Top Tips in Urology

By John McLoughlin, Neil Burgess, Hanif Motiwala and 3 more

The second edition of Top Tips in Urology provides highly clinical tips and rapid-reference "tricks of the trade" to the most common questions and problems that arise for both the practicing urologist and the urologic surgeon. Covering each of the major areas of urology and with contributions for experience practicing urologists and surgeons, this book is a unique book containing valuable information for all urologists dealing with patients on a day to day basis.

• Language: English
• Publisher: Wiley
• Release date: Dec 17, 2012
• ISBN: 9781118508039

John McLoughlin

Dr John McLoughlin has 40 years’ experience in the textiles industry. As the founder and managing director of consultancy firm JM Associates, he provides technical, quality assurance management and system-building services to the textiles industry, and has worked with high-profile clients including Matalan and Asda. Dr McLoughlin has also been a Senior Lecturer at Manchester Metropolitan University since 2006.

Book preview

PART 1

Open Urology

1

A technique to minimise the risk of ureteric injury in patients with an enlarged median lobe undergoing radical prostatectomy

Nikhil Vasdev and David Chadwick

With an increasing number of patients undergoing radical prostatic surgery (laparoscopic, robotic and open) for prostate cancer worldwide, there continues to be an increasing risk of ureteric injury. The risk is minimised with adequate identification of the ureteric orifices.

We present a ‘top tip’ of performing a cystoscopy and cannulating both ureteric orifices (UO) prior to performing prostatic surgery in patients with an enlarged median lobe in order to minimise the risk of inadvertent injury to the UO while opening the bladder during a radical prostatectomy (RP). The technique involves a cystoscopy and cannulation of both UO with ureteric catheters (Figure 1.1). The patient is then operated on using the planned technique of radical prostatectomy (laparoscopic, robotic and open) and the ureteric catheters are identified on opening of the bladder neck. Upon ­completion of this step the bladder neck and UOs are clearly identified at the time of excision of the prostate specimen and bladder reconstruction. We advocate this step to prevent inadvertent ureteric injury. Using this technique, the incidence of ureteric injury at our centre in patients undergoing open RP is 0.06% (1/1500). A demonstration of the median lobe is presented in Figure 1.2.

Figure 1.1 Open radical prostatectomy with large median lobe and laterally situated ureteric orifices.

Figure 1.2 Radical prostatectomy specimen with enlarged median lobe.

2

Novel methods to aid vesicourethral anastomosis in radical retropubic prostatectomy

Lehana Yeo, Rajindra Singh and Jhumur Pati

Vesicourethral anastomosis is a technically challenging aspect of retropubic radical prostatectomy. Here are two novel and inexpensive methods that may be used to facilitate anastomosis of the urethral stump to the bladder neck where direct visualisation of the stump is difficult (e.g. prominent bony spur or retracted urethral stump).

The first involves use of an anterior dental mirror. The mirror is typically angulated, providing indirect vision of the catheterised stump (Figure 2.1). Pretreatment of the mirror with an anti-fog prevents condensation.

The second involves insertion of a flexible cystoscope per urethra with irrigation running. Under direct vision, the cystoscope is advanced to the level of the transected urethra. Illumination from the cystoscope improves the view, produces telescoping of the retracted urethra and also angulation of the urethral stump, thus providing a clear view of the transected urethra.

Figure 2.1 Use of dental mirror to achieve indirect vision of the urethral stump (US). Pubic symphysis (PS). (Reproduced with permission from Lehana Y, Rajindra S, Jhumur P: Novel Methods to Aid Vesicourethral Anastomosis in Radical Retropubic Prostatectomy. Curr Urol 2011;5:209–212, S. Karger AG Basel.)

Image not available in this digital edition.

Our preference for construction of the anastomosis involves placing six sutures into the urethal stump at 2, 4, 6, 8, 10 and 12 o’clock positions. No special equipment is required as most theatres possess a dental mirror and both tips avoid the need for the patient to be put into the lithotomy position in order to allow direct perineal pressure.

The use of the flexible cystoscope would also be beneficial in laparoscopic or robotic