Circumcision Overall Purpose of Procedure Performed to prevent infection and inflammation of the glans a lower risk of urinary tract infections penile cancer and sexually transmitted diseases ID: 933270
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Slide1
GU Procedures
Operative Sequence
Slide2CircumcisionOverall Purpose of Procedure:Performed to prevent infection and inflammation of the glans.a lower risk of urinary tract infections, penile cancer and sexually transmitted diseases.
Circumcision may also be used to treat Phimosis: a constriction of the opening of the foreskin so that it cannot be drawn back over the tip of the penis.
Slide3CircumcisionDefine the procedure: Circumcision is the removal of some or all of the foreskin (Prepuce) from the penis
Slide4CircumcisionWound Classification: 1
Slide5Operative Sequence1- Incision2- Hemostasis3- Dissection
4- Exposure5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application
Slide6CircumcisionInstrumentation: Minor Instrument Tray/ Ped Tray (age specific).
What basic instruments will you expect to see in this tray? Positioning
: The patient is in supine position, arms tucked at the side or on arm boards. Surgeon stands on the left side of the patient.
Prepping
: Surgeon preference.
Hibiclense
or a
Betadine
Prep Kit. Prep groin area and far lateral on both sides.
Draping
: Standard draping procedure. 4 towels and a lap drape. Ask about towel clips.
Age specific – if
ped
- MD might want
ped
drape.
Slide7Circumcision cont. Operative SequenceDissection and Exposure
:Clamps are placed on the edge of the prepuce
.
Slide8Circumcision cont. Operative SequenceHemostasis: Handheld Bovie, hemostats, and free ties are utilized.
Slide9Circumcision Begin your Operative SequenceIncision
: 15 kb on #3 handle or Iris scissors for incision.
Slide10Circumcision cont. Operative SequenceExploration and Isolation: Any?
Slide11Circumcision cont. Operative SequenceSurgical Repair/Removal/Specimen Collection:
Iris, Tenotomy or Metz.
Long Incision on the dorsal side of the foreskin.
Incision is continued round the foreskin, circumferentially
.
Slide12Circumcision cont. Operative SequenceHemostasis and Irrigation:All bleeding is controlled with cautery. Use of warm Saline to irrigate.
Slide13Circumcision cont. Operative SequenceClosure:Wound edges are brought together with small absorbable suture.
Incision is dressed with wet gauze, petroleum impregnated gauze.
Slide14CircumcisionMajor Arteries:The dorsal arteries, which run in the interval between the corpora cavernosa on each side of the deep dorsal vein.
The dorsal and deep arteries are branches of the internal pudendal arteries.
The deep arteries are the principal vessels that supply the cavernous spaces (erectile tissue) in the three corpora.
Slide15CircumcisionMajor Veins:Blood from the cavernous spaces is drained by a venous plexus that joins the deep dorsal vein located in the deep fascia.
Major Nerves: pudendal nerve.
Slide16Orchidopexy
(aka –
Orchiopexy
)
GU Procedures
Operative Sequence
Slide17OrchidopexyDefine the procedure:to move an undescended testicle into the scrotum
Overall Purpose of Procedure:Relieve Cryptorchidism - a medical term referring to absence from the scrotum of one or both testes. This usually represents failure of the testis to move, or "descend," during fetal development.
Can lead to sterility due to heat in the abdomen.
Orchiopexy can also be performed to resolve a testicular torsion. If caught early enough and the blood supply can be restored to the testicle, this operation can be performed to prevent further occurrence of torsion.
Slide18OrchidopexyWound Classification: 1
Slide19Operative Sequence1- Incision2- Hemostasis3- Dissection
4- Exposure5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application
Slide20OrchidopexyInstrumentation: Minor Tray
Positioning: The patient is in supine position arms on arm boards.
Prepping
: Surgeon preference. Hibiclense or a Betadine Prep Kit. Prep from pubic line to iliac crest to groin and far lateral on both sides.
