Transcript Renal Tubule

SUR 122
Genitourinary
Surgery
Genitourinary System
 Terminology
 Anatomy & Physiology
 Pathology
 Diagnostic & Pre-operative Testing
 Anesthesia & Medications
 Basic Instrumentation, Supplies, & Equipment
 Incision Site Options
 Positioning, Prep, & Draping
 Dressings, Drains, & Post-operative Care
Terminology
 BPH – nonmalignant enlargement of prostate common with age
 Dialysis - waste product removal from the blood of a patient in
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renal failure
Enucleate – remove without cutting into
Epispadias – urethra terminates at base of penis or above
clitoris (congenital)
Gerota’s capsule – perirenal fascia that holds kidney in place
Impotence – inability to achieve erection
Hematuria – blood in the urine
Hilum- everything enters and leaves kidneys through this notch
Ptosis – drooping of an organ or part
Trigone – triangle-like space a bladder base
Terminology
 Hydrocele – fluid filled sac in the scrotum
 Hypospadias – urethra opens on ventral surface of
penis, perineum, or inside the vagina (congenital)
 Paraphimosis – retraction of prepuce results in
painful swelling of glans
 Phimosis – uncircumcised male prepuce won’t retract
from glans
 Wilm’s tumor - malignant neoplasm of a kidney in
children 3-4yrs.
 Anatomy video
 http://www.youtube.com/watch?v=xYTjvqzyd
9k
Male Reproductive System
 Large part external to body cavity
 Scrotum=pouch of skin that contains testis
 Testis are both endocrine & exocrine glands
 Exocrine=secrete sperm via ducts
 Endocrine glands produce testosterone
Male Reproductive System
 Testis
 Lobules with 3 cell types:
1. Seminiferous tubules
involved in spermatogenesis
2. Interstitial cells (cells of Leydig)
produce testosterone
3. Seratoli cells
provide nutrients for sperm
Male Reproductive System
 Sperm
 Male produces 300 million sperm per
day=120million per ml
 Less than 20 million per ml considered sterile
Male Reproductive System
 Sperm (3 parts)
1. Head
a. Acrosome contains
chemical hyaluronidase
which is an enzyme that
breaks down hyaluronic acid
(found in loose connective
tissue) that allows sperm to
penetrate the egg
b. Nucleus (haploid) contains
23 chromosomes (when
unites with egg also 23
chromosomes, chromosome
total becomes 46)
2. Midpiece
extension that contains large
amt of mitochondria (ATP)
3. Flagella
tail composed of a protein
that allows for movement
generated by ATP
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Male Hormones
1. FSH
 Tells interstitial cells to produce testosterone and
sperm in testis
2. LH
 Tells interstitial cells to develop and secrete
testosterone
3. Testosterone
 Stimulates development, growth and maintenance of
male reproductive system including sex
characteristics, maturation of sperm, and skeletal
muscle development
Ducts
1. Epididymis
 Series of ducts or channels that communicate with the testis
 Store sperm
 Area for sperm maturation
 Ciliated columnar cells secrete
2. Vas Deferens
 Loops up over bladder
 Transports sperm
 Ciliated columnar cells and smooth muscle (peristalsis) move
sperm
3. Ejaculatory duct
 Vas deferens merge into this posterior to bladder which merges
with the urethra (runs through the prostate)
Male Reproductive System
Summation
 Testis are located in the scrotum
 Testes produce sperm and testosterone
 Contain lobules containing seminiferous tubules
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where sperm arise
Lobules lead to ducts in the epididymis
Epididymis leads to ductus deferens
Ductus deferens open into urethra
Testis suspended by spermatic cord
Spermatic cord goes from inguinal ring to testis
Inguinal ring also contains ductus deferens, testicular
vessels (arterial, venous, and lymphatic), and nerves
Accessory Organs
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Seminal vesicles
Behind (posterior) bladder
Secrete into ejaculatory duct
60% liquid portion of semen
Prostate gland
Donut shaped as urethra runs
through it
Secretes 30% liquid portion of
semen directly into the urethra
Bulbourethral (Cowper’s)
glands
10% volume of semen
(lubricates head)
Neutralizes acidity of urethra
Secrete directly into urethra
Internal urinary sphincter
tightens w/ejaculation to
prevent mixing of urine
w/sperm
