STERILIZATION is a process by which an article, surface or medium is freed from all living micro organism either in the vegetative or spore state
The various agents used in sterilization can be classified as follows
a) physical agents:
1. sunlight
2. drying
3. dry heat : flaming, incineration, hot air
4. moist heat: pasteurization boiling, steam under normal pressure
5. filtration: candles,asbestos pads, membranes
6. radiation
7. ultrasonic and vibrations.
Chemical agents:
1. alcohols: ethyl isopropyl trichlorobutanol
2. aldehydes: formaldehyde, gluteraldehyde
3. dyes
4. halogens
5. phenols
6. surface active agents
7. metallic salts
8. gases
a)heat:
heat is a most reliable method of sterilization and shold be method of choice unless contraindicated. The factor influencing sterilization by heat
are:
1. nature of heat- dry heat or moist heat
2. temperature and time
3. number of micro organism present
4. characteristics such as species, strain, spring capacity
5. type of the material which the organism have to be eradicated
The killing effect of dry heat is due to protein denaturation, oxidative damage and the toxic effects of elevated levels of electrolytes.
The lethal effect of moist effect is due to denaturation and coagulation of protein
Dry Heat:
Flaming : inoculating loop of wire, the tip of the forceps and searing spatulas
Incineration : excellent method of safely destroying materials such as contaminated cloth, animal carcasses and pathological materials, plastics such as PVC
and polythene.
Hot air oven:
Most widely use dmethod of sterilization by dry heat
160c- for one hour- to sterilize glassware, forceps, scissors, scalpels, all glass syringes, swabs, some pharmeceutical products such as liquid
paraffin, dusting powder, fats and grease.
Monday, March 2, 2009
Hydrocele
It’s an abnormal collection of serous fluid in the tunica vaginalis of the testis or with in some part of the processes vaginalis.
Types :
Primary
Secondary
Primary hydrocele : The cause of, which is unknown.
Secondary hydrocele: When hydrocele is secondary to a disease in the testis and/or in the epididymis its usually small and lux.
a) Vaginal hydrocele
b) Encysted hydrocele of the cord
c) Infertile hydrocele
d) Congenital hydrocele
e) Funicular hydroceleis
f) Hydrocele of the canal of nuck
g) Hydrocele of hernial sac
h) Hydrocele in bisac
Symptom :
Swelling of the scrotum
Discomfort
Pain
Differential diagnosis :
Inguinal hernia
Haematocele
Pyocele
Filariasis of the scrotum
Cyst in relation to the epididymis
Encysted hydrocele of the cord
Tumors of the testis
Congenital hydrocele:
Congenital hydrocele in children is due to patent processus vaginalis. The opening of the processus vaginalis into the general peritaoneal cavity is
generally too small for the development of a hernia.through an inguinal incision, the processus vaginalis is dissected off. It is ligated and divided at the
neck and at the upper pole of the testis. The portion of the processus vaginalis within the inguinal canal is removed and the portion with the testis as
remains as tunica vaginalis.
Tapping :
This operation through not a radical treatment, is often indicated in case of old patients, who can well be tapped, which is painless, for a few
times for the rest of their lives.
While tapping, the position of the testis is ascertained by fingers and pushed posteriorly.
A wheal of local anaesthetic solution is raised in an area of the scrotal skin that is free of visible vessels and rather dependent. A fine Trocar
and a cannula are then trust into the sac through the scrotal wall.
The fluid is evacuated slowly to avoid shock. Once all the fluid has been evacuated, the cannula is withdrawn and the wound in the scrotal wall is
sealed with tinc iodine.
Injection treatment :
This treatment is not much practiced nowadays after tapping the hydrocele fluid 10ml of scleroscent solution (formed by combination of quinine
hydrochloride 2gm, Urethane 1gm in 15ml of water for injection of sodium tetradecyl solution) is injected into the cavity of tunica vaginalis. Gentle massage
is given to disperse the solution evenly. The scrotum is supported with a suspensory bandage. This treatment is necessary, may be repeated.
Jaboulay’s method of eversion of sac:
This radical method of operation is mostly practiced nowadays for small and medium size hydroceles. An incision is made on the scrotal wall, on the
side of the hydrocele. The incision is gradually depended till the tunica vaginalis is reached. In this process one will come across a few vessels which have
to be ligated. As soon as the tunica vaginalis is reached the sac is separated from the rest of the scrotal wall by finger. The sac is held in one hand and
with another hand the tunica vaginalis is incised. As soon as the incision is made fluid will come out of the sac. The two margins of the incisions are held
with two pairs of artery forceps and held upwards. The incision is extended upwards and down wards to allow the testis to come out through this opening. The
testis is brought out through the opening and the two margins of the tunica vaginalis are sutured behind the testis, so that the secreting surface of the
tunica vaginalis will be lying outside. Care must be taken not to strangle the testicular vessels. The scrotal wound is now sutured.
After dressing the wound, the patient should be instructed to wear suspensory bandage. Proper antibiotics should be administered. The stitches are
removed from the scrotal wall after 6days.
Lord’s procedure of excision of sac:
This operation is mainly indicated for big size hydroceles. The steps of operation is upto opening of te tunica vaginalis are same as those of the
previous mention nature of operation. The tunica vaginalis is now sutured with 10 to 12 catgut or Dexon sutures from the testis and the epididymis. When
these sutures are tied, the whole tunica is bunched at the edge of the testis.
Subtotal excision:
Complications :
Infection
Atrophy of the testis
Rupture
Haematocele
Hernia of the hydrocele sac
Calcification of the sac
Types :
Primary
Secondary
Primary hydrocele : The cause of, which is unknown.
Secondary hydrocele: When hydrocele is secondary to a disease in the testis and/or in the epididymis its usually small and lux.
a) Vaginal hydrocele
b) Encysted hydrocele of the cord
c) Infertile hydrocele
d) Congenital hydrocele
e) Funicular hydroceleis
f) Hydrocele of the canal of nuck
g) Hydrocele of hernial sac
h) Hydrocele in bisac
Symptom :
Swelling of the scrotum
Discomfort
Pain
Differential diagnosis :
Inguinal hernia
Haematocele
Pyocele
Filariasis of the scrotum
Cyst in relation to the epididymis
Encysted hydrocele of the cord
Tumors of the testis
Congenital hydrocele:
Congenital hydrocele in children is due to patent processus vaginalis. The opening of the processus vaginalis into the general peritaoneal cavity is
generally too small for the development of a hernia.through an inguinal incision, the processus vaginalis is dissected off. It is ligated and divided at the
neck and at the upper pole of the testis. The portion of the processus vaginalis within the inguinal canal is removed and the portion with the testis as
remains as tunica vaginalis.
Tapping :
This operation through not a radical treatment, is often indicated in case of old patients, who can well be tapped, which is painless, for a few
times for the rest of their lives.
While tapping, the position of the testis is ascertained by fingers and pushed posteriorly.
A wheal of local anaesthetic solution is raised in an area of the scrotal skin that is free of visible vessels and rather dependent. A fine Trocar
and a cannula are then trust into the sac through the scrotal wall.
The fluid is evacuated slowly to avoid shock. Once all the fluid has been evacuated, the cannula is withdrawn and the wound in the scrotal wall is
sealed with tinc iodine.
Injection treatment :
This treatment is not much practiced nowadays after tapping the hydrocele fluid 10ml of scleroscent solution (formed by combination of quinine
hydrochloride 2gm, Urethane 1gm in 15ml of water for injection of sodium tetradecyl solution) is injected into the cavity of tunica vaginalis. Gentle massage
is given to disperse the solution evenly. The scrotum is supported with a suspensory bandage. This treatment is necessary, may be repeated.
Jaboulay’s method of eversion of sac:
This radical method of operation is mostly practiced nowadays for small and medium size hydroceles. An incision is made on the scrotal wall, on the
side of the hydrocele. The incision is gradually depended till the tunica vaginalis is reached. In this process one will come across a few vessels which have
to be ligated. As soon as the tunica vaginalis is reached the sac is separated from the rest of the scrotal wall by finger. The sac is held in one hand and
with another hand the tunica vaginalis is incised. As soon as the incision is made fluid will come out of the sac. The two margins of the incisions are held
with two pairs of artery forceps and held upwards. The incision is extended upwards and down wards to allow the testis to come out through this opening. The
testis is brought out through the opening and the two margins of the tunica vaginalis are sutured behind the testis, so that the secreting surface of the
tunica vaginalis will be lying outside. Care must be taken not to strangle the testicular vessels. The scrotal wound is now sutured.
After dressing the wound, the patient should be instructed to wear suspensory bandage. Proper antibiotics should be administered. The stitches are
removed from the scrotal wall after 6days.
Lord’s procedure of excision of sac:
This operation is mainly indicated for big size hydroceles. The steps of operation is upto opening of te tunica vaginalis are same as those of the
previous mention nature of operation. The tunica vaginalis is now sutured with 10 to 12 catgut or Dexon sutures from the testis and the epididymis. When
these sutures are tied, the whole tunica is bunched at the edge of the testis.
Subtotal excision:
Complications :
Infection
Atrophy of the testis
Rupture
Haematocele
Hernia of the hydrocele sac
Calcification of the sac
INSERTION OF CHRONIC AMPULATORY PERITONEAL DIALYSIS
INSERTION OF CHRONIC AMPULATORY PERITONEAL DIALYSIS
Indications
1. Chronic ambulatory peritoneal dialysis is suitable for the majority of the patients with chronic renal failure
2. Patient in the remote areas distant from the heamodialysis
3. Any vascular diseases
4. Long term heamodialysis
5. Contraindicated to renal transplantation
6. After renal rejection
Contraindication:
Problems may be anticipated in the following group of patients those who have undergone :
1.Previous abdominal surgery where adhesions may obliterate the peritoneal cavity.
2.Those with large polycystic kidneys causing abdominal distention
3.Those with any abdominal hernias. These should be repaired before the insertion of peritoneal dialysis
4.A Cutanious Enterostomy or urinary diversion are relative but not absolute contraindication to peritoneal dialysis
Pre operative management
1. Staphylococcus aureus is an important pathogen and steps should be taken to identify and treat patients who are carriers of organism
2. Nasal and groin swabs are taken before surgery
Patient Preparation:
1. Position –Patient is positioned on the supine position
2. Anaesthesia—The Anaesthesia preferred is general anaesthesia or local anaesthesia
3. Skin preparation—determine the site of incision , begin the parts preparation, include area from the chest to mid thigh and down to the table at the
sides
4. Draping—four folded towels and a Laprotomy sheet
CAPD trolley
Procedure::
1. Under general anaesthesia, the abdomen is opened through the left or right lower paramedian incision of 2m length.
2. Anterior sheath is opened, rectus muscle is split open.
3. The peritoneum is opened for approximately 1cm or less.
4. Using a Roberts forceps the Oreopoulos catheter is inserted into the peritoneal cavity and positioned in the pelvis in front of the rectum but behind
the bladder ( uterus in women)
Wound Closure
1. The peritoneum is tightly closed around the catheter using a continous 2-0 chromic catgut suture the first of the two Dacron cuffs lying in the
muscle layer.
2. The final sutures may be placed through the cuff itself to encourage secure peritoneal closure this being facilitated by gentle traction on the
catheter . following peritoneal closure
3. Free inflow and drainage are tested using a saline filled syringe
4. The skin exit side is identified such that the second Dacron cuff lies 3cm away from the exit site is the subcutaneous tunnel; through a small stab
incision
5. A sharp plunger / introducer is pushed through the subcutaneocs tissues to the operative wound and the catheter is withdrawn
6. The rectus sheath is sutured with an absorbable suture eg. Dexon as is the deep fascia
7. The skin is sutured with 2-0 nylon
8. A titanium adaptor isintroduced into the end of the catheter and 5ml of dilute heparin solution (1000units/ml) are instilled into the catheter which
is the capped. Separate dressing are applied to the Laprotomy wound and exit site. The catheter is also taped to the skin to prevent excessive movement at
the exit site.
POST OPERATIVE CARE
The catheter should be flushed with 500ml dialysis solution.
Each day until CAPD is commenced. It is advisable to commence peritoneal dialysis 5-10 days after catheter insertion.
Earlier use of the catheter risks leakage of fluid around the catheter.
While a large interval may allow the intestine or omentum to become adherent to the catheter causing poor inflow or drainage.
The exist site dressing is changed daily using aseptic technique
Complication:
Failure of drainage is almost invariably caused by intestine or omentum wrapped around the catheter
Fluid leakage may manifest around the catheter
Pain and swelling into the anterior abdominal wall may occur due to the extravasation of fluid
Sepsis may develop around the cutaneous exit site. Antibiotics should be given.
Indications
1. Chronic ambulatory peritoneal dialysis is suitable for the majority of the patients with chronic renal failure
2. Patient in the remote areas distant from the heamodialysis
3. Any vascular diseases
4. Long term heamodialysis
5. Contraindicated to renal transplantation
6. After renal rejection
Contraindication:
Problems may be anticipated in the following group of patients those who have undergone :
1.Previous abdominal surgery where adhesions may obliterate the peritoneal cavity.
2.Those with large polycystic kidneys causing abdominal distention
3.Those with any abdominal hernias. These should be repaired before the insertion of peritoneal dialysis
4.A Cutanious Enterostomy or urinary diversion are relative but not absolute contraindication to peritoneal dialysis
Pre operative management
1. Staphylococcus aureus is an important pathogen and steps should be taken to identify and treat patients who are carriers of organism
2. Nasal and groin swabs are taken before surgery
Patient Preparation:
1. Position –Patient is positioned on the supine position
2. Anaesthesia—The Anaesthesia preferred is general anaesthesia or local anaesthesia
3. Skin preparation—determine the site of incision , begin the parts preparation, include area from the chest to mid thigh and down to the table at the
sides
4. Draping—four folded towels and a Laprotomy sheet
CAPD trolley
Procedure::
1. Under general anaesthesia, the abdomen is opened through the left or right lower paramedian incision of 2m length.
2. Anterior sheath is opened, rectus muscle is split open.
3. The peritoneum is opened for approximately 1cm or less.
4. Using a Roberts forceps the Oreopoulos catheter is inserted into the peritoneal cavity and positioned in the pelvis in front of the rectum but behind
the bladder ( uterus in women)
Wound Closure
1. The peritoneum is tightly closed around the catheter using a continous 2-0 chromic catgut suture the first of the two Dacron cuffs lying in the
muscle layer.
2. The final sutures may be placed through the cuff itself to encourage secure peritoneal closure this being facilitated by gentle traction on the
catheter . following peritoneal closure
3. Free inflow and drainage are tested using a saline filled syringe
4. The skin exit side is identified such that the second Dacron cuff lies 3cm away from the exit site is the subcutaneous tunnel; through a small stab
incision
5. A sharp plunger / introducer is pushed through the subcutaneocs tissues to the operative wound and the catheter is withdrawn
6. The rectus sheath is sutured with an absorbable suture eg. Dexon as is the deep fascia
7. The skin is sutured with 2-0 nylon
8. A titanium adaptor isintroduced into the end of the catheter and 5ml of dilute heparin solution (1000units/ml) are instilled into the catheter which
is the capped. Separate dressing are applied to the Laprotomy wound and exit site. The catheter is also taped to the skin to prevent excessive movement at
the exit site.
POST OPERATIVE CARE
The catheter should be flushed with 500ml dialysis solution.
Each day until CAPD is commenced. It is advisable to commence peritoneal dialysis 5-10 days after catheter insertion.
Earlier use of the catheter risks leakage of fluid around the catheter.
While a large interval may allow the intestine or omentum to become adherent to the catheter causing poor inflow or drainage.
The exist site dressing is changed daily using aseptic technique
Complication:
Failure of drainage is almost invariably caused by intestine or omentum wrapped around the catheter
Fluid leakage may manifest around the catheter
Pain and swelling into the anterior abdominal wall may occur due to the extravasation of fluid
Sepsis may develop around the cutaneous exit site. Antibiotics should be given.
SPINAL ANAESTHESIA
a) spinal anaesthesia is the simpler, easier, cheeper technique
b) it is applied between L2-L3 (or) L3-L4 space of the sub- arachnoid space and the center of action is the caude equina rather than spinal cord.
Things required:
25-27g needle
bupivacine
fentanyl
lignocaine jelly
position
seated
procedure
1.In the seated position the injectable local anaesthetics 1%lignocaine jelly is applied at the selected point.
3. After 30sec the spinal needle is injected over the L2-L3 (or) L3-L4 region
4. check for the flow of CSF
5. withdraw the needle immediately if patient complaint of shooting pain
6. fix the needle and attach the syringe containing drug and inject over 15 sec
Factors affecting spread of drug:
1.Gravity:
The position of patient in the 1st 15mm is important as the hyperboric solution spread is markedly influenced by gravity
2.Speed of injection
3.drug volume
level of block required
volume should be reduced in pregnancy and obesity
4.age has no significant correlation
b) it is applied between L2-L3 (or) L3-L4 space of the sub- arachnoid space and the center of action is the caude equina rather than spinal cord.
Things required:
25-27g needle
bupivacine
fentanyl
lignocaine jelly
position
seated
procedure
1.In the seated position the injectable local anaesthetics 1%lignocaine jelly is applied at the selected point.
3. After 30sec the spinal needle is injected over the L2-L3 (or) L3-L4 region
4. check for the flow of CSF
5. withdraw the needle immediately if patient complaint of shooting pain
6. fix the needle and attach the syringe containing drug and inject over 15 sec
Factors affecting spread of drug:
1.Gravity:
The position of patient in the 1st 15mm is important as the hyperboric solution spread is markedly influenced by gravity
2.Speed of injection
3.drug volume
level of block required
volume should be reduced in pregnancy and obesity
4.age has no significant correlation
EPIDURAL ANAESTHESIA
The epidural space is a low pressure space between the ligamentum flavum and the duramatter occupied by areolar tissue, loose fat and internal
vertebral venous plexus.
Located at the level of L3 –L4
Apparatus required:
16/18G toony needle
23/27G needle
Sensocaine
Procedure
• inject the 2% lignocaine jelly at the selected point to provide local anaesthesia
• wait 30 sec for lignocaine to act
• insert the epidural needle through the supra sinous ligament
• attaching a syringe with 7mi of saline and holding the hub of the needle firmly. Push the needle inwards steadily and continuosly and the needle
enters the epidural space with the saline flowing in freely
• avoid going beyond 5cm marking in the needle as the sub arachnoid space is likely to be entered.