Draping
: 4 towels and a lap drape. Ask about towel clips.
Slide21Orchidopexy Begin your Operative SequenceIncision: 15 kb on #3 handle for incision.
Incision over the external ring, extended into the deep inguinal ring
.
Anything wrong with this picture?
Slide22Orchidopexy cont. Operative SequenceHemostasis: Handheld Bovie and hemostats are utilized.
Slide23Orchidopexy cont. Operative SequenceDissection and Exposure:
Metz for dissection.Blunt dissection also used to ID Spermatic cord.
Slide24Orchidopexy cont. Operative SequenceExploration and Isolation:
The spermatic cord is freed high into the inguinal ring to provide enough slackness for the testicle to fall into the scrotum.
Slide25Orchidopexy cont. Operative SequenceSurgical Repair/Removal/Specimen Collection
:A tunnel must be created thru the external oblique fascia for the testicle to follow into the scrotum.
This tunnel can be created with blunt dissection or a
kelly
clamp.
Slide26Orchidopexy cont. Operative SequenceSurgical Repair/Removal/Specimen Collection
:A small incision is made into the scrotum to expose the scrotal septum.
The testicle is moved thru the tunnel into the scrotum.
Sutures (Chromic) are placed into the testicle and scrotal septum to hold testicle into place.
Slide27Orchidopexy cont. Operative SequenceHemostasis and Irrigation:Controlled with ESU.Warm Saline
Closure:Surgeon choice – Chromic with Bacitracin oint.
Slide28OrchidopexyMajor Arteries:external and internal pudendal arteries
Major Veins:The
scrotal veins
accompany the
arteries
and
join
the
external pudendal veins
.
Slide29Simple Nephrectomy
GU Procedures
Operative Sequence
Slide30Simple (Open) NephrectomyOverall Purpose of Procedure:The reasons for performing a simple nephrectomy include:
Cancer in the kidney. Large
stones in the kidney.
The kidney may be damaged and very small, causing high blood pressure.
The kidney may have an infection that antibiotic treatment cannot cure
.
Slide31Simple vs RadicalA simple nephrectomy is indicated in patients with irreversible kidney damage due to symptomatic chronic infection, obstruction, calculus disease, or severe traumatic injury.
Simple nephrectomy is also indicated to treat renovascular
hypertension due to
noncorrectable
renal artery disease or severe unilateral
parenchymal
damage caused by
nephrosclerosis
,
pyelonephritis
, reflux dysplasia, or congenital dysplasia of the kidney
.
Sometimes, just a part of the kidney may be removed
Slide32Simple vs RadicalRadical nephrectomy is the treatment of choice for localized renal cell carcinoma (RCC). In certain circumstances, radical nephrectomy is also indicated to treat locally advanced RCC and metastatic RCC.
Radical nephrectomy remains the procedure of choice for surgically resectable lesions
.
Your surgeon will also take out the adrenal gland and some lymph nodes.
Slide33Simple NephrectomyDefine the procedure: A simple nephrectomy is removal of an entire kidney. Wound Classification
: 1 WHY IS IT A CLASS 1?
Slide34Operative Sequence1- Incision2- Hemostasis3- Dissection
4- Exposure5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application
Slide35Simple NephrectomyInstrumentation: Major Tray, Long Abdominal Tray, Self Retaining Ret x2, Chest/Rib Tray (if you facility has one) Have Vascular tray in room -hold
What basic instruments will you expect to see in the Chest/Rib tray?
Positioning
: The patient is in lateral kidney position, lower arm tucked at the side or on an arm board, upper arm on arm board/
airplaned
. 2 Surgeons for this procedure. One in front of and one in back of patient.
Prepping
: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Prep from nipple line to iliac crest and far lateral on both sides.
Draping
: 4 towels and a lap drape. Ask about towel clips.
