Digital Surgical Atlas

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There are many components to Urologic education, but one which we feel is missing from the text books is a practical guide to Urologic procedures. In this surgical atlas, we review the management of surgical patients from before they enter the operating room to after they leave. We highlight key points of their pre- and post-operative care, underscore details which medical students or residents are likely to be asked in the OR, and present a multi-media atlas for step-by-step guidance through each procedure. By providing these features, we hope to make UrologyMatch an important reference source in this new era of surgical education.

Grades and Boards

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Grades

You needed good grades to get into college and good grades to get into medical school--getting into residency is no different. Grades in the first two years are important, but residency directors care much more about clinical clerkship performance. Strong grades in Core Surgery and Core Medicine clerkships are very desirable. A high grade in your Urology sub-intership(s) is extremely helpful. Beyond these specific clerkships, it is your overall pattern of grades that will stand out. What's most coveted, not surprisingly, is AOA, as this gives the residency admission committee the best evidence that you are among the top of your class. You can absolutely still match without being AOA, but it will be more difficult to match at top programs. Some top medical schools do not have AOA chapters, and ERAS allows you to select "No AOA Chapter At My School" option on the application. Bottom line: if you think your grades are marginal, you should find a good advisor to council you on where you stand.

Board Scores

Board scores are extremely important. They provide the most objective comparison of applicants and play a significant role in the selection of candidates for interviews. You will find that once you have made it to the interview round, these scores begin to carry significantly less weight. Here is a rough breakdown of scores:

< 215 - seek advice on whether you have a reasonable chance at matching; people do match with these scores, but only with a very solid application.

215-230 - your score may hurt you in the eyes of many programs, but many people match every year with these scores.

230-240 - these are solid scores and you should certainly do fine. If you are aiming for top-tier programs, however, this is hopefully not the strongest part of your application. 

240-250 - you are in great shape.

>250 - your board score is outstanding and will stand out.

Having USMLE Step 2 on your application is not at all necessary, but if you believe that your score on Step 1 is marginal, doing well on Step 2 can be a very strong move. The best advice is to take Step 2 after you submitted your ERAS application and all the schools have downloaded your USMLE score report (early November is perfect). Be sure that you do NOT select "automatic score reporting" when filling out the application. This way, if your Step 2 scores are high, you can instruct ERAS to release them to the residency programs in time to help you. If you do no better on Step 2 than on Step 1, do not release your scores and no one finds out. Every year we see applicants who apply with excellent Step 1 scores and poor Step 2 scores--these students have completely unnecessarily severely damaged their application.   Note, recently the UCSF program (see details) has announced a requirement that students must have Step 2 scores submitted prior to being ranked.


 


 

I. Basic Principles: Prostate Anatomy

guide book

ANATOMY OF THE PROSTATE

Detailed understanding of prostatic anatomy is essential for every urologist.

Figure 1: Prostate Anatomy
PS=pubic symphisis AFS=anterior fibromuscular stroma SV=seminal vesicle CZ, TZ, PZ=zones of prostate (see text)

Figure 2: Cystoscopic view of lateral lobes.
Edge of the verumontanum is seen at 6 o'clock.

Figure 3: Cystoscopic view of a large median lobe.
The ball-valve obstruction created by a median lobe in some men is clearly appreciated from this image.

II. Basic Principles: Benign Prostatic Hyperplasia (BPH) and Its Treatment

 Benign Prostatic Hyperplasia (BPH) and Its Treatment

Pathophysiology

Evaluation

Treatment

Watchful waiting

Medical Therapy

Surgical Therapy  (Thermal therapy, Laser prostatectomy , TURP , Open Prostatectomy)

 

Pathophysiology:

Evaluation of a Man with Lower Urinary Tract Symptoms indicative of BPH:

Treatment:

III. Basic Principles: Laparoscopic Fundamentals from the AUA

guide book

The link below will open a document in a new window:
Laparoscopic Fundamentals from the AUA

IV. Basic Principals: GU Pathology from the AUA

guide book

Click the link below to open AUAnet.org document in a new window.

GU Pathology from the AUA

V. Surgical Procedures: Lithalopaxy

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Bladder Stone Treatment

I will not cut for stone, even for patients in whom the disease is manifest;
I will leave this operation to be performed by practitioners.
-Hippocratic Oath

Before the advent of modern surgical techniques, treatment of bladder stones was a very risky venture. The most common approach to removing bladder stones, known as lithotomy, involved removal of the stone through a perineal incision in an awake patient after a metal sound was placed through the urethra to secure the stone's position in the inferior portion of bladder. Indeed, Hippocrates considered the procedure so risky that in his oath he advised that only the skilled professional attempt the feat. Some believe that Hippocrates' recommendation is the first designation of a surgical subspecialty.

Urinary stasis (whether from bladder outlet obstruction or neurogenic dysfunction), infection, and presence of a foreign body are the primary culprits for bladder stone formation.

Video 1: Classic "jack" stone in an elderly patient with bladder outlet obstruction (click to watch video)

 

Modern surgical armamentarium for treatment of bladder stones includes open surgery (suprapubic approach), manual cystoscopic lithalopaxy (crushing of stone with forceps), ultrasonic lithotripsy, pneumatic lithotripsy, electrodydralulic lithotripsy (EHL), holmium:YAG laser, and rarely extracorporeal shock wave lithotripsy.

Surgical Tips:

VI. Surgical Procedures: Orchiectomy - radical/simple

 Radical Orchiectomy

 Pre-Operative considerations:

1. Verify side of tumor - have imaging in the room

2. Make sure tumor markers have been drawn

3. Examine patient thoroughly prior to making incision -- this will help develop your testicular exam skills and verify side of tumor
*When performing testicular examination (in any setting), convince yourself that you are able to palpate (1) testicle proper, (2) epididymis, and (3) cord

4. A single dose of a second generation cephalosporin is appropriate prior to making incision.  

Intra-Operative considerations:

1. In supine position, lower abdomen, genitalia, and perineum are shaved, prepped, and draped

2. Incision is made over the inguinal ligament similar to an inguinal herniorrhaphy. Landmarks are the anterior superior iliac spine and the pubic symphisis (marked on image below)

3. Electrocautery is used to divide the subcutaneous fat and expose the external oblique fascia

4. The fat is bluntly cleaned off the fascia for better exposure, typically using a sponge and/or retractors (spreading down to fascia with two band retractors works very well)

5. Using a scalpel, a small incision is made in the external oblique fascia in line with the muscle fibers

6. Metzenbaum scissors are used to extend the fascial incision all the way to the external ring as well as in the opposite direction (toward internal ring)

a. Care is taken to first spread open the scissors underneath the fascia to clear off the ilioinguinal nerve

b. The nerve can often now be identified and set aside by placing a hemostat on the lateral edge of the fascia with the nerve lateral to the hemostat

c. Some may find tagging the medial and lateral fascial edges with suture useful to expedite closure later

d. It is important to open the external ring completely, dividing all of the fascial fibers -- this will faciliate delivery of the testis later

7. Grasping the edges of the fascia, the cord is bluntly dissected free

8. The cord is then encircled, often first with a finger (tease the cord off the pubic symphisis with thumb and finger) and then a Penrose drain is pulled through to fully retract the cord.

9. The Penrose drain is then wrapped a second time around the cord and clamped to completely constrict the cord

a. The theoretical goal is to prevent hematogenous micrometastases from being sent into the circulation during tumor manipulation

10. The testis is then delivered into the wound by pulling on the cord and pushing on the testis (it you find this step difficult, you did not divide all the necessary fibers of the external ring). Fascial attachments preventing delivery of the testis into the wound may need to be freed. One must be very careful not to violate scrotal skin. Blunt dissection with a surgical sponge to peel off the testicle from scrotal skin is very useful here (image below).

11. The gubernaculums is then clamped, divided and ligated. Again be absolutely sure you are not button-holing the scrotal skin (note how the scrotal skin in inverted into the wound on the image below -- if you violate the scrotal skin, you upstage the tumor and may change post-operative management!)

12. Attention is then turned to the superior portion of the cord and vas, which are separately clamped and divided as high as possible above where the Penrose was placed.

a. Ligation is typically performed with 2-0 silk or proline free ties and a suture ligature. Leave one suture long, so you can find it at RPLND.

b. It is important to drop the cord into the internal ring/retroperitoneum in order to faciliate cord removal at RPLND.

c. Be sure your ligation is secure -- bleeding into the retroperitoneum from a poorly secured testicular artery can be life-threatening.

13. Electrocautery is used to obtain hemostasis, careful attention needs to be paid to the scrotum to prevent hematoma formation

14. The external oblique fascia is then closed followed by the subcutaneous fat and the skin

15. A sterile dressing as well as fluffs and a scrotal support are then typically applied.

Post-Operative considerations:

1. Monitor patient for scrotal hematoma and retroperitoneal bleeding

2. Markers must be rechecked during a post-operative visit in ~ 4 weeks (remember T1/2 for AFP = ~5 days and for HCG = ~48 hours)

Simple Orchiectomy: 

1) In supine position, lower abdomen, genitalia, and perineum are prepped and draped

2) If bilateral orchiectomy, median raphe incision is made. If unilateral, can perform either median raphe or transverse hemiscrotal incision.

a. Skin traction is important when making scrotal incisions due to tissue laxity

3) Electrocautery is used to dissect through the dartos muscle and cremasteric fibers in order to expose the tunica vaginalis

4) A sponge is used to push the fibers off of the tunica vaginalis and fully deliver the testis/tunica vaginalis through the wound

5) Continue to use a sponge to clean off the tunica vaginalis such that it is fully exposed

6) Incise the tunica and expose the testis

7) With traction on the testis to expose the cord, bluntly dissect the cord into 2 or 3 segments. The vas is typically isolated in its own segment. Clamp, cut, and ligate each segment, typically with 2-0 silk. A suture ligature is often used due to risk of bleeding from the cord and the fact that it will quickly retract up into the pelvis once it is released.

8) Irrigate the wound and liberally electrocoagulate possible bleeders due to risk of scrotal hematoma

9) Close the dartos in a running layer and then the skin.

10) The wound is typically dressed with bacitracin, fluffs, and scrotal support.

VII. Surgical Procedures: Sacral Nerve Stimulation

Medtronic InterStim® Therapy for Urinary Control

 

Medtronic InterStim Therapy for urinary control has been shown to successfully treat certain bladder control problems in patients for whom more conservative treatments were unsuccessful. InterStim Therapy addresses the nerve component of bladder control problems by sending mild electrical pulses to the sacral nerve which influences the bladder and surrounding muscles that manage urinary function.

InterStim Therapy for is indicated for the treatment of non-obstructive urinary retention and the symptoms of overactive bladder, including urinary urge incontinence and significant symptoms of urgency-frequency alone or in combination, in patients who have failed or could not tolerate more conservative treatments. It is not indicated for mechanical obstruction such as benign prostatic hypertrophy, cancer, or urethral stricture.

Patients must undergo a trial assessment period, known as Peripheral Nerve Evaluation (PNE). Through a simple, in-office procedure, the physician places a temporary lead that is connected to a small external test stimulator. The trial assessment allows the patient to experience the effects of the therapy for approximately 3-7 days to help the patient and physician determine if long-term therapy will be beneficial. 

Peripheral Nerve Evaluation Procedure

Note: Complications can occur with the trial assessment, including movement of the wire, technical problems with the device, and some temporary pain.

If the PNE test is inconclusive or unsuccessful, a chronic lead test is recommended. This test utilizes a tined (chronic) lead, to reduce migration. Placement of the tined lead is performed through an outpatient procedure and is connected to the same external stimulator. With conclusive test results, this lead can remain in place and the implantable neurostimulator (INS) and lead extension would then be implanted.

Placement of the Permanent InterStim Tined Lead and Implantable Neurostimulator (INS)
Patient-reported results will allow the physician and the patient to make an informed choice regarding the long-term therapeutic success of the therapy. Permanent implantation of the InterStim tined lead and INS is performed after a successful PNE or chronic lead test.

Physician training is required prior to implantation of InterStim components and the product technical manual must be reviewed for detailed, step-by-step instructions of the implant procedure. A summary of the InterStim II device implant procedure is presented below:

 

  
  Patient is given MAC/local anesthetic near    
  the sacrum.

  Using bony topography or fluoroscopy as a guide,
  a foramen needle is inserted parallel to the
  sacral nerve, typically into the S3 foramen.