• Then place the catheter after checking it the filter by flushing with the saline
• Insert the catheter up to 15-20-cm
• Push the catheter in while removing the needle to prevent it being pulled out
• Then the catheter is withdrawn to 8-10cm and the filter is connected
• Test dose is administered to identify whether the catheter or needle is in IV or sub-arachnoid space
Drugs :
1. Bupivaccine 0.5% for anaesthesia and 0.1 –0.25% for analgesic
2. Fentanyl 2 to improve the quality of analgesia
3. Morphine and diamorphine to prolong the duration of analgesia
Volume
1. Depends upon the distance between the point of injection and the site of surgery
2. volume should be reduced in elderly obesity and pregnancy.
vertebral venous plexus.
Located at the level of L3 –L4
Apparatus required:
16/18G toony needle
23/27G needle
Sensocaine
Procedure
• inject the 2% lignocaine jelly at the selected point to provide local anaesthesia
• wait 30 sec for lignocaine to act
• insert the epidural needle through the supra sinous ligament
• attaching a syringe with 7mi of saline and holding the hub of the needle firmly. Push the needle inwards steadily and continuosly and the needle
enters the epidural space with the saline flowing in freely
• avoid going beyond 5cm marking in the needle as the sub arachnoid space is likely to be entered.
• Then place the catheter after checking it the filter by flushing with the saline
• Insert the catheter up to 15-20-cm
• Push the catheter in while removing the needle to prevent it being pulled out
• Then the catheter is withdrawn to 8-10cm and the filter is connected
• Test dose is administered to identify whether the catheter or needle is in IV or sub-arachnoid space
Drugs :
1. Bupivaccine 0.5% for anaesthesia and 0.1 –0.25% for analgesic
2. Fentanyl 2 to improve the quality of analgesia
3. Morphine and diamorphine to prolong the duration of analgesia
Volume
1. Depends upon the distance between the point of injection and the site of surgery
2. volume should be reduced in elderly obesity and pregnancy.
REGIONAL ANAESTHESIA
Local anaestehsia provide excellent preoperative anaesthesia and analgesia.
Local anaestehsia is defimed as the reversible loss of sensation to a restricted region of the body.
It is caused by the blockage of sensory nerve endings and conduction block
Spinal and epidural anaesthesia
Advantages:
1. Minimizes the stress
2. Provides both pre and post operative analgesic
3. reduce bleeding
4. effective muscle relaxation
5. safe recovery
6. Cheaper
Contra indication
1. sepsis at the size of injection
2. bleeding disorders
3. anticoagulant theraphy
4. hypovolaemia
5. hypertension
6. previous spinal injury
7. systemic sepsis
preoperative assessment
1. patient should be free from spinal abnormalities eg. Hyposcoliosis, skin incision etc
2. evaluation of coagulopathy and anticoagulopathy theraphy
3. informed consent
procedure:
1. Rapid intravenous infusion of saline
2. monitor the pulse, NIBP, heart rate and SPO2
precaution:
1. proper scrubbing of hands
2. gloves must be sterile
3. paintaing of skin with antibiotic should be done
position:
1. seated position
Local anaestehsia is defimed as the reversible loss of sensation to a restricted region of the body.
It is caused by the blockage of sensory nerve endings and conduction block
Spinal and epidural anaesthesia
Advantages:
1. Minimizes the stress
2. Provides both pre and post operative analgesic
3. reduce bleeding
4. effective muscle relaxation
5. safe recovery
6. Cheaper
Contra indication
1. sepsis at the size of injection
2. bleeding disorders
3. anticoagulant theraphy
4. hypovolaemia
5. hypertension
6. previous spinal injury
7. systemic sepsis
preoperative assessment
1. patient should be free from spinal abnormalities eg. Hyposcoliosis, skin incision etc
2. evaluation of coagulopathy and anticoagulopathy theraphy
3. informed consent
procedure:
1. Rapid intravenous infusion of saline
2. monitor the pulse, NIBP, heart rate and SPO2
precaution:
1. proper scrubbing of hands
2. gloves must be sterile
3. paintaing of skin with antibiotic should be done
position:
1. seated position
BLADDER NECK INCISION
ANTIBIOTIC:
Inj. Gentamycin 80mg
Anaesthesia :
Under spinal anaesthesia/ epidural anaesthesia
Position :
Patient is positioned on the table in a comfortable position
Skin preparation:
Usually cleaned with an antimicrobial solution (eg.betadine solution)
Begin at the umbilical region, covering at the pubic area, the inner thighs up to the anus.
Draping :
1 drape sheet under the buttocks
2 leggings, one for each leg
1 drape sheet over the andomen
Instrument :
• Cystoscopy sheath 22fr
• Bridge
• 30-degree telescope
• 0 degree telescope
• Cystoscopy sheath / BNI sheath (24fr / 26fr)
• Working element / resectoscope (forward moving finger grip) BNI knife
• Ball electrode
• Cable for resection
• Ellick evacuator
• Light source cable
• Camera
• Irrigation source / Y-connection
Miscellaneous things:
1. disposable syringe
2. xylocaine jelly 2%
3. foleys catheter 3 way
4. urobag
5. catheter introducer
6. normal saline
7. urethral dilators
urological procedure:
1. The objective is toproduce a single incision in the 7 0’clock position from just below the right ureteric orifice to alongside the vermontanum,
completely dividing all bladder neck fibres in the line of the incision through to the outer part of the capsule
2. the micro video operating system is particularly useful for this operation due to the magnified image on the video monitor, which encourage very
gentle strokes of the electrode as the bladder neck fibres pull apart
3. apply 2%xylocaine jelly per-urethrally
4. take the cystoscopy sheath 22fr and make the following connections
connect the bridge to the cystoscopy sheath
• insert the 30 degree telescope inside the cystoscopy sheath
• connect endo-camere to the telescope
• connect the light source to cystoscopy sheath
• connect the irrigation source
5. after all the connections have been made, the cystoscopy sheath will all the connections is inserted per-urethrally
6. visualize the urethra / vermontaneum / bladder and ureteric orifices.
7. remove the cystoscopy sheath and all the connections.
8. sometimes it may be required to dilate the urethra up to 26fr with the help of metal dilators for easy passage of the BNI sheath.
9. next the BNI cystoscopy sheath either 24fr (intermittent irrigation) / 26fr (continuous irrigation) is chosen depending on the surgeons choice, is
introduced per urethrally and its obturator is removed and the bladder emptied.
10. to the working element or the resectoscope the following connections are made.
• BNI knife / Collings knife
• 30 degree telescope
• Endocamera
• Light source
• Diathermy cable
11. the working element with the above connections are inserted through the 24 fr / 26 fr BNI sheath
12. the ureteric orifices are carefully identified with particular attention to the distances from the bladder neck.
13. the position of the verumontaneum is noted together wth the topography of any prostatic adenoma, which may influence theline of resection.
14. the bladder neck has the appearance of a wall of tissue preventing direct inspection of the bladder base.
15. the incision is started cautiously in the 7 0’clock position, just inside the internal urinary meatus, dividing the mucosa and exposing the bladder
neck fibres.
16. as the incision is deepened the bladder neck fibres can be seen to spring apart revealing further layers. They are progressively divided at this
level by delicate diathermy incision until the capsule is reached
17. this may be recognized by the sudden transition of a glistening translucent cobweb appearance to accompanying small globules fat
18. the incision is finally extended proximally to just below the right ureteric orifice and distally to alongside the verumontaneum
19. it should now be possible to view the base of the bladder vessels, which should be carefully sealed with the help of diathermy
20. if the mucasal bleeding troublesome this may be conviently dealt with a roller ball electrode
21. next remove the working element will all connections leaving the BNI sheath per urethrally
22. with the help of the ellick’s evacuator connected to the sheath, a bladder wash is done to remove clots
23. then put in the obturator and remove the BNI sheath
24. a 3 way urethral catheter is inserted per urethrally with the help of a catheter introducer ( 3-way for irrigation)
25. irrigation can be removed either on the 1st or 2nd post operative day depending on the patients condition.
Inj. Gentamycin 80mg
Anaesthesia :
Under spinal anaesthesia/ epidural anaesthesia
Position :
Patient is positioned on the table in a comfortable position
Skin preparation:
Usually cleaned with an antimicrobial solution (eg.betadine solution)
Begin at the umbilical region, covering at the pubic area, the inner thighs up to the anus.
Draping :
1 drape sheet under the buttocks
2 leggings, one for each leg
1 drape sheet over the andomen
Instrument :
• Cystoscopy sheath 22fr
• Bridge
• 30-degree telescope
• 0 degree telescope
• Cystoscopy sheath / BNI sheath (24fr / 26fr)
• Working element / resectoscope (forward moving finger grip) BNI knife
• Ball electrode
• Cable for resection
• Ellick evacuator
• Light source cable
• Camera
• Irrigation source / Y-connection
Miscellaneous things:
1. disposable syringe
2. xylocaine jelly 2%
3. foleys catheter 3 way
4. urobag
5. catheter introducer
6. normal saline
7. urethral dilators
urological procedure:
1. The objective is toproduce a single incision in the 7 0’clock position from just below the right ureteric orifice to alongside the vermontanum,
completely dividing all bladder neck fibres in the line of the incision through to the outer part of the capsule
2. the micro video operating system is particularly useful for this operation due to the magnified image on the video monitor, which encourage very
gentle strokes of the electrode as the bladder neck fibres pull apart
3. apply 2%xylocaine jelly per-urethrally
4. take the cystoscopy sheath 22fr and make the following connections
connect the bridge to the cystoscopy sheath
• insert the 30 degree telescope inside the cystoscopy sheath
• connect endo-camere to the telescope
• connect the light source to cystoscopy sheath
• connect the irrigation source
5. after all the connections have been made, the cystoscopy sheath will all the connections is inserted per-urethrally
6. visualize the urethra / vermontaneum / bladder and ureteric orifices.
7. remove the cystoscopy sheath and all the connections.
8. sometimes it may be required to dilate the urethra up to 26fr with the help of metal dilators for easy passage of the BNI sheath.
9. next the BNI cystoscopy sheath either 24fr (intermittent irrigation) / 26fr (continuous irrigation) is chosen depending on the surgeons choice, is
introduced per urethrally and its obturator is removed and the bladder emptied.
10. to the working element or the resectoscope the following connections are made.
• BNI knife / Collings knife
• 30 degree telescope
• Endocamera
• Light source
• Diathermy cable
11. the working element with the above connections are inserted through the 24 fr / 26 fr BNI sheath
12. the ureteric orifices are carefully identified with particular attention to the distances from the bladder neck.
13. the position of the verumontaneum is noted together wth the topography of any prostatic adenoma, which may influence theline of resection.
14. the bladder neck has the appearance of a wall of tissue preventing direct inspection of the bladder base.
15. the incision is started cautiously in the 7 0’clock position, just inside the internal urinary meatus, dividing the mucosa and exposing the bladder
neck fibres.
16. as the incision is deepened the bladder neck fibres can be seen to spring apart revealing further layers. They are progressively divided at this
level by delicate diathermy incision until the capsule is reached
17. this may be recognized by the sudden transition of a glistening translucent cobweb appearance to accompanying small globules fat
18. the incision is finally extended proximally to just below the right ureteric orifice and distally to alongside the verumontaneum
19. it should now be possible to view the base of the bladder vessels, which should be carefully sealed with the help of diathermy
20. if the mucasal bleeding troublesome this may be conviently dealt with a roller ball electrode
21. next remove the working element will all connections leaving the BNI sheath per urethrally
22. with the help of the ellick’s evacuator connected to the sheath, a bladder wash is done to remove clots
23. then put in the obturator and remove the BNI sheath
24. a 3 way urethral catheter is inserted per urethrally with the help of a catheter introducer ( 3-way for irrigation)
25. irrigation can be removed either on the 1st or 2nd post operative day depending on the patients condition.
LITHOLOPAXY
HISTORY
Evidence of bladder stone formation can be traced back to the Egyptian empire of 3000-4000 B.C. over the centuries many h……… but ingenious
methods of removing bladder stones have been devised. In developing centuries, bladder stones, particularly in particularly pre-pubertal boys still occur
frequently. However in the western world, it is elderly patients with bladder outflow obstruction who most commonly develop bladder stones. Men and women
with neuropathic bladder disorders particularly in the presence of an indwelling urethral catheter may also a quire baldder stones.
Principles :
When investigation reveals the presencde of the bladder sones, it is almost always beneficial to the patient that these should be removed. Although
open surgery may be required for the very largest, the majority are available to endoscopic treatment.
Pre operative preparation:
A .prophylactic antibiotic should be given
Lithopaxy trolly
1. Gown pack
2. Leggings
3. OT guaze
4. Abdominal swab
5. Bowel
6. Sponge holder
7. Betadine solution
8. Metal dilators
9. Disposable syringe 10ml
10. Y connection
11. 2%xylocaine jelly
12. Telescope 0degeree and 30 degree
13. Obturator and sheath (cystoscopy sheath 17fr,20fr,22fr)
14. Nephroscope sheath and obturator(25fr)
15. Nephroscope
16. Normal saline for irrigation
17. Graspers
1. Stone crushing forceps
2. Stone punch
3. Opticallithotrite
18. Ellick evacuator
19. Light source
Procedure:
1. The instrument which is used will depend on the size of stone
2. Although blind lithotrites are still available in many hospitals, the risk of crushing drainage with these is greater than with a an instrument which
is used under vision
3. For this reason, either a stone punch , an optical lithotrite or an electohydraulic disintegrator must be used
4. It isd often beneficial to dilate the male urethra so that the sheath of the operating instrument can be accomadated easily
5. An urethrotomy may be provoke bleeding which obscures vision. It6 is also important , if bladder outflow obstruction exista in the form of prostatic
enlargement, that the stone should be removed before trans-urethral prostatectomy again so that vison is not obscured by bleeding from the prostatic fossa.
Whatever instrument is used the urethra should be lubricated liberally with local anaesthetic jelly
Instruments :
1.Stone crushing forceps:
Stones smaller than 0.5cm in diameter can be crushed with forceps which can be passed through a cystoscope sheath
2.Stone punch:
This instrument is passed into the bladder on its obturator stone of upto 1.5cm in diameter can be grasped of crushed under vision
3.Optical lithotrite:
Optical lithotrite is a large heavy instrument which must be passed with care when the bladder is fully open stone of upto 3.5cm in diameter
can be grasped and crushed. When the stone has been crushed who fragments of 2cm or less, the stone punch can be used.
5. Electrohydraulic disintegration:
Large stones must be disintegrated using an electrohydraulic probe. A high tension spark is discharged across the end of the probe between the central core
of circumferential
Evidence of bladder stone formation can be traced back to the Egyptian empire of 3000-4000 B.C. over the centuries many h……… but ingenious
methods of removing bladder stones have been devised. In developing centuries, bladder stones, particularly in particularly pre-pubertal boys still occur
frequently. However in the western world, it is elderly patients with bladder outflow obstruction who most commonly develop bladder stones. Men and women
with neuropathic bladder disorders particularly in the presence of an indwelling urethral catheter may also a quire baldder stones.
Principles :
When investigation reveals the presencde of the bladder sones, it is almost always beneficial to the patient that these should be removed. Although
open surgery may be required for the very largest, the majority are available to endoscopic treatment.
Pre operative preparation:
A .prophylactic antibiotic should be given
Lithopaxy trolly
1. Gown pack
2. Leggings
3. OT guaze
4. Abdominal swab
5. Bowel
6. Sponge holder
7. Betadine solution
8. Metal dilators
9. Disposable syringe 10ml
10. Y connection
11. 2%xylocaine jelly
12. Telescope 0degeree and 30 degree
13. Obturator and sheath (cystoscopy sheath 17fr,20fr,22fr)
14. Nephroscope sheath and obturator(25fr)
15. Nephroscope
16. Normal saline for irrigation
17. Graspers
1. Stone crushing forceps
2. Stone punch
3. Opticallithotrite
18. Ellick evacuator
19. Light source
Procedure:
1. The instrument which is used will depend on the size of stone
2. Although blind lithotrites are still available in many hospitals, the risk of crushing drainage with these is greater than with a an instrument which
is used under vision
3. For this reason, either a stone punch , an optical lithotrite or an electohydraulic disintegrator must be used
4. It isd often beneficial to dilate the male urethra so that the sheath of the operating instrument can be accomadated easily
5. An urethrotomy may be provoke bleeding which obscures vision. It6 is also important , if bladder outflow obstruction exista in the form of prostatic
enlargement, that the stone should be removed before trans-urethral prostatectomy again so that vison is not obscured by bleeding from the prostatic fossa.
Whatever instrument is used the urethra should be lubricated liberally with local anaesthetic jelly
Instruments :
1.Stone crushing forceps:
Stones smaller than 0.5cm in diameter can be crushed with forceps which can be passed through a cystoscope sheath
2.Stone punch:
This instrument is passed into the bladder on its obturator stone of upto 1.5cm in diameter can be grasped of crushed under vision
3.Optical lithotrite:
Optical lithotrite is a large heavy instrument which must be passed with care when the bladder is fully open stone of upto 3.5cm in diameter
can be grasped and crushed. When the stone has been crushed who fragments of 2cm or less, the stone punch can be used.
5. Electrohydraulic disintegration:
Large stones must be disintegrated using an electrohydraulic probe. A high tension spark is discharged across the end of the probe between the central core
of circumferential
URETERORENOSCOPY
Indication
Calculi:
• lower, upper ureteric calculi
• renal calculi
• post ESWL steinstressae
• obstruction
• carcinoma plus suspicious of urothelial tumour
• diagnosis –unilateral gross haematuria
unilateral malignant cytology
therapeutic procedures- ureteral catheter
removal of foreign body
dilatation
preoperative management:
1. history and physical examination
2. informed consent from the patient
3. preoperative antibiotics
4. anaesthetic
diagnosis :
• evaluation of obstruction
• evaluation of unilateral gross haematuria
• evaluation of malignant cytology
urological procedure :
HISTORY:
Rigid Ureteroscope: the small rigid ureteroscope include those with a dimension of8.5 fr or less. These instrument were originally designed for use in the
distal ureter but some are long enough to pass to the renal pelvis in certain patients. The small diameter usually permits their passage into the ureter
without prior dilatation.
Flexible ureteroscope:
The possessively deflectable designed ureteroscopes possesses no mechanism for changing the direction of the tip and is of limitedclinical value.
The actively deflectable instruments possess an intrinsic mechanism for changing the direction of the tip of the endoscopes.
Procedure:
1. Apply 2%xylocaine jelly per urethrally
2. Take the cystoscopy sheath 22fr and make the following connection:
• Insert 30 degree telescope inside the cystoscopy sheath
• Connect the endo-camera to the telescope
• Connect the light source to the cystoscopy sheath
• Connect the irrigation source
3. after all connections have been made, the cystoscopy sheath with all the connections is inserted per urethrally
4. The urethra, the bladder and the ureteric orifices are visualized.
5. Take he ureteroscopes and make the following connections
• The endocamera
• The light source
• The irrigation source
6. some times the ureteroscope can be passed freely into the ureter without prior dilatation
7. in somecases urethral dilatation may be required, sometimes with the endoscope itself, by passive dilatation of the ureter with a ureteric catheter
or stent or by active dilatation-using graduated dilators or ballon dilating catheters.
