Chapter 40: Urology

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.

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.

Kidney and Adrenal

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 is essentially no anastomotic arterial flow, so the kidneys are prone to infarction when branch vessels are interrupted. The renal veins, which course anteriorly to the renal arteries, drain directly into the vena cava. The left renal vein passes anterior to the aorta and is much longer than the right renal vein. This explains why most surgeons prefer to take the left kidney for living donor transplantation. The left vein is in continuity with the left gonadal vein, the left inferior adrenal vein, and a lumbar vein. These veins provide adequate drainage for the left kidney in the event that drainage to the vena cava is interrupted. The right renal vein has no such collateral venous drainage.

The collecting system of the kidney is composed of several major and minor calyces that coalesce into the renal pelvis. The renal pelvis can have either a mainly intrarenal or extrarenal position. The renal pelvis tapers into the ureteropelvic junction (UPJ) where it joins with the ureter.

The adrenal glands lie superomedially to the kidneys within Gerota’s fascia. There is a layer of Gerota’s fascia between the adrenal and the kidney. However, in the presence of a tumor or inflammatory process, the adrenal can become very adherent to the kidney, and separation can be difficult. The arterial supply of the adrenals derives from the inferior phrenic, aorta, and small branches from the renal arteries. The venous drainage on the left is mainly through the inferior phrenic vein and through the left renal vein via the inferior adrenal vein. On the right, the adrenal is drained by a very short (<1 cm) vein to the vena cava. It can be avulsed by moderate traction and can be the source of troublesome bleeding.

Ureter

The ureters are muscular structures that course anterior to the psoas muscles from the renal pelvis to the bladder. The blood supply of the proximal ureter derives from the aorta and renal artery and comes mainly from the medial direction. However, once it crosses the iliac vessels at the pelvic brim near where the iliac vessels bifurcate, it derives its blood supply laterally from branches from the iliac arteries. The blood supply has implications for managing ureteral injuries. Mobilizing the distal ureter for anastomosis requires releasing its lateral attachments, which results in ischemia, so for this reason, distal ureteral injuries are typically managed by anastomosing the proximal ureter to the bladder.

The ureters course along the pelvic sidewall and pass under the uterine arteries in women, making them vulnerable to injury during hysterectomy, especially in the context of pelvic bleeding. They enter the bladder at the lateral aspect of the base. They course through the bladder musculature at an oblique angle and open into the bladder at the ureteral orifices that are relatively close to the bladder outlet.

Bladder and Prostate

The urinary bladder is situated in the retropubic space in an extraperitoneal position. A portion of the bladder dome is adjacent to the peritoneum, so ruptures at this point can result in intraperitoneal urine leakage. The anatomic relations of the bladder are dependent on the degree of filling. A very distended bladder can project above the umbilicus. At physiologic volumes (200–400 mL), the bladder projects modestly into the abdomen. The sigmoid colon lies superolaterally and may become adherent or fistulize to the bladder secondary to diverticulitis. The rectum lies posterior to the bladder in males, whereas the vagina and uterus are posterior in females.

In males, the prostate is in continuity with the bladder neck, and the urethra courses through it. The prostate has a significant component of smooth muscle and can provide urinary continence even in the absence of the external striated sphincter. The puboprostatic ligaments connect the prostate to the pubic symphysis, and pelvic fractures often result in proximal urethral injuries due to the traction that these ligaments provide. Between the prostate and the rectum lies Denonvilliers’ fascia, which is the main anatomic barrier that prevents prostate cancer from regularly penetrating into the rectum. Just beyond the apex of the prostate is the external (voluntary) sphincter, which is part of the genitourinary diaphragm.

Penis

The penis is composed of three main bodies, along with fascia, neurovascular structures, and skin. The corpora cavernosum are the paired, cylinder-like structures that are the main erectile bodies of the penis. Proximally, they lie along the medial aspects of the inferior pubic rami in the perineum. Distally, they fuse along their medial aspects and form the pendulous penis. The corpora cavernosum consist of a tough outer layer called the tunica albuginea and spongy, sinusoidal tissue inside that fills with blood to result in erection. The two corpora cavernosum have numerous vascular interconnections, so they function as one compartment. The cavernosal arteries, which are branches of the penile artery, course through the center of the corporal sinusoidal tissue. The sinusoidal tissue is innervated by the cavernosal nerves, which are autonomic nerves that originate in the hypogastric plexus and play a critical role in erection. Before entering the penis, the cavernosal nerves travel immediately adjacent to the prostate, which explains why they often are damaged at radical prostatectomy. Injury or excess traction of these nerves may cause erectile dysfunction. On the underside of the penis lies the corpus spongiosum, which surrounds the urethra. The spongiosum does not have the same tunical layers as the corpora cavernosum, so it does not exhibit the same firmness during erection. The tip of the penis, called the glans, is in continuity with the corpus spongiosum. This highlights the point that when men develop priapism—persistent erection for greater than 4 hours unrelated to sexual stimulation—the two corpora cavernosum remain rigid while the glans (derived from the corpora spongiosum) can be soft.