  Stimulation is applied to confirm appropriate
  needle placement. Desired responses include
  bellows movement, flexion of the great toe and
  reported sensations in the anus, perineum and
  vagina or scrotum.

 

  Once position of the foramen needle is
  confirmed, the foramen needle stylet is removed
  and replaced with a directional guide.
 

  
  Holding the directional guide in place,  
  the foramen needle is gently removed.

  A small incision is made on either side of the
  directional guide to allow for the introducer
  sheath to be placed over the directional guide.
  The directional guide is then carefully removed.

  The tined lead is placed into the introducer and
  advanced. Stimulation is applied and appropriate
  responses are verified.

  Once appropriate placement of the lead is
  verified, the introducer is withdrawn and the
  tines are deployed. Stimulation is applied to the
  lead and responses are verified.

 

  
  A pocket is created in the subcutaneous fat,
  typically in the upper buttock using blunt
  dissection and electrocautery. The INS is placed
  no deeper than 2.5 cm (1 in) below the skin and
  parallel to the skin.

 

  
  A tunnel is created from the lead incision site to
  the INS pocket and the lead is threaded through
  the tunneling straw.

  The lead is connected to the INS header.

  The INS is placed in the subcutaneous pocket
  which is thoroughly irrigated, with an antibiotic
  solution.

 
  Pocket is closed.

 

 

For additional information on InterStim Therapy and educational opportunities, visit http://professional.medtronic.com/sns

 

InterStim® Therapy for Urinary Control is indicated for the treatment of urinary retention and the symptoms of overactive bladder, including urinary urge incontinence and significant symptoms of urgency-frequency alone or in combination, in patients who have failed or could not tolerate more conservative treatments.

Contraindications: Diathermy. Patients who have not demonstrated an appropriate response to test stimulation or are unable to operate the neurostimulator.

Warning: This therapy is not intended for patients with mechanical
obstruction such as benign prostatic hypertrophy, cancer, or urethral stricture.

Precautions/Adverse Events: 

Safety and effectiveness have not been established for bilateral stimulation; pregnancy, unborn fetus, and delivery; pediatric use under the age of 16; or for patients with neurological disease origins such as multiple sclerosis.  The system may be affected by or adversely affect cardiac devices, electrocautery, defibrillators, ultrasonic equipment, radiation therapy, MRI, theft detectors/ screening devices.  Adverse events include pain at the implant sites, new pain, lead migration, infection, technical or device problems, adverse change in bowel or voiding function, and undesirable stimulation or sensations, including jolting or shock sensations. For full prescribing information, please call Medtronic at 1-800-328-0810 and/or consult Medtronic’s website at www.medtronic.com. Product technical manual must be reviewed prior to use for detailed disclosure.

USA Rx Only.  Rev 0409

IX. Surgical Procedures: Endoscopic Management of Upper Urinary Tract Urothelial Carcinoma (UTUC)

 

  I. Introduction

         Transitional cell carcinoma of the upper urinary tract (ureter and/or renal pelvis) accounts for approximately 2-5% of all urothelial carcinomas.  Traditionally, management of these lesions has consisted of open or laparoscopic nephroureterectomy with a bladder cuff or, if the lesion is distal, a distal ureterectomy with a bladder cuff and ureteral reimplantation.  This surgical approach to UTUC yielded a 45-90% cancer-specific survival at 5 years; 10-30% of these patients developed metastatic disease.  With the introduction of ureteroscopes and percutaneous techniques in the early 1980s and their continued technological improvements, direct visualization and treatment of an upper urinary tract urothelial tumor is now possible and efficient.  Historically, endoscopic management of UTUC was reserved for patients with bilateral disease, a solitary kidney, chronic kidney disease (CKD), or significant co-morbidities that would preclude a major abdominal operation (Note:  These indications are almost identical for the widespread adoption of partial nephrectomy for renal tumors).  Rendering a patient functionally or anatomically anephric is fraught with significant health risks, thus endoscopic management was employed.  One study cites the 5-year overall survival range for patients aged 55-84 with end-stage renal disease as 10-32%. 

As endoscopic management for UTUCs have became technically feasible for patients with absolute indications, data began to mature that showed equivalent 5-year cancer-specific and overall survival between patients treated with endoscopic, nephron-sparing approaches versus traditional extirpative management.  Table 1 is a synopsis of the most recent studies comparing open versus endoscopic management of UTUC.  In sum, these studies show that endoscopic management of UTUC has equivalent overall, cancer-specific, and metastatic-free survivals to traditional management for low-grade and low-stage UTUC tumors.  Patients who undergo endoscopic management do have a higher local recurrence rate (20-85%) and are subject to more procedures for long-term surveillance.  Most practioners are unwilling to subject patients with high-grade UTUC to endoscopic management unless absolute indications exist; as of yet, there is no data to support the use of endoscopic management for high-grade disease.

 

Series (year)

# of renal units

Median/mean follow-up (months)

Treatment (Ntx-u v. Endoscopic)

5-year survival (Low-grade v. high grade)

5-year survival (Ntx-u v. Endoscopic)

 

 

 

 

 

 

Wolf et al. (2010)

96

76.9

62 v. 34

OS: 73.0% v. 43.0%

CSS: 94.0% v. 75.0%

MFS: 91.0% v.67.0%

 

OS*: 47.8-71.8% v. 25.0-74.8%

CSS: 72.4-89.2% v. 85.7-100.0%

MFS: 63.5-87.8% v. 85.7-94.4%

 

Lucas et al. (2008)

120

45.8

79 v. 41

OS**: 66.4-75.4% v. 45.0-71.5%

CSS: 86.2-87.4% v. 68.6-75.0%

RFS: NR

OS: 72.1% v. 61.7%

CSS:  83.0% v. 81.6%

RFS:  NR

Roupret et al. (2006)

97

51.5-60.0

54 v. 43

OS: NR

CSS: 81.9% v. 47.3%

MFS: NR

OS: NR

CSS: 84.0% v. 80.7%

RFS: 75.3% v.71.5%

Sowter et al.^

(2007)

41

41.6

Endoscopic management only

n/a

OS: 80%

CSS:  100.0%

Recurrence rate:  74.3%

Krambeck et al. (2007)

37

2.9 yrs

Endoscopic management only

n/a

OS: NR

CSS:  49.3%

RFS:  27.1%

Elliott et al. (2001)

21

6.1 yrs

Endoscopic management only

OS^^: 66.0%

CS:  100.0%

Recurrence rate: 25-46%

n/a

* Ranges indicate difference between low-grade and high-grade disease

** Treatment modality grouped together when examining survival of low-grade tumors versus high-grade tumors

^ Endoscopic management only

^^ Low-grade tumors only

 Table 1.  Comparison of series employing endoscopic treatment of UTTCC as primary management strategy

 II.Technique

        Diagnostic ureteroscopy is employed as the first-line treatment for evaluation of a filling defect seen on CT urography, intravenous urography, or retrograde ureteropyelography.  A distal lesion can be accessed with a semi-rigid ureteroscope while a lesion in the proximal ureter or renal collecting system is best approached with a flexible ureteroscope.  The method for ureteral access is similar to the technique employed for ureteroscopy for stone disease (see Surgical Procedures Atlas VIII).

 

A brief step-wise approach to ureteroscopic evaluation and management of upper urinary tract urothelial carcinomas is presented below:

 

1.   A wire is placed into the desired kidney under fluoroscopic and cystoscopic guidance (Fig1).  The choice of wire is at the discretion of the operating urologist; we use a 0.038 Guidewire.  (See review of wires under ureteroscopy Atlas.)  During this portion of the procedure, take care to perform a thorough cystoscopic examination of the bladder as a bladder lesion will develop in 23-75% of patients with an UTUC.

     

     

     

     

     

     Figure 1: Placement of initial wire

     

 

 

 

 

 

2.    We then insert a dual-lumen access catheter over the existing wire (Fig 2) into the ureter for two reasons: the dual-lumen catheter passively dilates the distal ureter and we can obtain a selective cytology from the interested side and then place a second wire (0.038 Guidewire) without losing access to the kidney (Fig 3). 

 

 

 

 

 

 Figure 2: Placement of 2nd wire

 

 

 

 

 

 

 

 

  1.  
  2.  
  3.  
  4.  
  5.  
  6.  
  7.  Figure 3: Insertion of dual-lumen access catheter

 

 

 

 

 

 

 

3.  Once we have cytology, we then perform another retrograde pyelogram to outline the collecting system (Fig 4).

 

 

 

 

 

 Figure 4: Retrograde Pyelogram (make sure cytology
 has been obtained prior to injection of dye)

 

 

 

 

 

 

4.  For renal pelvic and/or calyceal lesions, we then advance the flexible ureteroscope under fluoroscopic guidance up into the renal pelvis over one of the Guidewires (Fig 5).  Once the ureteroscope is in good position, the Guidewire is removed and the second wire is used as a safety wire.

 

 

 

 

 

 Figure 5: Advancement of ureteroscope under
 fluoroscopic guidance.

 

 

 

 

 

 

4a. Sometimes you may have trouble traversing the distal ureter with the flexible ureteroscope.  Rather than using a balloon dilator to dilate the distal ureter, we have found that leaving the cystoscopic sheath in the bladder and using it to provide backing as you try to navigate the distal ureter is a helpful means to circumnavigate this potential impediment.  If you are ever in doubt or cannot bypass the distal ureter, simply leave a JJ stent and return for your diagnostic ureteroscopy in 1-2 weeks.

 

 5.  Once you have the ureteroscope in the renal pelvis (Fig 6), you can perform a thorough upper tract endoscopic examination, using fluoroscopy as an aid in accessing difficult calyces.

 

  1.  
  2.  
  3.  
  4.  
  5.  
  6.  
  7.  
  8.  
  9.  
  10.  Figure 6: Assessment of calyx with ureteroscope.
     Fuoroscopy is used to help direct the ureteroscope
     into appropriate anatomic location.  

 

 

 

 

 

6.  If you find a papillary lesion, obtain a repeat cytology with the ureteroscope directed at the lesion.  Then obtain multiple biopsies of the lesion with either a flat-wire basket or a 3 Fr. ureteroscopic biopsy forceps.

 

7.  Remember, grade correlates with stage.  In multiple series, low-grade tumors correlated with Ta or T1 disease in 86.6-100.0% of cases.  Similarly, high-grade tumors correlated with invasive TCC in 66.7-96.0% of cases.  Thus, a low-grade lesion is going to be superficial and should be treated endoscopically.  This may require multiple endoscopic treatments, however this is preferable in light of renal preservation.

 

8.  Once you have sufficient biopsies, the tumor then can be treated with either the Nd:YAG and/or Ho:YAG laser or a ureteroscopic Bugbee.  See Surgical Atlas VIII for a brief review of lasers.  In brief, Nd:YAG laser has a greater depth of penetration (4-6 mm) and can be used to coagulate the tumor.  The Nd:YAG laser does not need to touch the tumor for effect.  The Ho:YAG laser has a shallower depth of penetration (less than 0.5 mm) and can be used to ablate the tumor deeper.

 

9.  These are the recommended fibers and settings for each laser:

       a. 200 um or 365 um fiber

       b. Nd:YAG:  30W

       c. Ho:YAG:  1J and 10Hz

 

10.  In general, it is best to use the Nd:YAG laser first to coagulate the superficial portion of the tumor.  This laser’s depth of penetration is not as precise as the Ho:YAG, so care must be taken when treating the deeper portions of the tumor.  The Nd:YAG laser can perforate the ureter or the renal pelvis.  When ablating large lesions, it is helpful to begin ablation at the more proximal portion of the tissue and then work distally.  This hopefully helps to avoid advancing the fiber into the mucosa or wall of the ureter or renal pelvis.

 

11.  The Ho:YAG laser can then be used to ablate the deeper aspects of the tumor and detach the tumor from the underlying parenchyma/urothelium.  The Ho:YAG laser must be in direct or close contact of the tumor in order to treat the lesion.

 

12.    For difficult to access calyceal tumors, a 2 Fr. Bugbee electrocautery probe can be used to fulgurate a lesion.  The smaller probe allows for more ureteroscopic deflection in order to treat the difficult to access lesion.  When using the Bugbee electrocautery, fulgurate on the cutting mode.  This theoretically reduces the chance of an ureteral stricture or infundibular stenosis.

 

13.  Once tumor treatment is complete, the decision to leave a temporary ureteral stent is left to the treating urologist.  Nevertheless, there are few disadvantages to inserting a JJ stent in this setting.