Slide36Simple Nephrectomy Begin your Operative SequenceIncision
: 10 kb on #3 handle for incision.Flank incision
Incision over or between the 11
th
or 12
th
rib
.
Another approach – less used- incision under the rib cage.
Slide37Simple Nephrectomy Begin your Operative SequenceIncision:
If the surgeon(s) wants to remove the rib, instead of going between the ribs:Need Doyen rib rasp to remove the periosteum from the bone.
Have rib shear ready to remove bone.
Usually not sent as a specimen.
Do not take home with you for rib roast.
Slide38Simple Nephrectomy cont. Operative SequenceHemostasis: Handheld Bovie, hemostats, Hemoclips, and free ties are utilized.
Slide39Simple Nephrectomy cont. Operative SequenceDissection and Exposure:
Self retaining retractor is placed in wound.Some surgeons use two
Balfours
.
Slide40Simple Nephrectomy cont. Operative SequenceExploration and Isolation:
Incision is made thru the subcutaneous and oblique muscles.
Gerota's Capsule is
ID’d
A fibrous envelope of tissue that surrounds the kidney. Also called renal fascia and Gerota's fascia.
Slide41Simple Nephrectomy cont. Operative SequenceSurgical Repair/Removal/Specimen Collection
:The ureter is identified, clamped and ligated.
The kidney pedicle and renal Artery and Renal Vein are clamped and ligated.
Renal Vessels are usually triple clamped/tied for safety
.
Slide42Simple Nephrectomy cont. Operative SequenceSurgical Repair/Removal/Specimen Collection:
Care is taken to not damage the ureter.The kidney is then mobilized with blunt dissection.
The kidney is then removed from the wound.
Check the pedicle vessels for bleeding.
Slide43Simple Nephrectomy cont. Operative SequenceHemostasis and Irrigation:Controlled with ESU and chemical hemostasis.
Warm SalineClosure:Surgeon choice
Are we putting the rib back?
Slide44Simple NephrectomyMajor Arteries:Renal Arteries
Slide45Simple NephrectomyMajor Veins:The renal veins drain into the IVC.Major Nerves: renal plexus
Slide46Lap Hand Assisted NephrectomyWatch this video!This is how most nephrectomies are completed today.
Hand Assisted
Slide47Cysto
and TURP
Suprapubic
Prostatectomy
GU Procedures
Operative Sequence
Slide48CystoscopyCystoscopy is a procedure that allows the doctor to look at the inside of the bladder and the urethra using a thin, lighted instrument called a cystoscope
Slide49Cysto
Slide50Cysto
Slide51CystoCystoscopy may be done to:Find the cause of symptoms such as blood in the urine (hematuria), painful urination (
dysuria), urinary incontinence, urinary frequency or hesitancy, an inability to pass urine (retention), or a sudden and overwhelming need to urinate (urgency).
Slide52CystoFind the cause of problems of the urinary tract, such as frequent, repeated urinary tract infections or urinary tract infections that do not respond to treatment. Look for problems in the urinary tract, such as blockage in the urethra caused by an enlarged prostate, kidney stones, or tumors
Evaluate problems that cannot be seen on X-ray or to further investigate problems detected by ultrasound or during intravenous pyelography
(IVP), such as kidney stones or tumors.
Slide53CystoRemove tissue samples for biopsy. Remove foreign objects. Place ureteral catheters (stents) to help urine flow from the kidneys to the bladder.
Treat urinary tract problems. For example, cystoscopy
can be done to remove urinary tract stones or growths, treat bleeding in the bladder, relieve blockages in the urethra, or treat or remove tumors.
Place a catheter in the
ureter
for an X-ray test called retrograde
pyelography
. A dye that shows up on an X-ray picture is injected through the catheter to fill and outline the
ureter
and the inside of the kidney.
Slide54TURP(TRANSURETHRAL RESECTION OF PROSTATE).During transurethral resection of the prostate (TURP), an instrument is inserted up the urethra to remove the section of the prostate that is blocking urine flow.
