calculus clearance combined with postoperative ESWL for fragments is in the order of 80–85%.
Additional procedures that may become necessary
Cystoscopy and bladder biopsy
Retrograde ureteric stent insertion
Antegrade ureteric stent insertion
Nephrostomy insertion
Flexible renoscopy and stone fragmentation via PCNL tract
Benefits
Diagnostic: obtain samples of stone which can be sent for biochemical analysis
Therapeutic: remove symptomatic renal calculi, remove source of infection, prevent further stone burden development
Alternative procedures/conservative measures
Conservative: dietary advice, fluid intake advice
Medical: medical stone dissolution and expulsive therapy, treatment of underlying cause of stone formation
Surgical: ESWL, retrograde ureterorenoscopy and stone fragmentation, Retrograde ureteric stent insertion with ESWL, open/laparoscopic pyelolithotomy1
Serious/frequently occurring risks
Common: insertion of ureteric stent and urethral catheter that will need removal as separate procedure, bleeding (haematuria), passage of stone fragments, post-procedure discomfort
Occasional: the need for more than one puncture site to gain access to kidney and adequate stone clearance, incomplete stone removal, the need for further procedure for complete stone clearance, recurrence of new calculi, pleural effusions compromising respiratory function or necessitating the placement of an intercostal drain
Rare: severe bleeding requiring transfusion of blood or blood products, embolization of kidney, or as a final resort require nephrectomy,2 damage to adjacent organs (lung/bowel/spleen/liver) necessitating further emergency treatment, cardiovascular compromise (due to fluid absorption from irrigation solution3,4)
Blood transfusion necessary
Group and save/(rarely cross-match)
Type of anaesthesia/sedation
Local anaesthesia (very rarely performed in supine unfit patient)/regional anaesthesia/general anaesthesia
Follow-up/need for further procedure
Will require analgesia on ward postoperatively with subsequent removal of nephrostomy and catheter
KUB X-ray to identify residual stone fragments5
May require removal of ureteric stent
May require further treatment (further PCNL/ESWL/retrograde ureterorenoscopy) for residual stone fragments
Outpatient review with imaging as required on discharge
References
www.baus.org.uk (accessed 17 May
2011).Preputial adhesiolysis
Description
The prepuce, mucosal surface of the foreskin, and the glans penis have a common epithelium. The process of gradual separation and subsequent keratinization between the two layers takes place at any time between late gestation and adolescence. The term preputial adhesion is frequently used and there is often coexistent smegma (a white congealed discharge from the coronal glands and breakdown products of the preputial adhesions) which may act as a source of infection in cases of recurrent balanitis. Parents often worry about significant ballooning of the penis during urination.
Up to 60% of children between the ages of 6 and 9 years are unable to completely retract their foreskin; however, this disappears by the age of 17 years.
Patients or parents who do not wish for circumcision may choose release of preputial adhesions as a therapeutic option. This involves drawing back the foreskin and, using either blunt or sharp dissection, the foreskin is peeled away from the glans penis to the level of the coronal sulcus. If adhesions are fibrotic, dense or bleed excessively, then conversion to a formal circumcision may be advocated. Often petroleum jelly is placed on the exposed glans and the parents or patient is taught to pull the foreskin back regularly to prevent further adhesion formation, although no evidence exists to suggest this as a primary therapy for phimosis or preputial adhesions.
Additional procedures that may become necessary
Preputioplasty
Circumcision of foreskin
Frenuloplasty
Benefits
Diagnostic: in adults to identify any underlying pathology on foreskin or glans (i.e. malignancy) causing adhesion
Therapeutic: prevent recurrent episodes of balanoposthitis, ballooning of penis on urination
Alternative procedures/conservative measures
Conservative: no treatment, most cases of childhood adhesions are physiological and separation takes place over time, there is no evidence to suggest gentle foreskin retraction prevents phimosis
Medical: antibiotics and analgesia or topical anti-inflammatory agents for recurrent balanoposthitis
Surgical: circumcision of foreskin
Serious/frequently occurring risks
Common: temporary bleeding or oozing of serosanguineous (straw-coloured) fluid from raw surface of penis, temporary tenderness over penis
Occasional: infection of glans penis requiring antibiotic therapy, need for future circumcision, recurrence of adhesions requiring repeat procedure
Rare: cosmetic dissatisfaction, hyperaesthesia and sensitive glans penis post-procedure1
Blood transfusion necessary
None
Type of anaesthesia/sedation
Local anaesthesia/regional anaesthesia/general anaesthesia
Follow-up/need for further procedure
Outpatient review if required on discharge
Analgesia
Encourage moisturizer use over glans penis
Reference
www.baus.org.uk (accessed 17 May
2011).Prostatectomy (radical)
Description
Radical prostatectomy is the surgical removal of the entire prostate gland including its capsule. It is performed with curative intent for patients with localized prostate cancer with an appropriate life expectancy (>10 years) and who have a good performance status. Excision of the prostatic urethra and seminal vesicles is included in the specimen and commonly, the procedure includes simultaneous pelvic lymph node dissection either as a diagnostic (staging) marker or for therapeutic intent. Care is taken to reduce the risk of injury to the neurovascular bundle that runs infero-lateral to the prostate, the external urethral sphincter that lies distal to the verumontanum and the rectum posteriorly. If the presence of palpable disease extends laterally, the neurovascular bundle may be sacrificed to avoid compromise in cancer control.
