Comprehensive Overview of Urology Surgical Procedures

Cystoscopy

Cystoscopy is a urological procedure that utilizes a specialized instrument called a cystoscope to visualize the interior of the urethra and the bladder. There are two primary types of cystoscopes used in clinical practice: the flexible cystoscope and the rigid cystoscope. The choice of instrument often dictates the type of anesthesia required. A flexible cystoscopy typically utilizes local anesthesia, though it can also be performed under general anesthesia. In contrast, a rigid cystoscopy is performed under general anesthesia.

A cystoscopy is performed for several diagnostic and clinical reasons, including frequent urinary tract infections (UTIs), hematuria (the presence of blood in the urine), urinary frequency, and urinary urgency. It is also indicated in cases of urine retention, urine incontinence, and when a patient experiences pain or burning sensations during or after urination.

Ureteroscopy (URS)

Ureteroscopy (URS) involves the use of a ureteroscope to examine the interior of the ureters and the kidneys. The ureteroscope is characterized by being longer and thinner than a cystoscope, which allows the urologist to capture detailed images of the lining of the ureters and the kidney structures. Similar to cystoscopy, ureteroscopy instruments are categorized into two types: rigid and flexible.

Ureteroscopy is performed for both diagnostic and therapeutic purposes. During the procedure, a urologist can identify stones located within the ureters or kidneys, as well as detect abnormal tissue. Therapeutically, the urologist can treat identified problems by removing stones from the ureters or kidneys, treating narrowed ureters using balloon dilation, or performing a biopsy of ureteral tissue.

A specific application of the flexible ureteroscope is Retrograde Intrarenal Surgery (RIRS). This procedure follows a specific sequence:

1. The kidney stone is fragmented using a holmium laser.
2. The resulting stone fragments are collected using a tipless basket.

This process involves navigating the ureteroscope through the urethra, bladder, and ureter to reach the kidney.

Transurethral Resection of the Prostate (TURP)

Transurethral Resection of the Prostate (TURP) is a surgical treatment for Benign Prostatic Hyperplasia (B.P.H). The procedure utilizes an instrument known as a resectoscope, which is inserted through the tip of the penis into the urethra. TURP is considered the most effective treatment for prostate enlargement and is indicated for patients with moderate to severe urinary problems that have not responded to medical management.

TURP helps reduce urinary symptoms caused by B.P.H, including the frequent and urgent need to urinate, slow or prolonged urination, and nocturia (increased frequency of urination at night). It also addresses complications like UTIs and bladder stones. However, the procedure carries potential complications such as further UTIs, bleeding, and TURP syndrome, which is characterized by low sodium levels in the blood.

Transurethral Resection of Tumor (TURT)

Transurethral Resection of Tumor (TURT) is a procedure performed under general anesthesia to remove bladder tumors. It employs a resectoscope inserted through the tip of the penis, through the urethra, and into the bladder. Once the tumor is removed, a biopsy is sent to the laboratory for analysis.

Following the procedure, a size $22\,fr$ three-way Foley catheter is inserted to allow for irrigation with normal saline (N/S). Post-operative monitoring involves checking the patient's PCV (Packed Cell Volume) and P.T. (Prothrombin Time). After discharge, patients are typically required to attend follow-up appointments every $3\,\text{months}$. Potential complications of TURT include bleeding, bladder infection (cystitis), perforation of the bladder wall, and hematuria.

Suprapubic Cystostomy

Cystostomy, specifically suprapubic cystostomy, is a surgical procedure where an opening is made directly into the bladder from the skin surface located above the pubic bone. A catheter is inserted into the bladder through this opening and is held in place by either sutures or an internal balloon. This procedure can be designated as temporary, permanent, or performed as an emergency. The anesthesia options for a cystostomy include local, spinal, or general anesthesia (GA).

Indications for a suprapubic cystostomy include:

1. Acute urine retention.
2. A ruptured urethra.
3. Chronic urinary retention associated with a neurogenic bladder.

Urethral Stricture and Sachsea

A urethral stricture is defined as the narrowing of the urethra caused by scarring, specifically due to fibrosis. The etiology of these strictures is divided into two categories: congenital and acquired. Acquired strictures are typically the result of trauma or infection.

Diagnosis of a urethral stricture involves identifying symptoms such as decreased flow of urine, increased frequency, terminal dribbling, the sensation of incomplete bladder emptying, and urine retention. Risk factors for developing a stricture include recent UTIs or the previous use of a catheter. During a physical examination, a provider may note decreased urine flow or bulging in the suprapubic region. Other diagnostic tools include Uroflowmetry and radiological imaging such as a Urethrogram.

Treatment options for urethral strictures include:

1. Dilatation.
2. Internal urethrotomy.
3. External urethrotomy.
4. Urethroplasty.

Percutaneous Nephrolithotomy (PCNL)

Percutaneous Nephrolithotomy (PCNL) is a surgical procedure indicated for kidney stones that are too large for other treatments, usually those larger than $2\,cm$. The primary advantage of PCNL is that it serves as an alternative to open surgery, which requires a large flank incision. PCNL is performed through a much smaller skin incision of approximately $1\,cm$.

Pre-operative preparation for PCNL includes urine analysis, securing $2\,\text{units}$ of blood, and conducting blood tests including CBC, KFT, PT, PTT, and INR. The surgical site must be shaved, and the patient must remain NPO (nothing by mouth) after midnight. Additionally, patients must stop taking anticoagulant medications.

The PCNL procedure is performed under general anesthesia (GA) with the patient in the prone position, following these steps:

1. Lithotomy Position: A small retrograde catheter is placed up through the ureter using a cystoscope, and a Foley catheter is inserted.
2. Prone Position: A needle tract is created using a nephrostomy needle. This tract is dilated to approximately $1\,cm$ to allow for the placement of a plastic sheet. A nephroscope is then inserted to directly visualize the stone. Ultrasonic energy is used to fragment the stone into small pieces.
3. Drainage: A nephrostomy tube is inserted to facilitate drainage.

Complications associated with PCNL include bleeding, infection, and potential failure to successfully remove the stone.