Accessory Organs
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Penis
3 cylindrical tissue masses
Corpus cavernosum x 2 (upper)
Corpus spongiosum x1 (lower)
Urethra passes through corpus spongiosum
These three areas are surrounded by blood
sinuses
 Arteriole blood retention allows an erection
 Post-ejaculation pressure is released
Genitourinary System
 Kidneys
 Adrenal glands
 Ureters
 Urinary Bladder
 Urethra
 Prostate Gland (male)
Kidneys
 Location retroperitoneal
 At T-12 to L-3 vertebral column
 Encapsulated in perineal fat and fascia renalis
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capsule which hold them in position
Hilum medial area where renal artery and vein enter
and exit
Left larger
Right lower due to liver location
Functional unit is the nephron: filtration,
reabsorption, secretion
Nephron
 > 1 million per kidney
 2 types: juxtamedullary and cortical
 Each composed of capillary network:
 Renal corpuscle
 Renal tubule
Nephron
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Renal Corpuscle:
Bowman’s Capsule
Glomerulus
Renal Tubule:
Proximal Convuluted Tubule
Loop of Henle
Distal Convuluted Tubule
Collecting Tubule
Renal Corpuscle
1. Filtration
 Bowman’s Capsule (glomerulus encased by)
 Glomerulus (capillary network)
 Water and substances filtered from blood
Renal Tubules
2. Reabsorption
 Substances move from renal tubules into
capillaries (blood) surrounding the tubules
 Prevents needed body substances from
being lost in urine
 Proximal convuluted tubule (origin in
Bowman’s Capsule)
 Loop of Henle
 Distal Convuluted Tubule
Renal Tubules
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Secretion
Substances move from blood into tubules
(urine)
Distal Collecting Tubule
Collecting Tubule
Filtrate/Urine Pathway
 Fluid once it leaves the blood and is in the
nephron called filtrate, once leaves nephron
is called urine
 Nephron > papillary duct > minor and major
calyces > renal pelvis > ureters
Urinary Bladder
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Holds average of 800ml
Three layers: Submucosa, Muscularis, Inner Tunica Mucosa
Muscularis called detrusor muscle
Internal sphincter = smooth muscle = involuntary control
External sphincter = skeletal muscle = voluntary control
Stretch receptors in bladder signal brain via micturation reflex
About 400ml, brain relaxes internal sphincter
This signals you it’s time to go…
Inner Tunica mucosa is rugae surface (allows for stretching)
except in the trigone area which is a smooth surface
Adrenal Glands
 Suprarenal glands
 Endocrine glands: contain cortex and
medulla
 Cortex: secretion of fluid and electrolyte
balance controlling steroids and hormones
(aldosterone and cortisol)
 Medulla: produces, stores, & secretes
epinephrine (adrenaline) & norepinephrine
(noradrenalin)
Pathology of the Male Reproductive
System
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Phimosis
Hypospadias/Epispadias
BPH
Cancer of the Prostate
Cryptorchidism
Testicular Torsion
Testicular Cancer
Trauma
Phimosis
 Foreskin will not retract
 Congenital
 Geriatric
 Can cause infection, pain
 Tx: circumcision
Hypospadias
Epispadias
 Hypospadias
 Epispadias
 Urethral opening under
 Urethral opening on top
the penis or on the
perineum
 Urethral opening inside
the vagina
 Congenital
 Tx: Surgical repair
of the penis
 Urethral opening above
the clitoris
 Congenital
 Tx: Surgical repair
Cryptorchidism
 Failure of testes to descend into scrotum after
1 yr of age
 Found in abdomen or groin
 Often seen with inguinal hernia
 Premature birth
 Tx: HCG hormone therapy
Orchiopexy
Orchiectomy
Testicular Torsion
 Spermatic cord is twisted
 Tx: Orchiopexy
Testicular Cancer
 20-40yrs
 Infants with cryptorchidism higher risk
 Embarrassment leads to non-treatment which
allows progression of disease
 Tx: Orchiectomy
 Sperm may be stored
 Testicular implants available for cosmetic
purposes
BPH
 Hypertrophy
 Normal part of aging
 > 50 yrs
 Urethral narrowing can result
 Tx: Drug therapy ↓ prostate growth (medical)
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TURP (surgical)
Prostate Cancer
 > 50 yrs
 PSA (prostate specific
 Asymptomatic in early
stages of disease
 Symptom of blood in
the urine, likely too late
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antigen)