Stages of a radical retropubic prostatectomy. (a) incision of endopelvic fascia and lateral dissection of prostate; (b) dissection of dorsal venous complex between pubic arch and urethra; (c) suture ligation of dorsal venous complex; (d) sharp division of urethra to create urethral stump; (e) retrograde dissection of prostate off Denonvilliers fascia; (f) anastomosis of bladder neck to urethral stump.
After removal of the specimen, reconstruction of the bladder neck is performed with an anastomosis to the urethra. This is performed over a catheter which is traditionally left in situ for approximately 2 weeks. A drain is commonly placed following the procedure and removed 1–2 days following the operation (when drain volumes are minimal). Patients are sent home with their catheter in situ, which is commonly removed between 7 and 21 days; a cystogram is required only if there is a documented urine leak or if there are catheter-related problems. Some institutions routinely perform cystograms prior to catheter removal.
Characteristically the decision behind radical prostatectomy is made in a multidisciplinary setting and the patient may be offered other treatment options to secure oncological control. This can include external beam radiotherapy, active surveillance, and brachytherapy. Patients are counselled pre- and postoperatively with close liaison with the cancer nurse specialists throughout their journey.
Additional procedures that may become necessary
Pelvic lymph node dissection
Abdominal drain insertion
Urethral catheter placement
Postoperative radiotherapy/hormone therapy/chemotherapy (based on local policy)
Postoperative cystogram prior to catheter removal
Benefits
Diagnostic: allows histopathological grading and staging of disease where in certain circumstances upstaging of disease is seen
Therapeutic: the procedure is performed for curative intent and cancer control
Alternative procedures/conservative measures
Conservative: some patients may be suitable for an active surveillance protocol where PSA is monitored and interval re-biopsy is performed to identify change or upstaging of disease
Medical: hormonal therapy in either tablet or injection form may be used in a neo-adjuvant setting prior to further treatment or as a disease control measure in certain subgroup of patients
Radiotherapy: external beam radiotherapy to the prostate with curative intent may offer oncological control, Brachytherapy is whereby permanent implantable radioactive ‘brachytherapy’ seeds are placed within the prostate and is used to achieve oncological control
Surgical: the surgical approach can vary between open retropubic, open transperineal, laparoscopic, and robotic prostatectomy1
Serious/frequently occurring risks
General: postoperative pain, chronic wound or pelvic pain, wound infection requiring a period of antibiotics (oral/intravenous), incisional hernia, chest infection, cardiovascular event including myocardial infarction, deep vein thrombosis, pulmonary embolism, HDU/ITU admission, death (1:500 cases)
Common: temporary insertion of urethral catheter and abdominal drain, impotence due to unavoidable peri-prostatic neurovascular bundle injury (70–90%), failure to produce semen during orgasm, sub-fertility
Occasional: bleeding and blood loss requiring transfusion or further surgery to control bleeding, urinary incontinence requiring the use of incontinence pads or further surgery (5% patients beyond 6 months require >1 pad/day), residual cancer outside the prostate requiring a period of observation or treatment, recurrent disease, the need for radiotherapy/hormone therapy, postoperative catheter displacement requiring further procedure to reinsert catheter, postoperative urine or lymphatic collection requiring percutaneous or open drainage, bladder neck stenosis (5–8% of patients 2–6 months postoperatively)
Blood transfusion necessary
Group and save/cross-match 2–4 units (depending on starting haemoglobin)
Type of anaesthesia/sedation
General anaesthesia (often combined with regional anaesthesia for pain relief postoperatively)
Follow-up/need for further procedure
Removal of abdominal/perineal drain 1–2 days post-procedure (or when volume from drain decreases)
Removal of urethral catheter between 7 and 21 days (either with or without cystogram prior to trial of voiding)
Outpatient review at 4–6 weeks with repeat PSA
Multidisciplinary team review with histology
Possible need for adjuvant radiotherapy or hormone therapy in the future
Erectile dysfunction clinic for support with erectile dysfunction
Continence nurse regarding postoperative urinary incontinence
Postoperative support and counselling with cancer nurse specialist/oncology/urology
References
www.baus.org.uk (accessed 17 May
2011). www.baus.org.uk (accessed 17 May
2011).Retrograde pyelogram ± retrograde insertion of ureteric stent
Description
The ureters are tubular structures that run between the renal pelvis and the posterior-inferior wall of the bladder. They have the potential to obstruct due to intraluminal pathology (calculi, clots), mucosal or intramural pathology (TCC, fibroepithelial polyps), or extramural pathology (retroperitoneal fibrosis/retroperitoneal lymphadenopathy). The result is that renal drainage is compromised and this can lead to obstructive uropathy, deteriorating renal function and occasionally sepsis secondary to pyonephrosis.
Retrograde pyelography is the process by which contrast medium is instilled into the ureter and the pattern of filling is observed on fluoroscopy to identify pathology. Cystoscopy is performed and a ureteric catheter is placed down the cystoscope and gently inserted into the ureter by 1–2cm. Contrast medium is then pushed into the ureter and the pattern of ureteric filling is noted (noting irregularities, filling defects, etc.). The ureteric catheter is advanced further to the upper ureter and the renal pelvis is filled (looking for evidence of hydronephrosis and pelviureteric junction obstruction). The ureteric catheter is then withdrawn and subsequent drainage is visualized live on fluoroscopy.
Retrograde ureteric stent insertion may be necessary as a measure to relieve obstruction. Here a guide-wire is placed via cystoscopy into the kidney and a hollow tube is railroaded into the kidney. Most stents utilized are JJ stents (Figs. 11.6, 11.7), which have a pigtail coil proximally in the kidney and another in the bladder to avoid stent migration.
