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Surgical Procedures Notes

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Surgical Procedures Notes Cystoscopy Indications: haematuria protocol for bladder cancer; unusual cells found in urine sample look for bladder cancer; look at urinary blockage e.g. prostatic enlargement; look at urinary tract stones Procedure: cystoscope into urethra, up into bladder, sterile liquid flows to inflate the bladder. Can take a biopsy or remove a stone. Adverse effects: haematuria, pain. urethral damage can cause incontinence after rigid cystoscopy. Any other info: flexible=local anaesthetic, rigid=general anaesthetic

Ureteroscopy Indications: remove kidney stones Procedure: thin cystoscope up through urethra, bladder, then ureters. Can have a basket to retrieve stone fragments. Adverse effects: same as cystoscopy Any other info: 'pyeloscopy' can go up into the renal pelvis

Nephrectomy (radical) Indications: RCC, urothelial cancer of the kidney, living donor kidney transplantation. Renal masses >7cm. Procedure: general anaesthetic open or laparoscopic. Can be taken out transvaginally. Adverse effects: pain. Electrolyte and fluid balance disturbances due to kidney dysfunction. Infection, bleeding.

Partial nephrectomy Indications: solitary kidney tumour or when removing the entire kidney could result in kidney failure or dialysis due to pathology in the other kidney. Standard where the renal mass is <4cm. Also most masses 47cm in size. Procedure: GA open, laparoscopic or robotic Adverse effects: bleeding, pain, infection, urinary leak Any other info: better kidney function and quality of life than radical nephrectomy

Extracorporeal shock wave Lithotripsy (ESWL) Indications: treatment of kidney stones or gallstones (or salivary stones!)

Procedure: non-invasive. Acoustic pulse. USS-guided. Fragments the stones into smaller pieces that pass. Ureteric stent can be used as well. takes about an hour. Works best with stones 4mm-20mm diameter in the kidney. Lower success if in the ureters. Adverse effects: capillary damage with renal haemorrhage. Can lead to renal failure!
Any other info: alternatives are laser lithotripsy or percutaneous nephrolithotomy

Laser lithotripsy Indications: removal of stones from anywhere in urinary tract Procedure: via a cystoscope or utereroscope or pyeloscope, a laser fibre is used to deliver pulses to pulverise the stone into pieces so that they are washed out. LA or GA. Minimally invasive. Adverse effects: very safe

Percutaneous nephrolithotomy Indications: remove stones from the kidney that are larger than can be done by lithotripsy. Best: stones
>2cm near the renal pelvis. Procedure: do a retrograde pyelogram to locate the stone. Loin incision?needle passed into kidney pelvis. Guide wire inserted, Seldinger technique, pass a nephroscope to take out small stones. May have to crush first with ultrasound probes. Adverse effects: injury to colon or renal blood vessels, sepsis, pleural effusion if done through 11th intercostal space

Sclerotherapy Indications: treat blood vessel malformations, in particular varicose veins and haemorrhoids Procedure: can be Us-guided. Can use glycerol or foam sclerosants to control reflux from sapheno-femoral or sapheno-popliteal junctions. Non-invasive and quick. Adverse effects: rarely, DVT, thrombophlebitis, allergic reaction. If injected outside the vein, scarring and skin necrosis.

Carotid endarterectomy Indications: prevent stroke by correcting carotid artery stenosis. Stenosis >70% on duplex scan. Does not matter whether symptomatic or asymptomatic. Procedure: LA (rarely GA) open artery and remove atherosclerotic plaque. Assess cerebral perfusion using EEG. Alternatively, can do a carotid stent through a catheter from the femoral artery with balloon dilation and a wire-mesh stent. This is not as good. Adverse effects: perioperative stroke risk or TIA. Haematoma?tracheal compression. Hypoglossal nerve damage. Horner's syndrome is rare. Restenosis often occurs.

Contraindication: complete internal carotid artery obstruction (no point) or existing ipsilateral stroke (cannot cure, don't want to worsen) N.B.: If both arteries are suitable for repair, do not do both together, do them separately.

Abdominal aortic aneurysm repair Indications: elective when aneurysm diameter >5.5cm on USS. growth per year of >0.5cm. emergency haemorrhage or other high risk of rupture. When blood flow is compromised e.g. to renal arteries. Procedure: may be via an open incision or EVAR: endovascular aneurysm repair. In open, use a tube graft sutured the length of the aneurysm. EVAR=minimally invasive, via the groin and femoral arteries, place a stent-graft. Adverse effects: 3.4% mortality for elective open repair. 1.7% for EVAR. Stent migration. Spinal or mesenteric ischaemia and distal embolic events. 'endoleak'=failure of graft to stop blood flow to the aneurysm. Aortoenteric fistula?massive haemorrhage and death. EVAR is safer at the time but has a higher risk at 5 yrs so if life expectancy is long then do an open repair. It is not a risk of the operation to dislodge a thrombus. When doing an AAA repair of a suprarenal or juxtarenal AAA there is clamping above the renal arteries leading to 10-15% risk of end-stage renal failure. EVAR Contraindications: short neck length, tortuosity or angulation of iliac artery or aneurysm neck, iliac stenotic disease making catheter passing difficult.

Transurethral resection of prostate (TURP) Indications: BPH 'gold standard' surgical treatment. If medical fails or there are complications (bladder stones, bladder infection, hydronephrosis). Procedure: Remove part of prostate through urethra. Endoscopic. heated loop. General or spinal anaesthesia. Adverse effects: retrograde ejaculation - reduced fertility - 90%. Bladder incontinence, usually for a few weeks - 10%. Urethral strictures. Haematuria for 2 weeks. Clot retention, haematospermia. UTI. Urinary retention. Erectile dysfunction 10%, usually temporary. 8% failure rate. 6% lasting stress incontinence. 10%
will need a repeat TURP within 8rs. Need to avoid sex and driving for 2 weeks afterwards. Infection: UTI and prostatitis. Hypothermia. TUR syndrome: the isotonic fluid containing glycine pumped through the urethra is absorbed into the prostatic venous sinuses and then bloodstream if the procedure is over about one hour. Leads to a decrease in temperature, fluid overload and hyponatraemia. Glycine?ammonia overproduction. Alternatives: transurethral ultrasound-guided laser-induced prostatectomy (TULIP). Holmium laser ablation of the prostate (HoLAP). Open prostatectomy. TUIP.

Transurethral incision of the prostate (TUIP) Indications: BPH Procedure: resectoscope through urethra. Fairly similar.

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