genitourinary surgery

FRCS (Gen Surgery): A Road to Success.1st Edition, Doctors Academy Publications, Cardiff, UK, December 2013

Genitourinary surgeryPradip K Datta

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Clinical features

A. A 55-year-old man complains of recurrent dysuria for several months. He has frequency of micturition, suprapubic discomfort,passing turbid and very foul smelling urine. He has no clinical findings and is on the general surgical ward waiting a colonoscopy forincreasing constipation.

B. A 72-year-old man underwent an anterior resection and total mesorectal excision for rectal cancer three days ago. His urinarycatheter was removed in the morning. It is now 9 pm on a Friday and he complains of severe abdominal pain and distension nd hasnot passed any urine since removal of his catheter.

C. A 32-year-old woman has been admitted with increasing pain in her lower abdomen. On examination she has a distended lowerabdomen with a midline suprapubic mass. She has had this problem once before. She is not pregnant.

D. A 28-year-old man has been admitted as an emergency with sudden onset of very severe agonising pain in his left loin radiating to thefront and groin and into his testicle. He is writhing around in pain, is doubled up and is unable to lie still. He also complains ofstrangury.

E. A 22-year-old man complains of sudden onset of very severe pain in his suprapubic area radiating to his left groin and testis. He hasbeen nauseous and vomited a couple of times. On examination his left scrotum looks red and the left testis is pulled up.

F. A 26-year-old man has been admitted through the A & E department with severe pain in his abdomen and left loin having beeninvolved in a scrum while playing rugby. He was given analgesia for suspected lower rib fractures and muscle bruising. Thefirst time he passed urine on the ward it was heavily blood stained.

G. A 48-year-old woman has been admitted with severe pain in her left loin of eight hours duration. The pain is of a dull aching natureassociated with nausea, vomiting and rigors. On examination she is toxic with a temperature of 400 C, tachycardia of 120/min, bloodpressure of 150/70 mm Hg and extremely tender in her loin with overlying skin oedema.

H. A 28-year-old woman has presented with severe pain in her right lumbar region radiating to the iliac fossa and groin. The pain hasdoubled her up and she is unable to lie still in any comfortable position. For the past few weeks she has had dysuria and frequencyof micturition.

As an examination candidate you are expected to know about the diagnosis and immediate emergency management of a few conditions.In the vast majority of hospitals in the UK, urology will be managed by urologists. However, there may be hospitals where enoughurologists are not available so as to be able to provide emergency cover. Under those circumstances, urological emergencies may haveto be admitted under the general surgeons ‘on take’ and then handed over to the urologists later on.

Therefore a limited number of urological emergencies are discussed in this chapter. The diagnosis and emergency management inparticular are dealt with including a brief knowledge of the definitive treatment. In rare instances if the urological unit is not on call, thensome emergency procedures may have to be undertaken by the general surgeon.

The following conditions are discussed. You are expected to match the diagnosis with the clinical features bearing in mind that one singlediagnosis may fit in with more than one clinical scenario.

The following conditions are discussed. You are expected to match the diagnosis with the clinical features.

1. Acute testicular pain

2. Acute ureteric colic

3. Acute urinary retention

4. Pyonephrosis

5. Renal injury

6. Urinary bladder injury

7. Urinary tract infection

Diagnoses

Match the above diagnoses with the clinical features of the various conditions below.

GENITOURINARY SURGERYPradip K Datta

Synopsis

226 Genitourinary surgeryPradip K Datta


I. A 50-year-old woman fell on some rocks on the beach while walking her dog when he gave a sudden pull. She injured her lowerabdomen. She was found to have a fracture of her ischiopubic ramus and was tender in the suprapubic region. She was thereforeadmitted. The first time she passed urine, there was deep haematuria.


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Answer to question 1 : E

Testicular torsion

Questions

1. What will be the differential diagnosis in this patient?

2. What will be your management?

Answers

1. At the age of 22, torsion is the most likely diagnosis. Epidydimo-orchitis is to be excluded. This is much more insiduous in onset.The patient may complain of dysuria and frequnecy of micturition. This may be preceded by urethral discharge. The patient mayfeel feverish. Gentle palpation reveals thickened and tender epidydimis. Presence of pus cells in urine is very suggestive of infectionas would be a recent attack of mumps. The physical finding of relief of pain on elevating the scrotum in epidydimo-orchitis whilstin torsion the pain is worse, is hardly ever possible to elicit in a patient who is in agony.

