Urological surgery

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23 Urological surgery

Assessment

Examination

Examination should not be confined to the urinary system, as cardiological, neurological and gynaecological problems may be associated with urological symptoms and signs. Many urological patients are elderly and require an assessment of their fitness for further investigations and operative treatment. Furthermore, the patient’s cardiovascular status may be relevant to subsequent treatment: for example, administration of oestrogens for carcinoma of the prostate.

With the patient relaxed, the kidney can be balloted; lifted with one hand placed behind the loin and compressed by the other hand pressing downwards (Fig. 23.1). The ureter cannot be palpated. An enlarged bladder rises centrally out of the pelvis, is dull to percussion and may even be visible. In men, the hernial orifices, cords, testes and epididymes are examined with the patient standing and lying. If the foreskin is uncircumcised, it must be confirmed that it retracts and that the glans and meatus are normal. In women, the vulva, urethra and vagina must also be examined. A speculum examination should be carried out if there is any suspicion of vaginal or cervical abnormality. A full pelvic bimanual examination, whether in males or females, is best carried out under general anaesthesia with a muscle relaxant. A rectal examination is mandatory, not only to examine the prostate but also to detect abnormalities of the anal margin (haemorrhoids, fissures) and lower rectum (carcinoma).

Investigations

Special radiological investigations

In certain circumstances a retrograde ureteropyelogram may be necessary. This involves retrograde injection of contrast material through a catheter placed in the lower ureter (Fig. 23.4). Abnormalities of the renal vessels can be demonstrated by renal angiography. Computed tomography (CT) is now the preferred method for imaging renal tumours. A micturating cystourethrogram (MCU) will outline the bladder, detect ureterovesical reflux and examine the bladder neck and urethra. The bladder is filled with contrast material (via a catheter) and emptying is then studied by X-ray screening. An ascending urethrogram, in which contrast medium is injected into the urethra, can be used to define strictures. When used in conjunction with a MCU, a descending urethrogram can also be obtained.

Nuclear imaging

Radio-labelled substances are used for two main purposes:

Upper urinary tract (kidney and ureter)

Anatomy

The two kidneys lie retroperitoneally on the posterior abdominal wall. Each is approximately 12 cm long, 6 cm wide and 3 cm thick. The upper pole of the kidney lies on the diaphragm, which separates it from the pleura and the 11th and 12th ribs. Below this, it lies on the psoas, quadratus lumborum and transversus abdominis muscles from medial to lateral (Fig. 23.6). Anteriorly, the right kidney is covered by the liver, the second part of the duodenum and the ascending colon. The spleen, stomach, tail of pancreas, left colon and small bowel overlie the left kidney. The renal hilum lies medially and transmits from front to back the renal vein, renal artery and renal pelvis. The ureter begins at the renal pelvis and runs for 25 cm to the bladder. The abdominal ureter lies on the medial edge of the psoas muscle, which separates it from the tips of the transverse processes. It then crosses the bifurcation of the common iliac artery, which separates it from the sacroiliac joint, to enter the pelvis. The pelvic ureter runs on the lateral pelvic wall to just in front of the ischial spine, when it then turns medially and forward to enter the bladder. In the male, it is crossed by the vas deferens. In the female, it lies close to the lateral fornix of the vagina and is crossed by the uterine vessels, where it is vulnerable to damage during hysterectomy. The section of ureter that lies within the bladder wall functions as a flap valve to prevent reflux. Stones tend to impact at the three points where the ureter narrows: namely, the pelviureteric junction, the pelvic brim and the ureteric orifice.

Renal adenocarcinoma

Renal and ureteric calculi

Investigations

IVU or CT KUB provides all the necessary information on the position of the stone (Fig. 23.8). Routine hematological and biochemical tests are needed to assess renal function and to exclude metabolic causes. A urine sample is cultured to determine whether there is infection. If obstruction is acute, its relief is the prime clinical need; if it is chronic and has caused renal damage, the surgical approach depends on the function of the affected kidney. This is best determined by radioisotope methods (renography).