Surrounding all three bodies of the penis are the outer dartos fascia and the inner Buck’s fascia. The dorsal nerves of the penis, which provide sensation to the penile skin, derive from the pudendal nerves and, along with the dorsal penile arteries, travel along the dorsum of the penis within Buck’s fascia. The neurovascular bundle of the penis must be avoided during surgical exploration of the penis for injuries or reconstruction, as injury may result in permanent erectile and/or ejaculatory dysfunction.

Scrotum and Testes

The scrotum is a capacious structure that contains the testes and epididymes. Because of its dependent position, significant edema can develop when a patient is fluid overloaded. Additionally, since the scrotum is capacious, any significant bleeding will result in the accumulation of large hematomas—even as large as a basketball. Beneath the skin, from superficial to deep, are the dartos, external spermatic, cremasteric, and internal spermatic fascias. These layers are not always distinct. Beneath the internal fascia are the parietal and visceral layers of the tunica vaginalis, between which hydroceles form. The visceral layer of the tunica vaginalis is adherent to the testis. The noncompliant outer testis layer is the tunica albuginea. Inside the tunica are the seminiferous tubules. The blood supply enters the testis at the superior pole by way of the spermatic cord. In addition to the vas deferens, the cord carries three separate sources of arterial blood flow—the testicular artery that arises from the aorta below the renal artery, the cremasteric artery, and the deferential artery. Interruption of one of the arteries during vasectomy or inguinal surgery will not result in ischemia to the testis. Some children are born with an undescended abdominal testicle. Often, it is difficult to derive enough length to place the testicles in the scrotum. In these instances, the testicular artery is ligated as a first-stage operation, and the testicle is then delivered into the scrotum as a second-stage procedure (i.e., Fowler-Stephens orchiopexy). Most of these testicles remain viable as a result of collaterals. However, if a patient has undergone a prior Fowler-Stephens procedure, any manipulation of the collaterals during inguinal surgery may compromise the testicle. Venous drainage parallels the arterial inflow except that the left gonadal vein drains into the renal vein rather than the vena cava. Dilation of spermatic veins is called a varicocele and may be palpable when a patient is standing or with Valsalva. They do not need to be treated unless they cause discomfort, are discovered on infertility workup, or are found in children.

Bladder Cancer

The most common form of bladder cancer in the United States is urothelial carcinoma. Tobacco use is the most frequent risk factor, followed by occupational exposure to various carcinogenic materials such as automobile exhaust or industrial solvents. However, many patients develop bladder cancer without any identifiable risks.¹ Other forms of bladder cancer, such as adenocarcinoma and squamous cell carcinoma, occur in distinct patient populations. Patients with chronic irritation from catheters, bladder stones, or schistosomiasis infection are at risk for the squamous cell variant, whereas those with urachal remnants or bladder exstrophy have an increased risk of adenocarcinoma. However, the aforementioned variant histology should not be confused with urothelial carcinoma with variant transformation.

Bladder cancer can be categorized into invasive and noninvasive types. Management of urothelial carcinoma varies greatly, depending on the depth of invasion. A complete transurethral resection of the bladder tumor, which allows for staging of the tumor, is the first step. The tumor should be completely removed, if possible, along with a sampling of the muscular bladder wall underlying the tumor. An exam under anesthesia should be performed for all patients with newly diagnosed bladder tumors. The exam under anesthesia can help determine clinical staging and whether there is fixation of the bladder to adjacent structures. Radiologic imaging of most bladder tumors is of limited benefit in determining the presence, grade, or size/stage of a bladder tumor. However, in the presence of a known bladder tumor, unilateral or bilateral hydronephrosis is an ominous sign of locally advanced disease (at least muscle-invasive bladder cancer).² Computed tomography (CT) scans do provide valuable information regarding metastatic involvement of pelvic lymph nodes, liver, or lung. Historically, 25% of patients with preoperative CT scans demonstrating no evidence of lymphatic spread will actually have lymph node involvement during radical cystectomy and pelvic lymphadenectomy. The utility of a positron emission tomography (PET)-CT scan has emerged as an important imaging modality to minimize this rate to 5% to 10%. For patients who have disease invading into bladder muscle (T2), immediate (within 3 months of diagnosis) cystectomy with extended lymph node dissection offers the best chance of survival. Additionally, surgeons should send lymph node specimens in separate packets and not en bloc in an effort to increase nodal yield. Current long-term cure for those presenting with clinically localized disease has not significantly changed over the last two decades.³ The addition of neoadjuvant or adjuvant chemotherapy in those without discernible metastatic spread is gaining increasing acceptance and does provide a survival benefit.⁴ Patients with limited lymph node involvement may be cured with surgery alone, but those with extensive lymph node involvement have a dismal prognosis.

