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KEY POINTS

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  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 occult deposits of disease and require either adjuvant treatment or very close surveillance.

  3. Partial nephrectomy is the mainstay of treatment for small renal masses, whereas radical nephrectomy 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, renal vascular, or ureteral injuries.

  5. Distal ureteral injuries should only be treated with ureteroneocystostomy (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 or with the use of medical expulsive therapy, but larger stones (>6 mm) are better treated with ureteral stenting or lithotripsy.

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ANATOMY

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The anatomic structures that fall under the purview of genitourinary surgery are the adrenals, kidneys, ureters, bladder, prostate, seminal vesicles, urethra, vas deferens, penis, and testes. Some of these structures are situated 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.

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Kidney and Adrenal

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The kidneys are paired retroperitoneal organs that are invested in a fibro-fatty layer: fascia of Zuckerkandl posteriorly and Gerota’s fascia anteriorly. 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, an accessory renal artery, typically to the lower pole. Within the kidney, there ...

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