Urologic operation 16 0rchidectomy

Orchiectomy

Objective

In case of

•   Tumor or torsion of testis

-   Torsion of testis

•   Removal of testicles.

Position

Supine.

Anesthesia

General.

Procedure

1.  Incision can be made transcrotally or inguinally.

2.  The testis is identified, the spermatic cord ligated and the testis are removed.

3.  Repeated bilaterally if required.

4.  For testicular malignancy, high ligation of the spermatic cord is done.

5.  Radical lymphadenectomy may be performed through an abdominal incision to the level of the transection of the spermatic cord, are removed. A testicular prosthesis may be placed at the time of orchiectomy.

6.  Wound is closed.

Instruments

General Set

•   Cord hook (Fig. 11.17)

•   Cord clamp.

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UROLOGIC OPERATION 15 renal transplantation

Renal Transplantation

Objective

In case of renal failure:

•   Kidney from live donar

•   Or kidney from cadaver is transplanted to restore renal function.

Position

Supine.

Anesthesia

General.

Procedure

   1.  In live donor a nephrectomy is carried out as described care is mobilizing renal artery and vein so as not to injure them.

   2.  Ureter is similarly mobilized with perureteric tissue. Kidney perfused with cold irrigating fluid.

   3.  The iliac fossa of patient (RP) is used.

   4.  Oblique muscle cutting used for access.

   5.  Peritoneum pushed medially.

   6.  Internal iliac artery mobilized branches ligated.

   7.  External iliac vein mobilized.

   8.  Donor kidney renal vein anastomosed to external iliac vein.

   9.  End of internal iliac artery anastomosed to donor kidney renal artery.

10.  Ureter is implanted to bladder.

11.  Wound closed after placing kidney iliac fossa.

Instruments

•   General set

•   Laparotomy set

•   Deep set

•   Vascular clamps (Potts, De Bakey or Satinsky), 2

•   Large bulldog clamps (Potts), 4     (Fig. 8.126)

•   Small bulldong clamps (Potts), 4

•   Heparinized saline, and syringes with cannulae

•   Suction tubing, nozzles and tube anchoring forceps

•   Diathermy leads, electrodes and lead anchoring forceps

•   Tantalum marker clips and insertion forceps

•   Laparotomy ligatures and sutures

•   1 and 0.75 (5/0 and 6/0) Synthetic nonabsorbable or silk on small fine curved arterial needles for anastomosis.

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UROLAGIC OPERATION 14 nephtrctomy

Nephrectomy

Objective

In case of tumor or other disease:

•   removal of a kidney.

Position

Lateral.

Anesthesia

General.

Procedure

   1.  For benign disease a flank incision is made (with or without rib resection).

   2.  The kidney and ureter are mobilized.

   3.  The ureter is divided and the distal end ligated.

   4.  Vascular pedicle (artery and vein) is ligated.

   5.  For malignant disease a radical nephrectomy is performed.

   6.  A transperitoneal or anterior retroperitoneal incision is used.

   7.  For large upper-pole lesions, a transthoracic approach may be employed.

   8.  On the right side, the duodenum is protected with mois­tened laparotomy pads.

   9.  The vascular pedicle is transected and lymph node bearing tissue excised.

10.  The ureter is divided, and the kidney and surrounding fat, adrenal gland, and fascia are removed en bloc.

11.  If tumor is present in the renal vein, the vena cava is mobilized and the tumor embolus removed.

12.  The distal ureter is dissected free of surrounding tissues and a small cuff of bladder is excised with the intramural portion of the ureter.

13.  The bladder incision is repaired.

14.  A suprapubic cystostomy catheter may be placed and the distal ureter and bladder cuff are delivered into the flank.

15.  The flank incision may be closed with or without drainage.

16.  For trauma and some presentations of calculus disease involving only a portion of the kidney, a partial nephrec­tomy may be performed.

Instruments

•   General set

•   Deep instrument set

•   Kidney set

•   Thoracotomy tray, vascular procedures tray, and laparotomy procedures set (available)

•   Hemoclip appliers (assorted sizes and lengths) 

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UROLOGIC OPERAYION 13 cutaneous ureterostomy

Cutaneous Ureterostomy

Objective

In case of ureteral obstruction

•   opening of a ureteral stoma on the abdomi­nal wall.