8. ballon dilating catheters offer a convenient and effective technique for dilatation at any level in the ureter
9. several different types of ballons are available; the usual size employed are 15fr and 18fr, which offer adequate dilatation without ureteric damage
10. to use a ballon dilating catheter a guide wire is first placed cystoscopically. The ballon catheter is then advanced over the guide wire and the
ballon is placed to give full dilatation of the desire region
11. to expand the ballon and dilate the ureter, the ballon is filled with normalsaline and contrast medium in sufficient concentration to demonstrate the
ballons presence fluoroscopically.
12. the presence in the ballon is then increased and carefully monitored with an in-line gauge and should not exceed the manufactures recommended
specifications.
13. a ballon should then be deflated fully by aspirating the contrast-containing solution before the catheter is removed.
14. after dilation of the ureter the guide is placed cystoscopically and left in-situ.
15. then the ureteroscopy is inserted under vision and continuous irrigation.
16. the calculu can be either grasped by passing a stone grasper through the ureteroscope.
17. in case of an impacted stone, it can be broken with the help of the lithoclast, by passing the lithoclast probe through the ureteroscope and
fragmenting.
18. the big fragments can be removed with the help of a grasper.
19. the small fragments could be left to drain automatically.
20. the ureteroscope is removed and the cystoscopy sheath is inserted per-uretherally.
21. through the cystoscopy sheath the stent is inserted into the ureter and left insitu for about 2 weeks to facilitate complete drainage of the
remaining fragments.
22. the cystoscopy sheath is removed and a Foley’s catheter is left insitu.
Precaution :
Proceeding through guidewire
Deflating ballon before removal
Complication
Urethral stricture
Bladder perforation
OPEN VESICOLITHOTOMY
Antibiotic
Anaesthesia
Spinal anaesthesia
Position
Patient is positioned on the operating table in a supine position.
Skin preparation
In males: begin at the suprapubic region extending from 7.5cms(3 inches) above the umbilicus to the lower thighs, and down to the table at the
sides, the genitalia are also included
In females:begin at the pubic symphysis and extend downward over the labia. Clean each inner thighs, the vaginal vault, cervix upto the perineum and
anus.
Draping:
4 small sheets
2 large laprotomy
Required for the procedure:
1. Disposable gloves
2. OT guaze
3. Abdominal swab
4. Diathermy cable
5. Suction tube
6. Thoracic drain
7. 16fr foleys catheter
8. Urobag
9. Retractors
o Millin’s retractor
o Langenberg retractor
o Kelly’s retractor
o Deavers retractor
o Morris retractor
Forceps
o Toothed artery forceps
o Non toothed artery forceps
o Adson’s forceps (toothed)
Scissors
o Metzenbaum
o Straight mayo
Clamps
o Mosquito straight artery
o Mosquito curved artery
o Allis
o Babcock
o Kochear
o Towel clips
o Needle holder
Miscellaneous
o B.P. handle
o Suction yanker
Suture material
o 3-0 chronic catgut
o 2-0 ethilon
o Mersilk
Urological procedure
Exposure of the bladder
? The best approach to the blade is provide by the Pfannestiel’s incision.
? The incision is made on the skin using 11-size sterile blade just above the pubis symphysis.
? Following the same line of incision, the fat, the sub-cutaneous tissue and muscle are dissected respectively.
? A Millin’s self retaining rectractor is inserted to retract the muscle bellies.
? The bladder is filled with normal saline/antibiotic (500ml normal saline with inj. Gentmycin 80mg) and distend it if necessary.
? The peritoneum is pushed away from the bladder using a sponge on an artery forceps.
? Sometimes an 18G venflon is used for aspiration, to make sure the location of the bladder, before making the incision.
? The bladder is then incised, preferably using the diathermy needle to avoid loss of the blood.
? The urine is aspirated with the sucker.
? The Millin’s retractor is then readjusted so as to reveal the calculus.
? For removal of the calculus, a finger is introduced into the bladder t determine whether the stone is lying free in the bladder or is impacted in a
diverticulum’s.
? Free stones are removed with a lithotomy forceps or scoopes.
? Impacted calculi should be dislodged first and then removed.
? A bladder biopsy can be taken of any area of adjacent vesical mucosa in view of the occational complication of squamous cell carcinoma
? A self retaining foleys catheter of appropriate size(e.g. 18 or 20fr) is left in the bladder which is closed in one or two layers of continuous 3-0
chromic catgut
? A tube drain (about 20fr) is led out through the upper skin flap from the suture line in the wall of the bladder and secured with a stitch
? Themuscle bellies of the rectus are approximated with one or two loosely tied catgut sutures
? The appropriate of the rectus is then closed with a continuous or interrupted 3-0 catgut or 2-0 vicryl
? Lastly the skin is sutured with interrupted silk or nylon
? The suprapubic wound drain would be removed on the 2nd post operative drain
? A per urethral catheter is usually placed in the bladder and removed onteh 8th post operative day
? The skin sutures are usually removed on the 7th or 8th post operative day
? Sometimes cystoscopy may be necessary before doing an open vesicolithotomy hence check with the urologist before setting the trolley.
. electrodes. The strength and frequency can be varied. Care must be taken not to discharge the probe when it is incontact
with the bladder wall.
At the end of any procedure for crushing bladder stones, all the fragments must be removed using a ellick evacuator, bladder outflow obstruction must
subsequently be treated.
Post operative care:
An indwelling urethral catheter is necessary as much for the management of the bladder outflow obstruction as for the lithotripsy itself.
Complication :
? trauma to the urethra can occur because the instruments used are large and …………….
? Damage to the bladder wall may arise if the bladder wall is included in the famous of the instrument. This is a particular risk when the blind
lithotrite is used.
? Electrohydraulic disintegration causes damage of the probe and discharged when lying against the bladder wall.
? Extraperitoneal distruptions of the bladder may be treated by an indwelling catheter but intraperitoneal holes must be closed at Laprotomy
Calculi:
• lower, upper ureteric calculi
• renal calculi
• post ESWL steinstressae
• obstruction
• carcinoma plus suspicious of urothelial tumour
• diagnosis –unilateral gross haematuria
unilateral malignant cytology
therapeutic procedures- ureteral catheter
removal of foreign body
dilatation
preoperative management:
1. history and physical examination
2. informed consent from the patient
3. preoperative antibiotics
4. anaesthetic
diagnosis :
• evaluation of obstruction
• evaluation of unilateral gross haematuria
• evaluation of malignant cytology
urological procedure :
HISTORY:
Rigid Ureteroscope: the small rigid ureteroscope include those with a dimension of8.5 fr or less. These instrument were originally designed for use in the
distal ureter but some are long enough to pass to the renal pelvis in certain patients. The small diameter usually permits their passage into the ureter
without prior dilatation.
Flexible ureteroscope:
The possessively deflectable designed ureteroscopes possesses no mechanism for changing the direction of the tip and is of limitedclinical value.
The actively deflectable instruments possess an intrinsic mechanism for changing the direction of the tip of the endoscopes.
Procedure:
1. Apply 2%xylocaine jelly per urethrally
2. Take the cystoscopy sheath 22fr and make the following connection:
• Insert 30 degree telescope inside the cystoscopy sheath
• Connect the endo-camera to the telescope
• Connect the light source to the cystoscopy sheath
• Connect the irrigation source
3. after all connections have been made, the cystoscopy sheath with all the connections is inserted per urethrally
4. The urethra, the bladder and the ureteric orifices are visualized.
5. Take he ureteroscopes and make the following connections
• The endocamera
• The light source
• The irrigation source
6. some times the ureteroscope can be passed freely into the ureter without prior dilatation
7. in somecases urethral dilatation may be required, sometimes with the endoscope itself, by passive dilatation of the ureter with a ureteric catheter
or stent or by active dilatation-using graduated dilators or ballon dilating catheters.
8. ballon dilating catheters offer a convenient and effective technique for dilatation at any level in the ureter
9. several different types of ballons are available; the usual size employed are 15fr and 18fr, which offer adequate dilatation without ureteric damage
10. to use a ballon dilating catheter a guide wire is first placed cystoscopically. The ballon catheter is then advanced over the guide wire and the
ballon is placed to give full dilatation of the desire region
11. to expand the ballon and dilate the ureter, the ballon is filled with normalsaline and contrast medium in sufficient concentration to demonstrate the
ballons presence fluoroscopically.
12. the presence in the ballon is then increased and carefully monitored with an in-line gauge and should not exceed the manufactures recommended
specifications.
13. a ballon should then be deflated fully by aspirating the contrast-containing solution before the catheter is removed.
14. after dilation of the ureter the guide is placed cystoscopically and left in-situ.
15. then the ureteroscopy is inserted under vision and continuous irrigation.
16. the calculu can be either grasped by passing a stone grasper through the ureteroscope.
17. in case of an impacted stone, it can be broken with the help of the lithoclast, by passing the lithoclast probe through the ureteroscope and
fragmenting.
18. the big fragments can be removed with the help of a grasper.
19. the small fragments could be left to drain automatically.
20. the ureteroscope is removed and the cystoscopy sheath is inserted per-uretherally.
21. through the cystoscopy sheath the stent is inserted into the ureter and left insitu for about 2 weeks to facilitate complete drainage of the
remaining fragments.
22. the cystoscopy sheath is removed and a Foley’s catheter is left insitu.
Precaution :
Proceeding through guidewire
Deflating ballon before removal
Complication
Urethral stricture
Bladder perforation
OPEN VESICOLITHOTOMY
Antibiotic
Anaesthesia
Spinal anaesthesia
Position
Patient is positioned on the operating table in a supine position.
Skin preparation
In males: begin at the suprapubic region extending from 7.5cms(3 inches) above the umbilicus to the lower thighs, and down to the table at the
sides, the genitalia are also included
In females:begin at the pubic symphysis and extend downward over the labia. Clean each inner thighs, the vaginal vault, cervix upto the perineum and
anus.
Draping:
4 small sheets
2 large laprotomy
Required for the procedure:
1. Disposable gloves
2. OT guaze
3. Abdominal swab
4. Diathermy cable
5. Suction tube
6. Thoracic drain
7. 16fr foleys catheter
8. Urobag
9. Retractors
o Millin’s retractor
o Langenberg retractor
o Kelly’s retractor
o Deavers retractor
o Morris retractor
Forceps
o Toothed artery forceps
o Non toothed artery forceps
o Adson’s forceps (toothed)
Scissors
o Metzenbaum
o Straight mayo
Clamps
o Mosquito straight artery
o Mosquito curved artery
o Allis
o Babcock
o Kochear
o Towel clips
o Needle holder
Miscellaneous
o B.P. handle
o Suction yanker
Suture material
o 3-0 chronic catgut
o 2-0 ethilon
o Mersilk
Urological procedure
Exposure of the bladder
? The best approach to the blade is provide by the Pfannestiel’s incision.
? The incision is made on the skin using 11-size sterile blade just above the pubis symphysis.
? Following the same line of incision, the fat, the sub-cutaneous tissue and muscle are dissected respectively.
? A Millin’s self retaining rectractor is inserted to retract the muscle bellies.
? The bladder is filled with normal saline/antibiotic (500ml normal saline with inj. Gentmycin 80mg) and distend it if necessary.
? The peritoneum is pushed away from the bladder using a sponge on an artery forceps.
? Sometimes an 18G venflon is used for aspiration, to make sure the location of the bladder, before making the incision.
? The bladder is then incised, preferably using the diathermy needle to avoid loss of the blood.
? The urine is aspirated with the sucker.
? The Millin’s retractor is then readjusted so as to reveal the calculus.
? For removal of the calculus, a finger is introduced into the bladder t determine whether the stone is lying free in the bladder or is impacted in a
diverticulum’s.
? Free stones are removed with a lithotomy forceps or scoopes.
? Impacted calculi should be dislodged first and then removed.
? A bladder biopsy can be taken of any area of adjacent vesical mucosa in view of the occational complication of squamous cell carcinoma
? A self retaining foleys catheter of appropriate size(e.g. 18 or 20fr) is left in the bladder which is closed in one or two layers of continuous 3-0
chromic catgut
? A tube drain (about 20fr) is led out through the upper skin flap from the suture line in the wall of the bladder and secured with a stitch
? Themuscle bellies of the rectus are approximated with one or two loosely tied catgut sutures
? The appropriate of the rectus is then closed with a continuous or interrupted 3-0 catgut or 2-0 vicryl
? Lastly the skin is sutured with interrupted silk or nylon
? The suprapubic wound drain would be removed on the 2nd post operative drain
? A per urethral catheter is usually placed in the bladder and removed onteh 8th post operative day
? The skin sutures are usually removed on the 7th or 8th post operative day
? Sometimes cystoscopy may be necessary before doing an open vesicolithotomy hence check with the urologist before setting the trolley.
. electrodes. The strength and frequency can be varied. Care must be taken not to discharge the probe when it is incontact
with the bladder wall.
At the end of any procedure for crushing bladder stones, all the fragments must be removed using a ellick evacuator, bladder outflow obstruction must
subsequently be treated.
Post operative care:
An indwelling urethral catheter is necessary as much for the management of the bladder outflow obstruction as for the lithotripsy itself.
Complication :
? trauma to the urethra can occur because the instruments used are large and …………….
? Damage to the bladder wall may arise if the bladder wall is included in the famous of the instrument. This is a particular risk when the blind
lithotrite is used.
? Electrohydraulic disintegration causes damage of the probe and discharged when lying against the bladder wall.
? Extraperitoneal distruptions of the bladder may be treated by an indwelling catheter but intraperitoneal holes must be closed at Laprotomy
ORCHIDECTOMY
DEF : orchidectomy can be defined as removal of one or both the testicle
Indication :
Unilateral orchidectomy:
1. Unilateral orchidectomy are the removal of one testicle is performed for unilateral testicular disease.
2. In testicular maldescent ,when orchidopexy is not possible owing to lack of cord length or where a maldeveloped testicular remanant is not
salvageable
3. For trauma in crush injuries when complete testicular disruption may necessitate the removal or non viable organ.
4. For torsion where failure to relieve torsion has resulted in total infarction, it may be necessary to remove the destroyed organ.
5. For injection – on rare occasions, in uncontrolled acute pyogenic or tuberculous infection testicular destruction with scrotal ulceration may occur and
orchidecdtomy is indicated to secure heading
6. For malignant disease – a tumour arising in the body and in the testis is by for the most common indication for orchidectomy
7. in conjuction with inguinal hernial repair
NOTE:
In all cases of unilateral orchidectomy, the patient should be reassured that the removal of one testicles will in no way affect the patency or
fertility
Bilateral orchidectomy:
Bilateral orchidectomy is indicated for the endocrine control of prostatic carcinoma. It is based on the fact the activity of the prostatic
malignant process is subject to the hormonal influence of testicular androgens. Provides a simple method for the control of malignant disease.
Patient preparation
Position : the patient can be positioned on the table either in supine position or lithotomy position’
Skin preparation:
Begin at the scrotum, extending from the umbilicus to the midthighs and down to the table at the sides.
Anaesthesia
General, spinal, epidural, or local anaesthesia can be administered
Draping:
Folded t owels under the scrotum over the abdomen and 2 laprotomy side sheets
Orchidectomy tray:
1. gown pack
2. linen pack
3. surgical gloves
4. OT guaze
5. abdominal swab
6. bowel
7. sponge holder
8. towel clips
9. mosquito straight artery forceps
10. mosquito curved artery forceps
11. medium straight artery forceps
12. medium straight artery forceps
13. long straight artery forceps
14. long straight artery forceps
15. straight scissors
16. curved scissors
17. B P handle (bard parker)
18. scalpel
19. dissecting toothed forceps
20. dissecting non tothed forceps
21. allis tissue forceps
22. needle holder
23. blade 11 & 15
24. suture material 2-0 chromic
25. suture material 2-0,3-0 free ties
procedure:
1. The skin incision, which is made 1.25 cm above and parallel to the inguinal ligament is 5cm long and extends from above the pubic tubercle to the mid
night of the inguinal element
2. fat , superficial and deep fascia are divided in this in this line to expose the aponeurosis of the external oblique muscle and the external inguinal
ring
3. the aponeurosis is now divided in the line of the fibres from the apex of the external ring to the level of the internal ring, exposing the
underlying spermatic cord. The cord is then mobilized.
4. at the internal ring, the testicular veins join to form two or three well defined vessels these are identified and dissected free and ligated flush
with the muscles at the internal ring.
5. the vas is identified next clamped and divided and finally the remaining portion of the cord cantaining the testicular artery, and the artery of the
vas is ligated and divided.
6. it is considered important to proceed in this order when dealing with malignant disease of the testicle in orded to minimize venous embolization of
malignant cells prior to manipulation of the tumour.
7. the distal portion of the cord is now mobilized from its bed the gentle traction 2is to deliver the testis from the scrotum into the lower margin of
the wound.
8. attachments of the external spermatic fascia cremaster to the scrotal wall and surrounding tissues are gently separated by blunt dissection until the
gutenacular attachment of the lower ple of the testis scrotal wall is reached.
9. this fibrous attachment is then divided between haemostats and the testis removed
10. the wound is closed in layers.
1.Supcapsular orchidecdtomy
Incision :
The scrotum is elevated and a longitudinal incision is made through and stretched skin and dartos muscle to expose both testis
2.Evagination of testis :
Each testis is evaginated from the scrotum together with its coverings the tunica vaginalis is incised vertically of the testicle and
epididymis exposed
3.Incision of tunica albuginae:
The visceral tunica is incised vertically over the globe of thetestis
4.Removal of testicular substance:
The testicular tissue is separated from the inner surface of the tunica albuginae by blunt of sharp dissection. Careful haemostasis is required
in then region of the testis at the upper pole .
5.closure of tunica:
When all visible testicular tissue has been removed, the tunica is closed with a continuous vertical 3-0 chromic plain catgut suture and the
testicle is replaced in its scrotal covering.
6.closure of scrotum:
The scrotum is closed in two layers with a continuous vertical 3-0 chromic and interrupted 3-0 nylon sutures to the transverse skin incision.
There is no need to drain the scrotum
7.testicular prosthesis:
Should a letter simulation of the testicular body be required, it is possible to insert a silastic prosthesis into the tunica albuginae at the
time of operation.
Indication :
Unilateral orchidectomy:
1. Unilateral orchidectomy are the removal of one testicle is performed for unilateral testicular disease.
2. In testicular maldescent ,when orchidopexy is not possible owing to lack of cord length or where a maldeveloped testicular remanant is not
salvageable
3. For trauma in crush injuries when complete testicular disruption may necessitate the removal or non viable organ.
4. For torsion where failure to relieve torsion has resulted in total infarction, it may be necessary to remove the destroyed organ.