Normal value <4ng/mL
PSA laboratory test of
choice by men over 50
for early detection
Will be done if BPH
detected on digital
exam to r/o cancer
↑PSA f/u with biopsy
Pathology of the Urinary System
 Bladder Tumors
 Urinary Calculi
 Polycystic Kidney Disease
 Diabetic Nephropathy
 ESRD
 Renal Cell Carcinoma
 Congenital Nephroblastoma (Wilm’s Tumor)
Urinary Calculi/Stones
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Solid particles that form in one or both kidneys
May become lodged
Pass < 4mm stones 80% of the time
50% recurrence rate
3 types:
Calcium (75%) dietary imbalance/hyperparathyroidism
Magnesium ammonium phosphate (struvite) (15%) UTI
Uric Acid (6%) associated with gout
Cystine amino acid reabsorption failure
ESWL
 Extra-Corporeal Shock-Wave Lithotripsy
 Renal Calculi
 Historical: Done in large tub and patients were intubated and
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connected to the shock therapy unit
Present: Water-bed like unit under lower body. Stone lined up
with C-arm machine/cross-sectioned + Stone hit with shock
waves precisely
Avoid bone
Shocks gauged to match patient HR, otherwise patient can
experience arrhythmias if shock wave exceed HR
Usually range from 120/min to 60 /min
Other Methods of Stone Removal
 Cystoscopic / ureteroscopic /
nephroscopic lithotomy
 Direct extraction via
 Laser through
 Small Lithotripsy unit used through
 Percutaneous lithotomy
 Open lithotomy
Polycystic Kidney Disease
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Multiple fluid filled cysts in parenchyma of kidney
 One kidney could have thousands
 Kidney could weigh up to 22lbs.
 3 Types:
1. Autosomal dominant (hereditary)
 30-50yrs
 90%
2. Autosomal recessive (rare/congenital)
 Children
3. Acquired (long term kidney problems)
Diabetic Neuropathy (sclerosis)
 Uncontrolled diabetic
 Progressive disease>ESRD>dialysis
ESRD
 Kidney failure
 Final stage of many kidney diseases
 Filtration system in kidney < 10%
 50% are diabetics
 s/sx: ↓UO, ↑BUN and creatinine levels
 Death imminent without method of waste and
fluid removal
 Tx: Hemodialysis and Peritoneal Dialysis
Hemodialysis
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Vascular access
Temporary
Dual lumen catheter (Vas
Cath)
Permanent
PTFE loop graft
Creation of AV fistula
(cephalic and radial artery
most common)
Must mature, so will likely
have Vas Cath placed
 2 lumens: one for outflow
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and one for inflow
Dialysis machine has 2
compartments: one for
incoming blood and one for
dialysate
Between compartments is a
semi-permeable membrane
that filters like the kidney
Excess wastes and fluids go
into dialysate and are
disposed of
Important blood components
and proteins return to body
Peritoneal Dialysis
 Requires implantation of catheter into
peritoneal cavity (ex. Tenchkoff)
 Allows for infusion of dialysate which draws
out waste and fluids
 After proper amount of time, dialysate and
fluid/wastes are drained into a bag
 Peritoneum serves as filter
Pathology Affecting the
Adrenal Glands
 Cushing’s Syndrome
 Addison’s Disease
 Pheochromocytoma
Pathology of the Adrenal Glands
Cushing’s Syndrome
Overproduction of cortisol
Cortisol production:
Pituitary gland which stimulates ACTH (adrenal cortical trophic
hormone) which stimulates cortisol production
 Caused by: (80%) pituitary tumor or (20%) adrenal cortex tumor
 s/sx: HTN, central body obesity, hirsutism, osteoporosis, kidney
stones, emotional instability, abnormal menses
 Tx: surgical removal of tumor
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Pathology of the Adrenal Glands
 Addison’s Disease (Adrenal Insufficiency)
 Hormones needed to maintain fluid and
electrolyte balance, blood pressure, and a
normal stress response are inhibited
 s/sx: weight loss, weakness, fatigue, GI
disturbances, low BP, darkening of skin, hair
loss, mood/behavior changes
 Tx: medical hormone replacement therapy
Pathology of the Adrenal Glands
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Pheochromocytoma
Overproduction of adrenaline
Caused by tumor of the medulla
Excessive adrenaline creates severe hypertension
s/sx: HTN, severe headache, excessive sweating,
tachycardia, palpitations, anxiety, tremors, epigastric
