8.3 Genitourinary and Urological Procedures

8.3 Genitourinary and Urological Procedures

Urological surgery focuses on the diagnosis and operative treatment of disorders of the male and female urinary tract (kidneys, ureters, urinary bladder, urethra) and the male reproductive system (prostate, testes, epididymis, vas deferens, seminal vesicles, penis). Genitourinary (GU) procedures range from delicate microscopic vasovasostomies and complex endourological laser interventions to major open and robotic extirpative oncologic resections.

For the Tech in Surgery - Certified (NCCT TS-C) examination, the Intraoperative Care and Preparation category (Surgeon Support) and the Essential Knowledge Base surgical-procedures concept evaluate mastery of cystoscopic equipment assembly, fluid distention thermodynamics and conductivity, resection irrigants, transurethral prostatectomy protocols, open flank positioning, and reconstructive urinary diversions.

---

1. Genitourinary Anatomy and the Retroperitoneal Space

+-----------------------------------------------------------------------------+
|                        GENITOURINARY ANATOMICAL TRACT                       |
|                                                                             |
|        [RIGHT KIDNEY (T12-L3)]                [LEFT KIDNEY (T11-L2)]        |
|        (Retroperitoneal / Lower)              (Retroperitoneal / Higher)    |
|                  |                                      |                   |
|         [Right Renal Hilum]                    [Left Renal Hilum]           |
|          - Renal VEIN (Anterior)                - Renal VEIN (Anterior)     |
|          - Renal ARTERY (Middle)                - Renal ARTERY (Middle)     |
|          - Renal PELVIS (Posterior)             - Renal PELVIS (Posterior)  |
|                  |                                      |                   |
|           Right Ureter                           Left Ureter                |
|       (Over Psoas Muscle)                    (Over Psoas Muscle)            |
|                  |                                      |                   |
|                  +------------------+-------------------+                   |
|                                     |                                       |
|                             [URINARY BLADDER]                               |
|                          (Trigone: 2 UOs + 1 UO)                            |
|                                     |                                       |
|                                 [URETHRA]                                   |
|                         (Female 4cm / Male 20cm)                            |
+-----------------------------------------------------------------------------+

1. Kidneys and Adrenal Glands

• Location: Paired retroperitoneal bean-shaped organs lying on the posterior abdominal wall on either side of the vertebral column (T12 to L3). The right kidney sits slightly lower than the left due to the substantial mass of the overlying liver.
• Fascial Coverings (Superficial to Deep):
  1. Pararenal Fat: Outer layer of retroperitoneal adipose tissue.
  2. Gerota's Fascia (Renal Fascia): Dense, fibrous connective tissue envelope enclosing the kidney, adrenal gland, and perirenal fat.
  3. Perirenal Fat (Adipose Capsule): Thick cushion of fat directly encasing the fibrous capsule.
  4. True Fibrous Capsule: Smooth, tough fibrous membrane intimately adhering to the renal parenchyma.
• Renal Hilum Geometry (V-A-P Rule): The medial indentation where vascular and collecting structures enter and exit. From anterior to posterior, the structures are arranged:
  1. Renal Vein (Most Anterior)
  2. Renal Artery (Middle)
  3. Renal Pelvis / Ureter (Most Posterior)

2. Ureters

• Structure: Thick-walled, retroperitoneal muscular ducts (25–30 cm in length) that transport urine from the renal pelvis to the bladder via active peristaltic contractions.
• Three Physiological Constriction Points (Frequent Stone Impaction Sites):
  1. Ureteropelvic Junction (UPJ): Where the renal pelvis narrows into the proximal ureter.
  2. Crossing of the Iliac Vessels: At the pelvic brim where the ureter crosses anterior to the common/external iliac artery.
  3. Ureterovesical Junction (UVJ): Where the ureter traverses obliquely through the muscular detrusor wall into the bladder (the narrowest point of the entire ureter).