5. For injection – on rare occasions, in uncontrolled acute pyogenic or tuberculous infection testicular destruction with scrotal ulceration may occur and
orchidecdtomy is indicated to secure heading
6. For malignant disease – a tumour arising in the body and in the testis is by for the most common indication for orchidectomy
7. in conjuction with inguinal hernial repair
NOTE:
In all cases of unilateral orchidectomy, the patient should be reassured that the removal of one testicles will in no way affect the patency or
fertility
Bilateral orchidectomy:
Bilateral orchidectomy is indicated for the endocrine control of prostatic carcinoma. It is based on the fact the activity of the prostatic
malignant process is subject to the hormonal influence of testicular androgens. Provides a simple method for the control of malignant disease.
Patient preparation
Position : the patient can be positioned on the table either in supine position or lithotomy position’
Skin preparation:
Begin at the scrotum, extending from the umbilicus to the midthighs and down to the table at the sides.
Anaesthesia
General, spinal, epidural, or local anaesthesia can be administered
Draping:
Folded t owels under the scrotum over the abdomen and 2 laprotomy side sheets
Orchidectomy tray:
1. gown pack
2. linen pack
3. surgical gloves
4. OT guaze
5. abdominal swab
6. bowel
7. sponge holder
8. towel clips
9. mosquito straight artery forceps
10. mosquito curved artery forceps
11. medium straight artery forceps
12. medium straight artery forceps
13. long straight artery forceps
14. long straight artery forceps
15. straight scissors
16. curved scissors
17. B P handle (bard parker)
18. scalpel
19. dissecting toothed forceps
20. dissecting non tothed forceps
21. allis tissue forceps
22. needle holder
23. blade 11 & 15
24. suture material 2-0 chromic
25. suture material 2-0,3-0 free ties
procedure:
1. The skin incision, which is made 1.25 cm above and parallel to the inguinal ligament is 5cm long and extends from above the pubic tubercle to the mid
night of the inguinal element
2. fat , superficial and deep fascia are divided in this in this line to expose the aponeurosis of the external oblique muscle and the external inguinal
ring
3. the aponeurosis is now divided in the line of the fibres from the apex of the external ring to the level of the internal ring, exposing the
underlying spermatic cord. The cord is then mobilized.
4. at the internal ring, the testicular veins join to form two or three well defined vessels these are identified and dissected free and ligated flush
with the muscles at the internal ring.
5. the vas is identified next clamped and divided and finally the remaining portion of the cord cantaining the testicular artery, and the artery of the
vas is ligated and divided.
6. it is considered important to proceed in this order when dealing with malignant disease of the testicle in orded to minimize venous embolization of
malignant cells prior to manipulation of the tumour.
7. the distal portion of the cord is now mobilized from its bed the gentle traction 2is to deliver the testis from the scrotum into the lower margin of
the wound.
8. attachments of the external spermatic fascia cremaster to the scrotal wall and surrounding tissues are gently separated by blunt dissection until the
gutenacular attachment of the lower ple of the testis scrotal wall is reached.
9. this fibrous attachment is then divided between haemostats and the testis removed
10. the wound is closed in layers.
1.Supcapsular orchidecdtomy
Incision :
The scrotum is elevated and a longitudinal incision is made through and stretched skin and dartos muscle to expose both testis
2.Evagination of testis :
Each testis is evaginated from the scrotum together with its coverings the tunica vaginalis is incised vertically of the testicle and
epididymis exposed
3.Incision of tunica albuginae:
The visceral tunica is incised vertically over the globe of thetestis
4.Removal of testicular substance:
The testicular tissue is separated from the inner surface of the tunica albuginae by blunt of sharp dissection. Careful haemostasis is required
in then region of the testis at the upper pole .
5.closure of tunica:
When all visible testicular tissue has been removed, the tunica is closed with a continuous vertical 3-0 chromic plain catgut suture and the
testicle is replaced in its scrotal covering.
6.closure of scrotum:
The scrotum is closed in two layers with a continuous vertical 3-0 chromic and interrupted 3-0 nylon sutures to the transverse skin incision.
There is no need to drain the scrotum
7.testicular prosthesis:
Should a letter simulation of the testicular body be required, it is possible to insert a silastic prosthesis into the tunica albuginae at the
time of operation.
ARTERIO VENOUS FISTULA
Arterio venous fistula can be defined as the process of establishing a communicating prosthetic loop(shunt) or a direct communication between an artery and
vein ( fistula)
Indications
1)arteriovenous fistula is performed for providing an easy access for venipuncture with a large bore needle for purposes of haemodialysis
2)several varieties of arteriovenous communication may be achieved employinga buried synthetic prosthesis , an arteriovenous fistula or an external
prosthesis
sites of fistula:
radio-cephalic
brachio-cephalic
patient preparation
1)position:
the patient is positioned in supine with non-dominnt forearm extending on hand table
a) other arm may extended on an armboard
2)anaesthesia:
local anaesthesia
3)skin preparation:
Begin at the proposed site of shunt on forearm & hand from fingertips to several inches above the elbow.
Draping :
A large cuffed sheet is draped over the table under the area. A folded towel is wrapped around the area is clipped. A drape sheet is draped under the arm
is clipped. A drape sheet covers the shoulder is clipped under the arm. Use of additional drape sheets can be used to complete draping .
Arteriovenous tray:
1. Mosquito artery clamp
2. Mosquito artery clamp 4” STRAIGHT
3. Mosquito artery clamp (curved)
4. Rake’s/ cat’s paw retractor
5. Skin hook
6. Hudson’s toothed forceps 6”
7. Hudson’s non toothed forceps 6”
8. dissecting toothed forceps 6”
9. dissecting non- toothed forceps 6”
10. needle holder 6”
11. sponge holder
12. BP handle
13. bull dog (small tip)
14. bull dog (long tip)
15. heparin injector (small tip)
16. debakey vascular disease (fine tip)
17. sharp scissors (tungsten tip)
18. scissors 6”
19. pott’s scissors 8”
20. needle holder 6”
21. vessel dilators
22. aneurysm needle
23. Watson chain
24. internal mammary forceps
25. self retaining retractor
26. sertenskey (brachial clamp)
miscellaneous things:
1. vessel loop
2. infant feeding tube 6fr
3. sterile blade 11fr and 5 fr
4. disposable syringe (for local and flush) 10ml
5. disposable syringe (for heparin)2ml
6. heparin 1ml diluted with NS
7. injection xylocaine 1%
8. injection heparin 1ml
9. injection ampicillin 500mg
10. diathermy pencil and cable
11. earth pad
suture material
1. mersilk/ free ties 3-0
2. prolene 6-0 / 7-0 (for artery and vein)
3. etilon 3-0,26cms (for skin)
procedure :
1. The local anaesthesia is injected over the area to be operated
2. The incision is made over the selected arterial and venous sites. Often (the radical artery and cephalic vein of the proximal forearm)
3. The vein and the artery are well separated with the help of mosquito clamps and debakey forceps, for ease during anastamosis.
4. The artery to be anastamosed is clamped with the help of bull dog clamps
5. The vein is clamped with the help of mosquito artery clamps
6. One end of the vein is then tied with the help of 3-0 free ties and cut with the help of sharp scissors in case of end to side anastamoses is done
7. The other end of the vein to be anastamosed with the artery is well dilated with the help vein dilators of increasing sizes.
8. In case of side anastamoses is done then the vein is clamped with the help of bulldog calmps and the incision is made on the lumen of the vein with
the blade of a 11 size blade.
9. Next an incision is made on the lumen of the artery with the help of a pointed 11 blade and the arteriotomy is increased with a pott’s scissor
10. The free end of the vein is the mobilized towards the incision on artery and sutured with the help of 7-0 prolene
11. The site to the anastamosed can be regularly washed with heprin diluted in normal saline at regular intervals to help in easy anastamoses
12. After anastamoses is completed the vein clamp is removed first, followed by the lower arterial clamp and last the upper arterial bull dog
13. Check for any bleeding at the site of anastamoses
14. In case of slight bleedings give mild pressure and wait for sometime
15. If bleeding does not subside, suturing at the site of bleeding may be required.
16. Check to see if the trill is felt.
17. The wound site is then given a wash with antibiotic solution and the skin is sutured with 3-0 etilon
18. After completion of the skin suturing, the wound is closed with a protective dressing.
vein ( fistula)
Indications
1)arteriovenous fistula is performed for providing an easy access for venipuncture with a large bore needle for purposes of haemodialysis
2)several varieties of arteriovenous communication may be achieved employinga buried synthetic prosthesis , an arteriovenous fistula or an external
prosthesis
sites of fistula:
radio-cephalic
brachio-cephalic
patient preparation
1)position:
the patient is positioned in supine with non-dominnt forearm extending on hand table
a) other arm may extended on an armboard
2)anaesthesia:
local anaesthesia
3)skin preparation:
Begin at the proposed site of shunt on forearm & hand from fingertips to several inches above the elbow.
Draping :
A large cuffed sheet is draped over the table under the area. A folded towel is wrapped around the area is clipped. A drape sheet is draped under the arm
is clipped. A drape sheet covers the shoulder is clipped under the arm. Use of additional drape sheets can be used to complete draping .
Arteriovenous tray:
1. Mosquito artery clamp
2. Mosquito artery clamp 4” STRAIGHT
3. Mosquito artery clamp (curved)
4. Rake’s/ cat’s paw retractor
5. Skin hook
6. Hudson’s toothed forceps 6”
7. Hudson’s non toothed forceps 6”
8. dissecting toothed forceps 6”
9. dissecting non- toothed forceps 6”
10. needle holder 6”
11. sponge holder
12. BP handle
13. bull dog (small tip)
14. bull dog (long tip)
15. heparin injector (small tip)
16. debakey vascular disease (fine tip)
17. sharp scissors (tungsten tip)
18. scissors 6”
19. pott’s scissors 8”
20. needle holder 6”
21. vessel dilators
22. aneurysm needle
23. Watson chain
24. internal mammary forceps
25. self retaining retractor
26. sertenskey (brachial clamp)
miscellaneous things:
1. vessel loop
2. infant feeding tube 6fr
3. sterile blade 11fr and 5 fr
4. disposable syringe (for local and flush) 10ml
5. disposable syringe (for heparin)2ml
6. heparin 1ml diluted with NS
7. injection xylocaine 1%
8. injection heparin 1ml
9. injection ampicillin 500mg
10. diathermy pencil and cable
11. earth pad
suture material
1. mersilk/ free ties 3-0
2. prolene 6-0 / 7-0 (for artery and vein)
3. etilon 3-0,26cms (for skin)
procedure :
1. The local anaesthesia is injected over the area to be operated
2. The incision is made over the selected arterial and venous sites. Often (the radical artery and cephalic vein of the proximal forearm)
3. The vein and the artery are well separated with the help of mosquito clamps and debakey forceps, for ease during anastamosis.
4. The artery to be anastamosed is clamped with the help of bull dog clamps
5. The vein is clamped with the help of mosquito artery clamps
6. One end of the vein is then tied with the help of 3-0 free ties and cut with the help of sharp scissors in case of end to side anastamoses is done
7. The other end of the vein to be anastamosed with the artery is well dilated with the help vein dilators of increasing sizes.
8. In case of side anastamoses is done then the vein is clamped with the help of bulldog calmps and the incision is made on the lumen of the vein with
the blade of a 11 size blade.
9. Next an incision is made on the lumen of the artery with the help of a pointed 11 blade and the arteriotomy is increased with a pott’s scissor
10. The free end of the vein is the mobilized towards the incision on artery and sutured with the help of 7-0 prolene
11. The site to the anastamosed can be regularly washed with heprin diluted in normal saline at regular intervals to help in easy anastamoses
12. After anastamoses is completed the vein clamp is removed first, followed by the lower arterial clamp and last the upper arterial bull dog
13. Check for any bleeding at the site of anastamoses
14. In case of slight bleedings give mild pressure and wait for sometime
15. If bleeding does not subside, suturing at the site of bleeding may be required.
16. Check to see if the trill is felt.
17. The wound site is then given a wash with antibiotic solution and the skin is sutured with 3-0 etilon
18. After completion of the skin suturing, the wound is closed with a protective dressing.
Transurethral resection of prostate
Trans urethral resection of prostate is the removal of benign prostatic tissue trans cystoscopically
Indication:
a)it is indicated when the prostate is about 20-60gms
b)TURP is usually performed to relieve urinary obstruction caused by benign growth of the prostatic tissue
c)the procedure is particularly desirable when the patient is not fit for open surgery
patient preparation:
a)position:
the patient is positioned on the lithotomy position
b)anaesthesia:
regional or general anaesthesia
c)skin preparation:
paint the entire pubic region including scrotum & perineum with any antibiotic solution
d)draping:
TURP TRAY:
a)gown pack
b)linen pack
c)surgical gloves
d)towel glips
e)sponge holder
f)bowel
g)abdominal swab
h)ot gauze
5% betadine solution
2% Xylocaine jelly
I.V. set
20ml syringe
Y-connection
Diathermy cable
Light source cable
Ellicks evacuator
Fibre optic light source
Urethral dilators
3 way foley catheter
catheter introducer
urobag
normal saline
Glycine 3ltr
SCOPY Instuments:
Cystoscopy sheath with obturator(17,20,21)
Telescope(0,30degree)
Bridge
Turp sheath(22,24,26fr)
Resection loop
Ball electrode
Resectoscope-working element(movement by means of a spring with a movable finger grip) this enables the movement of the resectoscope from the bladder neck
towards the prostate
Resectoscope sheath with obturator (including connecting tubes for inflow & outflow)
Resectoscope sheath with fixed inner tube
*for cotinuos irrigation& suction
*with a protective tefon sheath to to prevent conduction of current & damage to the tip of telescope
PREOPERATIVE ORDERS
Informed consents
Nill from midnight
Preparation of parts
Inj tetanous toxoid ½ cc IM
Dulculox suppository 2 HS
Cross match arrange 2 units of blood
To follow anaesthetist order
Procedure
The external urethral orifice is the narrowest part of the male urethra if necessary do a meatatomy if meatus is narrow or dilate the urethra with sounds
and filiform
Always under vision to prevent false passage and injury
Vision should always be clear
First, do Cystoscopy and only then put resectoscope with visual obturator
Do not resect beyond the level of vermontanum as it may damage the external urethral sphincter leading to incontinence.
The urethral may be dilated if necessary
A well lubricated Cystoscope is inserted into the urethra, the bladder neck, the ureteric orifice, and the urinary bladder are examined
The resectoscope which is complete with the obturator and sheath is passed
The irrigation tubings, the fibrotic light cord and diathermic cable are connected
The abturator is removed & the operative element with the forward oblique telescope & cutting loop is inserted through the sheath
The bladder is continuosly irrigated
The urethra of the bladder trigone are reexamined
Electro resection is employed to remove pieces of hypertropid prostatic tissue
At intervals the fragments of tissue and blood clots are washed out of the bladder. The ellick evacuator may be employed for the same
Total removal of all fragments of tissue is desired
When resection is complete, the bladder and prostatic fossa are examined for residual unattached fragments of tissue
A 3 way foleys catheter is retained in the bladder with ccontinous irrigation
Maintenance of blood volume by adequate transfusion can be done in case of blood loss
Complication
Immediate
Primary haemmorhage : this is the most important and serious complication and may lead to clot retention resulting from blockage of catheter or
drainage tube by blood clots.
A bladder wash may be great use in this case
Bladder perforation:
Cardiovascular and vascular accidents
Inmtermediate (within 10 days)
Secondary haemorrhage:
Infection:
Slight infection after this type of operation is undesirable during to the presence of large raw surface in the prostatic bed. Administration of
prophylatic antibiotic has gone a long way in preventing infection occurring post operatively. In case a culture sensitivity report is in hand, the choice
of the antibiotic should be made according to the same . It is also well worth trying the effect of oral antibiotics post operatively to prevent infection
c)pulmonary embolism infection
d)myocardial infarction , cerebral thrombosis
remote (after 1 month)
incontinence:
it is common unless until the external urethral sphincter is damaged
urethral stricture
osteitis pubis
transurethral resection syndrome
1) it refers to a significant alteration in hemostasis produced by absorbtion of irrigation fluid during trans-urethral resection of the prostate gland
2) it results from the entrance of irrigating fluid into the vascular component through open venous sinuses or perforation in the prostatic capsule
3) even if isotonic irrigation like Glycine is used the problem of expanding the blood volume may cause hypertension and a decrease in electrolyte
concentration
4) the earliest symptom of Tur syndrome is restlessness followed by nausea ,vomiting, abdominal pain& distention the patient pales & perspires
5) the signs & symptoms of Tur syndrome & its complication include an increase in pulse rate, bradycardia & cardio-vascular collapse, dyspnea, cyanosis,
coma, convulsion & death.
TREATMENT OF TUR syndrome
1)it consist of producing a net loss of body water
2)if serum osmolality & plasma sodium are low, furosemide can be administered intra-venously
3)thye patient should be closely observed for signs of cardiovascular collapse with pulmonary or cerebral oedema.
Indication:
a)it is indicated when the prostate is about 20-60gms
b)TURP is usually performed to relieve urinary obstruction caused by benign growth of the prostatic tissue
c)the procedure is particularly desirable when the patient is not fit for open surgery
patient preparation:
a)position:
the patient is positioned on the lithotomy position
b)anaesthesia:
regional or general anaesthesia
c)skin preparation:
paint the entire pubic region including scrotum & perineum with any antibiotic solution
d)draping:
TURP TRAY:
a)gown pack
b)linen pack
c)surgical gloves
d)towel glips
e)sponge holder
f)bowel
g)abdominal swab
h)ot gauze
5% betadine solution
2% Xylocaine jelly
I.V. set
20ml syringe
Y-connection
Diathermy cable
Light source cable
Ellicks evacuator
Fibre optic light source
Urethral dilators
3 way foley catheter
catheter introducer
urobag
normal saline
Glycine 3ltr
SCOPY Instuments:
Cystoscopy sheath with obturator(17,20,21)
Telescope(0,30degree)
Bridge
Turp sheath(22,24,26fr)
Resection loop
Ball electrode
Resectoscope-working element(movement by means of a spring with a movable finger grip) this enables the movement of the resectoscope from the bladder neck
towards the prostate
Resectoscope sheath with obturator (including connecting tubes for inflow & outflow)
Resectoscope sheath with fixed inner tube
*for cotinuos irrigation& suction
*with a protective tefon sheath to to prevent conduction of current & damage to the tip of telescope
PREOPERATIVE ORDERS
Informed consents
Nill from midnight
Preparation of parts
Inj tetanous toxoid ½ cc IM
Dulculox suppository 2 HS
Cross match arrange 2 units of blood
To follow anaesthetist order
Procedure
The external urethral orifice is the narrowest part of the male urethra if necessary do a meatatomy if meatus is narrow or dilate the urethra with sounds
and filiform
Always under vision to prevent false passage and injury
Vision should always be clear
First, do Cystoscopy and only then put resectoscope with visual obturator
Do not resect beyond the level of vermontanum as it may damage the external urethral sphincter leading to incontinence.