Patients have multiple reconstructive options, including continent and noncontinent urinary diversions. The orthotopic neobladder has emerged as a popular urinary diversion for patients without urethral involvement. This diversion type involves the detubularization of a segment of bowel, typically distal ileum, which is then refashioned into a pouch that is anastomosed to the proximal urethra (neobladder) or to the skin (continent cutaneous diversion). Detubularization decreases intrapouch filling pressure, which improves urinary storage capacity. In the case of a neobladder, the external sphincter is still intact, and voiding is achieved through sphincteric relaxation and a Valsalva maneuver. In the case of the continent cutaneous diversion, patients attain continence by utilizing a bowel segment (appendix or tapered small bowel) that has a high length-to-lumen ratio. The most common diversion is noncontinent, the ileal conduit, whereby a segment of distal ileum is isolated with one end brought out through the abdominal wall as a urostomy. Ileal conduits are preferred for renal insufficiency because urine is not “stored” and therefore has less time in contact with the absorptive surface of the ileal segment. Conduits are also used when the bladder is unresectable, but urinary diversion is necessary due to intractable bleeding, severe voiding pain, and hydronephrosis. Each segment of bowel that is used offers its own advantages and inherent complications.

Patients with non–muscle-invasive bladder cancer (confined to the bladder mucosa or submucosa) can be managed with transurethral resection alone and adjuvant intravesical (instilled into the bladder) chemotherapy/immunotherapy. The use of these intravesical agents is critical since patients with non–muscle-invasive bladder cancer are at risk for tumor recurrence and progression. Tumor grade is extremely important in assessing the risk of disease progression. Those patients with high-grade disease or recurrent tumors can be treated with intravesical agents such as bacille Calmette-Guérin or mitomycin C. These agents decrease risk of progression and recurrence, by induction of an effective immunologic antitumor response in the case of bacille Calmette-Guérin and through direct cytotoxicity for mitomycin C. Those patients at high risk of progression who fail conservative therapy should be offered cystectomy. Because upper tract recurrence is fairly common (up to 17% of patients with carcinoma in situ), surveillance must be performed with retrograde pyelograms or CT urograms.

Surgical Approaches and Complications

The typical surgical approach for cystectomy is a lower midline incision from just above the umbilicus to the pubic symphysis. This allows adequate exposure of the pelvic contents, iliac vessels, and lower abdominal cavity. The peritoneum between the median umbilical ligaments (urachal remnant) also is taken with the specimen. In men, the prostate is removed with the bladder. In women, the uterus, ovaries (in postmenopausal women), and anterior wall of the vagina are removed with the bladder. The vagina may be spared, depending on the location and extent of the tumor, but significantly more operative bleeding results. Robotic approaches for cystectomy are increasingly used, but the urinary diversion is still usually performed through an open incision. The benefits of the robotic portion are decreased blood loss during the pelvic dissection (due to pneumoperitoneum) and the shortening of the time that the abdomen is open. However, recent evidence (randomized controlled trials of open versus robot-assisted radical cystectomy) did not demonstrate any difference in oncologic efficacy or complication rates.

Complications of bladder cancer surgery involve bladder perforation during transurethral resection of the bladder tumor, which requires catheter drainage for several days if small (common) or open repair if large and intraperitoneal (rare). Cystectomy and urinary diversion may result in prolonged ileus, bowel obstruction, intestinal anastomotic leak, urine leak, or rectal injury. A urine leak from the ureteroileal anastomoses is a common cause of ileus, intra-abdominal urinoma, abscess formation, and wound dehiscence. Deep venous thrombosis is common after cystectomy⁵ due to the advanced age of most patients, proximity of the iliac veins to the resection and lymph node dissection, and the presence of malignancy. Pulmonary embolism is one of the leading causes of death in the perioperative period after radical cystectomy. The utility of subcutaneous heparin in the perioperative period can minimize the risk of venous thromboembolism.

Testicular Cancer

Testicular cancer is the most common solid malignancy in men age 15 to 35 years.⁶ Most men are diagnosed with an asymptomatic enlarging mass (Fig. 40-1). A major risk for the development of testicular cancer is cryptorchidism. Although the debate continues over whether early surgical intervention to bring an undescended testis into the scrotum alters the future risk of cancer, it is generally accepted that doing so allows much easier monitoring for the development of a testicular mass.

Most neoplasms arise from the germ cells, although non–germ cell tumors arise from Leydig’s or Sertoli’s cells. The non–germ cell tumors are rare and generally follow a more benign course. Germ cell cancers are categorically divided into seminomatous and nonseminomatous forms that follow different treatment algorithms.

