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© 2008 Delmar Cengage Learning.
CHAPTER 20
Genitourinary Surgery
© 2008 Delmar Cengage Learning.
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Anatomy
• Suprarenal glands• Kidneys• Ureters• Urinary bladder
© 2008 Delmar Cengage Learning.
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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
© 2008 Delmar Cengage Learning.
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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
© 2008 Delmar Cengage Learning.
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Ureters• Conduct urine from the kidney to the
bladder• Muscular tubes• Small lumen• “S” shaped
© 2008 Delmar Cengage Learning.
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Kidney/Ureter
© 2008 Delmar Cengage Learning.
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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
© 2008 Delmar Cengage Learning.
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Urinary Bladder• Trigone
– Ureteral openings– Urethral opening– Base of the bladder
© 2008 Delmar Cengage Learning.
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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
© 2008 Delmar Cengage Learning.
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Urinary Calculi
• Small solid particles• Form in one or both kidneys• Travel through the urinary system• Partial or total obstruction
© 2008 Delmar Cengage Learning.
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Urinary Calculi• Calculi symptoms
– Dysuria– Polyuria– Passage of small amounts of urine– Flank pain– Nausea and vomiting
© 2008 Delmar Cengage Learning.
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Male Reproductive System• Penis• Testes• Ductus• Deferens• Seminal vesicles• Ejaculatory ducts• Prostate gland
© 2008 Delmar Cengage Learning.
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Penis
• Superficial structure• Cylindrical masses of cavernous tissue
– Two corpora cavernosa • Dorsal
– Corpus spongiosum• Midline
© 2008 Delmar Cengage Learning.
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Penis
• Glans penis• Prepuce
– Foreskin• Covers the glans penis
© 2008 Delmar Cengage Learning.
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Male Urethra• Passes through the prostate gland• Divided into three parts
– Prostatic– Membranous– Spongy
© 2008 Delmar Cengage Learning.
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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
© 2008 Delmar Cengage Learning.
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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
© 2008 Delmar Cengage Learning.
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Testis
© 2008 Delmar Cengage Learning.
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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
© 2008 Delmar Cengage Learning.
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Prostate Gland• Accessory gland• Lobulated gland (50 lobules)• Secrete prostatic fluid
© 2008 Delmar Cengage Learning.
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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
© 2008 Delmar Cengage Learning.
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Pathology• Adrenal Glands
– Pheochromocytoma• Tumor affecting the medulla• Overproduction of adrenaline
© 2008 Delmar Cengage Learning.
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Pathology• Urinary System
– Bladder tumors– Urinary calculi– Kidney disorders
© 2008 Delmar Cengage Learning.
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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
© 2008 Delmar Cengage Learning.
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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
© 2008 Delmar Cengage Learning.
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Kidney Disorders• Diabetic Nephropathy
– Sclerosis– Kimmelstiel-Wilson disease– Diabetic glomerulosclerosis– Caused by uncontrolled diabetes mellitus
© 2008 Delmar Cengage Learning.
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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
© 2008 Delmar Cengage Learning.
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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
© 2008 Delmar Cengage Learning.
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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
© 2008 Delmar Cengage Learning.
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Pathology Affecting the Male Reproductive System
• Phimosis• Hypospadias/Epispadias• Benign Prostatic
Hypertrophy (BPH)• Cancer• Cryptorchidism• Testicular Torsion
© 2008 Delmar Cengage Learning.
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Diagnostic Procedures• History and physical• Hematology• Urinalysis• Regular X-ray• KUB (kidney, ureter, bladder)
© 2008 Delmar Cengage Learning.
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Diagnostic Procedures• IVU• Retrograde urogram• MIBG• Biopsy• Endoscopy
© 2008 Delmar Cengage Learning.
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Special Considerations• Transurethral procedures• Specially equipped room
– Built-in table– Radiographic equipment– Darkroom– Drainage system
© 2008 Delmar Cengage Learning.
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Special Considerations• General instruments• Kidney instruments
– Rib instruments
© 2008 Delmar Cengage Learning.
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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
© 2008 Delmar Cengage Learning.
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Incisional Options• Gibson
– Extraperitoneal abdominal approach– Access the lower ureter
• Flank• Lumbar
– Adrenalectomy, renal biopsy, removal of low lying kidney
© 2008 Delmar Cengage Learning.
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Common Procedures
• Nephrectomy• Adrenalectomy• Renal transplant• ESWL• Cystectomy
© 2008 Delmar Cengage Learning.
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Common Procedures
• Marshall-Marchetti-Krantz (MMK)• Circumcision• Orchiopexy• TURP• Prostatectomy
© 2008 Delmar Cengage Learning.
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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
© 2008 Delmar Cengage Learning.
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Open Cystotomy• Alternate method of catheterizing the
bladder for drainage• Percutaneous• Open• Acute urinary retention
– Enlarged prostate
© 2008 Delmar Cengage Learning.
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Open Cystotomy
© 2008 Delmar Cengage Learning.
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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
© 2008 Delmar Cengage Learning.
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MMK
© 2008 Delmar Cengage Learning.
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Stamey Needle Placement