3. Urinary Bladder and Urethra

• Bladder Anatomy: Hollow muscular reservoir situated in the anterior pelvis behind the pubic symphysis. The smooth muscle coat is the detrusor muscle.
• The Trigone: A smooth, fixed triangular region at the bladder base formed by three orifices: the two ureteral orifices (UOs) superiorly/laterally and the internal urethral orifice at the bladder neck inferiorly.
• Urethral Dimensions:
  • Female Urethra: Approximately 4 cm (1.5 inches) in length. Its short span accounts for the significantly higher incidence of ascending urinary tract infections in females.
  • Male Urethra: Approximately 20 cm (8 inches) in length; divided into four anatomical zones: Prostatic urethra (passes through prostate), Membranous urethra (passes through urogenital diaphragm/external sphincter), Bulbar urethra, and Pendulous / Spongy (Penile) urethra (encased in corpus spongiosum).

---

2. Endourological Instrumentation and Procedures

+-----------------------------------------------------------------------------+
|                        RIGID CYSTOSCOPE ANATOMY                             |
|                                                                             |
|   [EYEPIECE / CAMERA] <===== [TELESCOPE (0°, 30°, 70°, 120°)]               |
|                                    |                                        |
|                                    v                                        |
|   [LIGHT POST] <========== [BRIDGE / DEFLECTOR (Albarran)]                  |
|                                    |                                        |
|                                    v                                        |
|   [IRRIGATION STOPCOCKS] <= [OUTER SHEATH (16-24 Fr)] <=== [OBTURATOR]      |
+-----------------------------------------------------------------------------+

1. Cystoscopic Hardware & Optics

• Sheaths (16 to 24 French): Hollow metal tubes through which instruments and fluids pass. Sized according to the French gauge (1 Fr = 0.33 mm diameter).
• Obturator: A smooth, blunt insert placed inside the sheath to prevent mucosal trauma during initial blind insertion through the urethra. Removed immediately once the sheath enters the bladder lumen.
• Optical Telescopes: Rigid rod-lens systems providing specific angles of visualization:
  • 0° Telescope: Direct straight-forward viewing; used for urethroscopy.
  • 30° Telescope: Forward-oblique viewing; standard lens for general bladder inspection, trigone visualization, and ureteral catheterization.
  • 70° Telescope: Lateral viewing; provides wide inspection of the bladder dome, lateral walls, and anterior neck.
  • 120° Telescope: Retrogastric / retrograde viewing; used to inspect the internal bladder neck.
• Albarran Deflector (Bridge): A specialized working bridge featuring a tiny hinged lever mechanism at the tip, manipulated via a thumb screw to direct fine guidewires, catheters, and laser fibers into the ureteral orifices.

2. Diagnostic & Therapeutic Endourology

• Retrograde Pyelogram (RPG): Under fluoroscopic guidance, a small ureteral catheter (e.g., whistle-tip or cone-tip) is passed through the cystoscope and engaged into the ureteral orifice. Radiopaque contrast (Isovue or Hypaque) is injected retrograde up the ureter to delineate filling defects, strictures, or calculi in the ureter and renal pelvis.
• Ureteroscopy (URS) & Laser Lithotripsy: A rigid or flexible semi-rigid ureteroscope (6–9 French) is advanced over a guidewire through the bladder and up the ureter. A Holmium:YAG laser fiber (200–365 micron) or Thulium fiber laser is passed through the working channel to fragment stones into fine dust/sand. Stone fragments are retrieved using nitinol stone baskets (e.g., helical or flat-wire baskets).
• Double-J Ureteral Stent (Pigtail Stent): A flexible polyurethane stent with curled ends placed over a guidewire. Anchors one end in the renal pelvis and the other in the bladder to maintain ureteral drainage following trauma, lithotripsy, or reconstructive surgery.

---

3. Transurethral Resection of the Prostate (TURP)

TURP remains the benchmark surgical intervention for moderate-to-severe urinary outflow obstruction caused by Benign Prostatic Hyperplasia (BPH).