 

14.  Percutaneous resection of UTUC is generally reserved for tumors larger than 1.5 cm or bulky proximal ureteral tumors.  The technique for this approach is very similar to a percutaneous approach for stone management (PCNL).  Once intrarenal access has been obtained, a cystoscopic resectoscope can be used to remove the tumor followed by deep laser ablation.

 

III. Complications

              The most common technical complications associated with endoscopic management of UTUC are similar to those seen with any upper tract endoscopic intervention:  ureteral perforation and ureteral stricture.  Reported rates of ureteral perforation and ureteral stricture are 1-4% and 9-12%.  Not all ureteral strictures are due to technical considerations and biopsy of the stricture must be performed to rule out recurrent disease.

 

IV. Recommended Readings

1.Bagley DH and Grasso M.  Ureteroscopic laser treatment of upper urinary tract neoplasms.  World Journal of Urology.  28: 143-9, 2010. 

2. Soderdahl DW et al.  Endoscopic treatment of upper tract transitional cell carcinoma.  Urologic Oncology.  23:  114-22, 2010.

 

 

This page was written for UrologyMatch.com by Daniel J. Canter, MD

Dr. Canter  is a graduate of the University of Pennsylvania Urology Residency Program.
He is currently a Society of Urologic Oncology Fellow at Fox Chase Cancer Center.

X. Surgical Procedures: Adrenalectomy

Surgery for Disorders of the Adrenal Gland 

Alexander Kutikov, MD and Robert G. Uzzo, MD


Fox Chase Cancer Center
Philadelphia, PA
www.foxchase.org

Background

The adrenal glands serve a critical function in physiological homeostasis.  Surgical indications for adrenalectomy vary from resection of benign and malignant neoplasms to surgical elimination of functional adrenal tissue in cases where excess adrinocorticotropic hormone (ACTH) levels cannot be controlled through other means.  In order to avoid overtreatment and minimize risks, the adrenal surgeon must be familiar with adrenal physiology, adrenal neoplasm biology, retroperitoneal anatomy, and nuances of adrenal imaging.  Furthermore, he/she also must be a full-fledged participant in multi-disciplinary care of these often complex patients. This overview provides a summary of the main surgical indications for adrenalectomy, summarizes the clinical approach to evaluating incidental adrenal masses, and reviews perioperative considerations in patients with adrenal disease.

 

Surgical Indications

Suspicion of Malignancy

The vast majority (>85%) of incidentally-discovered adrenal lesions prove to be benign adenomas 1,2.  Indeed, adrenocortical carcinomas (ACC) are exceedingly rare with an incidence of approximately 1 per million 3-5.  Differentiation between the two lesions is critical and pivots on 3 factors: (1) size, (2) imaging characteristics, and (3) growth kinetics.

            Median diameter of incidentally-discovered adrenal lesions is 3cm 6.   Lesions ≥6cm must be resected regardless of imaging characteristics, since >30% will prove malignant 7.  Definitive diagnosis of asymptomatic myelolipoma  – denoted by radiographic presence of macroscopic fat – is the one general exception to this rule 8.  Incidental adrenal lesions ≤4cm require thorough metabolic evaluation and follow-up imaging; however, routine resection is unnecessary 9,10.  Lesions between 4 and 6 cm in size are malignant in approximately 6% of cases, and most experts suggest resection in individuals who are at an acceptable risk for surgery 1,2,6,11,12.   Indeed, this 4 cm threshold has been reported to afford a 93% sensitivity and 42% specificity for diagnosis of malignant adrenal lesions 6. 

            Every surgeon that tackles adrenal disease must be fluent in radiographic evaluation of adrenal pathology.  Large, heterogeneous, poorly-circumscribed masses should immediately raise suspicion; however, most adrenal lesions are small, homogeneous, and have regular contours 13.  Indeed, attention to radiographic detail is especially important for non-functional lesions ≤4 cm that do not meet size criteria for resection.   

In addition to assessment of size, homogeneity, and contours, imaging affords determination of lesion density.  Adenomas are differentiated from other lesions by assessment of intra-cytoplasmic lipid content.   Non-contrast computed tomography (CT) affords near 100% specificity for diagnosis of adrenal adenomas 14.   Indeed essentially all lesions that exhibit attenuation of <10 HU on unenhanced CT are adenomas 9.  The sensitivity of this 10 HU radiographic cutoff, however, is imperfect, and some 30% of adrenal adenomas will register attenuation above this level 15-17.  Such lesions are deemed indeterminate; however, the majority of these lipid-poor adenomas that exhibit a density above 10HU can still be differentiated from other adrenal pathology using the so-called “washout” imaging technique.  Lesions that lose more than 40-60% of gained enhancement on delayed contrast-enhanced CT imaging (i.e. those that “washout”) should be managed as adenomas, since specificity of this technique approaches 100% 15-18.  Magnetic resonance imaging also can be useful for characterizing adrenal neoplasms.  Using opposed phase chemical-shift strategies, intracellular fat content of the adrenal lesions can be gauged 19.  Loss of signal intensity on out-of-phase sequences when compared to in-phase images demonstrates abundance of cytoplasmic lipid and identifies the lesion as an adenoma 13,20.  Although MR chemical-shift imaging is arguably superior to unenhanced CT in characterizing indeterminate lesions 21,22, CT washout studies are the gold standard imaging technique in characterizing lipid-poor adenoma19,23-25.   Indeed, MR-based washout techniques are not clinically useful, since gadolinium contrast agents do not possess the dose-dependent signal intensity properties that are inherent in iodinated contrast agents (i.e. gadolinium contrast agents do not “washout”) 19.

            Malignant transformation of adrenal incidentalomas has been estimated at 1 in 1000 7, and current recommendations suggest that all adrenal lesions that are not resected should be reimaged at 6, 12, and as possible 24 months following diagnosis 2,9.  Approximately 5% to 9% of adrenal masses grow at least 1 cm in diameter upon interval follow-up 7,26, and such growth has been suggested as a trigger for resection 2.   Nevertheless, patients who are taken to the operating room due to interval growth of an adrenal lesions must be candidly counseled that the chances of uncovering malignant pathology are extremely low 2.   

Functional Adrenal Mass

            As a general rule, all adrenal lesions that exhibit metabolic hyperactivity require resection.  Indeed metabolic testing is recommended for all adrenal incidentalomas, since over 11% will show metabolic activity upon evaluation  9 .  Cortisol-producing adenomas are found in 5.3% of cases, while aldosteronomas are uncovered in approximately 1% of patients with incidentally-discovered adrenal lesions.  Furthermore, some 5.1% of incidentalomas will prove to be pheochromoctyomas 1,2.         

Isolated Adrenal Metastasis

            A wide range of malignancies metastasizes to the adrenal gland 27,28.  In fact, retrospective series reveal that in patients with history of previous malignancy, 50% of new adrenal lesions prove metastatic 28,29.  Isolated metastases to the adrenal are at times resected; however, such cases require a thoughtful multidisciplinary approach 28,30-34.


Cushing’s Syndrome

In addition to treatment of ACTH-independent Cushing’s Syndrome such as resection of cortisol-producing adrenal adenoma, the adrenal surgeon is at times called upon to treat patients with ACTH-dependent conditions.   For instance, transsphenoidal surgical resection fails in 20 to 40% of patients with Cushing’s Disease 35,36.  In addition, relapse is seen in up to 25% of patients whose resection of an ACTH-producing pituitary adenoma is initially deemed successful37.   When at least one attempt at neurosurgical correction has failed, bilateral adrenalectomy may be considered by the multi-disciplinary team treating the patient.  Although rapid resolution of hypercortisolism can be expected, the adrenal surgeon must council the patient regarding life-long need for both glucocorticoid and mineralocorticoid replacement and a 10 to 30% chance of developing the Nelson-Salassa syndrome (aka Nelson syndrome) 38-41.  The syndrome is characterized by complications such as ocular chiasm compression, oculomotor deficiencies, and rarely a rise in intracranial pressure, due to progressive growth of the pituitary adenoma in the absence of appropriate glucocorticoid feedback 41.  Also, one is wise to warn the patient regarding the remote possibility of leaving residual functional adrenal tissue at the time of the bilateral adrenalectomy 42. 

Approximately 10% of Cushing’s Syndrome is caused by ectopic secretion of ACTH by malignant tissues 43.  Although resection of the primary ACTH-producing tumor is ideal, such approach is possible in only ~10% of patients 44.   Indeed, bilateral adrenalectomy is a therapeutic option in the appropriately-selected patient 43. 

Work-Up of Adrenal Incidentaloma

         A metabolic evaluation is necessary for all adrenal incidentalomas, since over 10% are metabolically active 9.  Hypersecretion of cortisol, and catecholamines should be evaluated in all-comers, while aldosterone hypersecretion only needs to be ruled out in those with history of hypertension 2,9.  The adrenal surgeon should have a low-threshold in recruiting expertise from endocrine specialists.  Such consultation is especially important when initial first-line testing returns positive results, since confirmatory testing is often sophisticated.

 Initial Evaluation for Hypercortisolism

            Approximately 5-8% of adrenal masses will exhibit cortisol hypersecretion (aka ACTH independent Cushing’s Syndrome) upon work-up 1,7.  In clinical practice, after exogenous steroid use is ruled-out, 3 main tests are employed: (1) the overnight low-dose dexamethasone suppression test (OST), (2) the late-night salivary cortisol test, and (3) the 24-hour urinary-free cortisol evaluation (UFC).  In general, all three tests provide relatively equivalent test characteristics 45; however, some reports and guidelines suggest that the UFC may not be appropriate for screening patients with adrenal incidentaloma due to inferior sensitivity 46-48.  Again, if this first-line testing is positive, consultation with endocrinology is advised.

Initial Evaluation for Hyperaldosteronism

            Hyperaldosteronism (aka Conn’s syndrome) stemming from an adrenal mass is exceedingly rare, as the condition is found in only ~1% of adrenal incidentalomas 1,49.  Some evidence does exist, however, that up to 5% of patients with newly diagnosed hypertension will be found to have an alodosterone-secreting adenoma upon work-up50.  Therefore, all patients with history of hypertension who are found to have an adrenal incidentaloma should be tested for aldosterone hypersecretion.  First-line screening consists of obtaining a morning plasma aldosterone to renin ratio (ARR).  In the setting of an aldosterone level of ≥15 ng/mL, an ARR of ≥20 is suggestive of Conn’s syndrome.  Confirmatory testing is mandatory and should involve endocrinologic experts49,51.  Although beyond the scope of this chapter, adrenal vein sampling is often advisable 52.

Initial Evaluation for Catecholamine Hypersecretion

            Approximately 5% of patients with adrenal incidentaloma will prove to have pheochromocytoma 2. Indeed, pheochromocytoma must be ruled out in all patients with adrenal mass, even in those in whom metastases are strongly suspected 53. Arguments that the work-up can be omitted in patients with masses that exhibit a density less than 10HU are weakened by isolated reports of rare low-density pheochromocytomas that possess an unenhanced attenuation of <10HU and demonstrate brisk contrast washout 54,55. 

            Clinical first-line testing for pheochromocytoma should include either free fractionated plasma metanephrines or 24-hour urinary fractionated metanephrine levels 56,57.  Although there is currently a debate regarding which test is superior, both evaluations afford excellent sensitivity and specificity 2,58.  As already stressed, endocrinological expertise is invaluable in patients in whom first-line testing is positive.

Follow-up Metabolic Testing

            Experts suggest that all patients with adrenal incidentaloma who have an initially negative metabolic work-up receive annual metabolic screening for 3 to 4 years following diagnosis9. Nevertheless, the percentage of patients who will develop de-novo metabolic activity is small (~2%) 7.

Perioperative Considerations

            By and large, periooperative care of patients undergoing adrenalectomy is routine. Although recent data suggest that biochemical adrenal insufficiency following adrenalectomy may be common (up to 22%), clinically significant adrenal insuffiency appears to be rare. Albeit rare, it is possible, and a high index of suspicion is mandatory.  Patients with Cushing Syndrome in whom the contralateral gland can be suppressed are at an especially high risk and should be monitored closely 46.  Prior to bilateral adrenalectomy, proactive therapy must be appropriately instituted, since Addisonian crises may result in death59. 