The urethral may be dilated if necessary
A well lubricated Cystoscope is inserted into the urethra, the bladder neck, the ureteric orifice, and the urinary bladder are examined
The resectoscope which is complete with the obturator and sheath is passed
The irrigation tubings, the fibrotic light cord and diathermic cable are connected
The abturator is removed & the operative element with the forward oblique telescope & cutting loop is inserted through the sheath
The bladder is continuosly irrigated
The urethra of the bladder trigone are reexamined
Electro resection is employed to remove pieces of hypertropid prostatic tissue
At intervals the fragments of tissue and blood clots are washed out of the bladder. The ellick evacuator may be employed for the same
Total removal of all fragments of tissue is desired
When resection is complete, the bladder and prostatic fossa are examined for residual unattached fragments of tissue
A 3 way foleys catheter is retained in the bladder with ccontinous irrigation
Maintenance of blood volume by adequate transfusion can be done in case of blood loss
Complication
Immediate
Primary haemmorhage : this is the most important and serious complication and may lead to clot retention resulting from blockage of catheter or
drainage tube by blood clots.
A bladder wash may be great use in this case
Bladder perforation:
Cardiovascular and vascular accidents
Inmtermediate (within 10 days)
Secondary haemorrhage:
Infection:
Slight infection after this type of operation is undesirable during to the presence of large raw surface in the prostatic bed. Administration of
prophylatic antibiotic has gone a long way in preventing infection occurring post operatively. In case a culture sensitivity report is in hand, the choice
of the antibiotic should be made according to the same . It is also well worth trying the effect of oral antibiotics post operatively to prevent infection
c)pulmonary embolism infection
d)myocardial infarction , cerebral thrombosis
remote (after 1 month)
incontinence:
it is common unless until the external urethral sphincter is damaged
urethral stricture
osteitis pubis
transurethral resection syndrome
1) it refers to a significant alteration in hemostasis produced by absorbtion of irrigation fluid during trans-urethral resection of the prostate gland
2) it results from the entrance of irrigating fluid into the vascular component through open venous sinuses or perforation in the prostatic capsule
3) even if isotonic irrigation like Glycine is used the problem of expanding the blood volume may cause hypertension and a decrease in electrolyte
concentration
4) the earliest symptom of Tur syndrome is restlessness followed by nausea ,vomiting, abdominal pain& distention the patient pales & perspires
5) the signs & symptoms of Tur syndrome & its complication include an increase in pulse rate, bradycardia & cardio-vascular collapse, dyspnea, cyanosis,
coma, convulsion & death.
TREATMENT OF TUR syndrome
1)it consist of producing a net loss of body water
2)if serum osmolality & plasma sodium are low, furosemide can be administered intra-venously
3)thye patient should be closely observed for signs of cardiovascular collapse with pulmonary or cerebral oedema.
RENAL TRANSPLANTATION
Renal transplantation is the renal replacement therapy for end stage renal disease (ESRD)
Indication
Irreversible glomerular filtration rate of less than 10ml/min
Serum creatinine level of greater than 8 mg/dl
Symptomatic uraemia
Patients contraindicated to dialysis as
1.Vascular problems
2.Cardiac disease
3.Diabetes mellitus
4.Long distance
Patients contraindicated to peritoneal dialysis as
1.Obesity
2.Hernia
3.Poor hygiene
4.Obliterated Peritoneal Space
Symptoms
1.Oedema
2.Uremia
3.Recurrent infection
4.Proteinuria
5.Hyponatremia
6.Hyperkalaemia
Preoperative
Patient preparation:
1. The pretransplantation evaluation is a multidisciplinary process that is performed well in advance of the renal transplantation operation and
immunosuppression.
2. The purposes of the evaluation are generally considered to be diagnose the primary disease and its risk of recurrence in the kidney graft and to rule
out active invasive infection, a high probability of operative mortality, non compliance, active malignancy & unsuitable anatomy for technical access.
Preliminary screening :
It includes
1.drug abuse
2.morbid obesity
Kidney disease recurrence:
1.Glomerulosclerosis
2.Hemolytic-uremic syndrome
3.Primary oxalosis
4.Diabetes mellitus
5. IGA nephropathy
Infection
Infection must be detected and treated before transplantation or prevented with immunization
1.Dental sepsis must be treated
2.Pulmonary infection
3.Cholecystitis
4.Small gall stones
5.Cholelithiasis has to be treated
]Serological testing includes for
a. Cytomegalo virus
b. Herpes simplex virus
c. Epstein-barr virus
d. Hepatitis b & c
Active malignancy :
1.Adenocarcinoma
2.Wilms tumour
3.Transitional cell carcinoma
4.Melanoma
To reduce the risk of cancer recurrence a waiting time of 2-5 cancer, free years from the time of the last cancer treatment is recommended for patients who
have had invasive malignancy.
• ABO blood group identify determined
• Negative micro toxicity
• Lymphocyte cross matching between recipient and donor.
Investigation :
1. Preliminary screening tests
2. Donor –CT angiography
3. Recipient –Doppler flow studies
4. Ultrasound
5. Uroflow
6. Cystoscopy biopsy (bladder)
7. Urodynamics
8. Renal CT
Further study of the urinary tract is indicated for a history of urologic abnormalities,
1. Non Glomerular Haematuria
2. Calculi
3. Hydronephrosis
4. Autosomal dominant polycystic kidney disease
5. Significant bladder residual urine
6. HLA typing – HLA-A,B and DR
Donor selection:
1. The basic criteria for a renal donor are on absence of renal disease, on absence of active infection and an absence of transmissible malignancy.
2. Whether the kidney is removed from a living donor, the surgical goals are to minimize warm ischaemia time, to preserve renal vessels and to presence
urethral blood supply.
Living donor:
Donor must assure of normal renal function after unilateral nephrectomy.
The better kidney is left with the donor
1. It is preferable to use right kidney from women who may become pregnant because of hydronephrosis and pyelonephritis of pregnancy
2. The living donor is unsuited when he has
• Mental dysfunction
• Significant renal disease
• Significant transmissible disease
• ABO incompatibility
• Positive cross match between donor lymphocytes and recipient serum.
Cadaver donor:
The criteria for an ideal cadaver kidney donor are
1. Normal renal function
2. No hypertension
3. No diabetes mellitus
4. No malignancy
5. Generalized viral / bacterial infection
6. Age between 6 and 45 years
7. Negative assays
For
• syphilis
• Hepatitis
• HIV
• Human T-lymphoproliferative virus
The principles of Cadaver donor organ retrieval are
1. Adequate exposure
2. Control of great vessels
3. Initiation of preservation insitu
4. Removal of organs
5. Completion of preservation
6. Removal of histocompatibility specimens
7. Removal of iliac vessels
8. Organ packaging
Evaluation of donor:
1. Psychological support
2. Family support – kidney disease
3. No evidence of diabetes
4. Hypertension
5. Haemoglobin
6. Renal function test
7. Urine analysis
8. Urine culture
9. 24-hour urine protein
Recipient operation:
1. After the patient is generally anaesthetized a prophylatic antobiotic is started just before the surgery & continued postoperatively
2. Immunosupperession is started before the surgery in case of cadaver recipient and a week before in case of living related graft recipient
3. Then a three way Foley catheter is placed in the bladder for the intraoperative fillingand draining of the bladder and the bladder is washed with
the broad spectrum antibiotic solution and it is clamped still the ureteroneocystostomy is performed
4. The kidney graft is usually placed extraperitonealy by the Gibson incision
5. The placement of the kidney on the right side provides wider arteries and veins for thye vascular anastamosis
6. In men’s the spermatic chord is preserved and iin case of women the round ligament is dissected between the ligatures
7. Before vascular occlusion heparin is give n intravenously to the recipient
8. The kidney must be kept cool by ice cool electrolyte
9. Then renal artery us usually anastamosed with the end of the internal iliac artery or to the side of the external iliac artery
10. The renal artery anastamosis is done before the vein
11. The renal vein is anatamosed to the external iliac vein
12. Furosemide is usually infused just before the release of vascular clamps
13. Then extravesical ureteroneocystostomy is performed
Rejection (or) renal allograft rejection:
There are four types of rejection
10. hyper acute rejection
11. accelerated rejection
12. acute rejection
13. chronic rejection
1.Hyper acute rejection
• It is analogous to a blood transfusion reaction
• It occurs immediately after renal revascularization
• It is an irreversible process mediated by performed circulating cytotoxic antibodies that develop after pregnancy, blood transfusion or an earlier
failed transplantation
• It is very rare when the micro lymphocytotoxicity cross match between recipient serum and donor lymphocytes is negative
• The graft turns from white to a mottled bluish black and should removed immediately.
2.Acute rejection
• It can occur any time after transplant
• The symptoms of acute kidney transplant rejection are those “the flu” accompanied by pain over an enlarged kidney graft, hypertension, decrease urine
output, fluid retention, increase serum creatinine levels and radioisotope renography indicating decrease renal blood flow, Glomerular filtration and tubular
filtration.
• Needle biopsy of the kidney graft is sometimes necessary for confirm the diagnosis of acute rejection.
• The typical histologic findings of acute renal allograft rejection are mononuclear cellular infiltration tubulitis and vasculitis
3.chronic rejection
• It is characterized by gradual decline in renal function associated with interstitial fibrosis, vascular changes and minimal mononuclear cell
infiltration.
1.
HLA Tissue Typing :
a. Human leukocyte antigen present in short arm of chromosome 6
b. It is divided into two classes.
HLA –Class l
Class ll
c. Autosomal class l antigens are known as HLA-A, HLA-B, HLA-C antigens and they are present on nearly all nucleated cells
d. They are detected by tissue typing T-lymphocytes, usually with a DNA polymerize chain reaction amplification technique
e. HLA-DR, HLA-DQ and HLA-DP antigens are class ll antigens present in the B lymphocytes activated by T lymphocytes, monocytes, macrophages, dendistic
cells and some endothelial cells.
f. HLA-DR antigens are detected by tissue typing B lymphocytes testing for HLA-DQ, HLA-DP are not routinely used.
Post operative care:
A .Fluid and electrolyte balance:
• 0.45% saline in 5% dextrose to replace estimated insensible losses
• 0.45% saline in 0% dextrose is given at 0 rate equal to the previous hours urinary output.
B.management of tubes and drains:
Catheter is removed within a week after a negative a culture repor
Closed suction drains are removed when the output is less than 50ml / 24hrs or in 3 weeks.
Complications:
1. .Early Graft dysfunction: It may due to
• Infection
• Renal allograft rejection
• Urinary obstruction
• Vascular obstruction
• Nephrotoxicity
• Hyperglycemia
• Dehydration
2 .Vascular complication:
• Kinking of the kidney grafts artery or vein
• Suture line stenosis
• Thrombosis
• Thrombophilia
3 Lymphocele
4. Haematuria
5. Ureteric leak
6. UTI
7. Vesicoureteral reflux
8 . Erectile dysfunction
9. Pulmnory infection –pneumonia
10.Obstructive and stones
11.Cancer due to immunosuppressant
12.New Diabetes Mellitus
Indication
Irreversible glomerular filtration rate of less than 10ml/min
Serum creatinine level of greater than 8 mg/dl
Symptomatic uraemia
Patients contraindicated to dialysis as
1.Vascular problems
2.Cardiac disease
3.Diabetes mellitus
4.Long distance
Patients contraindicated to peritoneal dialysis as
1.Obesity
2.Hernia
3.Poor hygiene
4.Obliterated Peritoneal Space
Symptoms
1.Oedema
2.Uremia
3.Recurrent infection
4.Proteinuria
5.Hyponatremia
6.Hyperkalaemia
Preoperative
Patient preparation:
1. The pretransplantation evaluation is a multidisciplinary process that is performed well in advance of the renal transplantation operation and
immunosuppression.
2. The purposes of the evaluation are generally considered to be diagnose the primary disease and its risk of recurrence in the kidney graft and to rule
out active invasive infection, a high probability of operative mortality, non compliance, active malignancy & unsuitable anatomy for technical access.
Preliminary screening :
It includes
1.drug abuse
2.morbid obesity
Kidney disease recurrence:
1.Glomerulosclerosis
2.Hemolytic-uremic syndrome
3.Primary oxalosis
4.Diabetes mellitus
5. IGA nephropathy
Infection
Infection must be detected and treated before transplantation or prevented with immunization
1.Dental sepsis must be treated
2.Pulmonary infection
3.Cholecystitis
4.Small gall stones
5.Cholelithiasis has to be treated
]Serological testing includes for
a. Cytomegalo virus
b. Herpes simplex virus
c. Epstein-barr virus
d. Hepatitis b & c
Active malignancy :
1.Adenocarcinoma
2.Wilms tumour
3.Transitional cell carcinoma
4.Melanoma
To reduce the risk of cancer recurrence a waiting time of 2-5 cancer, free years from the time of the last cancer treatment is recommended for patients who
have had invasive malignancy.
• ABO blood group identify determined
• Negative micro toxicity
• Lymphocyte cross matching between recipient and donor.
Investigation :
1. Preliminary screening tests
2. Donor –CT angiography
3. Recipient –Doppler flow studies
4. Ultrasound
5. Uroflow
6. Cystoscopy biopsy (bladder)
7. Urodynamics
8. Renal CT
Further study of the urinary tract is indicated for a history of urologic abnormalities,
1. Non Glomerular Haematuria
2. Calculi
3. Hydronephrosis
4. Autosomal dominant polycystic kidney disease
5. Significant bladder residual urine
6. HLA typing – HLA-A,B and DR
Donor selection:
1. The basic criteria for a renal donor are on absence of renal disease, on absence of active infection and an absence of transmissible malignancy.
2. Whether the kidney is removed from a living donor, the surgical goals are to minimize warm ischaemia time, to preserve renal vessels and to presence
urethral blood supply.
Living donor:
Donor must assure of normal renal function after unilateral nephrectomy.
The better kidney is left with the donor
1. It is preferable to use right kidney from women who may become pregnant because of hydronephrosis and pyelonephritis of pregnancy
2. The living donor is unsuited when he has
• Mental dysfunction
• Significant renal disease
• Significant transmissible disease
• ABO incompatibility
• Positive cross match between donor lymphocytes and recipient serum.
Cadaver donor:
The criteria for an ideal cadaver kidney donor are
1. Normal renal function
2. No hypertension
3. No diabetes mellitus
4. No malignancy
5. Generalized viral / bacterial infection
6. Age between 6 and 45 years
7. Negative assays
For
• syphilis
• Hepatitis
• HIV
• Human T-lymphoproliferative virus
The principles of Cadaver donor organ retrieval are
1. Adequate exposure
2. Control of great vessels
3. Initiation of preservation insitu
4. Removal of organs
5. Completion of preservation
6. Removal of histocompatibility specimens
7. Removal of iliac vessels
8. Organ packaging
Evaluation of donor:
1. Psychological support
2. Family support – kidney disease
3. No evidence of diabetes
4. Hypertension
5. Haemoglobin
6. Renal function test
7. Urine analysis
8. Urine culture
9. 24-hour urine protein
Recipient operation:
1. After the patient is generally anaesthetized a prophylatic antobiotic is started just before the surgery & continued postoperatively
2. Immunosupperession is started before the surgery in case of cadaver recipient and a week before in case of living related graft recipient
3. Then a three way Foley catheter is placed in the bladder for the intraoperative fillingand draining of the bladder and the bladder is washed with
the broad spectrum antibiotic solution and it is clamped still the ureteroneocystostomy is performed
4. The kidney graft is usually placed extraperitonealy by the Gibson incision
5. The placement of the kidney on the right side provides wider arteries and veins for thye vascular anastamosis
6. In men’s the spermatic chord is preserved and iin case of women the round ligament is dissected between the ligatures
7. Before vascular occlusion heparin is give n intravenously to the recipient
8. The kidney must be kept cool by ice cool electrolyte
9. Then renal artery us usually anastamosed with the end of the internal iliac artery or to the side of the external iliac artery
10. The renal artery anastamosis is done before the vein
11. The renal vein is anatamosed to the external iliac vein
12. Furosemide is usually infused just before the release of vascular clamps
13. Then extravesical ureteroneocystostomy is performed
Rejection (or) renal allograft rejection:
There are four types of rejection
10. hyper acute rejection
11. accelerated rejection
12. acute rejection
13. chronic rejection
1.Hyper acute rejection
• It is analogous to a blood transfusion reaction
• It occurs immediately after renal revascularization
• It is an irreversible process mediated by performed circulating cytotoxic antibodies that develop after pregnancy, blood transfusion or an earlier
failed transplantation
• It is very rare when the micro lymphocytotoxicity cross match between recipient serum and donor lymphocytes is negative
• The graft turns from white to a mottled bluish black and should removed immediately.
2.Acute rejection
• It can occur any time after transplant
• The symptoms of acute kidney transplant rejection are those “the flu” accompanied by pain over an enlarged kidney graft, hypertension, decrease urine
output, fluid retention, increase serum creatinine levels and radioisotope renography indicating decrease renal blood flow, Glomerular filtration and tubular
filtration.
• Needle biopsy of the kidney graft is sometimes necessary for confirm the diagnosis of acute rejection.
• The typical histologic findings of acute renal allograft rejection are mononuclear cellular infiltration tubulitis and vasculitis
3.chronic rejection
• It is characterized by gradual decline in renal function associated with interstitial fibrosis, vascular changes and minimal mononuclear cell
infiltration.
1.
HLA Tissue Typing :
a. Human leukocyte antigen present in short arm of chromosome 6
b. It is divided into two classes.
HLA –Class l
Class ll
c. Autosomal class l antigens are known as HLA-A, HLA-B, HLA-C antigens and they are present on nearly all nucleated cells
d. They are detected by tissue typing T-lymphocytes, usually with a DNA polymerize chain reaction amplification technique
e. HLA-DR, HLA-DQ and HLA-DP antigens are class ll antigens present in the B lymphocytes activated by T lymphocytes, monocytes, macrophages, dendistic
cells and some endothelial cells.
f. HLA-DR antigens are detected by tissue typing B lymphocytes testing for HLA-DQ, HLA-DP are not routinely used.
Post operative care:
A .Fluid and electrolyte balance:
• 0.45% saline in 5% dextrose to replace estimated insensible losses
• 0.45% saline in 0% dextrose is given at 0 rate equal to the previous hours urinary output.
