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
Monday, March 2, 2009
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.
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