Since the vast majority of solid testicular masses are cancerous, any observed mass on physical examination and/or documented on ultrasound is malignant until proven otherwise. Initial studies must include tumor markers, including α-fetoprotein, β-human chorionic gonadotropin, and lactate dehydrogenase. Elevated tumor markers are found almost exclusively in nonseminomatous germ cell tumors, although up to 10% of patients with localized seminomas and 25% with metastatic seminomas will have a modest rise in β-human chorionic gonadotropin. Chest and abdominal imaging must be performed to evaluate for evidence of metastasis. The most common site of spread is the retroperitoneal lymph nodes extending from the common iliac vessels to the renal vessels, and abdominal imaging should be performed in all patients. There is no role for percutaneous biopsy of testicular masses due to (a) the risk of seeding the scrotal wall; (b) changing the natural retroperitoneal lymphatic drainage of the testicle (because the testes have a remarkably predictable pattern of lymphatic drainage); and (c) the propensity of a testicular mass being cancerous. In cases where metastatic disease to the testicle is suspected, an open testicular biopsy by delivery of the testicle through the inguinal canal is recommended. Lymphoma (especially among the elderly) may involve one or both testes. Often, evidence of lymphoma usually is present elsewhere in the body, although relapses may be isolated to the testes.

Even in the absence of enlarged lymph nodes on CT imaging (stage I), occult micrometastatic disease is often present (30% of the time), so adjuvant surgery, radiation, or chemotherapy is offered. However, active surveillance protocols have been gaining traction for both seminoma and nonseminomatous tumors. Retroperitoneal lymph node dissection (RPLND) is potentially curative in the setting of limited lymph node involvement and has been the preferred adjuvant treatment of those with stage I nonseminomatous disease. Alternatively, patients with stage I nonseminomatous tumors can also choose to receive two cycles of chemotherapy. Pure seminoma is exquisitely radiosensitive, and stage I, IIa, and IIb disease can be treated with external-beam radiation to the retroperitoneal nodes. However, a single dose of carboplatin for stage I seminoma was found to be just as effective as radiation therapy. Both forms of germ cell tumors, in the setting of disseminated disease or large bulky lymph nodes, are best treated with four cycles of chemotherapy. However, teratoma frequently is a component of retroperitoneal lymph node metastasis, and it is not responsive to chemotherapy or radiation and can demonstrate aggressive malignant degeneration. Postchemotherapy RPLND for residual masses can be challenging. Large bulky metastases may encase the great vessels, and vascular graft placement after resection occasionally is required.

Surgical Approach and Complications

For orchiectomy, an inguinal incision is made over the external ring and carried laterally over the internal ring. It is important to not violate the scrotal skin during orchiectomy, for fear (mostly theoretical) of altering the lymphatic drainage of the testis. For RPLND, a midline incision usually is made from the xiphoid process to the umbilicus for most patients with stage I disease. If it is in a setting of a postchemotherapy residual mass, the incision is extended down to the pubic symphysis. The use of robotic-assisted RPLND is rarely used for stage I nonseminomatous disease, although with increasing demand for minimally invasive surgery, one would anticipate that it will be the happy compromise for those who wish to avoid a major incision but are not interested in active surveillance or systemic chemotherapy.

Complications of testicular cancer surgery include scrotal hematoma formation, which can be prevented by meticulous hemostasis. Complications after RPLND include bowel obstruction; excessive bleeding, particularly from retrocaval lumber veins; and chylous ascites. Patients who undergo a full, bilateral RPLND often suffer from ejaculatory dysfunction due to the interruption of the descending postganglionic sympathetic nerve fibers that are involved in seminal emission. For this reason, right and left templates have been developed that limit bilateral dissection (especially below the inferior mesenteric artery) and preserve some of these nerves with a low risk of leaving residual microscopic cancer.⁷

Kidney Cancer

Renal cell carcinoma (RCC) is a malignancy of the renal epithelium that can arise from any component of the nephron (Fig. 40-2). In 2012, there were over 64,000 new cases in the United States, with over 13,000 deaths.⁸ With the widespread use of imaging for many medical complaints, a stage migration has led to an increased incidence of small renal masses.⁹ Surprisingly, this has not led to lower mortality rates. Various histologic subtypes include clear cell, papillary (types I and II), chromophobe, collecting duct, and unclassified forms. Collecting duct and unclassified forms have dismal prognoses and do not routinely respond to systemic therapy. Benign lesions, common in the setting of a small renal mass, include oncocytomas and angiomyolipomas. Renal tumors are usually solid, but they also can be cystic. Simple cysts are very common and are not malignant, but more complex cysts may be malignant. The Bosniak classification system, based on septations, calcifications, and enhancement, is used to assess the likelihood of malignancy (Table 40-1).¹⁰

Most cases of RCC are sporadic, but many hereditary forms have been described. These syndromes frequently involve a germline mutation in a tumor suppressor gene. von Hippel-Lindau disease is associated with multiple tumors including clear cell RCC (Fig. 40-3). The involved gene, vhl, also frequently is mutated or hypermethylated in sporadic RCC.¹¹ Other rare forms include Birt-Hogg-Dubé syndrome, where patients get oncocytomas or chromophobe tumors. Patients with hereditary papillary RCC and hereditary leiomyomatosis develop papillary RCC.