JJ stent.
KUB radiograph demonstrating a JJ stent in situ.
Indications for ureteric stent insertion include:
Relief of obstruction (calculi, strictures—benign/malignant)
Prevention of obstruction (post-ureteroscopy)
Passive dilation of ureter (pre-ureteroscopy)
Long-term management of obstruction (patients receiving chemotherapy/radiotherapy)
Post-ureteric surgery/injury (ensure antegrade flow of urine and healing of ureter around stent
Prior to pelvic surgery to aid identification of ureter intraoperatively
Following endopyelotomy (for pelviureteric junction obstruction)
Stents can be made from a multitude of materials, which include biodegradable to short-term or long-term metallic stents. In certain circumstances short segment ureteric Memokath® stents are inserted for up to 5 years in the treatment of short-segment ureteric strictures.
Additional procedures that may become necessary
Retrograde pyelography (if stent only)
Retrograde stent insertion (if pyelography only)
Diagnostic/therapeutic ureteroscopy (stone fragmentation/endopyelotomy)
Biopsies of bladder/ureter
Antegrade percutaneous nephrostomy ± antegrade stent insertion
Benefits
Diagnostic: in adults to identify any underlying pathology of bladder/ureter/renal pelvis/kidney
Therapeutic: to improve the drainage of the kidney and prevent deteriorating renal function or obstructive uropathy
Alternative procedures/conservative measures
Conservative: in a non-functioning/poorly functioning kidney in the presence of obstruction, if the patient is asymptomatic then observation may be all that is necessary with renal function measurement and serial radiological imaging
Radiology: alternatives to retrograde pyelography include CT urogram, IVU, MAG3 renogram, CT KUB, ultrasound KUB
Medical: antibiotics for recurrent obstruction associated with sepsis
Surgical: nephrostomy and antegrade stent insertion, primary ureteroscopy and stone fragmentation or biopsies, endopyelotomy, pyeloplasty, ureterolysis, ureteric bypass surgery (all dependent on underlying pathology in question)
Serious/frequently occurring risks
Common: bleeding (haematuria), dysuria, temporary insertion of urethral catheter, temporary discomfort from stent causing pain, frequency, urgency, and haematuria, further procedure to remove stent (usually flexible cystoscopy, however, occasionally under general anaesthesia), use of X-ray imaging and associated radiation
Occasional: urinary tract infections requiring oral or intravenous antibiotics, trauma to urethra, prostate or bladder resulting in haematuria, diagnosis of bladder mucosal lesion/stone requiring treatment, difficulty in passing stent necessitating either nephrostomy and antegrade stenting or open surgery, need to perform ureterorenoscopy
Rare: stent encrustation, haematuria and clot retention necessitating further cystoscopy and washout, need for catheterization (temporary), urethral stricture formation, perforation of urethra/bladder necessitating temporary catheter insertion or open procedure to repair defect in bladder, contrast-associated allergic reaction/sensitivity
Blood transfusion necessary
None
Type of anaesthesia/sedation
Local anaesthesia (rarely performed via flexible cystoscopy)/regional anaesthesia/general anaesthesia
Follow-up/need for further procedure
Outpatient review or inpatient follow-up, depending on the underlying pathology
Stent change or removal date must be documented and discussed with patient
Some patients may require anti-cholinergic medication for severe stent symptoms
Stent advice sheet (coping with a ureteric stent)
Analgesia
References
www.baus.org.uk (accessed 17 May
2011). www.baus.org.uk (accessed 17 May
2011).Scrotal exploration for suspected torsion of testis
Description
The commonest indication for an emergency scrotal exploration is to exclude the diagnosis of torsion of the testis. Acute testicular torsion results when there is a twist in the blood supply of the testicle and epididymis, and must be suspected in any patient with acute-onset testicular pain between the ages of 10 and 30, in particular if there is a history of testicular maldescent. It is worthwhile noting that any age group can be affected.
Clinical examination may reveal a swollen testis, which is exquisitely tender and in an abnormal lie within the hemi-scrotum. There may be a reactive hydrocoele and the patient may present with referred abdominal pain or autonomic symptoms (i.e. vomiting).
Surgical exploration of the hemi-scrotum is an emergency. Delay in de-torting the testicle can result in permanent ischaemic damage resulting in atrophy, loss of testosterone production, and infertility or subfertility. There is a theory that antibodies directed at the contralateral testicle during the breakdown of the blood–testis barrier can further compound fertility. Both testes must be fixed in the presence of torsion, as the bell-clapper deformity that predisposes to this condition is likely to be bilateral.1
A midline vertical scrotal incision is used access each testicle. The testis in question is delivered into the wound. If it is torted, then the torsion should be corrected and the testis placed in a warm, saline-soaked swab for 10min. If the testis still appears black, then trans-scrotal orchidectomy should be performed with a transfixion suture securing the cord. If however, it pinks up, then fixation should be performed bilaterally. How this is done is surgeon dependent. Most will use a three-point fixation technique with non-absorbable sutures to prevent further torsion in two planes of rotation (Fig. 11.8). The wound is closed with absorbable sutures.
Three-point testicular suture fixation of testis.