Patients undergoing resection of pheochromocytoma also require thoughtful perioperative management.    Thought leaders recommend that all patients with pheochromocytoma undergo pre-operative catecholamine blockade, regardless of the severity of symptomatology 60.  Indeed today perioperative mortality rates in patients with pheochromocytoma are less than 3% 61.  In contrast, prior to routine perioperative blockade, mortality rates as high as 50% were reported62.

Alpha-blockade with or without alpha-methyltyrosine – an inhibitor of catecholamine biosyntheis – is the most widely recommended pre-operative regimen60. Calcium channel blockade for patients with mild symptomatology also has been popularized by some authors63.   In addition to catecholamine blockade, some experts recommend routine pre-operative cardiac evaluation that includes echocardiography to exclude presence of catecholamine-induced cardiomyopathy 64.    Furthermore, establishment of an adequate intravascular volume is paramount.  Patients are encouraged salt and fluid intake, once catecholamine blockade is started,  and some institutions pre-admit patients a day prior to surgery for aggressive intravenous fluid administration61.  In the post-operative period, the patient must be monitored for hypotension and hypoglycemia.  The former can be due to lasting effects of the pre-operative blockade, while the latter is caused by inhibition of insulin release during a high catecholamine state62,64.  Indeed, some centers monitor patients overnight in the intensive care unit following surgery for pheochromocytoma61. 


                    

           Robert G. Uzzo, M.D., F.A.C.S.                                                        Alexander Kutikov, MD

          G. Willing "Wing" Pepper Chair in Cancer Research                              Assistant Professor of Urologic Oncology
           Professor and Chairman, Department of Surgery                            Department of Surgical Oncology
                  Fox Chase Cancer Center                                                                 Fox Chase Cancer Center
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REFERENCES:

            1.         Young WF, Jr.: Management approaches to adrenal incidentalomas. A view from Rochester, Minnesota.  Endocrinol Metab Clin North Am 29:159-85, x, 2000
2.         Young WF, Jr.: The Incidentally Discovered Adrenal Mass. N Engl J Med 356:601-610, 2007

            3.         Aubert S, Wacrenier A, Leroy X, et al: Weiss system revisited: a clinicopathologic and immunohistochemical 
study of 49 adrenocortical tumors. Am J Surg Pathol 26:1612-9, 2002

            4.         Fassnacht M, Allolio B: Clinical management of adrenocortical carcinoma. Best Pract Res Clin Endocrinol Metab 
23:273-89, 2009

            5.         Roman S: Adrenocortical carcinoma. Curr Opin Oncol 18:36-42, 2006

            6.         Mantero F, Terzolo M, Arnaldi G, et al: A Survey on Adrenal Incidentaloma in Italy, 2000, pp 637-644

            7.         Barzon L, Sonino N, Fallo F, et al: Prevalence and natural history of adrenal incidentalomas. Eur J Endocrinol 
149:273-285, 2003

            8.         Han M, Burnett AL, Fishman EK, et al: The Natural History and Treatment of Adrenal Myelolipoma. The Journal 
of urology 157:1213-1216, 1997

            9.         Grumbach MM, Biller BMK, Braunstein GD, et al: Management of the Clinically Inapparent Adrenal Mass 
("Incidentaloma"). Ann Intern Med 138:424-429, 2003

            10.       Cicala MV, Sartorato P, Mantero F: Incidentally discovered masses in hypertensive patients. Best Practice & 
Research Clinical Endocrinology & Metabolism 20:451-266, 2008

            11.       Barry MK, van Heerden JA, Farley DR, et al: Can Adrenal Incidentalomas Be Safely Observed? World Journal of 
Surgery 22:599-604, 1998

            12.       Thompson GB, Young Jr WF: Adrenal incidentaloma. Current Opinion in Oncology 15:84-90, 2003

            13.       Korobkin M, Giordano TJ, Brodeur FJ, et al: Adrenal adenomas: relationship between histologic lipid and CT and MR findings. Radiology 200:743-7, 1996

            14.       Hamrahian AH, Ioachimescu AG, Remer EM, et al: Clinical Utility of Noncontrast Computed Tomography 
Attenuation Value (Hounsfield Units) to Differentiate Adrenal Adenomas/Hyperplasias from Nonadenomas: 
Cleveland Clinic Experience. J Clin Endocrinol Metab 90:871-877, 2005

            15.       Szolar DH, Korobkin M, Reittner P, et al: Adrenocortical Carcinomas and Adrenal Pheochromocytomas: Mass and Enhancement Loss Evaluation at Delayed Contrast-enhanced CT. Radiology 234:479-485, 2005

            16.       Korobkin M, Brodeur FJ, Francis IR, et al: CT time-attenuation washout curves of adrenal adenomas and 
nonadenomas. Am. J. Roentgenol. 170:747-752, 1998

            17.       Pena CS, Boland GWL, Hahn PF, et al: Characterization of Indeterminate (Lipid-poor) Adrenal Masses: Use of Washout Characteristics at Contrast-enhanced CT. Radiology 217:798-802, 2000

            18.       Heinz-Peer G, Memarsadeghi M, Niederle B: Imaging of adrenal masses. Curr Opin Urol 17:32-8, 2007

            19.       Hussain HK, Korobkin M: MR imaging of the adrenal glands. Magn Reson Imaging Clin N Am 12:515-44, vii, 2004

            20.       Namimoto T, Yamashita Y, Mitsuzaki K, et al: Adrenal Masses: Quantification of Fat Content with Double-Echo Chemical Shift In-Phase and Opposed-Phase FLASH MR Images for Differentiation of Adrenal Adenomas. Radiology 218:642-646, 2001

            21.       Israel GM, Korobkin M, Wang C, et al: Comparison of Unenhanced CT and Chemical Shift MRI in Evaluating Lipid-Rich Adrenal Adenomas. Am. J. Roentgenol. 183:215-219, 2004

            22.       Haider MA, Ghai S, Jhaveri K, et al: Chemical Shift MR Imaging of Hyperattenuating (>10 HU) Adrenal Masses: Does It Still Have a Role? Radiology 231:711-716, 2004

            23.       Caoili EM, Korobkin M, Francis IR, et al: Delayed Enhanced CT of Lipid-Poor Adrenal Adenomas. Am. J. Roentgenol. 175:1411-1415, 2000

            24.       Park BK, Kim CK, Kim B, et al: Comparison of Delayed Enhanced CT and Chemical Shift MR for Evaluating Hyperattenuating Incidental Adrenal Masses. Radiology 243:760-765, 2007

            25.       Boland GW, Blake MA, Hahn PF, et al: Incidental adrenal lesions: principles, techniques, and algorithms for imaging characterization. Radiology 249:756-75, 2008

            26.       Libe R, Dall'Asta C, Barbetta L, et al: Long-term follow-up study of patients with adrenal incidentalomas. Eur J Endocrinol 147:489-494, 2002

            27.       Bullock WK, Hirst AE, Jr.: Metastatic carcinoma of the adrenal. Am J Med Sci 226:521-4, 1953

            28.       Lenert JT, Barnett CC, Kudelka AP, et al: Evaluation and surgical resection of adrenal masses in patients with a history of extra-adrenal malignancy. Surgery 130:1060-1067, 2001

            29.       Frilling A, Tecklenborg K, Weber F, et al: Importance of adrenal incidentaloma in patients with a history of malignancy. Surgery 136:1289-96, 2004

            30.       Tanvetyanon T, Robinson LA, Schell MJ, et al: Outcomes of adrenalectomy for isolated synchronous versus metachronous adrenal metastases in non-small-cell lung cancer: a systematic review and pooled analysis. J Clin Oncol 26:1142-7, 2008

            31.       Mercier O, Fadel E, de Perrot M, et al: Surgical treatment of solitary adrenal metastasis from non-small cell lung cancer. J Thorac Cardiovasc Surg 130:136-40, 2005

            32.       Collinson FJ, Lam TK, Bruijn WM, et al: Long-term survival and occasional regression of distant melanoma metastases after adrenal metastasectomy. Ann Surg Oncol 15:1741-9, 2008

            33.       Mittendorf EA, Lim SJ, Schacherer CW, et al: Melanoma adrenal metastasis: natural history and surgical management. Am J Surg 195:363-8; discussion 368-9, 2008

            34.       O'Malley RL, Godoy G, Kanofsky JA, et al: The necessity of adrenalectomy at the time of radical nephrectomy: a systematic review. J Urol 181:2009-17, 2009

            35.       Pivonello R, De Martino MC, De Leo M, et al: Cushing's Syndrome. Endocrinol Metab Clin North Am 37:135-49, ix, 2008

            36.       Newell-Price J, Bertagna X, Grossman AB, et al: Cushing's syndrome. Lancet 367:1605-17, 2006

            37.       Patil CG, Prevedello DM, Lad SP, et al: Late recurrences of Cushing's disease after initial successful transsphenoidal surgery. J Clin Endocrinol Metab 93:358-62, 2008

            38.       Chow JT, Thompson GB, Grant CS, et al: Bilateral laparoscopic adrenalectomy for corticotrophin-dependent Cushing's syndrome: a review of the Mayo Clinic experience. Clin Endocrinol (Oxf) 68:513-9, 2008

            39.       Vella A, Thompson GB, Grant CS, et al: Laparoscopic adrenalectomy for adrenocorticotropin-dependent Cushing's syndrome. J Clin Endocrinol Metab 86:1596-9, 2001

            40.       Lacroix A: Evaluation of bilateral laparoscopic adrenalectomy in adrenocorticotropic hormone-dependent Cushing's syndrome. Nat Clin Pract Endocrinol Metab 4:310-1, 2008

            41.       Assie G, Bahurel H, Coste J, et al: Corticotroph tumor progression after adrenalectomy in Cushing's Disease: A reappraisal of Nelson's Syndrome. J Clin Endocrinol Metab 92:172-9, 2007

            42.       Kemink L, Hermus A, Pieters G, et al: Residual adrenocortical function after bilateral adrenalectomy for pituitary-dependent Cushing's syndrome. J Clin Endocrinol Metab 75:1211-4, 1992

            43.       Porterfield J, Thompson G, Young W, et al: Surgery for Cushing’s Syndrome: An Historical Review and Recent Ten-year Experience. World Journal of Surgery 32:659-677, 2008

            44.       Aniszewski JP, Young Jr WF, Thompson GB, et al: Cushing Syndrome Due to Ectopic Adrenocorticotropic Hormone Secretion. World Journal of Surgery 25:934-940, 2001

            45.       Elamin MB, Murad MH, Mullan R, et al: Accuracy of diagnostic tests for Cushing's syndrome: A systematic review and metaanalyses. Journal of Clinical Endocrinology & Metabolism 93:1553-1562, 2008

            46.       Tsagarakis S, Vassiliadi D, Thalassinos N: Endogenous subclinical hypercortisolism: Diagnostic uncertainties and clinical implications. J Endocrinol Invest 29:471-82, 2006

            47.       Mitchell IC, Auchus RJ, Juneja K, et al: "Subclinical Cushing's syndrome" is not subclinical: improvement after adrenalectomy in 9 patients. Surgery 142:900-5; discussion 905 e1, 2007

            48.       Nieman LK, Biller BM, Findling JW, et al: The diagnosis of Cushing's syndrome: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 93:1526-40, 2008

            49.       Young WF: Primary aldosteronism: renaissance of a syndrome. Clin Endocrinol (Oxf) 66:607-18, 2007

            50.       Rossi GP, Bernini G, Caliumi C, et al: A prospective study of the prevalence of primary aldosteronism in 1,125 hypertensive patients. J Am Coll Cardiol 48:2293-300, 2006

            51.       Mulatero P, Stowasser M, Loh K-C, et al: Increased Diagnosis of Primary Aldosteronism, Including Surgically Correctable Forms, in Centers from Five Continents. J Clin Endocrinol Metab 89:1045-1050, 2004

            52.       Young WF, Stanson AW, Thompson GB, et al: Role for adrenal venous sampling in primary aldosteronism. Surgery 136:1227-35, 2004

            53.       Tsvetov G, Shimon I, Benbassat C: Adrenal incidentaloma: clinical characteristics and comparison between patients with and without extraadrenal malignancy. J Endocrinol Invest 30:647-52, 2007

            54.       Blake MA, Krishnamoorthy SK, Boland GW, et al: Low-Density Pheochromocytoma on CT: A Mimicker of Adrenal Adenoma. Am. J. Roentgenol. 181:1663-1668, 2003