pain, weight loss, heat intolerance
 Tx: surgical removal of tumor
Genitourinary System
 Reproductive Organs:
 Female
Pathology of Female Genitourinary
and Reproductive System
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Benign
Cysts
Polyps (pedunculated lesion)
Fistulas
Dysplasia
Leiomyoma/Myoma/Fibroid
Fibroma
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Malignant
Vulvar
Vaginal
Cervical
Uterine
Ovarian
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Other
Endometriosis
Cystocele
Rectocele (posterior colporrhaphy)
Enterocele
Ectopic Pregnancy
Incompetent Cervix (cerclage)
Pre-operative & Diagnostic Testing
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H&P
UA
Hematology: CBC & HGB/HCT
Blood Chemistry: Blood Urea Nitrogen and Creatinine
KUB
IVP
Cystogram
Urethrogram
Cystoscopy
CT
MRI
Biopsy
Incisional Approaches
 Inguinal
 Scrotal
 Abdominal
 Thoracoabdominal pg. 603 Alexander’s
 Gibson pg. 755 Caruthers
 Flank pg. pg. 603 Alexander’s (more oblique)
 Lumbar pg. 603 Alexander’s (more vertical)
*Provide best exposure
Anesthesia
 General
 Spinal
 Epidural
 MAC with Local
Medications
 Antibiotics
 Contrast Media (Hypaque)
 Dyes (Methylene Blue, Indigo Carmine)
 Diuretics
Instruments
 Major Set
 Vascular Tray or CV Tray
 Extra Long Instrument Set
 Self-Retaining Abdominal Retractor
 Chest Tray: Finochetti, periosteotome, Doyan, rib
shears, rongeur, Bailey rib approximator
 Special: Mixters, Potts scissors, Vascular
instruments, Bladder & Prostate retractors,
Pedicle clamps, Stone/lithotomy forceps
Other Cystoscope Components
 Bridges (short and long)
 Cystoscopes: 12°, 30°, and 70°
Supplies
 Ureteral sounds (dilators)
 Flexible endoscope and accessories
 Rigid endoscope instrumentation
 Resectoscope
 Ellik evacuator
 Toomey irrigator/syringe
 Accessories: light cord, camera, insufflation
tubing, irrigation fluid
Irrigations
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Glycine
TURP
Water
Laser
NS
Cystograms
Supplies Continued
 Lubricant
 Foley catheter and drainage bag
 Alternative catheters (difficult insertion)
 Catheter guide (facilitates insertion)
 Urethral catheters
 Ureteral drainage bag(s)
Catheters
 Urethral
 Lumen Size range 8-30 French
 Ureteral
 Lumen Size range 3-14 French
 FYI: Divide French by 3 to get diameter of
lumen in mm
 Ex: 12 French catheter divided by 3 = 4mm in
diameter
Equipment
 OR Table with Foot Drop (lithotomy) & Radiographic
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Capability
Lead Aprons, Accessories
Quick Access to X-ray Development Room
IV Poles that will hold heavy fluid bags
Sitting stool
Multiple X-ray view boxes
Video Tower (light source, camera box, insufflator)
Cautery with bipolar capability
Positioning
 Lithotomy
 Supine
 Lateral
 Variations of Above
Prep
 Area of Involvement
 Begin at incision site and work way out
 Prep genital area last
 May not do a prep if urethral approach
Draping
 Laparotomy
 Universal
 Perineal
 Combination Laparotomy/Perineal
 Surgeon’s preference/approach
 Depends on position
Dressings
 Abdominal: steri-strips, telfa, xeroflo,
4x4s, ABD (surgeon’s preference)
 Vaginal packing
 Peri-pad
 Net panties
Drains
 JP
 Snyder
 Hemovac/Grenade
 Penrose
 Depends on location of surgical wound and
surgeon preference
Post-operative Care
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Discharge same day to 5 days hospitalization
Early ambulation
TED hose
Turn/cough/deep breath
Drink plenty of fluids
Avoid heavy lifting >10lbs. at least 6 weeks
urine may be pink tinged to red/should clear in few days
S/X Infection: incision red, warm, painful, purulent drainage
S/SX UTI: fever, chills, hematuria, flank pain, sudden increase
in urinary output
Complications
 Infection
 Nicking ureters, bladder, urethra, reproductive organs
 Hemorrhage (major blood vessel proximity)
 Adhesions
 Sciatic nerve damage due to spinal placement
 Blood clot (thrombosis)
 DVT
 PE (pulmonary embolus)
Summary
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Terminology
Anatomy & Physiology
Pathology
Diagnostic & Pre-operative Testing
Anesthesia & Medications
Basic Instrumentation, Supplies, & Equipment
Incision Site Options
Positioning, Prep, & Draping
Dressings, Drains, & Post-operative Care