Torsion of the hydatid of Morgagni is another possibility. Careful clinical examination (observation rather than palpation)would reveal that, although the patient is in pain, the testis looks normal with a blue pea-sized lump at its apex which is exquisitelytender. If the pain is not very severe and has been going on for sometime, a testicular tumour must be excluded. The usualsymptom is one of heaviness but if this gives rise to pain of recent onset, haemorrhage into a tumour might have occurred. Anurgent ultrasound is warranted along with bloods being sent for tumour markers.

2. Precious time should not be wasted in doing investigations. If the condition has lasted for more than 6 hours, the testis is likely tobecome non-viable. Although colour Doppler can be done to look for testicular blood supply, time is at a premium; explorationshould be carried out in case of any doubt. It is much better to explore an epidydimo-orchitis in error than to miss a torsion andnot operate on it thinking that the diagnosis is infection.

The operation for torsion is described in Chapter 21 (Answer 6). If the testis is necrotic, it is removed (consent being takenpreoperatively); the opposite testis is fixed. Insertion of a prosthesis is considered at a later date.

Operation for testicular torsion should be within the capability of any competent general surgeon. There are occasions when theurological unit is in a different hospital at the other end of the city and the patient arrives in another hospital where the accidentand emergency department is situated. It would be an example of gross mismanagement if the patient is transported to a differenthospital to be under the care of the urologist for exploration of testicular torsion and is found to have an infarcted testis only tobe operated upon by a junior urological trainee.

If the patient is found to have a torted hydatid of Morgagni, its base is ligated and appendage removed.

Diagnoses matched with clinical features and images



Answer to question 2 : D, H

Acute ureteric colic

Figure 26.1: Intravenous urogram at 3 hours after injection of contrastshowing the right kidney to have excreted. The left kidney shows delayedexcretion from a stone in the middle one-third of the ureter

Questions for D

1. What is your immediate management?

2. What is your subsequent management?

Answers for D

1. This is one of the most painful conditions that one can suffer from. Those who have had the misfortune to have had a myocardialinfarction in the past, always say that the ‘heart attack’ was much less painful. Therefore the primary aim is to relieve pain as soonas possible. To achieve this, an intravenous cannula is inserted into the back of the hand and 10 mg of morphine with an anti-emeticis given immediately. Although often referred to as ‘renal colic’, strictly speaking the condition should be referred to as ‘uretericcolic’. Colic does not occur in a solid organ like the kidney; colic emanates from a hollow tube like the ureter. Hence the termsshould be ‘renal pain’ and ureteric colic’. The patient is admitted and the analgesia is continued by diclofenac suppositories.

2. Once the patient is comfortable, the diagnosis has to be confirmed as an emergency before handing over to the urologist the nextday. Urine examination will show red blood cells. Spiral CT is ideal to confirm the diagnosis. If this is not readily available, a limitedintravenous urogram (IVU) is done. This would show delayed or no excretion of contrast on the affected side. Under suchcircumstances delayed films are taken at repeated intervals. This would show up the exact site of obstruction (Figure 26.1). Latefilms may also show extravasation of contrast from the renal pelvis into the perinephric space. If that is seen, the interventionalradiologist should decompress the renal pelvis by percutaneous nephrostomy under antibiotic cover.

Questions for H

1. What is your immediate management?

2. What is the subsequent management?

Answers for H

1. The immediate emergency management is the same as in scenario D above.

2. The IVU (Figure 26.2) shows the cause for this patient’s ureteric colic. The pelvicalyceal systems on both sides are facing medially- she has a horseshoe kidney which has an incidence of 1 in 1000. In the majority it is an incidental finding and discovered when anultrasound has been carried out for some other reason. The two kidneys are fused at their lower poles by the isthmus. The ureterstravel downwards having to pass above the isthmus. This anatomical anomaly causes stasis of urine, infection and formation ofstones. In future such a patient may develop pelvi-uretric junction obstruction with its attendent problems.

Stone in middleone-third of leftureter.


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The patient is started on the appropriate antibiotic and she is referred to the urologist. The usual definitive management forureteric stones is shown in Figures 26.3a and b.

Figure 26.2: Intravenous urogram showing horseshoe kidney.

Management of ureteric stone 1

Obstruction +/or Sypmtomatic

Non-obstructed +/or Asymptomatic

Infected Sterile

Urgenttreatment

Earlytreatment

> 5mm < 5mm

Expectant

Figure 26.3a: Management of ureteric stones.