            55.       Blake MA, Kalra MK, Sweeney AT, et al: Distinguishing Benign from Malignant Adrenal Masses: Multi-Detector Row CT Protocol with 10-Minute Delay. Radiology 238:578-585, 2005

            56.       Pacak K, Eisenhofer G, Ahlman H, et al: Pheochromocytoma: recommendations for clinical practice from the First International Symposium. October 2005. Nat Clin Pract Endocrinol Metab 3:92-102, 2007

            57.       Grossman A, Pacak K, Sawka A, et al: Biochemical diagnosis and localization of pheochromocytoma: can we reach a consensus? Ann N Y Acad Sci 1073:332-47, 2006

            58.       Eisenhofer G, Siegert G, Kotzerke J, et al: Current Progress and Future Challenges in the Biochemical Diagnosis and Treatment of Pheochromocytomas and Paragangliomas. Horm Metab Res 40:329-337, 2008

            59.       Asari R, Scheuba C, Kaczirek K, et al: Estimated Risk of Pheochromocytoma Recurrence After Adrenal-Sparing Surgery in Patients With Multiple Endocrine Neoplasia Type 2A. Arch Surg 141:1199-1205, 2006

            60.       Pacak K: Preoperative Management of the Pheochromocytoma Patient. J Clin Endocrinol Metab 92:4069-4079, 2007

            61.       Lenders JW, Eisenhofer G, Mannelli M, et al: Phaeochromocytoma. Lancet 366:665-75, 2005

            62.       Pacak K, Linehan W, Eisenhofer G, et al: Recent advances in genetics, diagnosis, localization, and treatment of pheochromocytoma. Annals of Internal Medicine 134:315 - 329, 2001

            63.       Ulchaker JC, Goldfarb DA, Bravo EL, et al: SUCCESSFUL OUTCOMES IN PHEOCHROMOCYTOMA SURGERY IN THE MODERN ERA. The Journal of urology 161:764-767, 1999

            64.       Kinney MAO, Narr BJ, Warner MA: Perioperative management of pheochromocytoma. Journal of Cardiothoracic and Vascular Anesthesia 16:359-369, 2002

XI. Surgical Procedures: Insertion of a JJ Stent

I.  Introduction

The goal of inserting a JJ stent is to relieve upper urinary tract obstruction (UTO).  The causes of UTO are numerous, but the most common causes are stone disease and extrinsic compression from non-urologic neoplasms.  

II. Technique

We will first detail the procedure for inserting a new JJ stent for UTO.  The method for replacing a JJ stent is very similar and will be mentioned briefly separately.

1. After performing a complete cystoscopic examination and identifying the ureteral orifice for the kidney that is obstructed, an open-ended ureteral catheter is placed into the appropriate distal ureter so that a retrograde pyelogram (RPG) can be performed to delineate the anatomy of the collecting system as well as the point of obstruction.  A wire is then placed through the ureteral catheter, and the wire and catheter are navigated up into the desired kidney past the point of obstruction under fluoroscopic and cystoscopic guidance.  The choice of wire is at the discretion of the operating urologist; we use a 0.038 Guidewire.  (See review of wires under ureteroscopy Atlas.)  Also, we use an open-ended ureteral catheter during this portion of the procedure because it can reduce ureteral mucosal trauma as well as providing backing for the wire, especially when one has to navigate a very tortuous ureter, similar to the one in Figure 1.  If one is having a very difficult time negotiating a tortuous ureter, either a Glidewire or Sensor tip wire can be substituted.

Figure 1.  Retrograde pyelogram demonstartaing severe hydronephrosis with a markedly tortuous ureter. Note how the ureteral catheter cannot navigate the kinking of the ureter.

 2. Once one has gained access to the kidney past the obstruction, one can either insert a dual-lumen access catheter over the existing wire or remove the wire from inside the open-ended ureteral catheter to perform another RPG if needed.  The benefits of a dual-lumen access catheter is that you can perform a RPG without potentially losing access as well as place another wire through the second port or collect cytology.

 3. With access gained, a JJ stent can then be chosen.  The appropriate stent length is a function of the patient’s height.  In general, a 6x24 stent will suffice for the vast majority of patients.  If one is going to err, err in choosing a longer stent because you can coil the extra length in the dilated collecting system or in the bladder.

 4. The JJ stent can be then placed under a combination of cystoscopic and fluoroscopic guidance or solely under fluouroscopic guidance. 

 5. Many people still prefer to use the cystoscope during stent placement.  In that case, if the cystoscopic sheath is no longer in the patient’s bladder, backload the wire through the sheath.  The sheath then can be passed over the wire into the bladder without the cystoscope much as you would pass an urethral sound.  The wire then can be backloaded through a working bridge as one attaches the cystoscope.  Some attendings do not like residents or fellows to blindly pass the sheath, so one may have to attach the sheath and cystoscope and backload the wire through the working bridge.  Cystoscopic access to the bladder can then be attained under direct vision.

Figure 2.  Placement of two JJ stents in renal pelvis. The proximal curls are well-placed. During the placement, the assistant surgeon will begin to slowly remove the wire to assure the curls as we see in the the figure. Once the curls are well-placed, attention will be placed directed to ensure appropriate cystoscopic placement of the distal curls in the bladder.

 6. Once the cystoscope is in place, the JJ stent is passed over the wire up until its distal end becomes flush with one of the nipples of a port of the working bridge.  The pusher is then advanced up to the JJ stent.

 7. At this point, it is very important that the surgeon and the assistant work in unison.  We usually prefer to have the surgeon look in the bladder while the assistant monitors fluoroscopy.  Communication is a must!

 8. The surgeon then uses the pusher to advance the stent up into the kidney.  He/she will do so until the second thick black mark denoting the distal end of the stent is seen.  The surgeon will keep the cystoscope looking at the ureteral orifice with irrigation running slowly so that vision is clear without overdistending the bladder.

 9. Once the second black mark is seen, the assistant will give the surgeon an idea of where the stent is in the kidney.  If the proximal end of the stent is located adequately in the renal pelvis, the assistant will slowly pull the wire under fluoroscopy to assess the location of the proximal curl. (Figure 2)  If adequate, the surgeon will then move the cystoscope back to the bladder neck and wait until the junction between the stent and pusher is seen.  Once seen, the wire can be pulled.  The distal curl can then be visualized in the bladder.

10.  There are a few tips you can use if there is trouble negotiating the point of obstruction.  First, it is imperative that the assistant is holding the wire tightly ensuring that there is no slack.  Second, one can place the nose of the cystoscopic sheath at the ureteral orifice on the stent to give “backing”.  Third, one can use the pusher to tap on the distal end of the stent with short forceful bursts.  This technique can be useful when negotiating an impacted stone.  Finally, if one is having a great deal of difficulty, the bladder can be emptied and the sheath can be placed right at the ureteral orifice and turned so that the stent is pressed up against the bladder wall.  At this point, one should try use short tapping bursts on the stent with the pusher.  All these steps usually result in bypassing the obstruction.

11.  If one prefers to use fluoroscopic guidance only for stent placement, the steps are essentially the same.  The key difference in using fluoroscopy is to know the landmarks at which to pull the wire.  The proximal end of the pusher has a metallic marker that can be seen radiographically.  This marker indicates the junction between the pusher and the distal end of the stent.  In a male, this interface should be seen at the top of the pubic symphysis before pulling one’s wire. (Figure 3)  In the female, one can use either a midpoint between the pubic symphysis and the midline of the inferior pubic arch or simply just use the midline of the inferior pubic arch. (Figure 3)

Figure 3.  Bony pelvic anatomy denoting location of where radioopaque marker on the pusher should be when removing the wire while placing a JJ stent under fluoroscopic guidance only. Note the appropriate placement of the distal curl in the bladder.

12.  The procedure for replacing a JJ stent is essentially the same as described above.  There are only a couple points that require comment.  First, when removing the indwelling JJ stent, grab the distal curl as close to the tip as possible.  Some urologists will pull the whole cystoscope out with the JJ stent to minimize the chance of losing access.  Others will simply pull the stent out through sheath.  Use fluoroscopy as you pull the stent out to ensure continued ureteral access.  Finally, placing a wire through the existing stent can be troublesome due to calcifications/debris.  Here are some helpful tips to try:  (1) cut the distal end of the stent that is outside the meatus—sometimes the calcifications are only distal; (2) use the stiff end of the Guidewire—if there is loose debris, the stiff end may be able to push through it; and (3) if all else fails, place a new open-ended ureteral catheter into the ureter next to the indwelling JJ stent.

III. Complications

The most common technical complication associated with JJ stent placement is either ureteral or renal pelvic perforation.  If this occurs, simply complete the procedure for management.  If one cannot bypass the obstruction or access is lost and cannot be regained, a percutaneous nephrostomy tube will need to be placed to relieve the UTO.

 

This page was written for UrologyMatch.com by Daniel J. Canter, MD

Dr. Canter  is a graduate of the University of Pennsylvania Urology Residency Program.
He is currently a Society of Urologic Oncology Fellow at Fox Chase Cancer Center.

XII. Surgical Procedures: Augmented Anastamotic Urethroplasty with Buccal Mucosal Graft Ventral Onlay

 Augmented Anastamotic Urethroplasty with Buccal Mucosal Graft Ventral Onlay

Lawrence L. Yeung M.D. and Steven B. Brandes M.D.

Washington University

St. Louis, MO

Pre-operative planning 

An accurate evaluation of the number, length, location, and lumen diameter of the stricture is of paramount importance in determining the surgical approach to a urethral stricture. A retrograde urethrogram (RUG) is most useful in evaluating the anterior urethra from the external meatus to the proximal bulbar urethra. A voiding cystourethrogram (VCUG) should also be performed in conjunction with the RUG to achieve an accurate depiction of the proximal and functional extent of the stricture. The VCUG allows for evaluation of the proximal urethra by obtaining images of the open bladder neck and distended posterior urethra.


 

 

 

 

 

Retrograde urethrogram demonstrating a 4 cm mid to proximal bulbar urethral stricture with 1 cm region of more severe stenosis

 

 

 

 

 

 

 

 

 

 

 

 


 

 

 

 

 

 Voiding cystourethrogram demonstrating opened bladder neck and membranous urethra and proximal extent of stricture with noted narrowing. This patient’s AUA symptom score was 30 with a maximum uroflow rate of 6 mL/second.

 

 

 

 

 

 

 

 

 

 

Timing of surgery

A stricture should be stable and no longer contracting before a urethroplasty is performed to minimize chances of surgery failure. Therefore, we prefer that the urethra not be instrumented for at least three months before any planned surgery, however, six weeks is usually acceptable. If the patient is in urinary retention or requires frequent intermittent self-catheterization, then we typically perform proximal urinary diversion with placement of a percutaneous suprapubic catheter to allow for resolution of any acute urethral inflammation and allow all strictured areas to declare themselves.

Surgical approach

The location of the stricture can help to determine the surgical approach for repair, however, one must also have a plan B, C, D, etc. in their armamentarium when treating a urethral stricture. In general, we prefer to place our grafts dorsally when repairing the mid to distal bulbar and penile urethra because of the lack of a robust amount of corpus spongiosum available to provide an adequate vascular bed (spongioplasty) for the graft in these locations. However, in the proximal bulbar urethra, we prefer to place our grafts ventrally where the spongiosum is thick and performing the anastamosis is technically easier than placing the graft dorsally and there is adequate corpus spongiosum to perform a spongioplasty.

An augmented anastamotic urethroplasty combines the principles of both excision and substitution urethroplasty. It is especially useful when there is a long stricture with a focal area of dense scar and spongiofibrosis that can be excised and the remaining strictured urethra spatulated (either dorsally or ventrally depending on the location of the stricture) and the anastamosis augmented with a graft or flap. We will demonstrate an augmented anastamotic urethroplasty using a ventral onlay of buccal mucosal graft for the 4 cm stricture with 1 cm area of denser stricture seen in the RUG/VCUG above.

Intraoperative Details
1. Position patient in dorsal (“social”) lithotomy using yellow fin stirrups with appropriate padding of all pressure points.

2. Place a 2-0 Prolene glans suture to place penis on stretch.

3. Place a 22 F red rubber catheter into the urethra up to the level of the stricture to help identify the urethra, taking care not to force the catheter through the stricture.

4. Use two penetrating towel clamps or 2-0 Prolene suture to tack the scrotum up to the suprapubic skin region temporarily until the Lonestar retractor is set up.