The most common sites of metastasis are the retroperitoneal lymph nodes and lungs, but liver, bone, and brain also are common sites of spread. Up to 20% to 30% of patients may present with metastatic disease, in which case, surgical debulking can improve survival, as shown in randomized controlled trials.^12,13 Patients with all but the smallest renal masses should undergo testing for the presence of metastatic disease including chest CT, bone scan, and liver function tests.

Patients with localized disease may be cured with either partial or radical nephrectomy (Fig. 40-4). The oncologic efficacy of partial nephrectomy (nephron sparing) appears to be similar to that of radical nephrectomy. However, patients with larger tumors or with a more central tumor location may be at increased risk for surgical complications. Nephron-sparing surgery should be considered in all patients, if feasible, as those patients undergoing a radical nephrectomy are at risk for future chronic kidney disease.¹⁴ The lack of harm from nephrectomy due to malignancy has been extrapolated from the fact that kidney donors do not routinely develop renal insufficiency. However, kidney donors are a highly selected group, and patients with renal tumors are typically older and have more comorbidities. Additionally, the risk of contralateral RCC is 2% to 3% in most series,¹⁵ and a partial nephrectomy may prevent the future need for dialysis in case of a contralateral kidney tumor. While we should all strive to preserve as many nephrons as possible, we do not have level 1 evidence that supports the use of partial nephrectomy over radical nephrectomy for patients with small renal masses.

Minimally invasive techniques for renal surgery have greatly changed the field of kidney cancer. Laparoscopic and robot-assisted laparoscopic renal surgery allows for more rapid convalescence and decreased narcotic requirements. While laparoscopic partial nephrectomy is challenging and is performed only in experienced hands due to its associated high rate of complications, the advent of robot-assisted surgery has changed the landscape. Surgeons are now capable of performing intracorporeal suturing with much greater ease. Ablative techniques such as cryoablation and radiofrequency ablation are also popular choices, especially among those who are poor surgical candidates. However, long-term results from these techniques are currently lacking due to their recent development. Active surveillance is another viable alternative for small renal masses, especially in patients with multiple comorbidities or advanced age. Most small renal masses are low grade with a slow growth rate, and patients very rarely progress to metastatic disease after limited follow-up of 2 to 3 years.¹⁶

Up to 10% of RCC invades the lumen of the renal vein or vena cava. The degree of venous extension directly impacts the surgical approach. Patients with thrombus below the level of the liver can be managed with cross-clamping above and below the thrombus and extraction from a cavotomy at the insertion of the renal vein (Fig. 40-5A). Usually, the thrombus is not adherent to the vessel wall. However, cross-clamping the vena cava above the hepatic veins can drastically reduce cardiac preload, and therefore, bypass techniques often are necessary. For thrombus above the hepatic veins, a multidisciplinary approach with either venovenous or cardiopulmonary bypass is necessary. In cases of invasion of the wall of the vena cava or atrium, deep hypothermic circulatory arrest may be used to give a completely bloodless field. Tumor thrombus embolization to the pulmonary artery is a rare but known complication during these cases and is associated with a high mortality rate (Fig. 40-5B). For cases of extensive tumor thrombus, intraoperative transesophageal echocardiography should be considered for monitoring and assessment of possible thrombus embolization. If a thrombus embolization occurs, a sternotomy/cardiopulmonary bypass with extraction of the thrombus may be life saving.

Patients undergoing resection of localized renal masses are at substantial risk of future recurrence. Many predictive features have been recognized, but the most widely accepted prognostic findings are tumor stage, grade, and size, each of which exerts an independent effect on recurrence. Isolated solitary recurrences, either local or distant, can be resected with long-term disease-free rates approaching 50%.¹⁷

