Genitourinary
Urology
Key Terms to know
• Urinary System • IVP (intravenous pyelogram)
• Renal hilum • BPH (Benign prostatic
• Renal pelvis hyperplasia)
• Renal fascia • Urodynamic studies
• Prostate gland • Cystoscopy
• Hypospadias • Ureteroscopy
• Phimosis
Anatomy – Urinary System
Adrenal glands
Kidneys
Ureters
Bladder
Urethra
Kidney Anatomy
Calyces
Renal pelvis
Renal Artery
Renal Vein
Medulla
Cortex
Ureter
Male Genitourinary Anatomy
• Scrotum
• Testicles
• Epididymis
• Vas deferens
• Seminal vesicles
• Prostate gland
• Bulbourethral glands
• Urethra
• Penis
Female Genitourinary Anatomy
• Kidney
• Adrenal glands
• Ureters
• Bladder
• Urethra
The Urethra
• Female
• Originating at the trigone
• Ending at the meatus
Male
Shared with the reproductive system and is not straight
• Originating at the trigone
• Prostatic urethra
• Membranous urethra
• Cavernous urethra
• Ending at the meatus
Procedural Indications
The purpose of Kidney disease Pain in the pelvis,
urological Urinary tract infections (UTIs): genitals, or kidneys
procedures is to Kidney stones Difficulty emptying or
restore function to Sexually transmitted infections holding the bladder
the GU system
organs, detect and (STIs) Frequent urination
inhibit disease, Prostate cancer Painful urination
including partial or Pelvic inflammatory disease Blood in the urine
total removal of (PID) Unusual smelling urine
diseased tissues and Benign prostatic hyperplasia Pain during sex
supporting (BPH) Pain during or after
structures. Urethritis ejaculation
Interstitial cystitis
Vesicoureteral reflux (VUR)
Congenital
Infections
Pathology Tumors (benign or malignant)
Trauma
Acquired
Culture and sensitivity
Urinalysis (UA: pH, protein, sugar, ketones,
Pre-Op nitrates, WBC, RBC, bilirubin)
Lab Creatinine (waste molecule that is
generated from muscle metabolism.)
BUN (Blood Urea Nitrogen) (Urea nitrogen
is what forms when protein breaks down)
Diagnostic Procedures
• IVP - Intravenous pyelogram
• RGP - Retrograde pyelogram
• KUB – Kidney, Ureters, Bladder
• Cystogram
• Cystoscopy
• Urethrogram
• Urodynamics
KUB/RGP
These are the most
common diagnostics
intraoperatively.
KUB: kidney, ureter,
bladder x-rays. Often helps
with positioning on bed or
to locate stone.
Retrograde pyelogram:
Uses contrast media to
identify stones, tumors, or
cysts of ureters or kidneys.
Major procedures
• Nephrectomy
• Adrenalectomy
• Prostatectomy
• Pyeloplasty ***
• Radical Cystectomy
• Incontinence Procedures
• Ureteral Procedures
Nephrectomy
There are several different pathologies and
approaches to nephrectomy procedures. Careful
positioning is very important!!
Positions
• Positions include supine with sandbag
under hip for subcostal, lateral for flank,
some supine with no modification.
• Need appropriate padding equipment.
• Pillows, foam, olympus pad, arm rest,
axillary roll.
Laparoscopic Nephrectomy
Partial nephrectomy
Thoracoabdominal
Trocars
Flank
Subcostal
Nephrectomy
Specialized GU Instruments
Pedicle clamps
Vascular Lig a Clips
Randall Stone Forceps
Used during open
procedures
involving kidney stones:
• NephroLITHotomy
• PyeloLITHOtomy
Kidney Transplant
Pyeloplasty
Surgical reconstruction or revision of the renal pelvis
to drain and decompress the kidney. Most commonly
it is performed to treat an uretero-pelvic junction
obstruction if residual renal function is adequate.
Adrenalectomy
• Surgical approach is much like that of a nephrectomy since
the adrenals set on top of the kidneys.