Management

Symptomatic treatment should be instituted as soon as the diagnosis is confirmed. Intramuscular diclofenac, a non-steroidal anti-inflammatory, is the most effective analgesic; pethidine is an alternative. The likelihood of spontaneous passage depends on the size of the stone and on its smoothness. A stone less than 0.5 cm in diameter should pass. Immediate treatment should be considered in cases of ongoing pain, renal obstruction or, more importantly, where there are signs of sepsis (infected obstructed kidney). Extracorporeal shock-wave lithotripsy (ESWL), the technique of focusing external shock waves to break up stones, has revolutionized the treatment of renal and ureteric stones. If a stone can be visualized on X-ray or ultrasound, then it can be treated by ESWL. Other stones can be visualized directly by passing a fine telescope up the ureter (ureteroscope) and the stones may be either broken up or removed intact. Some stones in the kidney that are unlikely to pass even if broken up are best treated by direct puncture of the kidney, insertion of a sheath and removal under vision with a nephroscope (percutaneous nephrolithotomy, PCNL). It is now very rare to remove stones from the renal tract at open operation. In cases of acute obstruction leading to sepsis (infected obstructed kidney) or renal impairment, decompression of the kidney either via insertion of a ureteric stent or percutaneous nephrostomy is required. Stones and infection within a kidney can be the cause of renal destruction and if the kidney contributes less than 10% of total renal function, then a nephrectomy is recommended.

Upper tract obstruction

Obstruction may be due to extrinsic, intrinsic or intraluminal causes (Table 23.1). In the kidney, stones within the pelvicalyceal system and a congenital abnormality of the pelviureteric junction (see below) are the main causes of obstruction leading to hydronephrosis. More rarely, a sloughed renal papilla, blood clot or tumour may be the cause.

Table 23.1 Causes of urinary tract obstruction

Extrinsic

Intrinsic

Intraluminal

Pelviureteric junction obstruction (idiopathic hydronephrosis)

Narrowing of the junction between the renal pelvis and the ureter is a common cause of hydronephrosis. As the aetiology is obscure, the term ‘idiopathic’ hydronephrosis is appropriate. This condition is seen in very young children. It is likely to be congenital and can be bilateral, but gross hydronephrosis may present at any age.

Management

Either laparoscopic or open pyeloplasty is performed to remove the obstructing tissue and refashion the pelviureteric junction (PUJ) so that the lower part of the renal pelvis drains freely into the ureter (Fig. 23.9). It is not possible to predict the degree of recovery of renal function after the relief of obstruction, but a kidney contributing less than 10% of total renal function should be removed.

Retroperitoneal fibrosis

Lower urinary tract (bladder, prostate and urethra)

Anatomy

The bladder is a muscular reservoir that receives urine via the ureters and expels it via the urethra. In children up to 4 years of age, it lies predominantly in the abdomen; in the adult it is a pelvic organ, well protected in the bony pelvis. Superiorly, the bladder is covered with peritoneum, which separates it from coils of small bowel, the sigmoid colon and, in the female, the body of the uterus. Posteriorly lie the rectum, the vas deferens and seminal vesicles in the male, and the vagina and supravaginal cervix in the female. Inferiorly, the neck of the bladder transmits the urethra and fuses with the prostate in the male and with the pelvic fascia in the female.

The bladder is composed of whorls of detrusor muscle, which in the male become circular at the bladder neck. They are richly supplied with sympathetic nerves that cause contraction during ejaculation, thereby preventing semen from entering the bladder (retrograde ejaculation). There is no such sphincter in the female. The bladder is lined with specialized waterproof epithelium, the urothelium. This is thrown into folds over most of the bladder, except the trigone where it is smooth.

The male urethra is 20 cm long; the prostatic urethra descends for 3 cm through the prostate gland, and the membranous urethra is 1–2 cm long and intimately associated with the main urethral sphincter, the rhabdosphincter. The spongy urethra is 15 cm long and is surrounded by the corpus spongiosus throughout its complete length, opening on the tip of the glans penis as the external meatus. The spongy urethra is further subdivided into the proximal bulbar urethra and the distal penile urethra. The female urethra is 3–4 cm long, descending through the pelvic floor surrounded by the urethral sphincter and embedded in the anterior vaginal wall to open between the clitoris and the vagina.

In the male, the prostate is pyramidal, with its base uppermost. It resembles the size and shape of a chestnut and surrounds the prostatic urethra. Traditionally described as having a median and two lateral lobes, it is better considered as being composed of a small central and a larger peripheral zone (Fig. 23.10).

Physiology

The micturition cycle

The micturition cycle has two phases.