Surgical Approach and Complications

Nephrectomy, either partial or radical, can be performed through a number of surgical approaches. Flank incisions over the eleventh or twelfth ribs from the anterior axillary line to the lateral border of the rectus muscle provide access to the kidney without entering the peritoneum. However, entry into the pleura is not uncommon. If small, the pleurotomy usually can be closed without need for a chest tube. The anterior subcostal approach also is used for nephrectomy. There is no risk for pleural entry, but this incision is transperitoneal, so ileus is somewhat more likely. Laparoscopic nephrectomy is now common, and robot-assisted laparoscopic partial nephrectomy is gaining significant traction in the management of small renal masses. For large tumors, particularly on the right side where the liver makes exposure of the tumor more difficult, a thoracoabdominal approach is very helpful. In these cases, the flank incision is made over the tenth rib and carried further posterior and anterior than a typical flank incision. The chest and abdominal cavities are intentionally entered for maximum exposure, and the diaphragm is partially divided in a circumferential fashion, which allows cephalad retraction of the liver. A chest tube is used postoperatively. The adrenal gland is no longer routinely removed unless the tumor is adherent to it. The benefit of lymph node dissection when the nodes are not clinically involved is uncertain.

Complications of radical nephrectomy include bleeding, pneumothorax, splenic injury, liver injury, and pancreatic tail injury. Partial nephrectomy has the added risks of delayed bleeding and urine leak. Ileus is not common when the peritoneal cavity is not entered.

Prostate Cancer

Prostate cancer is the most common nonskin malignancy in men, with an incidence of approximately 200,000 per year. Yearly screening consisting of digital rectal exam and serum prostate-specific antigen (PSA) testing has been a topic of much debate. The U.S. Preventive Services Task Force has advised against the routine use of prostate cancer screening. The American Urological Association has advised for screening for men 55 to 69 years of age. Patients of African American descent or those with a family history of prostate cancer should be considered for screening at an earlier age (as early as 40). Men with abnormal digital rectal exams or PSA elevation have an indication for prostate biopsy to determine the presence of the disease. With the advent of PSA screening, prostate cancer has experienced a stage migration, with most cases now discovered locally confined within the prostate. The majority of patients with prostate cancer will not die of the disease by 10 to 15 years, whether it is treated at diagnosis or not. However, those undergoing initial treatment have improved cancer-specific survival.¹⁸

Prostate cancer is graded according to the Gleason scoring system.¹⁹ A primary and secondary score are assigned based on the most common and second most common histologic patterns. Grades range from 1 for the most differentiated to 5 for the least. The grades are added to give the Gleason score. In current practice, scores below 6 are almost never assigned. Gleason score, preoperative PSA level, and digital rectal exam are used to estimate the likelihood of whether the cancer is localized, locally advanced, or metastatic. Prostate cancer with a high Gleason score (8 to 10) or a high PSA level (>20) is much more likely to have spread, often at a micrometastatic level. After definitive treatment, an increasing PSA is indicative of recurrent cancer.

The most common site of spread of prostate cancer is the pelvic lymph nodes and bone. For patients with high-risk disease based on clinical stage, grade on biopsy, and PSA level, staging includes bone scan and CT imaging to evaluate for bony metastases or pelvic lymphadenopathy. Multiple treatment options are available for men with localized disease, including radical prostatectomy (retropubic, perineal, or robotic-assisted laparoscopic approaches), brachytherapy, and external-beam radiation therapy. For low-risk disease, the efficacy of each treatment modality is thought to be similar. For low-risk disease, radical prostatectomy (open or robotic) can be performed with unilateral or bilateral cavernosal nerve sparing to limit postoperative erectile dysfunction (ED). For high-risk disease, either non–nerve-sparing surgery or external-beam radiation therapy plus androgen deprivation may be performed. The associated morbidity of each treatment differs, and it is important to discuss the side effects with patients. Irritative voiding and bowel symptoms are common after radiation therapy, with ED being a late side effect. Radical prostatectomy is associated with early incontinence and ED (depending on nerve sparing). Incontinence improves significantly with time, with <1% of men in experienced hands suffering severe long-term problems with urinary control. Likewise, ED improves with time. The large majority of younger men (<55 years of age) regain erectile function, often with the aid of oral medications, if both cavernosal nerves are spared.²⁰ Older men or those with no nerves or one nerve spared have lower rates of erectile function.

Active surveillance has emerged as a safe and viable option for men with anticipated survival of <10 years, low Gleason score (6), early-stage disease (cT1c), and small-volume disease as determined by biopsy. Patients should be monitored closely with digital rectal exam, PSA testing, and repeat biopsy at 1 to 2 years to assess the possible progression of disease. Once prostate cancer has spread, it is no longer curable. Medications that lower serum testosterone or that block the androgen receptor are able to control the disease, often for years, but the cancer inevitably becomes resistant to this treatment. Nevertheless, patients with noncurable prostate cancer can live many years, and a large number die of causes other than prostate cancer.