Additional procedures that may become necessary
Orchidectomy
Bilateral fixation of testicles
Excision of hydatid of Morgagni or appendix epididymis (appendages which are able to tort and cause testicular pain)
Insertion of scrotal drain
Benefits
Diagnostic: to identify the cause of acute scrotal pain. To exclude the diagnosis of acute testicular torsion
Therapeutic: prevent further testicular ischaemia, salvage the testicle and prevent further torsion bilaterally
Alternative procedures/conservative measures
Conservative: observation in cases of testicular torsion risks the loss of testicle
Medical: in cases where the history is longstanding or if symptoms, signs, urine dipstick testing suggest epididymo-orchitis, antibiotic therapy may be indicated with sonographic examination of testicles
Surgical: Exploration is the only true method of reliably excluding testicular torsion. Ultrasound scanning may add time, delay the diagnosis and prolong testicular ischaemia. Only use this when the history and clinical findings are not suggestive or equivocal2
Serious/frequently occurring risks
Common: discomfort
Occasional: wound infection, haematoma, uncomfortable palpable sutures, granuloma formation
Rare: further torsion despite fixation
Blood transfusion necessary
None
Type of anaesthesia/sedation
Regional anaesthesia/general anaesthesia
Follow-up/need for further procedure
Outpatient review if required on discharge
Analgesia
If the diagnosis is epididymo-orchitis, treatment with antibiotics may be indicated and follow-up ultrasound necessary
References
www.baus.org.uk (accessed 17 May
2011).Suprapubic catheter insertion (cystoscopic/blind/ultrasound guided)
Description
Suprapubic catheterization is a technique used to allow for bladder emptying in circumstances where urethral catheterization is not possible, tolerated or at the patient's choice to manage their lower urinary tract symptoms.
The catheter is situated approximately 2–3cm above the symphysis pubis and recent British Association of Urological Surgeons (BAUS) guidelines1 have standardized care associated with its insertion, use, and follow-up care.
Indications
For acute or chronic urinary retention where urethral catheterization is difficult or potentially dangerous
Neurological disease (i.e. multiple sclerosis/spinal cord injury)
Long term urethral catheter use resulting in ventral penile split/patulous urethra
Intractable urinary incontinence
Following operative intervention (i.e. stress urinary incontinence procedures/colorectal surgery/post-TURP in patients with large bladder residuals)
In cases of urethral trauma
Palliative use (in elderly patient care and comfort)
Urodynamic investigation (in cases where urethral catheterization is not possible)
Contraindications
Known bladder malignancy
Unexplained haematuria (exclude bladder malignancy)
Pelvic fractures (relative)
Coagulopathy (relative)
Lower abdominal surgery (relative)
Technique
Closed technique (blind): in cases of acute or chronic urinary retention where the bladder is palpable, and there is no evidence of lower abdominal surgery
Ultrasound guided: in cases where there is evidence of lower abdominal surgery, or a bladder that is not palpable, or difficult body habitus
Cystoscopic bladder filling: in cases where there is evidence of lower abdominal surgery, difficult body habitus, a bladder that is not palpable or identifiable easily on ultrasound scan. The patient is given general anaesthesia and active bladder filling with cystoscopic views of suprapubic catheterization is performed
Open: this is used again for difficult cases where an open cystotomy is performed and the catheter placed and secured within the bladder under direct vision. Often the catheter can be tunnelled subcutaneously to one side for comfort
Suprapubic catheter sets and equipment vary but the principle of aspiration of urine with a needle prior to introduction of trocar or guide-wire is essential to ensure adequate placement.
Additional procedures that may become necessary
Insertion of urethral catheter
Washout of bladder/clots
Cystoscopy guided
Biopsy of bladder mucosal lesion
Benefits
Diagnostic: identify cause of obstruction (cystoscopic), when used as part of urodynamics, to identify underlying bladder behaviour as a cause of symptoms
Therapeutic: to aid bladder drainage for indications as listed
Alternative procedures/conservative measures
Management conservative without catheter
Urethral catheterization
Suprapubic aspiration (in acute setting)
Flexible cystoscopy-guided catheter insertion
Surgical: open cystotomy and tunnelled suprapubic catheterization, permanent urinary diversion procedure
Serious/frequently occurring risks
Common: bleeding (haematuria), dysuria, temporary insertion of urethral catheter in addition to suprapubic catheter, need for regular change of suprapubic catheter (3–4 monthly)
Occasional: urinary tract infections requiring oral or intravenous antibiotics, trauma to urethra, prostate or bladder resulting in haematuria, diagnosis of bladder mucosal lesion/stone requiring treatment, blocking of catheter requiring flushing regularly, bladder discomfort, urgency, pain, or bladder stone formation requiring treatment
Rare: haematuria and clot retention necessitating further cystoscopy and washout, need for catheterization (temporary), urethral stricture formation, perforation of urethra/bladder necessitating temporary catheter insertion or open procedure to repair defect in bladder, injury to surrounding organs and viscera that results in requiring additional surgery (bowel perforation)2
Blood transfusion necessary
None/group and save (depending on context of insertion)
Type of anaesthesia/sedation
Local anaesthesia/regional anaesthesia/general anaesthesia
Follow-up/need for further procedure
Dependent on indication for suprapubic catheterization
First catheter change usually performed in hospital at 8–12 weeks (as per local policy)
Subsequent catheter changes can take place in the community (usually every 3 months)
Re-referral if complications with suprapubic catheter (i.e. blockage, recurrent infections, bypassing)
References
www.baus.org.uk (accessed 17 May
2011).Transrectal ultrasound ± guided biopsies of the prostate gland
Description
The commonest indication for transrectal ultrasound is to evaluate the prostate gland and via guided biopsies, it is the commonest method of diagnosing prostate cancer. Images of the prostate are obtained, following which accurate derived prostate volume can be calculated, and cysts, abscesses, and calcifications within the prostate including peripheral zone lesions suggestive of malignancy or inflammation can be identified.