B.management of tubes and drains:
Catheter is removed within a week after a negative a culture repor
Closed suction drains are removed when the output is less than 50ml / 24hrs or in 3 weeks.
Complications:
1. .Early Graft dysfunction: It may due to
• Infection
• Renal allograft rejection
• Urinary obstruction
• Vascular obstruction
• Nephrotoxicity
• Hyperglycemia
• Dehydration
2 .Vascular complication:
• Kinking of the kidney grafts artery or vein
• Suture line stenosis
• Thrombosis
• Thrombophilia
3 Lymphocele
4. Haematuria
5. Ureteric leak
6. UTI
7. Vesicoureteral reflux
8 . Erectile dysfunction
9. Pulmnory infection –pneumonia
10.Obstructive and stones
11.Cancer due to immunosuppressant
12.New Diabetes Mellitus
STENT REMOVAL
ANTIBIOTIC
Inj gentamycin 80mg
Anaesthesia
Under local anaesthesia (2%xylocaine jelly)
Position
The patient is positioned in a comfortable lithotomy position
Skin preparation
The skin is usually cleaned with a antimicrobial solution (eg. Betadine solution)
In women
Begin from the umbilical region, covering the pubic area, the inner thighs, the vaginal vault, cefrvix, perineum and anus.
In men
Begin from the umbilical region, covering the pubic area, the inner thighs, the scrotum and anus
Draping
1 small drape under the buttocks
2 leggings, one for each leg
1 small drape sheet over the abdomen
Instruments
Cystoscopy sheath with obturator (17fr/20fr/22fr)
Telescope 0 degree / 30 degree
Bridge
Light source cable
Endo camera
Biopsy forceps
Miscellaneous things
2%xylocaine jelly
Disposable syringe 10ml
I.V set
Normal saline 1 L bottle
Procedure
Apply 2%xylocaine jelly per urethrally
Take the cystoscopy sheath and make the following connections.
1.connect bridge to cystoscopy sheath
2.insert 0 degree telescope inside the cystoscopy sheath
3.connect Endo camera to the telescope
4.connect light source to the cystoscopy sheath
5.connect the irrigation source
After all connections have been made, check to see if all channels are closed (cystoscopy sheath and bridge)
Introduce the cystoscopy sheath per-urethrally after opening the irrigation channel
The bladder is filled with irrigation fluid, under direct vision, the urethra the bladder neck and the ureteric orifices are examined
Next remove the cystoscope obturator and introduce the biopsy forceps and under direct vision grasp the end of the ureteric stent
Gently remove the grasper along with the stent, to avoid injury to the ureter
At the end of the procedure the bladder should be emptied and the cystoscope sheath removed.
Inj gentamycin 80mg
Anaesthesia
Under local anaesthesia (2%xylocaine jelly)
Position
The patient is positioned in a comfortable lithotomy position
Skin preparation
The skin is usually cleaned with a antimicrobial solution (eg. Betadine solution)
In women
Begin from the umbilical region, covering the pubic area, the inner thighs, the vaginal vault, cefrvix, perineum and anus.
In men
Begin from the umbilical region, covering the pubic area, the inner thighs, the scrotum and anus
Draping
1 small drape under the buttocks
2 leggings, one for each leg
1 small drape sheet over the abdomen
Instruments
Cystoscopy sheath with obturator (17fr/20fr/22fr)
Telescope 0 degree / 30 degree
Bridge
Light source cable
Endo camera
Biopsy forceps
Miscellaneous things
2%xylocaine jelly
Disposable syringe 10ml
I.V set
Normal saline 1 L bottle
Procedure
Apply 2%xylocaine jelly per urethrally
Take the cystoscopy sheath and make the following connections.
1.connect bridge to cystoscopy sheath
2.insert 0 degree telescope inside the cystoscopy sheath
3.connect Endo camera to the telescope
4.connect light source to the cystoscopy sheath
5.connect the irrigation source
After all connections have been made, check to see if all channels are closed (cystoscopy sheath and bridge)
Introduce the cystoscopy sheath per-urethrally after opening the irrigation channel
The bladder is filled with irrigation fluid, under direct vision, the urethra the bladder neck and the ureteric orifices are examined
Next remove the cystoscope obturator and introduce the biopsy forceps and under direct vision grasp the end of the ureteric stent
Gently remove the grasper along with the stent, to avoid injury to the ureter
At the end of the procedure the bladder should be emptied and the cystoscope sheath removed.
CYSTOSCOPY
The endoscopical inspection of the lower urinary tract is called cystoscopy. It requires illumination, irrigation and optics.
A systemic approach is required when evaluating the urethra, prostate, bladder walls, dome, neck and urethral orifices cystoscopically.
Indication:
Direct visualization of the anterior and posterior urethra, bladder neck, and bladder.
Diagnosis of lower urinary tract disease.
To directly visualize the lower urinary tract anatomy and microscopic pathology
Both cytologic and histologic examination can be abtained cystoscopically.
Gross haematuria
Evaluation of voiding symptoms(obstructive and irritative)
Antibiotic :
Inj. Gentamycin 80mg /inj.cefotaxim 1gm iv
Anaesthesia
Under spinal anaesthesia
Position
The patient positioned on the operating table in a comfortable lithotomy position
Patient preparation:
It must be ensured that the patient does not have on UTI before cystoscopy.
Skin preparation
The skin is usually cleaned with an antimicrobial solution (eg.betadine solution)
In women:
Begin from the umbilical region, covering the pubic area, the inner thighs, the vaginal vault, cervix, perineum and anus.
In men
Begin from the umbilical region, covering the pubic area, the inner thighs, the scrotum and anus.
Draping
1 small drape sheet under the thighs
2 leggings, one for each leg
1 small sheet over the abdomen
Things for the procedure
Instrumentation for the procedure
Cystoscopy sheath with obturator 17fr/20fr/22fr
Telescope 0 degree and 30 degree
Bridge
Endo camera
Light source cable
Biopsy forceps
Bug bee
Urethral dilators
Miscellaneous things
Xylocaine jelly 2%
Disposable syringe 10ml
i.v.set
normal saline 1 litre bottle
foleys catheter 16fr
urobag
procedure:
Any urologic irrigants can be used for cystoscopy most often sterile water (or) saline is used.
If electrocoagulation is planned, it is necessary to avoid solutions containing electrolytes.
The choice of an endoscope with respect to size should be the same as for catheter size.
If diagnostic cystoscopy is performed a small instrument of 16fr/17fr is adequate and the larger endoscope is chosen for biopsy devices.
Systematic inspection of the entire urethra and bladder should be performed
during cystoscopy.
Before insertion of the instrument the urethral meatus should be inspected and meatatomy or dilatation should be performed if the meatal
size appears inadequate to accept the endoscope
The sheath of the cystoscopy is generally lubricant and the endoscope can be passed under direct vision with a 0 and 30 degree telescope.
In male, the penis should be grasped and straightend and the endoscope is passed through the fossa navicularis and the instrument is
generally passed after inspecting the anterior urethra
If there is resistence to the passage of the endoscope a smaller instrument should be passed or the urethra should be dilated
After entering the bulbar urethra the endoscope and penis are lowered and the instrument is passed into the membranous urethra
The external sphincter is identified and the scope is passed by the gentle pressure
Then, the instrument passes through the prastatic urethra and vermontanum
is noted, so that the prostatic urethra is inspected.
At the level of the bladder neck endoscpe is gently depressed in order to pass the instrument into the bladder over the bladder neck.
Inspection of the female urethra is easily performed by inserting endoscope under direct vision into the urethral meatus
After entering the bladder, the bladder surface , inter ureteric ridge, bladder neck along the trigone is inspected using the 30 degree
telescope after filling the bladder.
Using the 70-90 degree lens the lateral walls of the bladder finally, the dome and anterior bladder wall are evaluated
After complete inspection of the urethra and bladder the bladder is drained and the instrument is generally removed.
A systemic approach is required when evaluating the urethra, prostate, bladder walls, dome, neck and urethral orifices cystoscopically.
Indication:
Direct visualization of the anterior and posterior urethra, bladder neck, and bladder.
Diagnosis of lower urinary tract disease.
To directly visualize the lower urinary tract anatomy and microscopic pathology
Both cytologic and histologic examination can be abtained cystoscopically.
Gross haematuria
Evaluation of voiding symptoms(obstructive and irritative)
Antibiotic :
Inj. Gentamycin 80mg /inj.cefotaxim 1gm iv
Anaesthesia
Under spinal anaesthesia
Position
The patient positioned on the operating table in a comfortable lithotomy position
Patient preparation:
It must be ensured that the patient does not have on UTI before cystoscopy.
Skin preparation
The skin is usually cleaned with an antimicrobial solution (eg.betadine solution)
In women:
Begin from the umbilical region, covering the pubic area, the inner thighs, the vaginal vault, cervix, perineum and anus.
In men
Begin from the umbilical region, covering the pubic area, the inner thighs, the scrotum and anus.
Draping
1 small drape sheet under the thighs
2 leggings, one for each leg
1 small sheet over the abdomen
Things for the procedure
Instrumentation for the procedure
Cystoscopy sheath with obturator 17fr/20fr/22fr
Telescope 0 degree and 30 degree
Bridge
Endo camera
Light source cable
Biopsy forceps
Bug bee
Urethral dilators
Miscellaneous things
Xylocaine jelly 2%
Disposable syringe 10ml
i.v.set
normal saline 1 litre bottle
foleys catheter 16fr
urobag
procedure:
Any urologic irrigants can be used for cystoscopy most often sterile water (or) saline is used.
If electrocoagulation is planned, it is necessary to avoid solutions containing electrolytes.
The choice of an endoscope with respect to size should be the same as for catheter size.
If diagnostic cystoscopy is performed a small instrument of 16fr/17fr is adequate and the larger endoscope is chosen for biopsy devices.
Systematic inspection of the entire urethra and bladder should be performed
during cystoscopy.
Before insertion of the instrument the urethral meatus should be inspected and meatatomy or dilatation should be performed if the meatal
size appears inadequate to accept the endoscope
The sheath of the cystoscopy is generally lubricant and the endoscope can be passed under direct vision with a 0 and 30 degree telescope.
In male, the penis should be grasped and straightend and the endoscope is passed through the fossa navicularis and the instrument is
generally passed after inspecting the anterior urethra
If there is resistence to the passage of the endoscope a smaller instrument should be passed or the urethra should be dilated
After entering the bulbar urethra the endoscope and penis are lowered and the instrument is passed into the membranous urethra
The external sphincter is identified and the scope is passed by the gentle pressure
Then, the instrument passes through the prastatic urethra and vermontanum
is noted, so that the prostatic urethra is inspected.
At the level of the bladder neck endoscpe is gently depressed in order to pass the instrument into the bladder over the bladder neck.
Inspection of the female urethra is easily performed by inserting endoscope under direct vision into the urethral meatus
After entering the bladder, the bladder surface , inter ureteric ridge, bladder neck along the trigone is inspected using the 30 degree
telescope after filling the bladder.
Using the 70-90 degree lens the lateral walls of the bladder finally, the dome and anterior bladder wall are evaluated
After complete inspection of the urethra and bladder the bladder is drained and the instrument is generally removed.
URETHROPLASTY
Urethroplasty is applicable to all strictures of bulbar and penile portions and is the treatment of choice if simple measures fail.
Anatomical remarks:
The male urethra can be divided into different portions.
a)The posterior urethra:
It includes the a)Membranous urethra
b)Prostatic urethra
b)The anterior urethra
It includes
1) Navicularis
2) Penile urethra
3) Bulbar urethra
Causes of stricture:
a) Congenital
b) Traumatic –Bulbar urethra
c) Inflammatory –Post gonorrhea
Post urethral chancre
Tuberculous
d) Instrumental -Indwelling catheter
Endoscope
e) Post operative -Prostatectomy
Amputation of the penis
Preoperative Management
Investigation
a) Blood routine
b) Urine routine
c) RBS
d) BUN
e) Creatinine
f) Serum electrolytes
g) USG-KUB
h) Ascending urethrogram
i) Cytoscopy
2) Bowel preparation should be done
3) Anaesthetist order should be followed
PROCEDURE
1) TYPES OF URETHRPLASTY:
a) End-End Urethroplasty
b) Substitution Urethroplasty
c) Augmented Urethroplasty
d) Staged Urethroplasty
a) End-End Urethroplasty:
It is performed when excision of the diseased part is necessary resection of the short segment of strictured part of urethra
is done & re anastamosis of the clear edge is done.
b) Substitution Urethroplasty:
It is performed when the excision of the diseased part is necessary & while the stricture is more than 2cm
* It requires graft substitution for the diseased part
* Resection of the long segment of urethra & substitution with the graft is done .
c)Augmented Urethroplasty:
It is performed for the long strictures especially penile strictures which requires the incision of the
diseased part
*the strictured part of urethra incised & augmented with the graft especially with the free graft
d)staged urethroplasty:
in this procedure it is performed at two stages as the strictured urethra is laid open at the initial stage &
reanastamosis is performed at the later stage
GRAFTS:
Grafts are the flaps take from the different part of the ones own body to substitute the diseased part of the urethra.
a) free graft:
these are the grafts free from hair as *buccal mucosa
*bladder mucosa
*prepucal mucosa
b) pedicle graft :
these are the grafts with blood vessls as*scrotal skin
*penile skin
*perineal skin
PROCEDURE
A) anaesthesia:*epidural
*spinal
b)antibiotic:
inj gentamycin
inj cefataxim
c)position:*exaggerated lithotomy
d)incision:inverted u & lambda incision
BULBAR URETHROPLASTY
a) the patient is positioned on exaggerated lithotomy position & a midline perineoscrotal incision is made
b) the bulbo-cavernous muscle are separated in the midline & in patients with the proximal bulbar urethral stricture the central tendo of the perineum
is dissected
c) the bulbar urethra is then free from the bulbo- cavernous muscle & it is dissected from the corpora cavernosa .
d) the urethra is completely mobilized from the corpora cavernosa & rotated at 180 degrees & incisee along the dorsal surface.
e) The stricture is opened along its whole length.
f) The graft is harvested from the mouth (or) prepuse
g) Then the fenestrated ovoid preputial skin or buccal mucosa graft is spread fixed and quilted to the overlying tunica albuguina of the corporal
bodies.
h) The right mucosal margin of the opened urethra is sutured to the right side of the patch graft then the urethra is rotated to its oroginal position
i) Then the left urethral margin is sutured to the left side of the patch graft & the corporal bodies
j) The patch graft is entireky covered with the urethral plate.
k) The bulbo cavernosal muscle are approximated over the grafted area.
l) A small suction drain is placed & AN INDWELLING 16FR SILICONE FOLEY catheter is left in place.
m) Suprapubic catheterization is not necessary.
End-End urethroplasty:
a) midline perineo scrotal incision is made.
b) The subcutaneous fat & collies fascia is dissected & the bulbo cavernous muscle is ligated.
c) Then separate or dissect the spongism and urethra above and below the strictures.
d) Then cut and remove the strictured area
e) Mobilize the proximal and distal urethra spatulate and anastamose using 4-0 vicryl suture material.
f) A small suction drain is place and silastic 16fr silicon foley catheter is left in placed
g) SPC should be done
Post operative management:
1. the drain is removed on trhe 1st post operative day and the patient is discharged
2. the catheter is removed after 3 weeks
3. voiding cystourethrography is obtained
4. uroflowmetry and urine culture is repeated every 4 months durind the 1st year and yearly thereafter.
Anatomical remarks:
The male urethra can be divided into different portions.
a)The posterior urethra:
It includes the a)Membranous urethra
b)Prostatic urethra
b)The anterior urethra
It includes
1) Navicularis
2) Penile urethra
3) Bulbar urethra
Causes of stricture:
a) Congenital
b) Traumatic –Bulbar urethra
c) Inflammatory –Post gonorrhea
Post urethral chancre
Tuberculous
d) Instrumental -Indwelling catheter
Endoscope
e) Post operative -Prostatectomy
Amputation of the penis
Preoperative Management
Investigation
a) Blood routine
b) Urine routine
c) RBS
d) BUN
e) Creatinine
f) Serum electrolytes
g) USG-KUB
h) Ascending urethrogram
i) Cytoscopy
2) Bowel preparation should be done
3) Anaesthetist order should be followed
PROCEDURE
1) TYPES OF URETHRPLASTY:
a) End-End Urethroplasty
b) Substitution Urethroplasty
c) Augmented Urethroplasty
d) Staged Urethroplasty
a) End-End Urethroplasty:
It is performed when excision of the diseased part is necessary resection of the short segment of strictured part of urethra
is done & re anastamosis of the clear edge is done.
b) Substitution Urethroplasty:
It is performed when the excision of the diseased part is necessary & while the stricture is more than 2cm
* It requires graft substitution for the diseased part
* Resection of the long segment of urethra & substitution with the graft is done .
c)Augmented Urethroplasty:
It is performed for the long strictures especially penile strictures which requires the incision of the
diseased part
*the strictured part of urethra incised & augmented with the graft especially with the free graft
d)staged urethroplasty:
in this procedure it is performed at two stages as the strictured urethra is laid open at the initial stage &
reanastamosis is performed at the later stage
GRAFTS:
Grafts are the flaps take from the different part of the ones own body to substitute the diseased part of the urethra.
a) free graft:
these are the grafts free from hair as *buccal mucosa
*bladder mucosa
*prepucal mucosa
b) pedicle graft :
these are the grafts with blood vessls as*scrotal skin
*penile skin
*perineal skin
PROCEDURE
A) anaesthesia:*epidural
*spinal
b)antibiotic:
inj gentamycin
inj cefataxim
c)position:*exaggerated lithotomy
d)incision:inverted u & lambda incision
BULBAR URETHROPLASTY
a) the patient is positioned on exaggerated lithotomy position & a midline perineoscrotal incision is made
b) the bulbo-cavernous muscle are separated in the midline & in patients with the proximal bulbar urethral stricture the central tendo of the perineum
is dissected
c) the bulbar urethra is then free from the bulbo- cavernous muscle & it is dissected from the corpora cavernosa .
d) the urethra is completely mobilized from the corpora cavernosa & rotated at 180 degrees & incisee along the dorsal surface.
e) The stricture is opened along its whole length.
f) The graft is harvested from the mouth (or) prepuse
g) Then the fenestrated ovoid preputial skin or buccal mucosa graft is spread fixed and quilted to the overlying tunica albuguina of the corporal
bodies.
h) The right mucosal margin of the opened urethra is sutured to the right side of the patch graft then the urethra is rotated to its oroginal position
i) Then the left urethral margin is sutured to the left side of the patch graft & the corporal bodies
j) The patch graft is entireky covered with the urethral plate.
k) The bulbo cavernosal muscle are approximated over the grafted area.
l) A small suction drain is placed & AN INDWELLING 16FR SILICONE FOLEY catheter is left in place.
m) Suprapubic catheterization is not necessary.
