© 2008 Delmar Cengage Learning. CHAPTER 20 Genitourinary Surgery

© 2008 Delmar Cengage Learning.

CHAPTER 20

Genitourinary Surgery

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Anatomy

• Suprarenal glands• Kidneys• Ureters• Urinary bladder

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Supradrenal Glands

• On top of kidneys• Endocrine glands• Cortex

– Secretes steroid- type hormones

– Control fluid and electrolyte balance

• Medulla– Secretes epinephrine– Norepinephrine

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Kidneys• Differ in location and size

– Left is normally larger• Nephron is the functional unit

– Renal corpuscle– Renal tubule

• Filters blood• Excrete waste

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Ureters• Conduct urine from the kidney to the

bladder• Muscular tubes• Small lumen• “S” shaped

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Kidney/Ureter

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Urinary Bladder

• Collects urine• Lies in the anterior half of the pelvis• Male

– Lies on and is attached to the base of the prostate gland

• Female– Lies on the pelvic diaphragm

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Urinary Bladder• Trigone

– Ureteral openings– Urethral opening– Base of the bladder

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Bladder Tumors• Present with hematuria• Single growth or multiple present• Benign (papillomas) occur in young adults• Malignant neoplasms usually occur in men

over 50• Early removal transurethrally

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Urinary Calculi

• Small solid particles• Form in one or both kidneys• Travel through the urinary system• Partial or total obstruction

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Urinary Calculi• Calculi symptoms

– Dysuria– Polyuria– Passage of small amounts of urine– Flank pain– Nausea and vomiting

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Male Reproductive System• Penis• Testes• Ductus• Deferens• Seminal vesicles• Ejaculatory ducts• Prostate gland

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Penis

• Superficial structure• Cylindrical masses of cavernous tissue

– Two corpora cavernosa • Dorsal

– Corpus spongiosum• Midline

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Penis

• Glans penis• Prepuce

– Foreskin• Covers the glans penis

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Male Urethra• Passes through the prostate gland• Divided into three parts

– Prostatic– Membranous– Spongy

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Female Urethra• Only 4 cm long• Passes in front of the lower half of the

vagina• Skene’s glands provide lubrication

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Testes• Paired• Lie in the scrotum• Tunica vaginalis covers most of the testis,

epididymis, and lower end of spermatic cord

• Seminiferous tubules• Epididymis

– Maturation site

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Testis

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Ductus Deferens• Arises from the epididymis• Also known as the “vas deferens”• Ascends through the inguinal canal• Delivers semen to the prostatic urethra

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Prostate Gland• Accessory gland• Lobulated gland (50 lobules)• Secrete prostatic fluid

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Pathology• Adrenal Glands

– Cushing’s syndrome• Overproduction of cortisol

– Addison’s disease• Complication of certain illnesses – TB and AIDS• Renal insufficiency

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Pathology• Adrenal Glands

– Pheochromocytoma• Tumor affecting the medulla• Overproduction of adrenaline

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Pathology• Urinary System

– Bladder tumors– Urinary calculi– Kidney disorders

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Kidney Disorders• Polycystic Kidney Disease

– Occurs when the parenchyma of the kidney is replaced by multiple fluid filled benign cysts

– Autosomal dominant• Inherited• Symptomatic between the age of 30 and 40• 90% of PKD fall under this category

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Kidney Disorders• Polycystic Kidney Disease

– Autosomal recessive• Inherited• Extremely rare• Affects young children

– Acquired • Develops in patients with long term kidney disease

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Kidney Disorders• Diabetic Nephropathy

– Sclerosis– Kimmelstiel-Wilson disease– Diabetic glomerulosclerosis– Caused by uncontrolled diabetes mellitus

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Kidney Disorders• End-Stage Renal

Disease (ESRD)– Kidney failure– Kidneys functioning

under 10%– Half the population

with ESRD is diabetic– Dialysis – Kidney transplant

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Kidney Disorders• Renal Cell Carcinoma

– Adenocarcinoma– Most common type of kidney cancer– 8,000 deaths per year in the U.S.– Affects men twice as often– Usually appears between 50-60 years old– Directly linked to cigarette smoking

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Kidney Disorders• Congenital Nephroblastoma

– Wilms’ tumor– Malignant– Occurs primarily in children between 3-4

years– Surgical removal is recommended– Followed by radiation and chemotherapy

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Pathology Affecting the Male Reproductive System

• Phimosis• Hypospadias/Epispadias• Benign Prostatic

Hypertrophy (BPH)• Cancer• Cryptorchidism• Testicular Torsion

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Diagnostic Procedures• History and physical• Hematology• Urinalysis• Regular X-ray• KUB (kidney, ureter, bladder)

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Diagnostic Procedures• IVU• Retrograde urogram• MIBG• Biopsy• Endoscopy

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Special Considerations• Transurethral procedures• Specially equipped room

– Built-in table– Radiographic equipment– Darkroom– Drainage system

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Special Considerations• General instruments• Kidney instruments

– Rib instruments

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Cystoscope

Flexible Cystoscope

Rigid Cystoscope

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Flexible Ureteroscope

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Incisional Options• Inguinal

– Access the scrotal contents of an adult or child

• Scrotal– Access scrotal contents

• Abdominal

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Incisional Options• Gibson

– Extraperitoneal abdominal approach– Access the lower ureter

• Flank• Lumbar

– Adrenalectomy, renal biopsy, removal of low lying kidney

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Common Procedures

• Nephrectomy• Adrenalectomy• Renal transplant• ESWL• Cystectomy

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Common Procedures

• Marshall-Marchetti-Krantz (MMK)• Circumcision• Orchiopexy• TURP• Prostatectomy

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Nephrectomy• Subtotal removal

– Upper or lower pole of the kidney• Total removal

– Simple • Small malignancies

– Chronic obstructive disorders– Benign tumors– Transplant

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Open Cystotomy• Alternate method of catheterizing the

bladder for drainage• Percutaneous• Open• Acute urinary retention

– Enlarged prostate

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Open Cystotomy

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Stress Incontinence in Women• Restore posterior urethrovesical angle• Elevate base of bladder• MMK procedure

– Suprapubic suspension• Stamey procedure

– Endoscopic suspension– Stamey needle

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MMK

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Stamey Needle Placement