The indications for transrectal ultrasound include:
Accurate prostate volume measurements
Seminal vesicle and ejaculatory duct assessment in male infertility
Suspected prostatic abscess
Investigation in chronic pelvic pain for prostatic cysts or calculi
Abnormal digital rectal examination (DRE) may mandate biopsies
Elevated PSA (exception is very high PSA with abnormal DRE suggestive of metastatic prostate cancer) mandates biopsy
Previously normal biopsies with rising PSA
As part of active surveillance plan to re-biopsy patient
Brachytherapy planning for prostate cancer
Commonly a patient is counselled for a TRUS ± biopsies prior to the procedure. If biopsies are anticipated, then a prophylactic course of oral antibiotics is started 1 day prior to the procedure and continued for 3–5 days.
The procedure is carried out with a patient in left lateral position or in lithotomy position. An ultrasound probe is introduced into the rectum (Fig. 11.9) and the prostate is visualized in two planes for measurement of volume. Needle-guided biopsies are taken and a minimum of six cores obtained, three from each lobe. The increased number of biopsies improves the sensitivity of the test, however, it also increases the complication profile. Targeted biopsies of prostatic lesions are also taken as required, and seminal vesicle biopsies can add information regarding the stage of disease if prostate cancer is implicated.
Transrectal ultrasound-guided biopsy of prostate gland: an ultrasound probe is inserted into the rectum to guide the biopsy needle into the correct position where several core biopsies are taken from the prostate.
Additional procedures that may become necessary
Biopsies of prostate gland
Aspiration of cyst of prostate gland
Aspiration of abscess of prostate gland
Volume measurements
Benefits
Diagnostic: identify cause of symptoms, measure volume of prostate to plan treatment, identify cause of raised PSA, histopathological identification of prostate cancer, inflammation or benign adenomatous change, grading of prostate cancer, and upstaging of disease in patients on active surveillance protocol
Therapeutic: aspiration of symptomatic prostate cyst or abscess
Alternative procedures/conservative measures
Conservative: PSA follow-up and serial DRE, clinical and biochemical diagnosis of prostate cancer
Medical: antibiotics and anti-inflammatory agents in patients with prostatitis
Radiology: increasing evidence has been published suggesting the incorporation of MRI prior to TRUS biopsies to diagnose and map prostate cancer (particularly in younger patients with a palpable nodule—T2 disease)
Surgery: Patients who undergo TURP may have their prostate chips reviewed histopathologically for underlying prostate cancer
Serious/frequently occurring risks
Common: bleeding for up to 3 weeks post-procedure (haematuria, per rectal bleeding (significant rectal bleeding 0.5%), haematospermia), dysuria, vasovagal event immediately post-procedure
Occasional: acute retention of urine necessitating temporary insertion of urethral catheter, infection, and life-threatening septicaemia, requiring intravenous antibiotics and hospital admission (septicaemia 0.5%)
Blood transfusion necessary
None
Type of anaesthesia/sedation
Local anaesthesia/regional anaesthesia/general anaesthesia
Follow-up/need for further procedure
Dependent on indication for TRUS and biopsy
Review in outpatient clinic with outcome of histopathology
Discussion at local/regional multidisciplinary team meeting with histopathology
References
Transurethral resection of bladder tumour
Description
TURBT is the endoscopic resection of bladder lesions, and whether they are suspected to be benign or malignant, the tissue sample is sent for histopathological diagnosis.
Primary bladder tumours may be identified on ultrasound KUB, flexible cystoscopy, intravenous urogram, or CT pelvis. Patients often present with haematuria, recurrent urinary tract infections or lower urinary tract symptoms. TURBT has both a diagnostic and therapeutic role in the management of bladder malignancy.
Diagnostic:
Provide definitive histological diagnosis of bladder lesion
Assess muscle sample beneath bladder lesion to identify whether muscle invasive
Biopsy separate areas of bladder to assess the presence of CIS
Biopsy the prostatic urethra if radical surgery is considered
Allows re-staging of tumour in cases of recurrence
Therapeutic:
To achieve visual tumour resection and surrounding margin clearance in Ta/T1 disease (associated with adequate treatment in 70% new cases)
Decrease chance of tumour recurrence
Decrease chance of tumour progression of primary tumour
Palliative: palliative debulking TURBT followed by radiotherapy in the elderly unfit patient with muscle invasive bladder cancer1
All TURBT procedures must be preceded by an examination under anaesthesia to identify whether the bladder has a mass present, and whether it is fixed or mobile. TURBT is the mainstay of treatment in patients with superficial bladder tumours (TCC) with recurrences not amenable to ablative treatment via flexible cystoscopy.
Additional procedures that may become necessary
Random bladder biopsies
Prostatic urethral loop biopsies
Postoperative adjuvant intravesical chemotherapy (mitomycin C)
Urethral catheterization with irrigation
Benefits
Diagnostic: histopathological diagnosis, grading and staging of tumour, allows planning of further treatment, allows re-staging in recurrences
Therapeutic: for first presentation superficial tumours may be therapeutic if macroscopic clearance is achieved
Improvement in lower urinary tract symptoms associated with bladder tumour (i.e. strangury, haematuria, dysuria, recurrent urinary tract infections, urgency, etc.)