Surgical Approach and Complications

The approach for an open radical retropubic prostatectomy uses a lower midline incision from the pubic symphysis to approximately 5 cm below the umbilicus. The peritoneum is not entered. Lymph nodes are removed between the external iliac vein and obturator vessels bilaterally, although this may be omitted in cases where the probability of involvement is very low. Some regularly perform a wider dissection that may improve staging, although any therapeutic benefit is uncertain. The cavernosal nerves lay immediately posterolateral to the prostatic capsule. They may be spared if the cancer is not likely to penetrate the capsule on that side, which is a function of preoperative parameters such as biopsy results, PSA, and clinical examination. Robot-assisted laparoscopic radical prostatectomy has superseded laparoscopic prostatectomy due to the learning curve and increased agility that facilitates intracorporeal suturing. Benefits over open radical retropubic prostatectomy include lower blood loss and faster convalescence. Some claim faster return of continence and lower ED rates, but these findings have not yet been widely demonstrated.

Complications of prostatectomy depend on approach. Retropubic approaches may result in urine leaks, lymphocele, and very rarely, rectal or ureteral injury. Robotic prostatectomy uses a transperitoneal approach that can occasionally result in ileus, particularly in cases of a urine leak from the vesicourethral anastomosis. All approaches carry a small risk of urinary incontinence and a more substantial risk of ED.

Kidney

Renal injuries are more common during blunt trauma, accounting for 90% of injuries to the kidney. Any patient with a major deceleration injury, shock, or gross hematuria should undergo radiographic imaging of the kidneys. All patients with penetrating injuries to the flank or abdomen must undergo imaging unless unstable and requiring immediate exploration.

Renal injuries are classified by extent of damage (Table 40-2). Blunt traumatic injuries usually can be managed conservatively, while penetrating renal injuries usually require exploration. Urinary extravasation alone does not require exploration, but reimaging is necessary and, if persistent leakage is present, a stent or nephrostomy tube is indicated. All grade V vascular injuries should be considered for immediate exploration, as a delay of several hours greatly decreases the risk of renal salvage. High-grade renal injuries are associated with significant bleeding, but patients who are stable and without a pulsatile or expanding hematoma can be observed. Even in expert hands, the risk of renal loss at surgery is significant and must be considered before opening the retroperitoneum. Additionally, most grade IV injuries can be managed nonoperatively (Fig. 40-6).²¹ Patients typically are placed on restricted activity until hematuria resolves. Table 40-3 lists indications for assessing surgical intervention in renal trauma patients.

If immediate operative exploration for other injuries is required, renal injury staging can be performed while in the operating room. If concern exists over renal injury or the presence of a retroperitoneal hematoma, a single-shot, 10-minute delayed intravenous pyelogram (IVP) (2 mL/kg contrast) is useful at assessing the presence of two functional kidneys and extent of injury. If the IVP is abnormal or the hematoma is pulsatile, renal exploration should be performed.

Renal exploration should begin once the renal hilum is controlled. Although rarely necessary, temporary control of the renal hilum may decrease the need for nephrectomy when a significant injury is found on exploration. Complete exposure is necessary to evaluate the extent of injury. All nonviable tissue should be débrided and segmental and intralobar arteries ligated with 4-0 chromic or polydioxanone sutures. If the collecting system is injured, it should be repaired at this time. A stent and percutaneous drain should be considered to prevent urinoma formation. A partial vascular injury to the renal vein or artery can be repaired with 5-0 or 6-0 Prolene sutures. A complete injury may require débridement, and if an end-to-end anastomosis cannot be performed, a vascular graft may be required.

Ureter

The retroperitoneal location of the ureter protects it from external trauma, and blunt injury is rare but can occur with rapid deceleration injuries. Penetrating trauma may occur, but a high index of clinical suspicion is required to make the appropriate diagnosis. Any penetrating trauma involving the retroperitoneum should undergo evaluation with intraoperative inspection, IVP, or CT urogram. A retrograde pyelogram is the most sensitive test for ureteral injury, and a stent can be placed if a partial transection is observed. The ureter also is frequently injured intraoperatively, most commonly from open and laparoscopic surgical procedures including hysterectomy, low anterior colonic resections, or aortic surgery. Endoscopic procedures such as ureteroscopy also can lead to ureteral injury such as perforation and avulsion.

Surgical repair depends on location and extent of injury. A briefly misplaced suture may be removed usually without consequence. Partial injuries can be primarily repaired, although all devitalized tissue must be débrided to avoid delayed tissue breakdown and urinoma formation. Ureteral stents should be placed in this situation to facilitate healing without stricture. Lower ureteral injuries (below the iliac vessels) are best treated with ureteral reimplantation, as the blood supply can be tenuous, and strictures are more common with a distal uretero-ureterostomy. Midureteral level injuries can be treated with a uretero-ureterostomy if a spatulated, tension-free repair can be achieved. For longer defects, the bladder can be mobilized and brought up to the psoas muscle (psoas hitch). For additional length, a tubularized flap of bladder (Boari flap) can be created and anastomosed to the remaining ureter. Renal mobilization with nephropexy by anchoring to the psoas muscle can provide additional length. Autotransplantation, transuretero-ureterostomy, and ileal ureter are rarely needed in the acute setting.

