Chapter 4 Urinary Tract Surgery

   

 4.1 PRE-REQUIST:

Knowledge of:

• - Anatomy
• - Physiology
• - GPE
• - Urinary Tract Exam (UTE)

Palpate: Kidney, Bladder, Prostate, Urethra for size, shape, contour, consistency, thickness, masses & pain

UTE Must Include:

• - TPR, CRT - Mouth; - ulcers, pallor, uremic breath
• - Abdominal palpation: Pain
• Kidney: - sym; contour, consistency, size, pain
• - Prostate: - Size, shape, position, pain

Other diagnostics required:

• CBC, UA
• Electrolyte Ca.P. Na, K, cl
• Radiograph, Renal function test

Excretory urograms:

• Quantitative assessment of renal anatomical capacity.
• Obst. uropathy
• Congenital anomalies
• Radiolucent uroliths
• kidney rupture

4.2 KIDNEYS:

• Smooth, bean shaped
• Rt - (T13) L1, L2, L3
• L - L2, L3, L4

Have to be absolutly sure of remaining kidney function 

Anesthesia:

Minimal anesthesia is optimal anesthesia

• - Reversible narcotic agents, nitrous oxide & O2
• - Ketamine & Methoxyflurane contra-indicated due their renal involvement
• - Biotal & Halothane
• - Epidural & Spinal 

4.3 NEPHRECTOMY:

INDICATIONS:

• Unilateral conditions e.g.
• Solitary Renal cysts
• HIydronephrosis
• Polycystic disease with pyelonepheritis
• Dioctophyma renale
• Neoplasia
• Traumatic Renal rupture
• Ectopic ureters 

Technique for Nephrectomy:

• Position: Dorsal recumbency
• Incision: xiphoid to umbilicus; midline wound edges retracted by Belfour retractor
• Procedure:
• - lift descending portion of duodenum to expose right kidney
• - lift descending colon to expose left kidney with tissue forceps, grasp the peritoneum over the caudal pole of the kidney and incise with scissors
• - Insert a finger in the opening and peel the peritoneum from the kidney
• - Reflect perirenal fat to expose renal artery, vein and ureter
• - ureter is ligated as close to the bladder as possible and devided between ligatures.
• - Separately ligate renal artry & vein using a three clamp technique with 2/0 non absorbable suture.
• - The clamp closest to aorta is removed and 1st ligature tightened over its imprint. Artery is double ligated and transfixed. Similarly, vein is transected.
• - Viscera is returned to normal position.
• - Abdomen closed in routine fashion.

4.4 NEPHROTOMY 

Indications:

• - Uroliths
• - Dioctophyma renale
• - No irreversible damage 

Procedure:

• Exposure: - Same as for nephrectony
• - Assistant holds the kidney in cup of the hand
• - occlude renal vessels by digital pressure or vascular clamps (Bulldog clamps).
• - A single incision to the depth of renal pelvis is preferred to repeated incision
• - Beware not to bisect the kidney or renal pelvis
• - Remove calculus or parasites, take cultures & irrigate with N/S or R/L.
• - Close kidney capsule in a continuous by 3/0 PGA on a swedged on 3/8 circle needle; include a small amount of Renal cortex.
• - Apply gentle tension to suturea during closure. 

Alternately - three deep horizontal mattress sutures through cortex with 2/0 absorbable suture or hold the incision closed by hand for 15 minutes. No sutures needed in renal cortex or capsule.

• - Release renal vessels
• - Return kidney to abdomen; replace organs, close abdomen;

POST OPERATIVE:

• a) Get uroliths analyzed and culture and sensitivity done
• b) post-operative hematuria may persist for 4-6 days.

4.5 PARTIAL NEPURECTOMY

Indication: - when lesion confined to one pole

PROCEDURES:

Exposure - same as above

• - reflect capsule
• - A ligature of #1 chromic 2ut or Dexon is applied around the affected pole to isolate the lesion and a small amount of normal tissue proximal to it.
• - Tighten the ligature slowly to cut through the renal parenchyma - Pole is then removed by amputation distal to the ligature.
• - If renal pelvis or a calyx is exposed; the defect shold be closed with a simple continous suture of 4-0 chromic catgut or Dexon
• - Reflected capsule is drawn over the exposed surface and sutured with 4/0 synthetic absorbable suture.
• - Release occlusion of renal vessels - Return the kidney to abdomen at its original place -- Close laparotomy incision

4.6 URETER

a) Congential Abnormalities:

• - Ureteral Agenesis - rare
• - Ectopic ureters - mostly in females
• - Ureterocele - dilation of the intravesicular ureter
• - Congenital ureteral valves: Transverse fold of vestigeal mucosa made prominent by circular layer.

b) Aquired Lesions:

• - Pyoureter
• - Ureterectasis e.g. hydroureter, calculi, obstruction, neoplasia. blood clot
• - Rupture

4.7 ECTOPIC URETER:

• - Opens at abnormal position
• -- Unilateral/Bilateral
• - Accompanies other U.T. abnormalities
• Signs: - urinary Incontinenance since birth
  • - perivulvular excoriations
• Dx: GPE, contrast radiography; R/O spinal injury, U.T.
• infection, calculus, neoplasia, hypoestrogenism,
• Iatrogenic surgical damage
• Rx: Ureteronephrectomy - if other kidney normal.
• Competent ureterovesical anastomosis. 