Alternative procedures/conservative measures
Conservative/palliative: if tumour burden is small and the patient is not suitable for anaesthesia, then symptomatic control may be appropriate
Flexible cystoscopy and diathermy destruction of tumour/laser tumour destruction in patients who are high risk for general/regional anaesthesia or have very small superficial recurrences on check cystoscopy
Radiotherapy
Chemotherapy
Combination chemo-radiotherapy (therapeutic or palliative)
Radical cystectomy (see 
p.290)
Urinary diversion procedure
Palliative care
Serious/frequently occurring risks
Common: bleeding (haematuria), dysuria, temporary insertion of urethral catheter with bladder irrigation, need for the administration of intravesical chemotherapy to prevent recurrence, need for regular check cystoscopy
Occasional: urinary tract infections requiring oral or intravenous antibiotics, no guarantee that this one procedure can prevent recurrence or cure, incomplete tumour resection in larger tumours, trauma to urethra, prostate or bladder resulting in haematuria, need for further definitive therapy
Mitomycin C (intravesical postoperative): transient irritative LUTS (15%), rash over genitalia or palms of hands, (rare: systemic toxicity)
Blood transfusion necessary
Group and save/cross-match (depending on preoperative haemoglobin and tumour mass)
Type of anaesthesia/sedation
Regional anaesthesia/general anaesthesia
Follow-up/need for further procedure
Dependent on indication for TURBT
Review in outpatient clinic with outcome of histopathology
Discussion at local/regional multidisciplinary team meeting with histopathology
Check flexible cystoscopy follow-up/general anaesthesia check cystoscopy (first check) depending on local policy
May require interval tumour re-resection depending on histology or tumour burden
References
www.baus.org.uk (accessed 17 May
2011).Transurethral resection of prostate gland/open prostatectomy (transperineal/Millen's)
Description
Surgery for benign occlusive prostate disease categorized into two groups, endoscopic surgery and open surgery. Endoscopic treatment includes bladder neck incision, bladder neck resection, TURP, laser vaporization of prostate (i.e. PVP), and laser enucleation of prostate (i.e. HoLEP). Open surgery includes transvesical prostatectomy and simple retropubic (Millen's) prostatectomy. Although laser enucleation is gaining popularity as a treatment modality, particularly for larger prostates that would usually be subjected to open surgery, the vast majority of urologists perform TURP as the gold standard surgical treatment.
TURP is an endoscopic procedure that utilizes a cutting loop via a resectocope to shave away prostate chips. The prostate tissue is resected to the capsule and the chips are washed out of the bladder to undergo histopathological analysis.
Indications for TURP
Lower urinary tract symptoms refractory to medical management and lifestyle advice
Obstructive uropathy secondary to occlusive prostate disease (high pressure-chronic retention)
Recurrent acute retention of urine
Bladder stones secondary to occlusive prostate disease
Haematuria secondary to benign prostatic enlargement
Transurethral resection of prostate gland: beginning of lateral lobe resection.
Transurethral resection of prostate gland: completed prostate resection cavity.
Simple (Millen's) prostatectomy: the prostate is exposed via a Pfannenstiel or lower midline incision, the dorsal vein complex is suture ligated and the capsule opened. The adenoma is then developed by finger dissection and the adenoma enucleated.
In both procedures a catheter is left for 5 days and a drain is left in situ for 24–48h.5
Indications for open prostatectomy
Large prostate (>100mL)
Patient habitus or limited hip abduction which does not facilitate positioning for TURP
Failed TURP secondary to bleeding
Large bladder calculi necessitating open cystolithotomy combined with prostatectomy
Open simple prostate surgery is not advised in patients with prostate cancer, or in patients who have had a previous prostatectomy.
Additional procedures that may become necessary
Bladder biopsies
Prostatic urethral biopsies
Bladder neck incision
Transrectal ultrasound and biopsies under general anaesthesia (abnormal prostate on rectal examination)
Urethral catheterization with irrigation
Suprapubic catheter for patients with high preoperative residual volumes
Benefits
Diagnostic: histopathological diagnosis of prostate tissue, assess response of symptoms to bladder outflow surgery
Therapeutic: to treat occlusive prostate for indications as listed
Alternative procedures/conservative measures
Conservative: lifestyle changes, dietary and fluid intake advice
Medical: A-antagonists, 5-A-reductase inhibitors, hormone treatment in patients with prostate cancer can reduce prostate volume and either improve symptoms or render the patient catheter free
Surgical: bladder neck incision, bladder neck resection, transurethral resection of prostate gland, laser vaporization of prostate (i.e. PVP), and laser enucleation of prostate (i.e. HoLEP), radical prostatectomy in prostate cancer patients suitable for this mode of treatment
Serious/frequently occurring risks
Common: bleeding (haematuria), dysuria, frequency, temporary insertion of urethral catheter with irrigation, no semen production (retrograde ejaculation –20% if transurethral incision of bladder neck, 75–80% if TURP), non-resolution of symptoms
Occasional: urinary tract infections requiring oral or intravenous antibiotics, trauma to urethra, prostate or bladder resulting in haematuria, diagnosis of bladder mucosal lesion/stone requiring treatment, bleeding requiring return to theatre/further cystoscopy and washout/blood transfusion, impotence (20%), incontinence of urine (temporary/permanent), need for repeat procedure (10%), failure to void necessitating further catheterization
Rare: urethral stricture formation, perforation of urethra/bladder necessitating temporary catheter insertion or open procedure to repair defect in bladder, transurethral resection syndrome (absorption of irrigation fluid causing confusion, congestive cardiac failure, dilutional hyponatraemia), finding of unsuspected cancer in removed prostate tissue necessitating further treatment2–4
Open prostatectomy: need for temporary urethral catheterization, need for temporary wound drain, retrograde ejaculation and associated sub-fertility, frequency, urgency of urination, bleeding requiring further surgery or transfusion of blood, impotence (10%), wound infection requiring antibiotics, incisional hernia, incontinence of urine (temporary/permanent), need for intensive care admission (cardiovascular/respiratory/neurological compromise/death)5
Blood transfusion necessary
Group and save/cross-match (depending on preoperative haemoglobin)
Type of anaesthesia/sedation
Regional anaesthesia/general anaesthesia
Follow-up/need for further procedure
Dependent on indication for prostate surgery
Review in outpatient clinic with outcome of histopathology with repeat flow rate and residual volume assessment
Discussion at local/regional multidisciplinary team meeting with histopathology if necessary
References
www.baus.org.uk (accessed 17 May
2011). www.baus.org.uk (accessed 17 May
2011). www.baus.org.uk (accessed 17 May
2011).Ureterorenoscopy (diagnostic/therapeutic)
Description
Ureterorenoscopy can be performed in an antegrade or retrograde fashion. Classically retrograde ureterorenography is performed with a rigid ureteroscope or flexible ureteroscope. A rigid ureteroscope is a straight instrument is able to negotiate the length of the ureter. They vary in size and number of working channels. They are ideal to exclude ureteric pathology and to treat intraluminal pathology. A flexible ureteroscope has the advantage of a flexible tip which allows for controlled deflection of the end of the scope. It is ideal to diagnose or treat renal pelvis or calyceal lesions or calculi.
