Chapter 40

1. In the surgical treatment of invasive bladder cancer, a thorough lymph node dissection is essential.

2. Patients with testicular cancer without radiographic evidence of metastasis often harbor microscopic deposits of disease and require either adjuvant treatment or very close surveillance.

3. Nephrectomy is the mainstay of treatment for localized renal cell carcinoma, and it also provides a survival benefit in the setting of metastatic disease.

4. The vast majority of renal trauma can be treated conservatively, with early surgical intervention reserved for persistent bleeding or renal vascular injuries.

5. Distal ureteral injuries should only be treated with bladder reimplantation because of the high failure rate of distal uretero-ureterostomies.

6. Extraperitoneal bladder ruptures can be treated conservatively but intraperitoneal ruptures typically require surgical repair.

7. Nearly all episodes of acute urinary retention can be treated with conservative measures such as decreasing narcotic usage and increasing ambulation.

8. Testicular torsion is an emergency where successful testicular salvage is inversely related to the delay in repair, so cases with a high degree of clinical suspicion should not wait for a radiologic diagnosis.

9. Fournier's gangrene is a potentially lethal condition that requires aggressive débridement and close follow-up due to the frequent need for repeat débridement.

10. Most small ureteral calculi will pass spontaneously, but larger stones (>6 mm) are better treated with ureteral stenting and lithotripsy.

The anatomic structures that fall under the purview of genitourinary surgery are the kidneys, adrenals, ureters, bladder, prostate, seminal vesicles, urethra, vas deferens, and testes. They are situated mainly outside the peritoneum, but urologic surgery frequently involves intraperitoneal approaches to the kidney, bladder, and retroperitoneal lymph nodes. Furthermore, urologists must be familiar with the techniques of intestinal surgery for the purposes of urinary diversion and bladder augmentation.

The kidneys are paired retroperitoneal organs that are invested in a fibro-fatty layer: Gerota’s fascia. Posterolaterally, the kidneys are bordered by the quadratus lumborum and posteromedially by the psoas muscle. Anteriorly they are confined by the posterior layer of the peritoneum. On the left, the spleen lies superolaterally, separated from the kidney and Gerota’s fascia by the peritoneum. On the right, the liver is situated superiorly and anteriorly and also is separated by the peritoneum. The second portion of the duodenum is in close proximity to the right renal vessels and, during right renal surgery, it must be reflected anteromedially (Kocherized) to achieve vascular control. The renal arteries, in the typical configuration, are single vessels extending from the aorta that branch into several segmental arteries before entering the renal sinus. The right renal artery passes posterior to the vena cava and is significantly longer than the left renal artery. Occasionally, the kidney is supplied by a second renal artery, typically to the lower pole. Within the ...

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