End-End urethroplasty:
a) midline perineo scrotal incision is made.
b) The subcutaneous fat & collies fascia is dissected & the bulbo cavernous muscle is ligated.
c) Then separate or dissect the spongism and urethra above and below the strictures.
d) Then cut and remove the strictured area
e) Mobilize the proximal and distal urethra spatulate and anastamose using 4-0 vicryl suture material.
f) A small suction drain is place and silastic 16fr silicon foley catheter is left in placed
g) SPC should be done
Post operative management:
1. the drain is removed on trhe 1st post operative day and the patient is discharged
2. the catheter is removed after 3 weeks
3. voiding cystourethrography is obtained
4. uroflowmetry and urine culture is repeated every 4 months durind the 1st year and yearly thereafter.
RADICAL NEPHRECTOMY
INDICATION:
Renal cell carcinoma
SURGICAL TECHNIQUE:
The incision extends from the angle of the 12th rib posteriorly
to 8-15cms beyond the tip of the 12th rib anteriorly
The three muscle layers (external and internal oblique and transverses muscles) are divided, carefully avoiding the intercostals and
sub-costal nerves.
Then the ureter is exposed and snared, the perirenal fat displaced and the posterior aspect of the kidney exposed.
The peritoneum, which adheres to the kidney is separated and the kidney mobilized the peritoneum is closed with vicryl sutures.]
Dissection of the upper pole of kidney from fatty tissue and supra renal gland is achieved by blunt dissection. One should also look for
accessory vessels and ligate them or coagulate them is required.
Delivery of the lower pole is also achieved in the same way.
After both the poles of the kidney have been mobilized and renal artery, renal vein and the ureter are dissected.
Care should to avoid injury to the ovary or testicular vein on the left side and the suprarenal veins on both sides.
The renal artery is snared and the kidney turned medially to expose the renal vein, which is located behind and above the artery.
After double ligation with vicryl division of the renal artery is done.
The renal vein is treated in the same way.
The kidney is removed after division of the perinephric fat overlying Gerota’s fascia the lymph nodes around the area.
A 20Fr silastic tube drain is placed with its tip within the gerota’s fascia, it is brought out through the gerota’s fascia, through a
separate stab incision.
The wound is closed in layers
SUB CAPSULAR:
SURGICAL TECHNIQUE:
The incision extends from the angle of the 12th rib posteriorly
to 8-15cms beyond the tip of the 12th rib anteriorly
The three muscle layers (external and internal oblique and transverses muscles) are divided, carefully avoiding the intercostals and
sub-costal nerves.
The gerota’s fascia is then incised with scissors, followed by blunt dissection.
The ureter is exposed and snared, the perirenal fat displaced and the posterior aspect of the kidney exposed.
The peritoneum adherent, the sabcapsular area is opened. . Dissection of the
upper pole of kidney from fatty tissue and supra renal gland is achieved by blunt dissection. One should also look for accessory vessels and ligate them or
coagulate them is required
Delivery of the lower pole is also achieved in the same way.
After both the poles of the kidney have been mobilized and renal artery, renal vein and the ureter are dissected.
Care should to avoid injury to the ovary or testicular vein on the left side and the suprarenal veins on both sides.
The renal vein is snared and the kidney turned medially to expose the renal artery, which is located behind and above the vein.
After double ligation with vicryl division of the renal artery is done.
The renal vein is treated in the same way.
The kidney is removed after division of the ureter between clamps.
A 20Fr silastic tube drain is placed with its tip within the gerota’s fascia, it is brought out through the gerota’s fascia, through a
separate stab incision.
The wound is closed in layers.
Renal cell carcinoma
SURGICAL TECHNIQUE:
The incision extends from the angle of the 12th rib posteriorly
to 8-15cms beyond the tip of the 12th rib anteriorly
The three muscle layers (external and internal oblique and transverses muscles) are divided, carefully avoiding the intercostals and
sub-costal nerves.
Then the ureter is exposed and snared, the perirenal fat displaced and the posterior aspect of the kidney exposed.
The peritoneum, which adheres to the kidney is separated and the kidney mobilized the peritoneum is closed with vicryl sutures.]
Dissection of the upper pole of kidney from fatty tissue and supra renal gland is achieved by blunt dissection. One should also look for
accessory vessels and ligate them or coagulate them is required.
Delivery of the lower pole is also achieved in the same way.
After both the poles of the kidney have been mobilized and renal artery, renal vein and the ureter are dissected.
Care should to avoid injury to the ovary or testicular vein on the left side and the suprarenal veins on both sides.
The renal artery is snared and the kidney turned medially to expose the renal vein, which is located behind and above the artery.
After double ligation with vicryl division of the renal artery is done.
The renal vein is treated in the same way.
The kidney is removed after division of the perinephric fat overlying Gerota’s fascia the lymph nodes around the area.
A 20Fr silastic tube drain is placed with its tip within the gerota’s fascia, it is brought out through the gerota’s fascia, through a
separate stab incision.
The wound is closed in layers
SUB CAPSULAR:
SURGICAL TECHNIQUE:
The incision extends from the angle of the 12th rib posteriorly
to 8-15cms beyond the tip of the 12th rib anteriorly
The three muscle layers (external and internal oblique and transverses muscles) are divided, carefully avoiding the intercostals and
sub-costal nerves.
The gerota’s fascia is then incised with scissors, followed by blunt dissection.
The ureter is exposed and snared, the perirenal fat displaced and the posterior aspect of the kidney exposed.
The peritoneum adherent, the sabcapsular area is opened. . Dissection of the
upper pole of kidney from fatty tissue and supra renal gland is achieved by blunt dissection. One should also look for accessory vessels and ligate them or
coagulate them is required
Delivery of the lower pole is also achieved in the same way.
After both the poles of the kidney have been mobilized and renal artery, renal vein and the ureter are dissected.
Care should to avoid injury to the ovary or testicular vein on the left side and the suprarenal veins on both sides.
The renal vein is snared and the kidney turned medially to expose the renal artery, which is located behind and above the vein.
After double ligation with vicryl division of the renal artery is done.
The renal vein is treated in the same way.
The kidney is removed after division of the ureter between clamps.
A 20Fr silastic tube drain is placed with its tip within the gerota’s fascia, it is brought out through the gerota’s fascia, through a
separate stab incision.
The wound is closed in layers.
NEPHRECTOMY
IT IS DEFINE AS REMOVAL OF KIDNEY
A nephrectomy is the surgical removal of a kidney, the organ that filters waste from the blood and produces urine. There are two
kidneys, right and left. Each is about 4 inches to 5 inches long.
They are located at the back of the abdomen, just below the diaphragm, behind the liver on the right, and the spleen on the left.
A portion of each kidney is protected by the lowest one or two ribs and by the muscles that cover the back and side of the body
Depending on the reason for a nephrectomy, all or part of one kidney or both kidneys will be removed:
1. SIMPLE NEPHRECTOMY
2. SUB CAPSULAR
3. RADICAL NEPHRECTOMY
1. SIMPLE NEPHRECTOMY:
It involves removal of the kidney and the upper ureter without removing the perinephric fat or gerota’s fascia.
2. SUB CAPSULAR:
It is not a preoperatively planned approach to nephrectomy, but rather an expedient way to complete a nephrectomy when one encounters marked
fibrosis involving the perinephric fat and the renal capsule.
3. RADICAL NEPHRECTOMY:
By definition is the removal of the kidney, the perinephric fat overlying gerota’s fascia the lymph nodes around the area also removed. The
prime condition of this type of nephrectomy is Adenocarcinoma.
A nephrectomy may be used to remove a kidney for the following reasons:
• The kidney has a cancerous (malignant) tumor. This usually requires a radical nephrectomy.
• The kidney has been damaged by infection, kidney stones, anruction of urine outflow or cysts.
• The patient has severe high blood pressure (hypertension) caused by renal artery stenosis. In this condition, a diseased artery results in damage to
one kidney. Nephrectomy usually does not cure the high blood pressure in this illness, but it can make control of blood pressure more manageable.
• Severe trauma, such as an automobile accident, has damaged the kidney beyond repair
• A living donor has agreed to donate one kidney for transplantation
• A transplanted kidney has been rejected by the recipient's body and is not functioning. This is called an allograft nephrectomy and is different
surgically from removing the patient's own kidney.
PREPARATION:
About one week before surgery, you will need to stop taking aspirin and other blood-thinning medications. Beginning at midnight on the
night before surgery, you must not eat or drink anything. This reduces the risk of vomiting during surgery. As part of the general preparations for surgery,
your doctor will review your allergies and medical and surgical histories. If you are a woman, and there is any chance that you might be pregnant, you must
tell your doctor before surgery.
SIMPLE NEPHRECTOMY
Principles and Justification:
INDICATION:
Nephrectomy is indicated in the followed cases:
1. Non functioning kidney secondary to pyelonephritis, vascular lesion (eg: post traumatic), glomerulonephritis or acquired cystic disease.
2. Non functioning dysplastic kidney (congenital)
3. Sclerotic kidney in renal hypertension
4. Non functioning kidney in calculous disease
5. Hydronephrosis (congenital or acquired) with loss of function and parenchymal atrophy.
6. Pyonephrosis
7. Xanthogranulomatus pyelonephritis
8. Non functioning kidney in renal tuberculosis.
CONTRAINDICATION: Contraindication for this procedure include
poor general condition, coagulation disorders or severe cardiorespiratory disease.
PRE OPERATIVE PREPARATION:
1. Overall and differentiated renal function must be assessed by creatinine clearance estimation and isotope renography.
2. Any urinary tract infection must be treated .
3. If tuberculosis is suspected or verified, anti tuberculos treatment is essential for both before and during the procedure.
4. Generally the patient have stable cardio circulatory function, perioperative and postoperative elastic support of the legs should be provided,
and all blood clot ting parameters should be normal (caution is advised in patients on anticoagulant theraphy).
5. Cross matched blood must be available during the operation, and low dose heparin prophylaxis is advisable.
ANAESTHESIA:
GENERAL ANAESTHESIA+EPIDURAL ANAESTHESIA
POSITION:
1. The lateral position is usually the position of choice when the approach is lumbar or transthorasic, the affected side is up (in case of
unilateral nephrectomy)
2. The patient’s waist his over the middle break in the table, and the rest of the body is flexed.
3. The arm on the unaffected side is extended on an arm board; a mayo stand padded with a pillow may support the arm on the affected side
4. The leg unaffected side is extended, and the uppermost leg is flexed with a pillow between the legs, adequate padded is needed around the feet
and ankles
5. The position is secured by wide adhesive tape at the shoulder, thighs and legs, fastened to the undersurface of the table.
SKIN PREPARATION:
Begin at the level of the 12th rib extending from the axilla to 2-3 inches below the iliac crest, and down to the table anteriorly and
posteriorly.
DRAPING:
Folded towels
Transverse sheet
INSTRUMENT TROLLEY:
Mosquito straight artery forceps : 6
Mosquito curved artery forceps : 6
Straight artery forceps (medium) 6” : 6
Straight artery forceps (large) 8” : 6
Curved artery forceps (medium) 6” : 6
Curved artery forceps (large) 8” : 6
Right angled artery forceps (small) : 1
Right angled artery forceps (large) : 1
Needle holder : 2
Allis tissue forceps : 6
Babcock : 6
Kochear : 6
Straight scissors : 1
Curved scissors : 1
B.P handle : 1
Scalpel : 1
Blades 10, 11,15 : 1
Self retaining retractor : 2
Langenbeck retractor : 2
Morris retractor : 2
Kelly’s retractor : 2
Deavers retractor : 2
Non toothed forceps (small) : 1
Non toothed forceps (medium) : 1
Toothed forceps (small) : 1
Toothed forceps (medium) : 1
Pull sucker : 1
MISCELLANEOUS ITEMS
Steridrape : 1
Towel clips : 3
Peanuts : 5
Vessel loops : 4
SUTURE MATERIAL
1-Vicryl
2-0 Chromic
2-0 Ethilon (for skin)
1-0, 2-0, 1, 3-0 Sutpack (for artery and vein)
OPERATION
SURGICAL ACCESS:
The choice of approach is determined not only the type of disease (benign or malignant), but also by the patient’s anatomy (obesity, age),
surgical history, the type of renal disease, general condition, cardiocirculatory function and the surgeons own preference.
A transperitoneal chevron incision may be chosen for patients on dialysis when bilateral nephrectomy is necessary before renal transplantation:
alternatively, both kidneys can be removed without changing the patient’s position by using a bilateral dorsal lumbotomy with the patient prone. In renal
trauma the kidney should always approached from an anterior transperitoneal incision for early control of the renal capsule.
INCISION:
The incision extends from the angle of the 12th rib posteriorly
to 8-15cms beyond the tip of the 12th rib anteriorly
The three muscle layers (external and internal oblique and transverses muscles) are divided, carefully avoiding the intercostals and sub-costal
nerves.
The gerota’s fascia is then incised with scissors, followed by blunt dissection.
The ureter is exposed and snared, the perirenal fat displaced and the posterior aspect of the kidney exposed.
The peritoneum, which adheres to the kidney is separated and the kidney mobilized the peritoneum is closed with vicryl sutures.
Dissection of the upper pole of kidney from fatty tissue and supra renal gland is achieved by blunt dissection. One should also look for accessory
vessels and ligate them or coagulate them is required.
Delivery of the lower pole is also achieved in the same way.
After both the poles of the kidney have been mobilized and renal artery, renal vein and the ureter are dissected.
Care should to avoid injury to the ovary or testicular vein on the left side and the suprarenal veins on both sides.
The renal vein is snared and the kidney turned medially to expose the renal artery, which is located behind and above the vein.
After double ligation with vicryl division of the renal artery is done.
The renal vein is treated in the same way.
The kidney is removed after division of the ureter between clamps.
A 20Fr silastic tube drain is placed with its tip within the gerota’s fascia, it is brought out through the gerota’s fascia, through a separate stab
incision.
The wound is closed in layers.
POST OPERATIVE CARE:
1. The patient should be mobilized on the first day after surgery.
2. Low dose anticoagulant treatment is given until the patient is discharge.
3. Intravenous fluid replacement is required until bowel activity returns to normal (usually on the second postoperative day).
4. Serum electrolytes, blood urea nitrogen, creatinine and blood count should be monitored on the first day after surgery, and as necessary thereafter.
COMPLICATION:
1. Haemorrhage may rise from small vessels in the adrenal region (fatty tissue,etc) or from the renal pedicle.
2. If significant haematoma is revealed in ultrasonagraphy in the renal fossa, surgical exploration `is necessary.
3. Post operative chest infections are a cause of morbidity.
4. Iileus may be prolonged because of perioperative handling of the bowel, retroperitoneal haematoma or premature resumption of oral fluids.
A nephrectomy is the surgical removal of a kidney, the organ that filters waste from the blood and produces urine. There are two
kidneys, right and left. Each is about 4 inches to 5 inches long.
They are located at the back of the abdomen, just below the diaphragm, behind the liver on the right, and the spleen on the left.
A portion of each kidney is protected by the lowest one or two ribs and by the muscles that cover the back and side of the body
Depending on the reason for a nephrectomy, all or part of one kidney or both kidneys will be removed:
1. SIMPLE NEPHRECTOMY
2. SUB CAPSULAR
3. RADICAL NEPHRECTOMY
1. SIMPLE NEPHRECTOMY:
It involves removal of the kidney and the upper ureter without removing the perinephric fat or gerota’s fascia.
2. SUB CAPSULAR:
It is not a preoperatively planned approach to nephrectomy, but rather an expedient way to complete a nephrectomy when one encounters marked
fibrosis involving the perinephric fat and the renal capsule.
3. RADICAL NEPHRECTOMY:
By definition is the removal of the kidney, the perinephric fat overlying gerota’s fascia the lymph nodes around the area also removed. The
prime condition of this type of nephrectomy is Adenocarcinoma.
A nephrectomy may be used to remove a kidney for the following reasons:
• The kidney has a cancerous (malignant) tumor. This usually requires a radical nephrectomy.
• The kidney has been damaged by infection, kidney stones, anruction of urine outflow or cysts.
• The patient has severe high blood pressure (hypertension) caused by renal artery stenosis. In this condition, a diseased artery results in damage to
one kidney. Nephrectomy usually does not cure the high blood pressure in this illness, but it can make control of blood pressure more manageable.
• Severe trauma, such as an automobile accident, has damaged the kidney beyond repair
• A living donor has agreed to donate one kidney for transplantation
• A transplanted kidney has been rejected by the recipient's body and is not functioning. This is called an allograft nephrectomy and is different
surgically from removing the patient's own kidney.
PREPARATION:
About one week before surgery, you will need to stop taking aspirin and other blood-thinning medications. Beginning at midnight on the
night before surgery, you must not eat or drink anything. This reduces the risk of vomiting during surgery. As part of the general preparations for surgery,
your doctor will review your allergies and medical and surgical histories. If you are a woman, and there is any chance that you might be pregnant, you must
tell your doctor before surgery.
SIMPLE NEPHRECTOMY
Principles and Justification:
INDICATION:
Nephrectomy is indicated in the followed cases:
1. Non functioning kidney secondary to pyelonephritis, vascular lesion (eg: post traumatic), glomerulonephritis or acquired cystic disease.
2. Non functioning dysplastic kidney (congenital)
3. Sclerotic kidney in renal hypertension
4. Non functioning kidney in calculous disease
5. Hydronephrosis (congenital or acquired) with loss of function and parenchymal atrophy.
6. Pyonephrosis
7. Xanthogranulomatus pyelonephritis
8. Non functioning kidney in renal tuberculosis.
CONTRAINDICATION: Contraindication for this procedure include
poor general condition, coagulation disorders or severe cardiorespiratory disease.
PRE OPERATIVE PREPARATION:
1. Overall and differentiated renal function must be assessed by creatinine clearance estimation and isotope renography.
2. Any urinary tract infection must be treated .
3. If tuberculosis is suspected or verified, anti tuberculos treatment is essential for both before and during the procedure.
4. Generally the patient have stable cardio circulatory function, perioperative and postoperative elastic support of the legs should be provided,
and all blood clot ting parameters should be normal (caution is advised in patients on anticoagulant theraphy).
5. Cross matched blood must be available during the operation, and low dose heparin prophylaxis is advisable.
ANAESTHESIA:
GENERAL ANAESTHESIA+EPIDURAL ANAESTHESIA
POSITION:
1. The lateral position is usually the position of choice when the approach is lumbar or transthorasic, the affected side is up (in case of
unilateral nephrectomy)
2. The patient’s waist his over the middle break in the table, and the rest of the body is flexed.
3. The arm on the unaffected side is extended on an arm board; a mayo stand padded with a pillow may support the arm on the affected side
4. The leg unaffected side is extended, and the uppermost leg is flexed with a pillow between the legs, adequate padded is needed around the feet
and ankles
5. The position is secured by wide adhesive tape at the shoulder, thighs and legs, fastened to the undersurface of the table.