Options of treatment

Upper 1/3 Lower 1/3

Figure 26.3b: Management of ureteric stones.URS = Ureteroscopy US = Ultrasound EHL = Electrohydraulic lithotripsy

Middle 1/3

• Push – pull• Push – bang• Open

URS disintegration +/-stent- US- EHL- Laser- Ballistic- Open

• URS & Dormiabasket

• Ballisticlithotripsy



Answer to question 3 : B, C

Acute urinary retention

Questions for B

1. Describe your management.

2. What might be the long term outcome?

Answers for B

1. This patient needs to be catheterised as soon as possible as abdominal distension will create stress on the incision besides thepatient being in pain and being very uncomfortable. He needs to be given adequate analgesia to make him comfortable and relaxed.Under strict asepsis, with very good uretheral local anaesthetic with gel, a well-lubricated catheter is passed.

Once the patient is up and about, a further trial without catheter is given. If successful, the patient is referred for an electiveurological opinion. If unsuccessful, a catheter is inserted and the patient referred for an urgent urological opinion. In case acatheter cannot be passed, force should never be used.

Difficulty in the passage of a catheter may be because of a large median lobe of the prostate or grossly elongated prostaticurethera from very large lateral lobes. In the latter instance, the reason for failure is that the catheter gets curled up within thelong prostatic urethra. If a catheter cannot be negotiated, a catheter introducer can be tried (Figure 26.4). This should be donepreferably under a general anaesthetic. The Maryfield catheter introducer is a much better instrument than the wire introducer.The latter, used by inserting it into the catheter lumen, is a dangerous instrument liable to produce false passages; it should not beused. The Maryfield catheter introducer should only be used by an experienced surgeon otherwise a false passage may result withdisastrous consequences. If a catheter has not been successfully passed, a suprapubic catheter is introduced (see below fordetails).

If passage of a urethral catheter has been unsuccessful, suprapubic catheterisation is carried out. This procedure should be wellwithin the competence of any general surgeon. Local anaesthetic (LA) is infiltrated in the midline at the highest point where thedome of the bladder is felt. While infiltrating LA, the needle is gently pushed into the baldder and urine aspirated for anatomicalconfirmation. A commercial suprapubic catheterisation kit is available. A sharp knife is used to make a small midline incisionthrough skin and linea alba; the edges are retracted and the trocar and cannula inserted into the bladder. The trocar is removedand the Foley catheter is inserted through the cannula and the balloon inflated. The cannula splits off and is easily removed. Thecatheter is anchored with a purse-string skin suture.

2. Once the acute phase has been successfully treated, the patient requires a urological opinion. Amongst patients who undergo aresection for rectosigmoid carcinoma, 10 -15% fail to pass urine after their bowel operation. This may be due to exacrebation ofpre-existing symptoms of bladder outlet obstruction or neurogenic bladder dysfunction from operative damage to pelvic autonomicplexus of nerves. With the catheter in place the patient is referred for urgent urological opinion for urodynamic studies anddefinitive treatment.

Questions for C

1. What might be the underlying problem in this patient?

2. What is your plan of management?

Answers for C

1. This young woman has had a second episode of acute retention of urine. This should be immediately relieved by analgesia andcatheterisation. The patient should be referred to a neurologist as a neurological event may be the most probable cause eg. anearly symptom of multiple sclerosis.

2. This patient needs thorough medical evaluation followed by consultation by urologist who would ask for urodynamic studies.

Figure 26.4: Maryfield catheter introducer (comes in 3 sizes): The well-lubricated Foley catheter is slottedinto the groove on the convex side of the introducer; both are once again generously lubricated and thenpassed preferably under a general anaesthetic or intravenous sedation.


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2. The immediate management consists of resuscitation of the patient, confirmation of the diagnosis followed by definitive treatment.The patient who is toxic from possible septic shock needs to be given oxygen and started on intravenous fluids and given analgesia;bloods are sent for culture along with routine haematological and biochemical investigations. Intravenous broad spectrum antibioticsare started.

The diagnosis is confirmed by ultrasound of the kidneys and an IVU to make sure that the opposite kidney is functioning normally.The affected kidney will show no function. The interventional radiologist should drain the pus in the renal pelvis by a percutaneousnephrostomy under US or CT guidance. With a catheter in the renal pelvis, the patient should now improve and the acute stagewould have been relieved.