5. Make a midline perineal incision from the base of the scrotum to approximately 2 cm above the anus.

6. Use electrocautery to dissect through the subcutaneous fat and Colle’s fascia to expose the bulbospongiosus muscle.

7. Set up the Lonestar retractor to facilitate with exposure and secure the bottom of the retractor to the buttock skin using the penetrating towel clamps that are released from the scrotum from step 4.

8. Open the bulbospongiosus muscle sharply in the midline where the muscle fibers decussate in an avascular plane, and dissect it off the urethra using a combination of blunt dissection with the surgeon’s finger and a Kittner sponge. Retract the muscle onto the Lonestar using the hooks. Case must taken during dissection of the bulbospongiosus muscle so that it does not become macerated in order to preserve ejaculatory function.


9. Distract the urethra to one side using DeBakey forceps (treat it as you would a vascular structure) and then sharply dissect it free from the underlying corporal body by cutting down onto it using Metzenbaum scissors to roll the urethra over to one side, and then complete the circumferential dissection by repeating this maneuver on the other side. Care must be taken to not injure the corpus spongiosum or bleeding will occur. Small, perforating vessels from the corpus spongiosum to the corpus cavernosum can be easily controlled with bipolar cautery.

 a.  If a ventral onlay is to only be performed without plans for an augmented anastamosis (for strictures with an adequate urethral plate), then the urethra does not need to be mobilized circumferentially. The stricture can be exposed through a ventral urethrotomy and the graft sewn into place in this location. This is a quicker and easier operation to perform.

10. Encircle the urethra with a ¼ inch penrose drain to facilitate with retraction.

11. Dissect the urethra proximally by mobilizing the entire bulb and dividing the central tendon and separating it from the perineal body, as well as distally to the suspensory ligament of penis to provide adequate mobilization.

12. Flexible cystoscopy via the suprapubic tract can be performed to facilitate identification of the proximal extent of the stricture by turning the overhead lights down and marking the location of the cystoscope light on the urethra.


13. Inject methylene blue per urethra with 60 mL syringe to stain the urethral mucosa, which can help with identification of the mucosa after the urethra is opened. The scarred urethra and corpus spongiosum are white, so staining the mucosa facilitates suturing.

14. Transect the urethra across the region where the stricture is densest with the most spongiofibrosis present.

15. Place bulldog clamps on proximal and distal ends of transected urethra to obtain hemostasis.

 

16. Cut back on the stricture until a lumen is identifiable to allow for spatulation.

17. Spatulate urethra on ventral aspect of the proximal and distal ends of the urethra through the scarred mucosa until healthy appearing mucosa is reached. Place 4-0 Vicryl stay sutures at the apex and 3 and 9 o’clock positions on the urethral mucosa to facilitate with exposure of the lumen.


18. Calibrate the urethra proximally and distally to 28-30F with a bougie à boule to ensure all strictured urethra is opened.

19. Reapproximate the ends of the urethra while keeping the penis on stretch to prevent chordee or penile shortening and measure the resultant urethral defect to determine the size of graft that needs to be harvested. The paper packaging from sterile gloves can be cut out into the shape of the urethral defect and used as a template in the mouth to guide with the graft harvest.

20. Harvest the buccal mucosa graft.

Buccal mucosa graft (BMG) harvest technique

21. Have the anesthesiologist tape the endotracheal tube to the contralateral side from the graft harvest. Nasotracheal intubation is not necessary.

22. Wash the face and inner mouth with 1% hydrogen peroxide soaked sponges.

23. Pack the tongue medially with a 4 X 4 gauze

24. Mark the opening of Stensen’s duct for identification purposes, which is located next to the second molar.


25. Place 2-0 Prolene stay sutures 2 cm lateral and 1 cm posterior from the vermillion border of the mouth.

26. Place a Steinhauser buccal mucosal stretcher on the cheek and a mouth prop in the midline to hold the mouth open.

27. Mark out a graft 2 cm wide by 5-6 cm long (or use a template made with sterile paper glove packaging) with tapered ends to facilitate closure of the defect. Each cheek typically can yield a 6 cm long graft. Be sure to keep the cephalad margin away from Stensen’s duct and the anterior margin at least 1 cm away from the vermillion border to prevent retraction and esthetic problems of the mouth.

28. Inject 10-20 mL of 1% xylocaine with epinephrine 1:100,000 solution with a 22-gauge spinal needle to create a submucosal wheal under the entire graft and wait a few minutes before dissection to maximize hemostasis. Any bleeding can be controlled with bipolar cautery. Monopolar cautery should be avoided as the facial nerves are in proximity to this location.

29. Place three 3-0 chromic stay sutures at the apex and the two corners of the graft. Use the edge of a knife handle to push down on the middle of the graft to provide counter-traction and use a number 15 blade to score the graft edges down to the fat. Use Metzenbaum scissors to dissect the graft superficial to the buccinator muscle. An index finger and a gauze soaked in epinephrine solution provides counter-traction against the buccinator muscle.


 

30. After the graft is harvested, pack an epinephrine soaked gauze into the mouth to facilitate with hemostasis. 


31. De-fat the graft while it is stretched over the surgeon’s index finger by pressing the mid portion of Metzenbaum scissors down against the graft and cutting the fat off.


32. Pin the graft to a foam pad and scrape the remainder of the fat with the edge of a number 15 blade to emulsify it.  The graft is ready when newsprint lettering is visible through the graft.


33. After the graft is de-fatted, close the harvest site with interrupted 3-0 chromic suture.

Augmented anastamosis with dorsal end-to-end anastamosis and ventral BMG onlay technique

34. Place a 4-0 Vicryl stay suture at each apex of the BMG and hang it from the Lonestar retractor.

35. Place the penis on full stretch to prevent penile shortening and then mark out where distal end of graft should lie on the corpora to allow for a tension free anastamosis of the two ends of the dorsal urethral plate.

36. Place five 4-0 Vicryl interrupted sutures (soaked in mineral oil to facilitate passage of suture through tissue) taking bites of proximal and distal urethral mucosa as well as a bite of the tunica of the corpora underneath to anchor the dorsal end-to-end anastamosis. Tag the two lateral sutures with a hemostat.

37. Place three to five proximal 4-0 Vicryl sutures through proximal spatulated apex of urethral mucosa and then pass the suture through the BMG (epithelium side facing lumen of urethra) in the corresponding site and tie down.


38. Suture the right lateral edge of BMG to urethral mucosa, while taking a small bite of the tunica of the corpora laterally, with a running 4-0 Vicryl up toward distal end of urethral opening. Repeat this for the left side of the graft.

39. Place final 16F silicone catheter into bladder through the penis and inflate the balloon.

40. Complete anastamosis with interrupted 4-0 Vicryl through the distal apex.

41. Perform spongioplasty by undermining the tunica of the spongiosum off the urethra with a #15 blade to facilitate its closure. Run the spongiosum closed vertically with 4-0 Vicryl and then close the transverse defect with running 4-0 Vicryl suture as well.


42. Close bulbospongiosus muscle with running 2-0 Vicryl.

43. Close deep fat and then Colles with running 3-0 Vicryl.

44. Close skin with 4-0 Vicryl running horizontal mattress suture.

Post-operative considerations

An ice pack can be placed to the cheek for 24 hours to decrease pain and swelling from the BMG harvevst. We prescribe Peridex swish-and-spit four times a day as prophylaxis against infection of the buccal mucosa harvest site for about one week. The Foley is left in place for 3 weeks and then a peri-catheter retrograde urethrogram is performed to rule out contrast extravasation before the catheter is  removed. 

 

 

 


Lawrence Yeung, M.D.
Urologic Reconstructive Fellow

 

Steven B. Brandes, M.D.
Professor, Surgery
Director, Section of Reconstructive Urology
Urology Residency Director

XIII. Surgical Procedures: Percutaneous Nephrolithotomy (PCNL)

Percutaneous Nephrolithotomy (PCNL)

Boston Scientific is a proud sponsor of the following educational content. To learn more about our Stone Management products and services, please click here

Overview
Management of nephrolithiasis through percutaneous techniques is most often reserved for stones greater than 1.5 cm to 2.0 cm, in a staghorn configuration, behind a stenosed infundibulum, in a calyceal diverticulum, in a kidney with ureteropelvic junction obstruction, or in anomalous kidneys (Figure 1). Stone-free rates for non-staghorn renal stones approach 95% with PCNL as compared to 85% with ureteroscopy and 75% with ESWL. For staghorn renal calculi, stone free rates reach 78% with PCNL and 54% with ureteroscopy. PCNL has largely replaced open and laparoscopic surgery in the management of complex and large renal stones. Compared to open surgery, PCNL allows patients quicker convalescence, less morbidity, and decreased cost.

 

 

 

 

Figure 1: Percutaneous nephrolithotomy (PCNL) is a percutaneous procedure for management of renal calculi. Generally, a rigid nephroscope is utilized. The two most common indications for PCNL are renal stones >2cm in size and staghorn calculi. (image generated using drawMD for iPAD: www.drawMD.com)

 

 

 

 

 

 

Pre-operative Considerations
Because bacteria form biofilm on stone surfaces, even patients with sterile urine cultures and staghorn or infectious calculi must be treated with appropriate antibiotics for approximately two weeks prior to the procedure. Pre-operative broad spectrum antibiotics must also be given prior to the beginning of each procedure (please see AUA Best Practice Statement: (http://www.auanet.org/content/media/antimicroprop08.pdf ). Thoughtful use of pre-operative imaging affords delineation of anatomy and quantification of stone burden.

Contraindications
Absolute contraindications to PCNL include uncorrected coagulopathy and an active, untreated urinary tract infection. Any coagulopathy must be correct and infections treated prior to proceeding with PCNL.

Positioning and Room Setup
At many centers, the patient arrives in the operating room with percutaneous access—generally a small nephroureteral catheter placed by interventional radiology that affords entry access to the ureter through the desired calyx . Some urologists obtain percutaneous access themselves at the time of the procedure. Positioning is one of the most critical aspects of the procedure. The patient is intubated supine on the stretcher on which they entered the operating room. The patient is then “flipped” prone onto the operating room table. To cushion the patient’s ventral surface, either gel pads or pillows can be used. A foam face rest should be used to keep the patient’s head and neck in line with the rest of the body and keep the ET tube secure. Make sure the patient is centered on the table, as an off-center patient can make using the C-arm difficult. The upper extremity on the side of the procedure should be placed in a modified “superman” position as it prevents the surgeon from excessive leaning on the patient’s upper extremity during the procedure. The angle at the axilla should be 90O or less to prevent brachial plexus injury. The angle at the elbow should be 90O or greater. The contralateral upper extremity can be placed at the patient’s side. In male patients, be sure the patient is not laying on his genitalia. The legs should be in normal anatomic position and the feet and ankles should be padded (Figure 2).

 

 

 

 

Figure 2: Patient with a right nephroureteral access catheter placed prone on the operating room table in preparation for PCNL.

 

 

 

 

 

 

 

At this point bring in the C-arm and get it appropriately positioned. It is best to have the fluoroscopic view box next to the endoscopic view box to maximize efficiency (Figure 3)


 

 

 

 

Figure 3: Standard arrangement of operating room equipment for right-sided PCNL.

 

 

 

 

 

 

After prepping and draping (Figure 4), make sure to set up all of your cables and instruments in an organized fashion. The light cords, camera cords, and lithotripter cords should all be set up prior to beginning the procedure. Also, the nephroscope should be set up and placed on the patient’s dorsal surface so that it is readily available when needed.




 

 

Figure 4: Appearance of the surgical field after appropriate prepping and draping. 

 

 

 

 

 

 

 

 

Procedure

Figure 5 demonstrates the scout fluoroscopic image of a typical PCNL case. In this particular instance, a retrograde external ureteral catheter is seen in the renal pelvis in addition to the usual 5-French open-ended antegrade nephroureteral access catheter that had been placed by interventional radiology. External retrograde stenting is at times necessary in order to facilitate antegrade access by injecting contrast into the retrograde catheter. Such access is especially important when the stone burden is radiolucent. As such, effective communication between the urology and interventional radiology services is paramount during pre-operative planning.



 

 

 

 

 

Figure 5: Initial scout image at start of procedure (see text for details). Most urologists orient the image to correspond to the patient’s position on the OR table to facilitate live radiographic interpretation.

 

 

 

 

 

Step 1: Under fluoroscopic guidance, a wire is passed into the percutaneous nephroureteral access catheter, down the ureter and into the bladder. The access catheter is removed, leaving only the wire.