• The right adrenal is triangular in shape
• The left is crescent in shape
• Adrenalectomy can be performed for a variety of reasons:
• Adrenal disorders
• Various tumors
• Hormonal therapy
Cushings Syndrome
• Too much cortisol
• Sweating
• Striae
• Dilation of capillaries
• Central obesity
Addison’s Disease
• Not enough cortisol &
aldosterone production
• Fatigue
• Muscle weakness
• Weight loss
Prostrate Gland
• Musculoglandular Structure, Size of
a Chestnut
• Conical; Lies with Base Close to Bladder
• Secretes Alkaline Fluid to Nourish and Give
Mobility to Sperm
Prostatectomy
• Suprapubic: performed for VERY large
but benign disease.
• Radical Retropubic: performed for
cancer.
• Perineal: performed very rarely for
cancer.
• TURP: performed for large, benign
disease.
Suprapubic Prostatectomy
• Transverse or low midline incision in
abdomen.
• Bladder is opened and prostate is
enucleated through bladder. Extra
Count!!
• Increased risk for intraoperative
hemorrhage and post-op leakage of
urine around suprapubic catheter.
TURP
• Transurethral resection of prostate: removal of prostate by
resecting small pieces of tissue by means of electrocautery
or laser.
When setting up for cysto type procedures, you will
always need a cystoscope, light, camera, and fluids.
When doing a TURP you will add a resectoscope, bovie,
a basin of water or glycine and an Ellik evacuator.
Radical Retropubic
• Low midline incision in abdomen.
• Entire prostate is removed including a division of vas
deference and seminal vesicles.
• Reanastomosis of urethra and bladder.
• Usually requires drain.
Perineal Prostatectomy
• Extreme Lithotomy position with perineal
incision.
• Increased risk for intraoperative
hemorrhage.
• Very high risk for post-op incontinence.
Radical Cystectomy
• Complete removal of the bladder.
• Requires ileoconduit with ostomy for
drainage of urine.
• Involved anatomy: bladder, ureters,
intestines.
• Large midline incision through
abdomen.
Incontinence Procedures
• Procedures to eliminate incontinence
problems are numerous.
• Considerations for procedures are:
• Cause of incontinence
• Age of patient
• Health (smoker, diabetic)
• Previous bladder surgery
• Previous prostate surgery
Urodynamic Studies
• When considering a procedure for incontinence, often
studies will be done to determine the degree, type of
incontinence.
• These studies are called Urodynamic studies.
• These determine bladder capacity, ability to empty
bladder, and measure residual urine.
• Urodynamic studies are most often performed in the
doctor’s office.
“Sling procedures” performed transvaginaly have
replaced many of the open abdominal procedures.
Prolapsed bladder
Fascia material for sling
Cystos
• Cystos, ureteroscopies, and TURPs are all performed
endoscopically via urethra.
Resectoscope
Cystoscope set
Flexible cystoscope
Obturator
• Metal rod with blunt, rounded tip
• Prevents end of sheath from abrading
mucosal lining of urethra as it is inserted
• May be either straight or deflecting
Cysto rooms are typically set up with a fluoro
table, leg holders, and x-ray functions. This
allows diagnostic studies and procedures to be
performed at the same time.
Cysto Instrumentation
snowmen
Just for fun !!!!
Bx. Forcep Ball electrode
Injection needle Cytology brush
Kidney Stone Types
• Calcium stones. Most kidney stones • Uric acid stones. Uric acid stones can
are calcium stones, usually in the form in people who are dehydrated,
form of calcium oxalate. Dietary those who eat a high-protein diet and
factors, intestinal bypass surgery those with gout. Certain genetic
and several different metabolic
disorders can increase the factors and disorders of the blood-
concentration of calcium in urine. producing tissues also may predispose
you to uric acid stones.
• Struvite stones. Struvite stones
form in response to an infection, • Cystine stones. These represent only
such as a urinary tract infection. a small percentage of kidney stones.
Struvite stones can grow quickly and They form in people with a hereditary
become quite large. disorder that causes the kidneys to
excrete excessive amounts of certain
amino acid (cystinuria).
Ureteral Stones/Kidney Stones
Noninvasive treatment for stones.