Slide55TURPTURP is now the most common surgery used to remove part of an enlarged prostate. Open prostatectomies (in which an incision is made into the abdomen) generally are needed only when the prostate is very large.
Slide56TURP
Slide57TURP
Slide58FluidsOld School: Glycine is fluid of choiceNew School
: NACL!!! Usually the team will not use NACL due to the fact that they can’t use the electrode needed for a TURP with NACL present. However, too much NACL will throw the fluid balance of your patient off. Your pt can end up with fluid toxicity!
New systems are bipolar instead of monopolar.
Slide59Suprapubic Prostatectomy
Slide60Suprapubic Prostatectomy
Slide61Suprapubic ProstatectomyOverall Purpose of Procedure:Performed to treat BPH (benign prostatic hypertrophy) and for cancer of the prostate.Inguinal nodes may be removed for diagnosis of metastasis.
Slide62Suprapubic ProstatectomyDefine the procedure: The prostate gland is removed via a
suprapubic (above the pubic bone) incision.Three primary approaches are commonly employed:
S
uprapubic
- removal through an incision above the pubis and through the urinary bladder;
R
etropubic
– same incision as for
suprapubic
but without entering the urinary
bladder
Transurethral
(TRANSURETHRAL RESECTION OF PROSTATE).
Slide63Radical vs Simple Radical vs Simple Prostatectomy
Radical – nerve sparingSimple – not so much! Simple coring of the prostate. No nerves spared.
Slide64Suprapubic ProstatectomyThe major advantage of the suprapubic approach over the retropubic approach is that it permits better visualization of the bladder neck and
ureteral orifices and, therefore, is better suited for patients with the following conditions:
Enlarged, protuberant, median prostatic lobe
Bladder
diverticulum
Large bladder
calculi
Obesity (to a degree that makes access to the
retropubic
space more difficult)
Slide65Bladder Diverticulum
Slide66Suprapubic ProstatectomyWound Classification: 2
Slide67Operative Sequence1- Incision2- Hemostasis3- Dissection
4- Exposure5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application
Slide68Suprapubic ProstatectomyInstrumentation: Major Tray, Long Abdominal Tray, Self Retaining Ret, Prostate Tray (if you facility has one) Have Vascular tray in room -holdWhat basic instruments will you expect to see in the Prostate tray? McDougal?
Positioning
: The patient is in supine position (possible low Lithotomy), arms tucked at the side or on arm boards. Surgeon stands on the left side of the patient. Slight Trendelenburg possible, might need shoulder boards.
Prepping
: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Prep mid-chest to groin area and far lateral on both sides. Watch for pooling of prep around groin. Catheter?
Draping
: 4 towels ( Top, side, side, under scrotum) and a lap drape. Ask about towel clips.
Slide69Suprapubic Prostatectomy Begin your Operative SequenceIncision
: 10 kb on #3 handle for incision.Made into the space of Retzius
(named after a Swedish professor of anatomy, Anders
Retzius
.)
The separation of
transversalis
fascia and peritoneum contains loose fatty tissue allowing for the filling of the bladder. This space is called the
retropubic
space of
Retzius
.
Slide70Suprapubic Prostatectomy cont. Operative SequenceHemostasis: Handheld Bovie, hemostats, Hemoclips, and free ties are utilized.
Slide71Suprapubic Prostatectomy cont. Operative SequenceDissection and Exposure:
Self retaining retractor is placed in wound.Have MANY sutures available.
Chromic,
Vicryl, Monocryl
etc
.
Slide72Suprapubic Prostatectomy cont. Operative SequenceExploration and Isolation:2 traction sutures or Allis Clamps are placed in the bladder wall and an incision is made between them (
cystotomy).
The bladder wall edges are them lifted up and away, providing visualization of the bladder neck, ureters and prostate
.