+-----------------------------------------------------------------------------+
|                        TURP RESECTOSCOPE & WORKFLOW                         |
|                                                                             |
|   [RESECTOSCOPE SETUP]                                                      |
|   - Iglesias Working Element (Spring-loaded thumb mechanism)                |
|   - Monopolar or Bipolar Tungsten Cutting Wire Loop                         |
|   - 30° Telescope & High-Flow Dual-Stopcock Continuous Flow Sheath          |
|   - Non-conductive fluid (1.5% Glycine / 3% Sorbitol) or Normal Saline      |
|                                                                             |
|   [INTRAOPERATIVE RESECTION]                                                |
|   - Prostatic adenoma systematically resected into tissue "chips"           |
|   - Ellik Evacuator / Toomey Syringe flushes chips from bladder             |
|   - Technologist strains tissue chips through a mesh filter for pathology   |
|                                                                             |
|   [POST-PROCEDURE DRAINAGE & TRACTION]                                      |
|   - 3-Way 24 Fr Foley Catheter with 30 mL Retention Balloon                 |
|   - Continuous Bladder Irrigation (CBI) initiated to prevent clot block     |
+-----------------------------------------------------------------------------+

TURP Irrigation Fluids & Electrical Safety

• Monopolar Electrosurgical Resection: Requires non-conductive, non-electrolytic irrigating fluids such as 1.5% Glycine or 3% Sorbitol. If electrolyte solutions (e.g., 0.9% Normal Saline) are used with monopolar current, the electrical current disperses through the fluid ions, preventing tissue cutting and causing thermal injury.
• Bipolar Electrosurgical Resection (TURis): Modern bipolar resectoscopes allow the cutting current to pass between the active loop and return ring directly in an isotonic 0.9% Normal Saline bath, substantially lowering the risk of dilutional hyponatremia.

[!CAUTION] TURP Syndrome Pathophysiology and Emergency Management: During prolonged monopolar TURP (>60 minutes) or when high irrigation pressures are used (irrigation bags hung >60 cm above the patient), non-conductive hypotonic fluid (1.5% Glycine) is absorbed directly into the systemic circulation through severed prostatic venous plexuses.

• Clinical Triad: (1) Severe Dilutional Hyponatremia (serum Na+ dropping below 120 mEq/L), (2) Circulatory Fluid Overload / Hypervolemia (hypertension followed by reflex bradycardia, pulmonary edema), and (3) CNS Toxicity (cerebral edema, headache, confusion, blurred vision/transient blindness from glycine retinal toxicity, twitching, seizures, coma).
• Immediate Interventions: (1) Terminate resection immediately, (2) Administer IV loop diuretics (Furosemide / Lasix), (3) Administer IV Hypertonic 3% Saline slowly to restore serum sodium, (4) Insert 3-way Foley and apply balloon traction.

Evacuating Prostatic Chips

Prostatic tissue is resected into small fragments ("chips") that float inside the bladder. The surgeon attaches an Ellik evacuator (a double-glass bulb device filled with sterile irrigant) or a Toomey syringe to the resectoscope sheath, squeezing and releasing the bulb to create a turbulent suction vortex that draws chips into the trap. The surgical technologist empties the evacuator into a mesh specimen strainer, collects all fragments, and submits them in formalin labeled "Prostatic Tissue Chips".

Post-TURP 3-Way Foley Catheter Dynamics

At the conclusion of the procedure, the surgeon places a 3-way 22–24 French Foley catheter with a 30 mL balloon:

• Lumen 1 (Balloon Port): Inflated with 30 to 50 mL of sterile water and pulled taut against the bladder neck / prostatic fossa to mechanically compress venous bleeders (traction hemostasis).
• Lumen 2 (Drainage Port): Drains urine, blood, and irrigation fluid into a collection bag.
• Lumen 3 (Irrigation Inflow Port): Connected to high-volume 3,000 mL bags of sterile saline for Continuous Bladder Irrigation (CBI). CBI flow is titrated to maintain clear, light-pink urinary drainage and prevent intraluminal blood clot formation.