Kidney stones are often “blasted” with a
machine (ESWL) transmitting sound
waves
Ureteral stones - most often removed
endoscopically.
Ureteral Stent with Tether
Catheters
Urethral: Drainage of bladder
Self-retaining, non retaining,
2-way, 3-way
Specialty tips such as coude.
Suprapubic
The most common size for a
foley catheter in an adult pt.
is 14fr.-18fr.
Exceptions are for surgical
procedures, trauma, or scar
tissue.
Sizing of catheters for
children is age and size
dependant.
Catheters
• Ureteral: Drainage of kidney
or identification of ureters.
Much longer and thinner than
urethral catheters
• Used in some open urological
or colon surgeries
Penile/Scrotal
Torsion: Twisting of a testicle, often a
result of trauma or a partially undescended
testicle(children). Requires orchiopexy or
an orchiectomy if the blood supply was
compromised too long.
Hydrocelectomy: Fluid filled sac around
scrotum.
Orchiectomy: Removal of testicle.
Possible reasons are ischemia, infection,
testicular cancer, prostate cancer. Scrotal
approach or inguinal approach.
Hydrocelectomy
Testicular Tumors
Orchiectomy
Medscape
Often an inguinal incision is used
rather than scrotal for suspected cancer.
Scrotal Orchiectomy
Testicular Prosthetic Implant
• Following an orchiectomy,
testicular implants are placed via a
suprapubic or scrotal approach
pending type of implant
Varicocelectomy
• High ligation of gonadal veins of
testes
• To reduce venous backflow of
blood into the venous plexus of the
testes and to improve
spermatogenesis
Chordee Repair
• A congenital downward curvature
of the penis caused by a band of
connective tissue usually between
the opening of the penis and the
glans penis
• Release of the connective tissue
allowing the penis to assume a
normal position
Implants
▪ Penile implants are “Total
Procedures”
▪ Aseptic Technique is very
important!
▪ No Sharps, no lint.
▪ There are a few types of implants
and a few approaches taken for
procedures.
3 piece
inflatable
Semi rigid/malleable
2 piece inflatable
Pediatric Urology
• Hypospadius repair: Urethral opening is on
the ventral side of penis. Different degrees of
severity requiring 1-3 stages of repair.
• Ideally repaired between the ages of 6 months
to 2 years. Need delicate
instrumentation/suture
• Foreskin often does not appear normal at
birth. Circumcision is not performed and
foreskin possibly used during the procedure
with circ. performed as part of the surgery.
Hypospadius
5fr. Pediatric feeding tubes are often used in place of
foley catheters. They are smaller and more flexible.
Orchiopexy
Performed for an undescended
testicle or for a testicle that may
spontaneously twist.
Sometimes requires an inguinal
incision vs. a scrotal incision only.
Often laparoscopically
performed.
Circumcision
• Performed at any stage in life.
Newborn to adult. Slightly
different approach taken
depending on age of patient.
• Suture should be age/size
appropriate
• Treatment of Phimosis or
paraphimosis in adults.
Circumcision
• Dorsal slit
• Placement of bell
• Placement of foreskin over bell
and tying off
• Attachment of bell to arm
• Incision removing the foreskin
Ureteroneocystostomy
(ureteral reimplant)
• Ureteral Reflux: abnormal flow of urine
from your bladder back up the ureters.
• Primary-birth defect in the valve
• Secondary-due to a urinary tract
malfunction, often caused by infection.
• Medications for infection/grow out of
it.
• Deflux: injects a bulking agent around
the opening of the affected ureter to
try to strengthen the valve's ability to
close properly
• Open belly: grade IV-V
Ureteral Reflux
Deflux Tx
Polycystic Kidneys
• Genetic disorder
• Profoundly enlarge the
kidneys
• Reduced kidney function
leading to kidney failure
• Dialysis or kidney
transplantation
Wilm’s Tumor
• Surgery
(nephrectomy)
• Chemo
• Radiation
(depending on
cancer/tissue
cells)
• AKA: Nephroblastoma
• Occurs primarily in children
The End!!