Step 2: An 11-blade scalpel is used to incise the skin approximately 1.5 cm. A second wire must then be placed down the ureter. This can be done with a dual lumen access catheter or a wide caliber catheter that is often included in the dilator set. One wire should be secured as a safety wire.

Step 3: The next step is to dilate the fascia so the nephroscopic sheath can be placed into the collecting system. This can be achieved either with rigid dilators or a balloon dilator. The surgeon should not dilate more than 1-2 cm past the inner edge of the
renal parenchyma to prevent injury to the renal pelvis and/or hilum. The rigid dilators create a working tract by sequentially upsizing the dilators over the working wire. Once the 30 French dilator is inserted, the working sheath is placed over the dilator into the collecting system. In modern practice, rigid dilators have largely been replaced by high-pressure nephrostomy tract balloon dilators. The non-compliant balloon radially dilates the tract at extremely high pressures (up to ~17 atm). The surgeon places the balloon over a wire into the renal pelvis (be certain, the balloon is not in the UPJ!) and inflates the balloon with contrast, watching for “waist” of the fascia to dissipate (Figure 6). Once the tract is dilated, the working sheath is advanced over the balloon into the renal pelvis (Figure 7).

Step 4: At this point, a nephrostogram should be done to confirm placement of access sheath. Once placement is confirmed, some physicians will remove the working wire, while some will leave it in place for duration of procedure (Figure 7).



 

 

 

Figure 6: Fluoroscopic image demonstrating a balloon dilator filled with contrast. The fascial “waist” is no longer present and the 30 French access sheath is ready to be passed into the collecting system over the balloon.

 

 

 

 

 



 

 

 

 

 

Figure 7: Fluoroscopic image demonstrates a working sheath in kidney with 2 wires passing down the UPJ into the ureter.

 

 

 

 

 

 

Step 5: Introduce the nephroscope into the sheath and visually examine the collecting system. Identify and assess stone burden (Figure 8). Irrigation during PCNL should be an isotonic solution (generally, normal saline) to prevent dilutional hyponatremia
secondary to venous uptake. Employing hypotonic irrigants such as water can be lethal. Irrigation fluid should be kept between 60cm-80cm above the patient to prevent excessive intrapelvic pressures and pyelocaliceal backflow.

Step 6: Fragment stones as necessary and remove them from collecting system. There are a variety of tools used for removing stones. These include tricep forceps, alligator forceps, and stone baskets. Generally the stone is too large to simply remove
through the access sheeah and fragmentation is necessary. Several types of lithotripters are commonly utilized (Link to lithotripter article). A pneumatic lithotripter uses mechanical force to break the stone by acting like a small jackhammer (Figure 9). An ultrasonic lithotripter uses ultrasound waves to fragment calculi. Modern devices often couple a suction port with the device to keep the stone in close proximity to probe and to remove pulverized fragments. Laser lithotripters also can be employed for stone fragmentation (see link for discussion of laser settings).


 

 

 

 


Figure 8: View of renal calculus through nephroscope.

 

 

 

 

 

 



 

 

 

 

 

Figure 9: Pneumatic lithotripter (metallic probe at bottom of image) is a common tool used to pulverize renal stones during PCNL.

 

 

 

 

 

Step 7: Once the stones have been fragmented, the residual stone debris should be removed. At times it is not possible to access all calyces with rigid instruments and a flexible nephroscope/cystoscope can be used through the access sheath to assess for presence of residual stone fragments. If residual fragments remain, a basket or a 3- pronged grasping forceps should be used to either remove the fragments or manipulate them into a location within reach of rigid instruments (Fig. 10).

Step 8: Thorough visual and fluoroscopic inspection must be used to insure stonefree status (Fig. 11).




 

 

Figure 10: 3-prong grasping forceps being used through a flexible nephroscope to grasp a stone in a calyx that could not be reached by rigid nephroscopy.

 

 

 

 

 

 




 

 

Figure 11: Calyx free of stone on visual examination.


 

 

 

 

 

Step 9: Once the stones burden is treated, generally a nephrostomy tube is placed into the collecting system either via the access sheath or over the safety wire. Contrast is injected and its position is confirmed fluoroscopically. Some physicians at times will also leave a catheter across the UPJ to facilitate secondary procedures if necessary. So called “tubeless” PCNLs have gained popularity. Only a double JJ stent is left in the urinary system and the parenchymal tract is filled with a cellulose-based hemostatic agent (Fig. 12).




 

 

Figure 12: Schematic demonstrating drains following a “tubeless” PCNL. The percutaneous track is generally filled with a cellulose-based hemostatic agent and a JJ stent is left in place to fascilitate antegrade drainage. (image generated using drawMD for iPAD: www.drawMD.com)

 

 

 

 

 

 

Complications
PCNL is an invasive surgical procedure. Patients must be thoroughly counseled on its possible complications. These include but are not limited to: sepsis, urine leak, perinephric hematoma, splenic injury, bowel injury, liver injury, pneumothorax, hydrothorax, hemothorax, hemorrhage, and pseudoaneurysm. The complication rate ranges from 1.1%-7%.

 

 

Andrew Harris, MD
Cheif Resident, University of Pennsylvania

XIV. Surgical Procedures: Guide to Ureteroscopy

Guide to Ureteroscopy

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Principles:
1) Ureteroscope technology continues to improve (See ureteroscope overview article). The key components are the diameter of the scope (now down as low as 7.5Fr), the lumen of the working port (around 3.5 Fr), and the diameter of the working element (eg. laser fiber or basket). Water flow decreases as the diameter of the working element approaches the diameter of the port making visualization more difficult.

2) “Safety wire”: Always have an extra wire fully up the ureter and set securely aside when performing ureteroscopy. The rationale is that if there is any significant trouble during the procedure (eg. ureteral perforation or “red-out”), the ureteroscope can be removed and a stent can be placed over the safety wire.

3) Patients with pre-existing urinary infections, or, particularly, an infected stone, can become quickly septic with significant ureteral manipulation. Ureteroscopy should be avoided in these patients.

 

 

 

 

 

 

 

Figure 1: Flexiable ureteroscopes can access the entire urinary collecting system for treatment of stones throughout the upper urinary tract.


 

 

 

 

 

Wire review:
There are numerous different types of wires which are used in Urologic procedures reflecting the many different ways in which wires are utilized. Their most common functions are to a) gain access to the ureter, and b) act as the inner component of a coaxial system allowing stents, catheters, and other working devices to be safely passed into the collecting system. The basic characteristics of interest which differ among wires are flexibility, lubricity, and shaft stiffness. Wire diameters typically range from 0.018 to 0.038 inches, with 0.035 and 0.038 wires used most frequently. The tips are often made flexible in order to minimize ureteral trauma. Here, we review the most commonly used wires.

1) Guide or “House” wire: Standard all-purpose wire with moderate stiffness. It is the most commonly employed wire and is often used for placement of ureteral stents and/or initial access to a ureter.

2) Hydrophilic or “Glide” wire: Very slippery and flexible. Comes in both angled-tip and straight-tip varieties. Utilized to gain access where access is difficult. Examples include ureteral orifices which will not pass a ureteral catheter, ureters with a stone or stricture blocking passage of a wire, or urethras which will not allow a Foley catheter to pass. Note: difficult to handle due to slipperiness, therefore needs to be exchanged for another wire once access is achieved.

3) Super-stiff: These very rigid wires provide secure access to a ureter and are used to pass sheaths, stents, or other working devices such as balloon dilators.

4) Double flexible tip: These wires with moderate shaft stiffness are primarily utilized for passing the flexible ureteroscope. The advantage of the 2nd flexible tip is that it decreases trauma to the (expensive) ureteroscope as it is passed over the wire.

 

Ureteral access and pyeloscopy:
1) Cystoscopy to gain access to the bladder

2) A 5 Fr open-ended ureteral catheter is typically used to gain access to the ureteral orifice, though the ureter can also be directly cannulated with a wire

3) A retrograde pyelogram may be performed through the ureteral catheter to delineate the anatomy of the collecting system

4) Using fluoroscopic guidance, a wire is then passed through the ureteral catheter and up the ureter into the renal pelvis. This is often a double floppy tip wire which will be used to pass the ureteroscope.

5) The ureteral catheter is then removed

6) A second wire—the “safety wire”—is then passed by any of a variety of means. Steps 2-4 may be repeated, or devices such as a ureteral access sheath or a dual lumen ureteral access catheter may be employed.


8) The double floppy tip wire is used to pass the ureteroscope. The flexible ureteroscope is passed under fluoroscopic guidance over the wire all the way up to the renal pelvis (unless there is a ureteral stone or stricture blocking its path)


9) Fluid is attached to the ureteroscope. This is typically pressurized normal saline.

10) Pyeloscopy is then performed. Contrast can be first injected through the ureteroscope to delineate the calyceal system. The calyces are then systematically visualized with the ureteroscope.

11) Further procedures such as laser lithotripsy, stone basketting, ureteral biopsy, etc.can now be performed

12) When complete, the ureteroscope is gradually removed with visualization of the entire ureter

13) The safety wire is still in place and can now be used for placement of a stent if necessary. Otherwise, the wire can be removed.

Laser lithotripsy:
- Holmium:YAG laser is most commonly used

- The laser is delivered using flexible quartz fibers which come in different diameters, typically approximately 200, 365, and 550 microns. Larger fibers deliver more energy faster, however the flexibility decreases with increased diameter

- Key concept: maintain contact with stone in order to fragment it while avoiding contact with urothelium. The urothelium will bleed with trauma, making visualization difficult.

- The two main techniques employed for lithotripsy are to  1) fracture the stone into multiple tiny fragments which will pass on their own or may be basketted, or 2) gradually “dust” each stone, a tedious process but with the goal of clearing the entire upper tract by the end of the procedure

 

 

 

 

 

 

 

Figure 2: Ureteroscopic view of an 8mm proximal ureteral stone. A safety wire is seen at 10 o'clock. (click to watch video).

 

 

 

 

 

 

 

 

 

 

Post-op management:
- Patients are typically discharged the same day as the procedure.

- Patient should expect renal colic post-op, and, if stent placed, may have intermittent flank and lower abd pain while stent is in place.

- There is a significant risk of UTI post-op. Patients should receive single-dose IV abx (fluoroquinolone or cefazolin) pre-op. Patients may be sent home with up to 3 days of oral antibiotics for UTI prophylaxis although there is minimal evidence to support this practice.

- Patients undergoing ureteroscopic manipulation of a solitary kidney are at highrisk for post-obstructive diuresis. These patients usually need to be admitted and their fluid balance and electrolytes need to be closely monitored.

XV. Basic Principles: Ureteroscopes -- Overview and Technical Specifications

Ureteroscopes: overview and technical specifications

Boston Scientific is a proud sponsor of the following educational content. To learn more about our Stone Management products and services, please click here

Overview
Ureteroscopy has become the mainstay of treatment for ureteral stones and intrarenal stones smaller than 1.5 cm and refractory to ESWL. In the past several years ureteroscopes have become smaller and more technologically advanced with better optics to facilitate ureteroscopic management of nephrolithasis. This article reviews the technical specifications of flexible and semi-rigid ureteroscopes.


Flexible ureteroscopes.
Flexible ureteroscopes (Figure 1) have one working channel, a deflecting tip, and a fiberoptic viewing system (Figure 2). An “intuitive” scope has a deflection direction that coincides with the direction of the deflection control, so moving the thumb control down moves the tip of the scope down. The angle deflection can range from 1800-3100, allowing for visualization of the entire upper urinary tract including each renal calyx. The working channel on flexible ureteroscopes is typically 3.6 French (Fr), allowing for irrigation and up to a 3 Fr working device for laser fibers, baskets, grasping forceps, etc. If multiple passes into the ureter are expected, then a ureteral access sheath can be used. This facilitates repeat ureteroscopy by obviating the need to run the scope up the ureter over a wire (or enter the ureter freehand), thus saving time in the operating room. Access sheaths range from 10 fr-16 Fr and are listed by inner/outer diameter such that an 11/13 access sheath has a inner diameter of 11 Fr and outer diameter of 13 Fr. Typical lengths are 20, 28, 35, and 55 cm. Choice of length is dictated by sex (shorter in female) and location of access point (longer for more proximal). For example, a 35 cm sheath is good for proximal access in a female and mid-ureteral access in a male.