---

4. Open and Robotic Prostatectomy

+-----------------------------------------------------------------------------+
|                   OPEN PROSTATECTOMY APPROACHES (FOR BPH)                   |
|                                                                             |
|   [SUPRAPUBIC (Transvesical)]           [RETROPUBIC (Millin)]               |
|   - Incision: Lower midline             - Incision: Lower midline           |
|   - Entry: ANTERIOR BLADDER WALL        - Entry: ANTERIOR PROSTATIC CAPSULE |
|   - Bladder IS opened                   - Bladder IS NOT opened             |
|   - Ideal for concurrent bladder stones - Excellent anatomical visualization|
|   - Requires suprapubic cystostomy tube - Lower risk of urinary fistulae    |
+-----------------------------------------------------------------------------+

1. Simple Prostatectomy (for Massive Benign Prostatic Hyperplasia >80-100g)

• Suprapubic (Transvesical) Prostatectomy: The space of Retzius is entered, the anterior bladder wall is incised vertically, the bladder lumen is explored, and the surgeon enucleates the hypertrophied prostate lobes digitally from inside the bladder neck. Hemostasis secured with figure-of-eight chromic sutures at 5 and 7 o'clock; requires both a Foley catheter and a Malecot or Pezzer suprapubic cystostomy tube.
• Retropubic (Millin) Prostatectomy: The anterior prostatic capsule is incised transversely without opening the bladder wall. The adenoma is enucleated under direct vision, the capsule is closed with running absorbable sutures, and a standard Foley catheter is placed.

2. Radical Prostatectomy (Open Retropubic & Robotic RALP)

• Indication: Localized adenocarcinoma of the prostate.
• Resection: En bloc removal of the entire prostate gland, seminal vesicles, ampullae of the vasa deferentia, and bilateral pelvic (obturator/iliac) lymph nodes, followed by a meticulous vesicourethral anastomosis between the bladder neck and the transected membranous urethra.
• Robot-Assisted Laparoscopic Prostatectomy (RALP): The modern gold standard utilizing the Da Vinci robotic surgical platform. Patient placed in steep Trendelenburg position (30°–45°). Specialized robotic instruments include Maryland bipolar forceps, ProGrasp forceps, monopolar curved scissors, and large needle drivers. Nerve-Sparing Technique: Precise dissection along the prostatic pseudocapsule preserves the bilateral neurovascular cavernosal bundles running at the posterolateral prostate margins, maximizing postoperative erectile potency and urinary continence.

---

5. Renal, Adrenal, and Transplant Surgery

+-----------------------------------------------------------------------------+
|                   LATERAL DECUBITUS FLANK POSITION FOR KIDNEY               |
|                                                                             |
|                             [Operating Table Flexed]                        |
|                                      /\                                     |
|                                     /  \  <-- Kidney Rest Elevated          |
|             [HEAD]                 /    \                  [FEET]           |
|              (---)               /        \                (====)           |
|             |     |____________/            \______________|    |           |
|                                                                             |
|   * Lower leg FLEXED 90°, upper leg STRAIGHT with pillows between           |
|   * Axillary Roll placed under dependent thorax (protects brachial plexus)  |
|   * Dependent ear and eye padded; kidney incision over 11th or 12th rib     |
+-----------------------------------------------------------------------------+

1. Radical vs. Simple Nephrectomy

• Radical Nephrectomy: Standard treatment for primary Renal Cell Carcinoma (RCC). En bloc resection of the kidney, Gerota's fascia, perirenal fat, ipsilateral adrenal gland, and regional lymph nodes.
  • Critical Vascular Step: The surgical technologist must have heavy vascular clamps (Satinsky, Herrick, Guyon, or DeBakey), heavy silk ties (0 and #1 silk), vascular clips, or an endoscopic vascular stapler loaded and ready. The surgeon strictly ligates and transects the renal artery FIRST before the renal vein. Ligating the renal vein first traps arterial inflow, causing massive renal parenchymal engorgement, swelling, and catastrophic capsular rupture and hemorrhage.
• Partial Nephrectomy (Nephron-Sparing Surgery): Excision of localized renal tumors while preserving remaining functioning renal parenchyma. Renal vessels are temporarily occluded with bulldog vascular clamps; renal hypothermia is achieved by packing the kidney in sterile iced saline slush (extending safe warm ischemia time beyond 20–30 minutes). Defect closed with 2-0/3-0 absorbable sutures on blunt needles over surgical bolsters (Surgicel / Gelfoam).