The patient is supine with the legs elevated (lithotomy position). Cystoscopic cannulation of the ureter is performed with a guide-wire (or sometimes two) placed into the kidney. This safety guide-wire acts as a route for the rigid or flexible ureteroscope. Fluoroscopy is used as an adjunct to ‘screen’ the ureteroscope and check its position (Fig. 11.12). Once the procedure is complete, a ureteric stent may be placed postoperatively.
Fluoroscopic view of flexible ureterorenoscopic fragmentation of intrarenal calculi.
Additional procedures that may become necessary
Endoscopic lithotripsy
Retrograde endopyelotomy (laser)
Endoscopic incision of ureteric strictures
Dilatation of ureteric strictures
Placement of ureteric stent (Memokath®)
Treatment of calyceal diverticular lesions
Treatment of malignant urothelial tumours
Treatment of benign tumours or bleeding lesions
Benefits
Diagnostic:
Investigation of abnormal radiological findings, i.e. filling defects
Determine the aetiology of ureteric obstruction
Identifying cause of positive urinary cytology results, culture results, or other test results (if normal cystoscopic findings)
Evaluation of ureteric injury
Therapeutic:
Endoscopic lithotripsy
Retrograde endopyelotomy (laser)
Endoscopic incision of ureteric strictures
Dilatation of ureteric strictures
Placement of ureteric stent (Memokath®)
Treatment of calyceal diverticular lesions
Treatment of malignant urothelial tumours
Treatment of benign tumours or bleeding lesions
Alternative procedures/conservative measures
Conservative: in a non-functioning/poorly functioning kidney in the presence of obstruction, if the patient is asymptomatic then observation may be all that is necessary with renal function measurement and serial radiological imaging, spontaneous stone passage
Medical: medical expulsive therapy for stone passage
Radiology: alternatives to retrograde pyelography include CT urogram, IVU, MAG3 renogram, CT KUB, ultrasound KUB
Surgical: nephrostomy and antegrade ureterorenoscopy (all dependent on underlying pathology in question), ESWL/PCNL
Serious/frequently occurring risks
Common: bleeding (haematuria), dysuria, temporary insertion of urethral catheter, insertion of ureteric stent with need to remove/exchange this, no guarantee of cure
Occasional: urinary tract infections requiring oral or intravenous antibiotics, trauma to urethra, prostate, bladder or ureter resulting in haematuria, recurrence of stricture in ureter, need to biopsy lesion in bladder or ureter, need for further therapy, failure to pass the ureteroscope due to narrow ureter, necessitating further procedure, stone recurrence, incomplete stone clearance
Rare: haematuria and clot retention necessitating further cystoscopy and washout, false passage creation or perforation of urethra/bladder/ureter necessitating prolonged period of catheter insertion/stent/conversion to open procedure to repair defect (ileal loop interposition), need for nephrostomy1–4
Blood transfusion necessary
None
Type of anaesthesia/sedation
Regional/general anaesthesia
Follow-up/need for further procedure
Follow-up is dependent on underlying pathology
Radiological follow-up scans
Removal of stent as outpatient
Failed procedure may necessitate nephrostomy or antegrade stent insertion
References
www.baus.org.uk (accessed 17 May
2011). www.baus.org.uk (accessed 17 May
2011).Urethral dilation (cystoscopy—male/female)
Description
Stricturing disease of the urethra is a pathological process that involves fibrotic scar tissue formation within the tissues surrounding the urethra resulting in a narrowing of the lumen. Patients can present with decreased flow, incomplete bladder emptying, dysuria, haematuria, recurrent urinary tract infections and obstructive uropathy. Diagnosis is made with history, clinical examination (external urethral meatus), flow-rate studies, retrograde/antegrade urethrography, or urethroscopy.