3. The definitive management is to be taken over by the urologist. Once the patient’s parameters (white cell count and inflammatorymarkers) are normal, the cause of obstruction is determined (probably a stone). An isotope renogram would be required to assessthe selective function of the affected kidney. If the kidney function is minimal (< 10%), a subcapsular nephrectomy (Figure 26.6) iscarried out. If the affected kidney has reasonable function, appropriate surgical treatment is carried out to relieve the obstruction.

Answer to question 4 : G

Pyonephrosis

Questions

1. Define and explain the pathology in pyonephrosis.

2. Outline your immediate management.

3. What is the definitive management?

Answers

1. Pyonephrosis is defined as an infected hydronephrsis where the renal pelvis is converted into a bag of pus. The condition may bepreceded by acute pyelonephritis. It may occur as a complication of an impacted stone in the renal pelvis or a stag-horn calculus(Figure 26.5). Unless promptly treated, it results in rapid destruction of renal parenchyma and loss of function of the affectedkidney.

Figure 26.5: Plain x-ray of abdomen showing stag-horn calculusof right kidney.



Figure 26.6: Subcapsular nephrectomy for pyonephrosis where the kidney had minimal function.


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Answer to question 5 : F

Renal injury

Figure 26.7a: IVU in left renal injury Showing:(i) scoliosis with concavity to left, (ii) elevation of left hemidiaphragm, (iii)extravasation of contrast, (iv) loss of left psoas shadow, (v) normal right kidney.



Figure 26.7b: IVU of same patient as in Figure 26.7a : normal function 6 months later following conservativemanagement for the renal injury.

Questions

1. Describe your initial management.

2. What is your definitive management?

Answers

1. This patient should be resuscitated following blunt injury to his left loin and abdomen. It is presumed that the ATLS protocol wouldhave been followed. His airway would be fine and will have been on oxygen. He should be given analgesia and thoroughly examined.There may be loss of the loin curve from a perirenal haematoma – a sign best observed from the back. Abdominal examination isdone to exclude any intraperitoneal injury. Bloods are sent for routine haematological and biochemical investigations. This shouldbe followed by an IVU which is primarily done to make sure that the other kidney is normal; it may also show obliteration of thepsoas shadow from a perinephric haematoma and urinary extravasation (Figure 26.7a). An ultrasound is done to assess the size ofthe haematoma. Every time the patient passes urine a specimen is stored preferably in a transparent bottle with the time writtenon the bottle (Figure 26.8). This would give an idea if the haematuria is getting less with time in which case observation cancontinue. If the condition of the patient deteriorates, it may indicate other intraperitoneal injuries and a contrast CT scan shouldbe done. The urologist should be involved whilst these investigations are in the pipeline.


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2. The definitive management is referral to the urologist. One should be aware that haematuria following minor trauma in a youngfit individual indicates a congenital abnormality of the kidney such as congenital hydronephrosis (pelvi-ureteric junction obstruction)or a horse-shoe kidney. In the latter blunt trauma to the central abdomen may cause haematuria.

In a situation where a laparotomy is indicated for intra-abdominal trauma where renal damage has been diagnosed preoperatively,the operation is carried out as a team with the urologist. A transperitoneal incision is always made. This is because it would beeasier to control the renal vessels from the front and also other injuries can be seen and dealt with appropriately. If there is noother organ injury and the only abnormality seen at laparotomy is a perirenal haematoma, this should not be disturbed and leftalone as it is well contained in the retroperitoneal space. Exploring a perirenal haematoma almost always results in an unnecessarynephrectomy. Sometimes prior to laparotomy when haematuria is persistent, consultation with the interventional radiologist forthe possibility of selective renal angiography is worth discussing; renal artery embolisation might be considered. In the vastmajority of isolated renal injuries, the usual management is conservative with repeated US to make sure that the perirenalhaematoma has resolved followed by an IVU to determine return of normal renal function (Figure 26.7b).

Figure 26.8: Conservative management in renal injury: urine saved at repeated intervals toshow that haematuria is diminishing.



Answer to question 6 : I

Urinary bladder injury

Questions

1. Why do you think this patient has haematuria?

2. What is your management?

Answers

1. This patient has haematuria because the fracture pelvis has resulted in damage to her urinary bladder. This could be due tobladder contusion or rupture. The latter would most probably be extraperitoneal considering that she has a fracture of her pelvis.