2. Living-Donor and Cadaveric Kidney Transplantation

• Donor Nephrectomy: The left kidney is routinely preferred for harvesting because the left renal vein is significantly longer than the right (the left renal vein crosses anterior to the aorta to reach the IVC, while the right renal vein drains directly into the adjacent IVC).
• Recipient Heterotopic Implantation: The donor kidney is placed in the recipient's contralateral Iliac Fossa (e.g., left donor kidney implanted into right iliac fossa) within the extraperitoneal space through a Gibson or curved lower quadrant incision.
• The Three Transplant Anastomoses:
  1. Renal Vein: Anastomosed end-to-side to the recipient's External Iliac Vein using continuous 5-0 or 6-0 Polypropylene (Prolene) on a double-armed taper needle.
  2. Renal Artery: Anastomosed end-to-side to the recipient's External Iliac Artery (or end-to-end to the Internal Iliac Artery) using continuous 5-0 or 6-0 Prolene.
  3. Ureteroneocystostomy: The donor ureter is tunneled submucosally through the detrusor muscle and anastomosed to the bladder mucosa using 4-0 or 5-0 absorbable suture (Vicryl/PDS) over a temporary double-J ureteral stent.
• Intraoperative Transplant Pharmacology: Prior to unclamping the vascular anastomoses, the anesthesiologist administers Mannitol (osmotic diuretic to stimulate immediate renal tubular flow), Furosemide (Lasix), and IV Heparin.

---

6. Bladder Extirpation, Urinary Diversions, and Scrotal Surgery

+-----------------------------------------------------------------------------+
|                        ILEAL CONDUIT (BRICKER DIVERSION)                    |
|                                                                             |
|   1. Right & Left Ureters Spatulated & Mobilized                            |
|   2. 15-20 cm Segment of Distal Ileum Isolated (Mesentery Preserved)        |
|   3. Bowel Continuity Restored (GIA / TA Stapled Ileoilial Anastomosis)     |
|   4. Proximal End of Isolated Ileal Segment Closed (TA Stapler / Sutures)   |
|   5. Both Ureters Anastomosed to Proximal Segment (Wallace / Bricker)       |
|   6. Distal End Brought Out as Cutaneous Stoma in RLQ (Everted Rosebud)     |
+-----------------------------------------------------------------------------+

1. Radical Cystectomy & Urinary Diversion

• Indication: Muscle-invasive (Stage T2+) transitional cell carcinoma (urothelial carcinoma) of the bladder.
• Radical Cystectomy Resection Extent:
  • In Males: En bloc resection of the urinary bladder, prostate gland, seminal vesicles, distal ureters, proximal urethra, and bilateral pelvic lymph nodes.
  • In Females (Anterior Pelvic Exenteration): En bloc removal of the bladder, urethra, uterus, fallopian tubes, ovaries, and anterior vaginal wall.
• Ileal Conduit (Bricker Procedure - Non-Continent Diversion):
  • A 15–20 cm segment of terminal ileum (located ~15 cm proximal to the ileocecal valve) is resected, maintaining its vital mesenteric vascular arcade.
  • Bowel continuity is immediately re-established with an ileoileal anastomosis.
  • The proximal end of the isolated ileal loop is oversewn or stapled closed.
  • Both spatulated ureters are anastomosed to the proximal ileal segment (Bricker or Wallace technique) over infant feeding tubes or single-J stents.
  • The distal open end of the conduit is brought through the rectus abdominis muscle in the right lower quadrant and matured as an everted, protruding cutaneous stoma (Brooke / "rosebud" stoma) that drains continuously into an external urostomy appliance bag.
• Continent Diversions:
  • Indiana Pouch: A continent catheterizable reservoir constructed from the cecum and terminal ileum; patient self-catheterizes the stoma periodically.
  • Orthotopic Neobladder (Studer Pouch): An artificial bladder constructed from detubularized ileum, positioned in the native pelvis, and anastomosed directly to the urethra, allowing normal voluntary urethral voiding.

2. Testicular, Scrotal, and Penile Procedures