Position

Lateral or supine.

Anesthesia

General.

Procedure

1.  A flank incision is made.

2.  The ureter is exposed and dissected free.

3.  The ureter transected as far as possible exits out a stoma site (sutured) to the abdominal skin.

Instruments

•   General set.

•   Deep instrument set.

•   Self-retaining abdominal retractor (e.g. Balfour).

•   Hemoclip appliers (various sizes and lengths).

•   Iris scissors and fixation forceps (ureteroureterostomy).

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UROLOGIC OPERATION 12

Ureterolithotomy, Pyelolithotomy and Nephrolithotomy

Objective

In case of:

•   Stones in the upper urinary tract

•   Removal of calculi from

     a.  Ureter

     b.  Renal pelvis

     c.  Kidney.

Position

•   Lateral (upper ureter)

•   Supine (lower ureter, kidney).

Anesthesia

General.

Procedure

   1.  Flank incision is made with rib resection (twelfth) optional.

   2.  For stones within the renal parenchyma (nephrolithotomy).

   3.  Temporary interruption of the renal circulation.

   4.  Parenchyma incised and the calculus removed.

   5.  Fatty tissues may be used to bolster the suture line.

   6.  Stones in the renal pelvis (pyelolithotomy) or in the proximal ureter (ureterolithotomy).

   7.  Extracted through incisions overlying the stones.

   8.  Collecting system is irrigated and sutured closed.

   9.  Calculi in the distal ureters are approached retroperito­neally.

10.  Inguinal, lower midline abdominal, or transverse oblique incision.

11.  The stone is palpated, noting that the ureter proximal to it may be dilated.

12.  Control of the ureter proximal and distal to the stone is achieved with vessel loops or atraumatic clamps.

13.  The ureter is opened and the stone retrieved.

14.  Irrigation may be employed and the ureter is closed.

Instruments

•   General set

•   Deep instruments set

•   Kidney set

•   Thoracotomy tray, vascular procedures tray, and gastro­intestinal procedures tray (available)

•   Hemoclip appliers (assorted sizes and lengths)

•   Asepto syringe

•   Vessel loops and umbilical tapes

•   Dissectors (e.g. peanut)

•   Penrose drain 1" (retraction)

•   Gil-Vernets sinus hooks (Fig. 11.16).

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Urologic operation 11 transuretral prostatectomy

Transurethral Prostatectomy

Objective

In case of prostatic enlargement. The prostate tissue is removed with the help of a resectoscope.

Position

Lithotomy.

Anesthesia

Epidural or General.

Procedure

1.  Neutral electrode applied to thigh.

2.  Urethra dilated.

3.  Resectoscope introduced.

4.  Prostate removed using diathermy loop.

5.  Bleeding coagulated.

6.  Resectoscope removed.

7.  Self-retaining catheter.

Instruments

•   Bladder sounds or bougies set

•   Supply of sterile water or 1.5 glycine, etc. for irrigation

•   Connecting tubing and nozzles for resectoscope

•   Electro-resectoscope or ‘cold punch’ or laser hot yag instru­ment

•   Fiber light or electric cable and light or low voltage source

•   Electric cable and batteries

•   Diathermy leads, lead anchoring forceps and diathermy apparatus

•   Urethral catheter, 3 way self-retaining (Foley size 18, 20 or 22 Charriere gauge)

•   20 ml syringe and sterile water for inflating cuff of catheter.

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UROLOGIC OPERATION 10 pereneal prostatectomy

Perineal Prostatectomy

Objective

In case of:

•   Malignancy of prostate

•   Excision of the prostate gland through the perineum.

Procedures

1.  Curvilinear incision is made in the perineum.

2.  For malignancy the entire gland, its capsule, the seminal vesicle, and distal portion of the vasa are excised.

3.  Care is taken to avoid injury to the rectum.

4.  A urethrovesical anastomosis is performed after a trans­urethral Foley catheter is placed.

5.  The wound is drained and the incision is closed.

Instruments

•   General set

•   Hemoclip appliers (assorted) (Fig. 11.11)

•   Perineal prostatectomy retractors; lateral, anterior, bifurcated (e.g. Young) (Fig. 11.15).

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