Surgery E2: Uro/Gyn

How does cryptorchidism present?

non-palpable testes in the scrotum assess to make sure it is not a retractile testicle; MC location is suprascrotal just outside external ring

What workup needs to be done for cryptorchidism?

scrotal US

What is the tx for cryptorchidism?

orchiopexy (recommended btwn 6-18 months)

*open, alt: laparoscopic

What is 1-stage Fowler-Stephens orchiopexy?

*laparoscopic

gonadal vessels are divided and the testis is dissected off a pedicle of the vas deferens to bring it down

What is 2-stage Fowler-Stephens orchiopexy?

*laparoscopic

clips placed to divide the gonadal vessels, dissection of the testis is deferred for 6 months allowing for optimal development of collaterals before proceeding w/ testicular relocation

What is 2-stage Shehata technique orchiopexy?

*laparoscopic

performed in 2 stages, has the benefit of relocating intraabdominal testis w/o sacrificing the main testicular vessels

What are potential complications of an orchiopexy?

testicular atrophy, testicular ascent

What are the benefits of orchiopexy?

reduce risk of infertility, corrects patent processus vaginalis (predisposes to hydrocele or hernia), allows for exam of testis (malignancy)

What are sx of testicular torsion?

acute testicular pain or swelling, absence of cremasteric reflex, testicle may be abnormal or lying transverse

What workup is needed for testicular torsion?

STAT scrotal US w/ doppler

STAT uro consult

What is the tx for testicular torsion?

immediate surgical detorsion & bilateral orchiopexy to the scrotum

*if done w/in < 6 hrs, 90-100% salvage rate

What is the tx for testicular torsion if the testis are nonviable?

orchiectomy

What are the complications of correcting testicular torsion?

loss of testis, infection, infertility, cosmetic deformity, loss or diminished exocrine/endocrine function

What are sx of an urethral injury?

blood at meatus, painful urination or inability to void, palpable bladder, swelling, hx trauma, uro surg, dyspareunia

What is the workup of an urethral injury?

retrograde urethrogram (gold standard)

*CT preferred if assessing intraabdominal (kidney, ureter, bladder)

What is the tx for an urethral injury?

cystoscopy w/ urethral repair

*leave in post-op foley until completely healed

What is the normal size of the prostate?

30-80 cc (size of walnut)

What are the sx of BPH?

urinary frequency, hesitancy, urgency; nocturia, weak stream, dribbling, can lead to obstruction → retention; untx → permanent damage to detrusor muscle

What workup is needed for BPH?

transrectal US -preferred if pursuing surgery

PSA, UA, DRE, IPSS, PVR, uroflow

What is the medical management of BPH?

Alpha blockers: 1st line: Tamsulosin (Flomax) alt: -zosin

5-alpha reductase inhibitors: Finasteride (ideal for prostates > 30g)

What are indicates for surgical tx of BPH?

postvoid residual volume > 100mL, acute/chronic urinary retention, gross hematuria > 1 event, recurrent UTIs

What is the surgical tx for BPH?

TURP

prostatectomy, TUVP, laser enucleation, temporary implanted prostatic device, TUNA

What are the RF for prostate cancer?

AA, > 60 yo, + FHx in 1st degree relative

What are sx of prostate cancer?

asx early on, elevated PSA, BPH w/ LUTS; advanced → anemia, wt loss, bone pain

What workup is needed for prostate cancer?

prostate biopsy (gold standard) → use Gleason score

DRE, trend PSA, MRI prostate - assign PIRADS score (4-5 = sus)

What is Grade 1 (Gleason score < 6)?

well-formed gland; low risk of cancer

What is Grade 2 (Gleason 3+4=7)?

predominantly poorly-formed glands w/ lesser component of well-formed glands; intermediate risk of cancer

What is Grade 3 (Gleason 4+3=7)?

predominantly poorly formed glands; intermediate risk of cancer

*most prostate cancers fall into this group

What is Grade 4 (Gleason = 8)?

only poorly formed glands; high risk

What is Grade 5 (Gleason 9 or 10)?

lacks gland formation (or w/ necrosis); high risk

What are non-surgical tx options for prostate cancer?

external beam radiation, brachytherapy (radioactive seed implants)

What are surgical tx options for prostate CA?

robotic or laparoscopic-assisted prostatectomy (radical prostatectomy) -offers definitive cure

TURP, open prostatectomy, TUNA

What are complications for prostate surgery?

hematuria post op, painful or difficult urination, infection, retrograde ejaculation, bleeding, impotence, incontinence

What is a total hysterectomy?

removes entire uterus and cervix

*can be robotic assisted, laparoscopic, transvaginal, or abdominal

What is a partial hysterectomy?

only removes the uterus and leaves the cervix

What is a radical hysterectomy?

removes the uterus, cervix, and upper part of the vagina

What are the indications for a hysterectomy?

CA, fibroids, endometriosis, uterine prolapse, chronic pelvic pain, abn vaginal bleeding

What is the post-op care for a hysterectomy?

foley cath x 24 hrs, maintenance IVFs, abx prn, NPO and work up to regular diet, antithrombotic therapy according to risk, pain managment

What are complications of a hysterectomy?

injury to nearby organs, dyspareunia, early menopause, complications from anesthesia, DVT or PE, infection, heavy bleeding

What is a myomectomy?

surgical excision of uterine fibroids (leiomyomas)

*abdominal, laparoscopic, robotic, hysteroscopic

When is an endometrial ablation indicated?

pts w/ heavy or abnormal menstrual bleeding

What is colporrhaphy?

surgical repair of a defect in the vaginal wall; indicated for pts w/ pelvic organ prolapse

What are indications for a hysteroscopy?

AUB, infertility, removal of intrauterine growths

What is sacrocolpopexy?

laparoscopic or robotic assisted approach to repair pelvic organ prolapse that uses a synthetic mesh that is attached to the pelvic organs that have prolapse and attaches it to the pelvic bones