Slide73Suprapubic Prostatectomy cont. Operative SequenceSurgical Repair/Removal/Specimen Collection:
Prostate mucosa is incised with the ESU.Bladder neck is incised with the ESU.
Urethra is transected.
Enucleation = in this case it means to remove the prostate en bloc without trauma to the bed of the tissue.
(
Enucleation
usually
refers to the removal of the eye, leaving the eye muscles and remaining orbital contents intact)
Slide74Suprapubic Prostatectomy cont. Operative SequenceSurgical Repair/Removal/Specimen Collection:This is where the book goes into closure.
What step have we not covered?
Slide75Suprapubic Prostatectomy cont. Operative SequenceSurgical Repair:
We must reattach the urethra!Using 2-0 Vicral sutures on 5-8 circle tapered needles, full thickness sutures are placed at 12, 3, 6, and 9 o'clock positions through the urethral mucosa, smooth muscle, striated urethral sphincter, and fascia. At the 6 o'clock position the suture is placed with care to avoid injuring the neurovascular bundles, which are located posterior to the striated sphincter. At the 12 o'clock position the suture incorporates the anterior dorsal vein/striated urethra sphincter hood.
Slide76Suprapubic Prostatectomy cont. Operative SequenceHemostasis and Irrigation:Many, many, many chromic and Vicryl sutures and hemoclips and ESUWarm Saline
Closure:Surgeon choice
Slide77Suprapubic ProstatectomyMajor Arteries:the inferior vesical and middle rectal arteries which are branches of the internal iliac artery.
Slide78Suprapubic ProstatectomyMajor Veins:prostatic venous plexus around the sides and base of the prostate which drains into the internal iliac veins. Major Nerves:
Parasympathetic fibers arise from the pelvic splanchnic nerves (S2, S3, and S4). The sympathetic fibers are from the inferior hypogastric plexuses.
Slide79VidsRobotic: Weill Cornell Robotic Prostatectomy
Actual View:
Nerve Sparing Prostate Cancer
Slide80Penile Implant
Slide81Penile Implant
Slide82ImplantsPenile implants are artificial devices implanted inside the penis that allow men with erectile dysfunction (ED) to achieve an erection. They're also sometimes used to treat Peyronie's disease, a disorder that causes bent or painful erections. There are two basic designs of implants:
Inflatable. Also called hydraulic, inflatable implants can be pumped up to create an erection and then deflated.
Semirigid
.
These implants are always somewhat firm.
Slide83HistoryFirst introduced in the 1970s, penile implants were the most reliable treatment for erectile dysfunction until the 1980s when medications injected into the penis became available. In the 1990s, oral agents such as sildenafil (Viagra) were introduced.
Slide84There are two basic types of penile implants1) Semirigid rods.
This type of implant is always firm. The penis may be bent away from the body to have sex and toward the body to conceal the device.
Slide85Old SchoolOld School manual implant.
Slide86New School
Slide872) Inflatable implantsThree-piece implants use a fluid-filled reservoir implanted under the abdominal wall, a pump-and-release valve placed inside the scrotum, and two inflatable cylinders inside the penis. Before sex, the patient pumps the fluid from the reservoir into the cylinders to cause an erection. After sex, the pt release the valve inside the scrotum to drain the fluid back into the reservoir.
The two-piece model currently available in the United States works in a similar way to a three-piece design, but the fluid reservoir is part of the pump mechanism implanted in the scrotum.
Slide88New SchoolPumps in abdomen, thigh or scrotum.
Slide89Slide90Slide91In the United States, inflatable devices are the most common type of penile implant.Three-piece inflatable devices are used in about 70 percent of penile implants. Two-piece inflatable devices are used about 20 percent of the time. Semirigid devices are the least used, accounting for about 10 percent of implants.
Slide92Penile Implant - Minimally Invasive Perito TechniqueA “must watch” video!