2. The management should be bed rest, analgesia and an indwelling catheter. This would prevent clot retention of urine. Moreover,the exact type of injury could be determined by doing a cystogram through the catheter (Figure 26.9). In the female it amounts torupture at the bladder neck which in effect is extraperitoneal rupture of the bladder. The definitive treatment is to leave thecatheter for two to three weeks. The management is well within the competence of the general surgeon. An algorithm for traumato the genitourinary tract is shown in Figure 26.10.

Cystogram showingextravasation of urinefrom extra-peritonealrupture of bladder

Figure 26.9: Cystogram showing extravasation of urine from extra- peri-toneal rupture of bladder.

Management of trauma of the genito-urinary tract

Kidneys Ureters Urinary bladder Urethra

Usually from bluntabdominal trauma

Usually iatrogenicMembranousBulbous

? Urethrogram

SPC

- US- CT- Renal angiogram if embolisation contemplated- Conservative

Operation Extra-peritoneal 80%

Intraperitoneal20%

Laparotomy SPC or in femalesurethral catheter

SPC= Supra-pubic cystostomy

Figure 26.10: Algorithm for the management of trauma of the genito-urinary tract.


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Answer to question 7 : A

Urinary tract infection (UTI)

Air in urinary bladderFigure 26.11: C T scan in colo-vesical fistula showing air in the urinary bladder.

Air in urinarybladder

Figure 26.12: Barium enema in colo-vesical fistula showing air in the urinary bladder.



Questions

1. What might be the cause of this patient’s UTI?

2. How are you going to investigate this patient?

3. What is your treatment?

Answers

1. This patient has features of UTI with the passage of foul smelling urine. He is awaiting colonoscpy for constipation which meansthat he has symptoms of possible chronic large bowel obstruction. In the absence of symptoms of bladder outflow obstruction,recurrent UTI in a male should alert one to the possibility of vesico-colic fistula. Constipation gives greater credence to that as acause. A symptom that patients do not volunteer is pneumaturia; hence a leading question with regard to passing air bubbles in theurine needs to be asked. The foul smelling urine is due to faecaluria. The large bowel needs to be investigated with this in mind.The conditions responsible for such a fistula are: sigmoid diverticulitis, sigmoid carcinoma and colonic Crohn’s disease.

2. Besides doing all the routine haematological and biochemical investigations including inflammatory markers, urine should be sentfor culture and sensitivity (MSU for C & S) and the patient started on appropriate antibiotics until the culture report is obtained.The patient needs a colonoscopy. In case of diverticulitis full colonoscopy may not be possible because of diverticular stricture.Biopsy is done of abnormal areas and colonic carcinoma is excluded. Contrast CT scan is done to visualise the entire large boweland air in the urinary baldder (Figure 26.11); barium enema as an alternative investigation may show air in the urinary bladder(Figure 26.12) or barium in the urinary bladder (Figure 26.13). If there is a suggestion of haematuria in the history, cystoscopy isdone. This is useful to wash out the bladder as it may be full of debris of faecal origin. Interestingly, an inflamed area may be seenin the vault of the bladder from which air bubbles may be seen to come out.

3. Once the presence of the vesico-colic has been established and the cause confirmed, definitive treatment is carried out. Thepatient is operated upon with a view to colonic resection according to the formal protocols of bowel preparation, antibiotic coverand DVT prophylaxis.

If the diagnosis is diverticular disease, the inflamed bowel will be found to be stuck to the vault of the urinary bladder. The bowelsegment needs to be pinched off the bladder, the site of the fistulous tract in the bladder closed and sigmoid resection (anteriorresection) with end-to-end anastomosis carried out. An indwelling urinary catheter is left for a week.

If the underlying cause for the fistula is a colonic carcinoma, an adequate portion of the bladder wall is resected as a formal partialcystectomy with en bloc anterior resection and end-to-end anastomosis. The bladder is repaired around an indwelling catheterwhich is left for 10 days. This procedure is best done as a team with the urologist, particularly because this patient should be onregular cystoscopic survelliance as a post-operative follow up.

In case the cause is colonic Crohn’s disease, the procedure should be similar to the one above but the extent of bladder resectionneeds to be minimal.

Figure 26.13: Barium enema in colovesical fistula showing barium in urinary bladder.Barium in urinary bladder

genitourinary surgery

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