Disease processes that cause urethral stricture formation include:
Infection (gonococcal urethritis)
Inflammation (BXO resulting in meatal or submeatal stenosis)
Trauma (pelvic fractures, urethral instrumentation including post-TURP, cystoscopy, catheterization, post-radical prostatectomy)
Urethral dilation is a process whereby sounds of increasing diameter are passed along the urethra with lubrication in an attempt to open a stricture or narrowing of the urethra. It is designed to stretch the urethra with minimal scarring.1
Additional procedures that may become necessary
Urethral catheterization
Suprapubic catheterization
Optical urethrotomy
Bladder biopsies
Future therapy (ISC/referral for urethroplasty)
Meatotomy/meatal dilatation (for distal meatal strictures where the urethra cannot be cannulated with the optical urethrotome)
Benefits
Diagnostic: diagnose underlying stricture, length of stricture, and proximity to external urethral sphincter
Therapeutic: to improve symptoms associated with urethral stricture and prevent complications from bladder outflow obstruction
Alternative procedures/conservative measures
Conservative: manage patient conservatively with regular urine flow-rate examination, residual volume measurements and monitor serum creatinine and evidence of upper tract dilatation on ultrasonography in the patient who wishes no further treatment and is asymptomatic. In patients who are able to perform ISC, this is an option to prevent further re-stricturing. It requires good hand–eye coordination and dexterity and may be difficult in the older patient
Medical: patients with BXO with meatal stenosis may require topical steroid treatment to limit the progression of disease
Surgical:
Optical urethrotomy
Suprapubic catheter insertion (to avoid trauma to stricture or urethra, and to provide a conduit for antegrade and retrograde urethrography to plan future treatment
In males, excision and primary reanastomosis of urethra
Tissue transfer procedure (urethroplasty with buccal or pedicled skin flap). The latter two techniques should be performed following adequate imaging of urethra, in younger patients or in patients with recurrent stricture formation who do not wish to have repeat dilatation/urethrotomy procedures. These are often carried out in specialist centres that deliver a urethral reconstruction service
Serious/frequently occurring risks
Common: bleeding (haematuria), dysuria, temporary insertion of urethral catheter
Occasional: urinary tract infections requiring oral or intravenous antibiotics, trauma to urethra, prostate or bladder resulting in haematuria, recurrence of stricture (this is particularly so if bleeding is associated with urethral dilation as it implies that there has been further trauma to the urethra), need to biopsy lesion in bladder, need for further therapy (including ISC, optical urethrotomy, referral for specialist stricture treatment—urethroplasty/excision and anastomosis, need to insert suprapubic catheter
Rare: haematuria and clot retention necessitating further cystoscopy and washout, failure of procedure due to complete urethral occlusion, false passage creation or perforation of urethra/bladder necessitating prolonged period of catheter insertion or conversion to open procedure to repair defect in bladder, erectile dysfunction, decreased continence (if stricture involves or lies adjacent to external urethral sphincter)2–4
Blood transfusion necessary
None
Type of anaesthesia/sedation
Local/regional or general anaesthesia
Follow-up/need for further procedure
Dependent on findings of stricture
If catheter inserted, trial without catheter can be scheduled between 24h and 5 days post-procedure
Review in outpatient clinic with flow rate assessment, RV, and symptomatic review
Referral to learn ISC
Referral for definitive surgical procedure for stricture
References
www.baus.org.uk (accessed 17 May
2011). www.baus.org.uk (accessed 17 May
2011). www.baus.org.uk (accessed 17 May
2011).Vasectomy
Description
Vasectomy is the surgical procedure by which a section of the vas deferens is removed from each side to achieve permanent sterility. Although it is deemed that every man of legal age and able to give consent can decide in favour of vas ligation for the purpose of sterilization, there are certain preconditions that many surgeons or physicians look for. This is primarily to provide weight towards their decision prior to offering the operation. These include:
A certain number of children are required in the family of the patient
A stable relationship is required
Ideally the partner should accompany the man during the consultation or ideally back the decision for vasectomy
The procedure can be carried out under local or general anaesthesia depending on patient preference. The vas is palpated and the cord is infiltrated with local anaesthetic. Once the vas deferens is isolated through the skin, it is clamped and the scrotal skin incised over a distance of 0.5–1.0cm. The vas is then separated from its overlying sheath and divided between two clips. A segment might be sent for histopathology to confirm it is truly vas deference that has been ligated. Both ends can be ligated or coagulated by diathermy to occlude the lumen. The wound is closed with a single absorbable suture.1
Follow-up of patients must be accurate and patients must be told to continue using barrier contraception or for partner to use oral contraception until two negative semen samples are achieved on two different tests spaced 2 weeks apart (usually 12 and 14 weeks, as per local policy).
Additional procedures that may become necessary
Nil
Benefits
Diagnostic: histopathological confirmation of benign vas deferens tissue is important in documenting accurate ligation of the structure
Therapeutic: as a permanent method of contraception
Alternative procedures/conservative measures
Other forms of contraception (male or female) including barrier contraceptive, oral contraceptive agents and implantable contraceptive agents
Surgical: female laparoscopic tubal ligation
Serious/frequently occurring risks
Common: irreversible procedure, scrotal bruising and pain, two semen samples required demonstrating the absence of live sperm before unprotected intercourse
Occasional: bleeding (scrotal haematoma resulting in either slow re-absorption or further procedure to evacuate clot)
Blood transfusion necessary
None
Type of anaesthesia/sedation
Local/regional/general anaesthesia
Follow-up/need for further procedure
Scrotal support for up to one week
Warm sit down bath after 48h to soak and remove dressing
Follow-up with semen analysis at 12 and 14 weeks (to ensure azoospermia) as per local policy. Patient to continue using other forms of contraceptive until this is achieved
References
www.baus.org.uk (accessed 17 May
2011).