Ureteral Calculi

• - rare
• - Fragmentation of renal calculus
• - Associated with pyclonephritis and hydronephrosis
• Dx - Radiographs, proximal ureteroectasis and hydronephrosis.
• Rx - Narcotics, smooth muscle relaxtants; rarely surgery.

4.8 URETERAL ANASTOMOSIS 

Indications

Calculi, rupture, ectopic ureter 

Technique:

• - Ureter incised obliquely/transversely
• - Sutured with 5/0-6/0 chronic gut over a ureteral catheter
• - Leave catheter in place for 5-6 days

4.9 URETEROVESICAL ANASTOMOSIS

a) Extravesical Technic:

• - Stab incision in bladder
• - Tunnel in submacosa 5:1
• - Spatulaled end sutured to bladder mucosa with 4/0 dexan

b) Intravesical Technic:

• - Bladder opened
• - Tunnel in submucosa
• - Ureter with drawn through tunnel and anchored to mucosa 

4.10 BLADDER

a) Congenital Abnormalities:

• Cystic Agenesis - hypoplasia
• Patent Urachus
• Urachil cyst
• Urachal diverticulum; chronic source of cystitis.

b) Acquired Lesions:

• Rupture, Herniation, Prolapse
• Cystic Lithiasis,
• Parasitism- Capillaria plica,
• Neoplasia papilloma, leiomyomas, Fibroma, Hemangioma, lymphoma, transitional cell carcinoma and squamous cell carcinoma. 

CYSTOTOMY & CYSTECTOMY

Indication:

• Urachal cyst, urachal diverticulum
• Patent urachus, Rupture, cystourolithiasis 

Technique:

• Anesthetize & catheterize
• Incision - Ventral midline umbilicus to pubis
  • - Enter Abdoman
  • - Incise bladder on dorsal gurface
  • - Remove calculus
  • - Irrigate with N/S or R/L
  • - Mucosa closed with 3/0 PDS in interrupted fashion with knotts in lumen. Serosa and mucosa closed with continous Cushing or Lembert sutures of chromic gut
  • - close abdomen routinely. 

4.11 URETHRA 

Prolapse of the Male urethra:

• Mostly seen in 9 to 13 months of age
• Associate with sexual excitement 

Signs

• Incontinence, Hematuria, bleeding from prepuce 

Treatment

• Reduce prolapse, purse string suture applied
• - Excision

4.12 URETHBOTOMY

• Indications:
• Obstruction, Injury, Neoplasm, Iatrogenic 

Technique:

• Sites: Prepubic, Scrotal, Perineal, Pelvic Urethra
• Incision: Position variable?-- Ventral midline ospenis to scrotum
  • - Preplace a urinary catheter
  • - Separate retractor penis
  • - Cut through corpus covernosum penis (CCP) &
  • Corpus cavernosum Uretherae (CCU) to open Urethral Mucosa &
  • Remove calculi
  • - Irrigate <->
  • - Suture Mucosa and CCU with 5/0 PDS,
  • - Sutured CCP next with 3/0 PS
  • - Suture S/C with 3/0 PDS & skin with 2/0 nylon
  • - remove catheter in 3 days postop 

4.13 URETHROSTOMY (Canine)

Indication:

• Recurrent Stone & Stricture 

Sites:

• Prepubic, Scrotal and perineal 

Position eg :Scrotal - Dorsal recumbency

• - Elliptical incision around Scrotal Sac
• - Severe Tunica dartos & discard sac
• - Castrate the dog
• - Retract Retractor Penis M.
• - Incise urethra over urinary catheter
• - Extend incision to 5 to 8 times the dizmeter of urethra
• - Suture at the corners first
• - CCP & Peripenile tissue to S/C with 4/0 PS
• - CCU & Mucosa to skin edges with 4/0 Nylon
• - Remove obstruction; Culture & irrigate
• Post op: - Prevent post operative Mutillation of wound edges
• - Slight p.o. hemorrhage during excitement and urination
• - Prolonged ab & medical urolithisis management

4.14 FELINE PERINEAL URETHROSTOMY: 

Indication:

Recurrent FUS

Position:

Ventral Recumb. perinum elevated tail held cranialy

Incision:

• -- Elliplical, Ablate prepuce & Scrotum
• - Ligate scrotal & preputial vessels
• - Castrate ? ligate dorsal penile art.
• - Reflect Penis dorsolaterally and free from ischial attachments
• - Free the pelvic attachment
• - Reflect and remove retract penis lluscle
• - Incise penile Urethra over a probe upto pelvic urethra.
• - Suture peripenile tissue to s/c with 4/0 PDS
• - Suture uretheral Mucosa to skin with 4/0 nylon - Place a through and through mattress stitch through body of penis just caudal to glans and amputate
• - Catheterize bladder and irrigate
• - Remove stitches in 7-10 days 

Post Op:

• - Medical Management of cystitis
• - C/D diet