SKIN PREPARATION:
Begin at the level of the 12th rib extending from the axilla to 2-3 inches below the iliac crest, and down to the table anteriorly and
posteriorly.
DRAPING:
Folded towels
Transverse sheet
INSTRUMENT TROLLEY:
Mosquito straight artery forceps : 6
Mosquito curved artery forceps : 6
Straight artery forceps (medium) 6” : 6
Straight artery forceps (large) 8” : 6
Curved artery forceps (medium) 6” : 6
Curved artery forceps (large) 8” : 6
Right angled artery forceps (small) : 1
Right angled artery forceps (large) : 1
Needle holder : 2
Allis tissue forceps : 6
Babcock : 6
Kochear : 6
Straight scissors : 1
Curved scissors : 1
B.P handle : 1
Scalpel : 1
Blades 10, 11,15 : 1
Self retaining retractor : 2
Langenbeck retractor : 2
Morris retractor : 2
Kelly’s retractor : 2
Deavers retractor : 2
Non toothed forceps (small) : 1
Non toothed forceps (medium) : 1
Toothed forceps (small) : 1
Toothed forceps (medium) : 1
Pull sucker : 1
MISCELLANEOUS ITEMS
Steridrape : 1
Towel clips : 3
Peanuts : 5
Vessel loops : 4
SUTURE MATERIAL
1-Vicryl
2-0 Chromic
2-0 Ethilon (for skin)
1-0, 2-0, 1, 3-0 Sutpack (for artery and vein)
OPERATION
SURGICAL ACCESS:
The choice of approach is determined not only the type of disease (benign or malignant), but also by the patient’s anatomy (obesity, age),
surgical history, the type of renal disease, general condition, cardiocirculatory function and the surgeons own preference.
A transperitoneal chevron incision may be chosen for patients on dialysis when bilateral nephrectomy is necessary before renal transplantation:
alternatively, both kidneys can be removed without changing the patient’s position by using a bilateral dorsal lumbotomy with the patient prone. In renal
trauma the kidney should always approached from an anterior transperitoneal incision for early control of the renal capsule.
INCISION:
The incision extends from the angle of the 12th rib posteriorly
to 8-15cms beyond the tip of the 12th rib anteriorly
The three muscle layers (external and internal oblique and transverses muscles) are divided, carefully avoiding the intercostals and sub-costal
nerves.
The gerota’s fascia is then incised with scissors, followed by blunt dissection.
The ureter is exposed and snared, the perirenal fat displaced and the posterior aspect of the kidney exposed.
The peritoneum, which adheres to the kidney is separated and the kidney mobilized the peritoneum is closed with vicryl sutures.
Dissection of the upper pole of kidney from fatty tissue and supra renal gland is achieved by blunt dissection. One should also look for accessory
vessels and ligate them or coagulate them is required.
Delivery of the lower pole is also achieved in the same way.
After both the poles of the kidney have been mobilized and renal artery, renal vein and the ureter are dissected.
Care should to avoid injury to the ovary or testicular vein on the left side and the suprarenal veins on both sides.
The renal vein is snared and the kidney turned medially to expose the renal artery, which is located behind and above the vein.
After double ligation with vicryl division of the renal artery is done.
The renal vein is treated in the same way.
The kidney is removed after division of the ureter between clamps.
A 20Fr silastic tube drain is placed with its tip within the gerota’s fascia, it is brought out through the gerota’s fascia, through a separate stab
incision.
The wound is closed in layers.
POST OPERATIVE CARE:
1. The patient should be mobilized on the first day after surgery.
2. Low dose anticoagulant treatment is given until the patient is discharge.
3. Intravenous fluid replacement is required until bowel activity returns to normal (usually on the second postoperative day).
4. Serum electrolytes, blood urea nitrogen, creatinine and blood count should be monitored on the first day after surgery, and as necessary thereafter.
COMPLICATION:
1. Haemorrhage may rise from small vessels in the adrenal region (fatty tissue,etc) or from the renal pedicle.
2. If significant haematoma is revealed in ultrasonagraphy in the renal fossa, surgical exploration `is necessary.
3. Post operative chest infections are a cause of morbidity.
4. Iileus may be prolonged because of perioperative handling of the bowel, retroperitoneal haematoma or premature resumption of oral fluids.
Testicular Biopsy
Testicular biopsy is a procedure to obtain a sample of tissue from the testicles.
Indication :
Indicated in Azoospermia men with testis of normal size and consistency, palpable vasa deferentia and normal FSH levels. Under these circumstances, a
biopsy distinguishes obstructive azoospermia from primary semniferous tubule failure.
The biopsy should be performed bilaterally. Good spermatogenesis is some times found in small firm testes whereas biopsies of larger healthy testes may
reveal maturation arrest.
Open testicular biopsy:
Anaesthesia:
Under local, general or spinal anaesthesia
Antibiotics
IV antibiotics of surgeon’s choice.
Position:
Supine position
When performing testes biopsy, the surgeon must provide an adequate tissue sample using a technique that avoids trauma to the specimen and avoid
injury to the epididymis and testicular blood supply.
The scrotal skin is stretched tightly over the anterior surface of the testis and confirm that the epididymis is posterior.
Bilateral 1cm transverse scrotal incision provides good exposure with a minimal scrotal skin bleeding. Alternatively a single vertical incision in
the median raphe may be employed
The incision is carried through the skin and the dartos muscle and the tunica vaginalis is opened.
The edge of the tunica vaginalis are held open with hemostats and any bleeding vessels are cautrerized.
A 3-4mm incision is made in the tunica albuginea with a 15degree microknife and small crossing vessels can be cauterized with a cautery. A pea
sized sample of seminiferous tubules is excised with a pair of Iris scissor.
The specimen is then deposited directly into either Bouins solution, Zenker’s solution or buffered Gluteraldehyde solution.
Then the tunica vaginalis is closed with a running 5-0 polypropylene suture for hemostasis.
The skin may be closed with a 5-0 monocryl suture.
Uses of testicular biopsy:
Diagnostic testicular biopsy is performed only on azoospermia patients.
Most clinician perform bilateral testicular biopsy but in patients with discrepant testicular volume the biopsy on the longer testes is
done.
The purpose of a diagnostic testicular biopsy is to differentiate between obstructive and non obstructive azoospermia.
Testicular biopsy is also performed for the management of patients with non obstructive azoospermia for sperm retrieval and IVF.
The Testicular biopsy may be performed either to obtain prognostic information or to harvest sperm for cryopreservation.
Testicular biopsy is not indicated in patients with oligospermia because the result will not alter theraphy
A Biopsy is rarely performed to rule out partial ductal obstruction in patients with severe Oligospermia, normal sized testes and normal FSH
values.
Interpretation :
The most commonly employed classification patterns are based on the appearance of spermatogenesis ranging from normal to sertoli cells only with
maturation arrest and hypospermato genesis in between
The examination should evaluate the size and the number of semniferous tubules the thickness of the semniferous tubule basement membrane, the relative and
type of germ cells with in the semniferous tubules, the degree of fibrosis in the intrestitium the presence of condition of leydig cells
COMPLICATIONS:
Haematoma
Wound infection
Inadvertent biopsy of the epididymis
Indication :
Indicated in Azoospermia men with testis of normal size and consistency, palpable vasa deferentia and normal FSH levels. Under these circumstances, a
biopsy distinguishes obstructive azoospermia from primary semniferous tubule failure.
The biopsy should be performed bilaterally. Good spermatogenesis is some times found in small firm testes whereas biopsies of larger healthy testes may
reveal maturation arrest.
Open testicular biopsy:
Anaesthesia:
Under local, general or spinal anaesthesia
Antibiotics
IV antibiotics of surgeon’s choice.
Position:
Supine position
When performing testes biopsy, the surgeon must provide an adequate tissue sample using a technique that avoids trauma to the specimen and avoid
injury to the epididymis and testicular blood supply.
The scrotal skin is stretched tightly over the anterior surface of the testis and confirm that the epididymis is posterior.
Bilateral 1cm transverse scrotal incision provides good exposure with a minimal scrotal skin bleeding. Alternatively a single vertical incision in
the median raphe may be employed
The incision is carried through the skin and the dartos muscle and the tunica vaginalis is opened.
The edge of the tunica vaginalis are held open with hemostats and any bleeding vessels are cautrerized.
A 3-4mm incision is made in the tunica albuginea with a 15degree microknife and small crossing vessels can be cauterized with a cautery. A pea
sized sample of seminiferous tubules is excised with a pair of Iris scissor.
The specimen is then deposited directly into either Bouins solution, Zenker’s solution or buffered Gluteraldehyde solution.
Then the tunica vaginalis is closed with a running 5-0 polypropylene suture for hemostasis.
The skin may be closed with a 5-0 monocryl suture.
Uses of testicular biopsy:
Diagnostic testicular biopsy is performed only on azoospermia patients.
Most clinician perform bilateral testicular biopsy but in patients with discrepant testicular volume the biopsy on the longer testes is
done.
The purpose of a diagnostic testicular biopsy is to differentiate between obstructive and non obstructive azoospermia.
Testicular biopsy is also performed for the management of patients with non obstructive azoospermia for sperm retrieval and IVF.
The Testicular biopsy may be performed either to obtain prognostic information or to harvest sperm for cryopreservation.
Testicular biopsy is not indicated in patients with oligospermia because the result will not alter theraphy
A Biopsy is rarely performed to rule out partial ductal obstruction in patients with severe Oligospermia, normal sized testes and normal FSH
values.
Interpretation :
The most commonly employed classification patterns are based on the appearance of spermatogenesis ranging from normal to sertoli cells only with
maturation arrest and hypospermato genesis in between
The examination should evaluate the size and the number of semniferous tubules the thickness of the semniferous tubule basement membrane, the relative and
type of germ cells with in the semniferous tubules, the degree of fibrosis in the intrestitium the presence of condition of leydig cells
COMPLICATIONS:
Haematoma
Wound infection
Inadvertent biopsy of the epididymis
Hypospadias repair
Hypospadias is defined as the abnormal opening of the urethral meatus on the ventral side of the penis proximal to the tip of the glans penis.
Generally it has the
a) Abnormal opening of the urethra
b) Abnormal curvature of the penis commonly known as chordee
c) Dorsal hooding or foreskin
Types
a) Anterior :Glandular
Coronal
Sub coronal
b) Middle: Distal penile
Mid penile
Proximal penile
c) Posterior: Scrotal
Perineal
Penoscrotal
Surgical Technique:
The Hypospadias repair must be done before 2yrs of age
Trolly contains:
1. Marking pen
2. Meatal dilators
3. Tourniquet (Red rubber catheter, or vessel sling or umbilical tape)
4. BP handle 3and 7
5. Surgical blade 15 and 11
6. Paediatric toothed Adson’s forceps
7. Paediatric non toothed Adson’s forceps
8. Debakey forceps
9. Fine scissors curved
10. Fine scissor straight
11. Paediatric short scissor
12. Paediatric fine needle holder
13. Mosquito artery forceps curved 2 1/2”
14. Mosquito artery forceps curved 4”
15. Mosquito artery forceps curved 6”
16. Mosquito artery forceps straight 2 ½”
17. Mosquito artery forceps straight 4”
18. Mosquito artery forceps straight 6”
19. Kidney tray
20. SPC Trocar set
21. Syringe 10ml
22. Syringe 5ml
23. Peanut
24. Feeding tube 6Fr
25. Feeding tube 8 Fr
26. Vessel loop
27. Foleys catheter 6/8/10fr
28. Urobag
Suture Material:
29. 4-0 prolene
30. 6-0PDS
31. 4-0 vicryl
32. 5-0 catgut
33. Bipolar with paediatric forceps
The correction of hypospadias basically involves five principles as
a) Orthoplasty – Correction of chordee
b) Urethroplasty
c) Meatoplasty
d) Glanduloplasty
e) Skin correction
For anterior and middle hypospadias single stage repair is done whereas for posterior hypospadias as multistage technique is preferred.
Techniques of hypospadias repair:
1.FlipFlap Mathew technique
2.Tabularized graft technique
3.Onlay graft technique
4.Tubularized incised plate technique-Snodgrass Technique-Most common procedure used now a days.
Complication
a) Urethrocutaneous fistula
b) Stricture
c) Diverticulum
d) Persistant chordee.
Generally it has the
a) Abnormal opening of the urethra
b) Abnormal curvature of the penis commonly known as chordee
c) Dorsal hooding or foreskin
Types
a) Anterior :Glandular
Coronal
Sub coronal
b) Middle: Distal penile
Mid penile
Proximal penile
c) Posterior: Scrotal
Perineal
Penoscrotal
Surgical Technique:
The Hypospadias repair must be done before 2yrs of age
Trolly contains:
1. Marking pen
2. Meatal dilators
3. Tourniquet (Red rubber catheter, or vessel sling or umbilical tape)
4. BP handle 3and 7
5. Surgical blade 15 and 11
6. Paediatric toothed Adson’s forceps
7. Paediatric non toothed Adson’s forceps
8. Debakey forceps
9. Fine scissors curved
10. Fine scissor straight
11. Paediatric short scissor
12. Paediatric fine needle holder
13. Mosquito artery forceps curved 2 1/2”
14. Mosquito artery forceps curved 4”
15. Mosquito artery forceps curved 6”
16. Mosquito artery forceps straight 2 ½”
17. Mosquito artery forceps straight 4”
18. Mosquito artery forceps straight 6”
19. Kidney tray
20. SPC Trocar set
21. Syringe 10ml
22. Syringe 5ml
23. Peanut
24. Feeding tube 6Fr
25. Feeding tube 8 Fr
26. Vessel loop
27. Foleys catheter 6/8/10fr
28. Urobag
Suture Material:
29. 4-0 prolene
30. 6-0PDS
31. 4-0 vicryl
32. 5-0 catgut
33. Bipolar with paediatric forceps
The correction of hypospadias basically involves five principles as
a) Orthoplasty – Correction of chordee
b) Urethroplasty
c) Meatoplasty
d) Glanduloplasty
e) Skin correction
For anterior and middle hypospadias single stage repair is done whereas for posterior hypospadias as multistage technique is preferred.
Techniques of hypospadias repair:
1.FlipFlap Mathew technique
2.Tabularized graft technique
3.Onlay graft technique
4.Tubularized incised plate technique-Snodgrass Technique-Most common procedure used now a days.
Complication
a) Urethrocutaneous fistula
b) Stricture
c) Diverticulum
d) Persistant chordee.
ENDOPYELOTOMY
Endopyelotomy is one of the method of treatment for adults and older children with primary or secondary pelviureteric junction obstruction.
Indication:
PUJ obstruction – Primary or Secondary associated with small pelvis
Imaging Investigation:
Ultrasound
Intravenous pyelogram
Diuretic renogram
CT scan is essential to look for a crossing vessel.
Procedure
Anaesthesia
General anesthesia
Position
Lithotomy position for cystosopy and prone position for Endopyelotomy
Antibiotics
IV antibiotics based on urine culture report
Things
Surgical procedure
Initially Cystoscopy is performed and 6fr ureteric catheter is placed to allow opacification and distention of the renal pelvis and to assist in passage of a guide wire.
The patient is then placed in prone position and the shoulder and hips are padded to assist in ventilation and prevent pressure complication.
Under fluoroscopic control a posterior middle calyx is accessed, thus providing adequate visualization of the pelviureteric junction while minimizing the incidence of pneumothorax.
The procedure is initiated with transparenchymal route and a guide wire is then passed into the renal pelvis after dilatation of the tract to accomodate a 30fr sheath. A safety guide wire is passed down the ureter into the bladder.
Then the nephroscope is introduced through the amplatz sheath and the pelvicalyceal system is inspected.
A cold knife, laser or electrocautery may be used to incise the tissue.
The incision is oriented posterolaterally . This incision should extend in depth until periureteral fat is visualized and the PUJ is funnel shaped.
An endopyelotomy stent is placed to bridge the incised ureter.
The stent exits the flank as a nephrostomy tube.
The nephrostomy may be clamped and removed after 2-3 days. The stent is generally removed at 6 weeks.
Contraindications for the procedure:
Coagulopathy
Large redundant pelvis
Crossing vessels
Strictures greater than 2cms etc.
Complication:
Failure to relieve obstruction if stenosis is greater than 1.5cm in length.
Intraoperative haemorrhage.
Post operative care:
Antegrade nephrostogram should be performed if the patient has fever,flank pain,irritative voiding symptoms postoperatively.
Advantages :
Reduces operative time
Minimizes blood loss
Less scars and sutures
Short periods of hospitalization.
Indication:
PUJ obstruction – Primary or Secondary associated with small pelvis
Imaging Investigation:
Ultrasound
Intravenous pyelogram
Diuretic renogram
CT scan is essential to look for a crossing vessel.
Procedure
Anaesthesia
General anesthesia
Position
Lithotomy position for cystosopy and prone position for Endopyelotomy
Antibiotics
IV antibiotics based on urine culture report
Things
Surgical procedure
Initially Cystoscopy is performed and 6fr ureteric catheter is placed to allow opacification and distention of the renal pelvis and to assist in passage of a guide wire.
The patient is then placed in prone position and the shoulder and hips are padded to assist in ventilation and prevent pressure complication.
Under fluoroscopic control a posterior middle calyx is accessed, thus providing adequate visualization of the pelviureteric junction while minimizing the incidence of pneumothorax.
The procedure is initiated with transparenchymal route and a guide wire is then passed into the renal pelvis after dilatation of the tract to accomodate a 30fr sheath. A safety guide wire is passed down the ureter into the bladder.
Then the nephroscope is introduced through the amplatz sheath and the pelvicalyceal system is inspected.
A cold knife, laser or electrocautery may be used to incise the tissue.
The incision is oriented posterolaterally . This incision should extend in depth until periureteral fat is visualized and the PUJ is funnel shaped.
An endopyelotomy stent is placed to bridge the incised ureter.
The stent exits the flank as a nephrostomy tube.
The nephrostomy may be clamped and removed after 2-3 days. The stent is generally removed at 6 weeks.
Contraindications for the procedure:
Coagulopathy
Large redundant pelvis
Crossing vessels
Strictures greater than 2cms etc.
Complication:
Failure to relieve obstruction if stenosis is greater than 1.5cm in length.
Intraoperative haemorrhage.
Post operative care:
Antegrade nephrostogram should be performed if the patient has fever,flank pain,irritative voiding symptoms postoperatively.
Advantages :
Reduces operative time
Minimizes blood loss
Less scars and sutures
Short periods of hospitalization.
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