Technical specs on the most commonly employed flexible ureteroscopes are as follows:

• ACMI DUR-8 Elite – Distal diameter 8.7 Fr, working channel 3.6 Fr, length 64 cm, deflection 310° up and 170° down
• Storz Flex-X - Distal diameter 7.5 Fr, working channel 3.6 Fr, length 67 cm, deflection 270° up and down
• Olympus URF-P5 - Distal diameter 5.3 Fr, working channel 3.6 Fr, length 70 cm, deflection 180° up and 275°







Figure 1: Flexiable Urteroscope

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 2: View from Flexible Urteroscope

 

 

 

 

 

 

 

 

 

 

Semi-rigid ureteroscopes
Most semi-rigid ureteroscopes (Figure 3) have dual working channels--one for irrigation and one for a wire, laser fiber, basket, etc. These chambers range from 2.5 Fr to 3.6 Fr. Those with only 1 working channel have variable sizes from 4-6 Fr. They also vary in length from 33-42.5 cm, some models also have a slight angle to them to facilitate passage in the ureter. Semi-rigid ureteroscopy is preferable for distal ureteral stones. Once above the iliac vessels rigid semi-rigid ureteroscopy can become difficult and
dangerous as the ureter may not be as flexible above this point and the rigid scopes don’t bend very well, although proximal access may be feasible in female patients. For stones above the point of safe passage, flexible ureteroscopy is best.

Technical specs on the most commonly employed semi-rigid ureteroscopes are as follows:

• Gyrus ACMI MICRO-6 – 41 cm long, 6.9 Fr diameter, working channel #1=3.4 Fr and #2=2.3 Fr.
• Gyrus ACMI MICRO-7 -33 cm or 42 cm long, 7.7 Fr diameter, working channel #1=5.4 Fr.
• Stryker RU - 33cm long, 6.9 Fr diameter, working channel #1=3.4 Fr and #2=2.5 Fr.
• Storz 27410SK – 34 to 43 cm long, 7.5 diameter, working channel #1=3.6 Fr and #2=2.5 Fr.

 

 

Figure 3: Semi-Rigid Urteroscope

 

 

 

 

 

 


 

Andrew Harris, MD
Cheif Resident, University of Pennsylvania

XVI. Basic Principles: Lithotripsy Techniques

Lithotripsy techniques

Boston Scientific is a proud sponsor of the following educational content. To learn more about our Stone Management products and services, please click here

Overview
A variety of the techniques are available for dealing with nephrolithiasis. These include laser, electrohydraulic, pneumatic, ultrasonic, electromagnetic, piezoelectric, and shockwave lithotripsy. This article reviews the techniques for the primary forms of lithotripsy utilized in urology.

Extracorporeal Shockwave Lithotripsy (ESWL)
ESWL works by producing shockwaves from an external source aimed and focused on an intracorporeal source. The shockwaves build strength and force as they approach the stone to cause fragmentation. The shockwaves are produced from either an electrohydraulic, electromagnetic, or piezoelectric source. The patient is placed on the ESWL table and fluoroscopy is used to place the stone close to the crosshairs, indicating the point of maximal energy delivery. Once appropriately positioned the procedure can begin. Most ESWL machines have a standard protocol for energy delivery, all of which start with minimal energy delivery that can then be increased during the procedure. The shocks per minute can begin at range of 60-90 shocks/minute and are often increased to up to 120 shocks per minute. There is some evidence that a slow shock rate (60-80 shocks/minute) is more effective than fast shock rates (eg. 120 shocks/minute). Throughout the procedure, fluoroscopy should be intermittently used to ensure that the stone is in the crosshairs. Once the stone begins to break, the energy no longer needs to be increased. ESWL can induce cardiac arrhythmias by way of energy delivery to the heart. If the patient starts to have premature ventricular contractions (PVCs) during the case, he/she should be gated. This allows the shockwave production to correlate with the R wave of the QRS complex of the heart rate, thus delivering the shock during the resting phase of the cardiac cycle. Leaving a patient that is beginning to show signs of cardiac instability (eg. PVCs) ungated is dangerous as these patients can progress to ventricular tachycardia, supraventricular tachycardia, or other cardiac arrhythmias. Other potential complications of ESWL include perinephric hematoma, bleeding, obstruction from stone fragments, and pain (Figure 1).









Figure 1: ESWL Machine

 

 

 

 

 

 

 

Laser lithotripsy
Lasers produce energy by exciting electrons that can then release the energy in the form of light. Most lasers function by turning this energy into a plasma bubble that produces a shockwave upon collapse. The most widely used laser lithotripter is the holmium:YAG laser and is available in 200, 365, 550, and 1000 micrometer fibers. The holmium:YAG laser has a pulse duration of 250-350 microseconds, functions at a wavelength of 2140 nm, and a depth of penetration of 0.5-1.0 mm. This particular laser works by causing stone vaporization through a photothermal mechanism, rather than by producing a shockwave. When performing laser lithotripsy, the fiber should be placed in contact with the stone and irrigation should be available as fragmentation may cause decreased visibility. The tip of the laser must be visible at all times while activated as it will fragment whatever is in front of it, including a wire or the ureteral wall. It is best to avoid drilling a hole through the stone. In general, the best technique is to start on the center of the stone and work outward, vaporizing the stone. By the end of the procedure, there should only be one fragment left that may be removed with a basket. If being placed through a flexible instrument then a 200 or 365 mm fiber should be used. The procedure should begin with 0.6 joules and a pulse rate of 6 hertz. If need be, the pulse rate can be increased for quicker fragmentation (Figure 2).









Figure 2: Laser Lithotripsy

 

 

 

 

 

 

 

 

Electrohydrolic Lithotripter (EHL)
The EHL uses an underwater spark discharge to generate a plasma channel that vaporizes the water near the electrode and produces a hydraulic shockwave. The hydraulic shockwave impacts and fragments the stone. If the shockwave misses the stone, it will release energy on whichever portion of the urothelium encountered and can cause ureteral or bladder perforation. Also, if the stones are loose, the shockwave can propel stones in a retrograde fashion. The probe should be placed >2 mm from the end of the endoscope and within 1 mm of the stone. The procedure should begin with 50-60 volts in short or single bursts. The energy can be increased as need to effectively fragment the stone. If the insulation from the tip of the catheter loosens, a new probe should be used (Figure 3).









Figure 3: EHL

 

 

 

 

 

 

 

Pneumatic Lithotripters
A pneumatic lithotripter works by essentially jackhammering the stone by direct contact. This mechanism is very effective in fragmenting stones and is also very safe, unless the lithotripter probe is moved off of the stone, potentially damaging whatever is in front of the probe. Success rates are 73%- 100%, with ureteral perforation rates up to 2.6%. However, given the mechanism of action, the chance of retrograde migration is greater than with other modalities. The probe is placed in direct contact with the stone, a clear visual is imperative, and the stone is pinned against the bladder, ureteral wall, or kidney prior to activating the probe. Again, the goal is to fragment the stone into multiple small fragments that can be removed or pass spontaneously.






Figure 4: Pneumatic Lithotripter

 

 

 

 

 

 

 





Figure 5: Stone with Indentation and fragments from pneumatic lithotripter

 

 

 

 

 

 

Ultrasonic Lithotripsy
Ultrasonic lithotripters work by using ultrasound waves at 23,000 to 25,000 Hz to cause stone fragmentation by vibration with minimal effect on surrounding tissues. These lithotripters also have a suction port that allows small fragments to be removed during lithotripsy. Using these lithotripters in the ureter is not as effective as aforementioned lithotripters. However, they are very effective when utilized via percutaneous access for treatment of renal stones.

The probe is applied directly onto the stone surface, but done gently to prevent the stone from moving. It is best to pin the stone against the urothelium and fragment the stone until it can be removed or the fragments can pass.

There are a combination of Pneumatic/Ultrasonic lithotripters available.


Cystolithalopaxy forceps
Cystolithalopaxy forceps are used to crush stones in the bladder. The forceps will crush anything in them, including the bladder wall. The bladder must be distended so bladder wall isn’t involved in the forceps. This is an effective technique; however, visualization can become difficult with multiple uses secondary to urothelial trauma.









Figure 6: Cystolithalopaxy

 

 

 

 

 

 

 

 


 

 

 

Andrew Harris, MD
Cheif Resident, University of Pennsylvania

XVII. Basic Principles: Laser Settings

Laser Settings

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Overview
Laser is an acronym for Light Amplification by Stimulated Emission of Radiation. Electrons gain energy from an external source of energy; this energy can then be released as photons. The emitted photons have significant temporal and spatial coherence, delivered in a narrow beam. This allows a high level of energy to be delivered onto an object—eg. a stone or mass. The medium used to create the specific wavelengths is how lasers are named: holmium, neodymium, KTP, etc. In urology, lasers are used for the treatment of nephrolithiasis, benign prostatic hypertrophy, penile cancer, penile condyloma, urothelial carcinoma, and urethral stricture disease. This article reviews the different lasers employed in urologic surgery and the typical settings for the most common uses of each laser.

Holmium: YAG
The Holmium: YAG (Yttrium-Aluminum-Garnet) laser uses holmium put into a YAG crystal. It emits a wavelength of 2140 nm to deliver energy in a pulsatile fashion. This laser uses a thermomechanical mechanism of action, creating a bubble of vaporization at the tip of the laser fiber. This bubble expands and dissipates energy onto the object directly in front of the bubble. It can be used for BPH surgery, stones, urethral strictures, bladder neck contractures, and urothelial carcinoma (Figure 1). Holmium has a penetration depth of <0.5 mm.

Recommended settings are (Figure 2):
• Bladder tumors: 0.6 to 1.2 joules at a frequency of 8-10 hz
• Stones: Begin at 0.6 – 0.8 joules and a pulse rate of 6-8 hertz. The pulse rate can be increased for quicker fragmentation.
• Bladder neck contractures: 2 joules at 40 hertz
• Prostate ablation: 2 joules at 40 hertz

 








Figure 1: Holmium laser fiber, safety wire seen above stone, red light is to aim laser.

 

 

 

 

 

 

 

 

 





Figure 2: Holmium Laser Settings

 

 

 

 

 

Neodymium:YAG
The Neodymium:YAG laser uses neodymium put into a YAG crystal. This laser emits a wavelength of 1064 nm. It has a deeper penetration than and better coagulation compared to the holmium laser. It isn’t well absorbed by body pigments and works by coagulative necrosis with tumor sloughing rather than ablation. The Nd:YAG laser is best suited for the treatment of urothelial carcinoma. Of note, the most dangerous complication from using this laser thermal damage to structures on the other side of the tumor (eg. bowel). Nd:YAG has a penetration depth of 5-6 mm.

 Recommended settings are:
• Bladder tumors: 20-30 watts for 2 seconds
• Renal pelvis tumors: 15-20 watts for 3 seconds

 

 

KTP
The KTP laser (potassium-titanyl phosphate) uses a Nd:YAG laser passed through a KTP crystal to create a green beam with a wavelength of 532 nm. This doubles the frequency and, therefore, halves the wavelength. It penetrates half the depth of the Neodymium but otherwise has characteristics of the Nd:YAG. The KTP laser can be used for BPH surgery, incision of urethral strictures, bladder neck contractures, and superficial penile cancer. The Nd:YAG remains better for urothelial carcinoma given its increased depth of penetration.

Recommended settings for the KTP laser settings are as follows:
• Photoselective vaporization of the prostate: 80 watts to 180 watts for vaporization; 20-30 watts for coagulation (Figures 3 and 4). Start at 80 watts to allow the fiber to warm up, then progress higher.

 

 

 

 

 

 

 

 

Figure 3: KTP laser with red light showing direction of beam.

 

 

 

 

 

 

 

 







Figure 4: KTP laser with beam activated.

 

 

 

 

 

 

 

 

 


CO2
The CO2 laser was one of the first lasers developed. The CO2 laser emits an invisible beam and has a wavelength of 10,600 nm. This wavelength is highly absorbed by water making the depth of penetration minimal (0.1 mm). However, the heat from this laser penetrates to 0.5 mm and can induce thermal coagulation. Given its significant absorption it is capable of incising and removing small superficial lesions. The CO2 laser is mainly used for superficial penile lesions such as condyloma and carcinoma.

Recommended settings are:
• Skin (eg. penile) lesions: setting: 5-10 watts. The laser is applied until the tissue turns white, signifying adequate vaporization.

 

 

 

 

 

Andrew Harris, MD
Cheif Resident, University of Pennsylvania