Bladder

Bladder injury can occur from penetrating and blunt trauma. The diagnosis should be entertained for any lower abdominal or pelvic trauma. Intraperitoneal ruptures are less common than retroperitoneal injuries but may be seen in the setting of a full bladder before injury. Bladder injuries often are associated with pelvic fractures and may frequently occur in conjunction with urethral injuries. Nearly all patients present with gross hematuria, although occasionally microscopic hematuria is present. A delayed presentation can be associated with intoxication, but it also may occur as a result of iatrogenic injury. These patients often have electrolyte abnormalities such as metabolic derangements, azotemia, and leukocytosis from urine absorption. Patients clinically present with fevers or a prolonged ileus.

Radiographic evaluation begins with either a fluoroscopic or CT cystogram. It is vital to avoid underfilling, as it may lead to a false-negative study. A preset amount can be instilled based on age calculations, which is typically approximately 300 to 400 mL in adults. The bladder can be filled under gravity by raising the Foley catheter to 15 cm above the pubic ramus. The contrast material should be allowed to fill to the natural capacity of the bladder. It is important to have a postdrainage film to assess for persistent contrast, which may indicate a rupture.

Extraperitoneal bladder injuries can typically be managed with catheter drainage for 7 to 10 days. If intraoperative exploration is to occur for other injuries, repair can be performed at that time. For patients with pelvic injuries that require placement of metal hardware, repair of the bladder rupture should be performed concurrently. Intraperitoneal bladder injuries should be explored immediately and repaired. However, in cases of a missed intraperitoneal injury, patients often do well with catheter drainage only. For large ruptures after repair, a suprapubic tube is recommended, but a large urethral catheter is sufficient for smaller injuries. All injuries, especially those managed nonoperatively, should be followed up by a cystogram to document healing before catheter removal.

Urethra

Urethral injuries can be divided by anterior (penile and bulbar urethra) and posterior (membranous and prostatic) location. Any patient with blunt pelvic trauma, blood present at the urethral meatus, hematuria, inability to void, or perineal hematoma should be considered to have a urethral injury until proven otherwise. Urethral injuries should be anticipated with pubic ramus fractures and occur in 10% of unilateral ramus and 20% of bilateral rami injuries.²²

Staging is performed by retrograde urethrography. This study can be easily performed in the trauma suite with the patient in an oblique position and a 12F catheter placed in the urethral meatus. With the penis placed on traction, 30 mL of contrast is instilled while an x-ray is obtained during filling. The addition of fluoroscopy is a valuable addition to the procedure but can be omitted if not available. A partial or complete disruption can be diagnosed based on extravasation or filling of the proximal urethra. Catheter placement can be attempted in patients with partial urethral injuries. Those with complete disruptions should have placement of a suprapubic tube.

Anterior injuries often are related to blunt straddle injuries and penetrating trauma. Blunt anterior urethral injury can be managed in multiple ways, and only small series are available in the literature to compare methods. Immediate surgical repair is not recommended in the acute setting with the exception of low-velocity penetrating injuries. If the patient is stable with minimal hematoma formation, repair should be considered. In the setting of a 1- to 2-cm defect, the urethra can be débrided, spatulated, and anastomosed in an end-to-end, watertight fashion. Large defects should have treatment deferred, as grafts or flaps may be required for repair and the success may diminish with infections. For most cases, catheter drainage is recommended. Many advocate avoiding placement of a urethral catheter, as it may convert a partial tear to a complete dissection. However, a single gentle passage performed by a urologist is safe. For a complete disruption, the placement of a suprapubic tube is recommended; however, a stricture at the site of injury may ensue.

Posterior urethral injuries usually result from pelvic crush injuries and shearing forces causing a prostatomembranous disruption. The patient’s other injuries dictate urologic management. Initial open surgical exploration of the urethral injury should be avoided due to altered anatomy, risk of bleeding, and high likelihood of incontinence and ED from injury of adjacent nerves. Patients can be managed with suprapubic tube and delayed repair or with delayed primary realignment. Primary endoscopic realignment, when possible, leads to decreased rates of strictures without increasing adverse outcomes.^23,24

Urethral strictures can be caused by trauma or inflammatory conditions. They should be staged with either a retrograde urethrography or voiding cystourethrogram (VCUG). Patients with short defects may be amenable to dilatation or cystoscopic urethrotomy. Depending on location, length, and severity, open repairs may be required. Long defects may require grafting to avoid significant penile shortening. Young patients should be considered for open surgical management to definitely repair the stricture due to the tendency of strictures to recur when treated with simple dilation.

Testes

Testicular injury most commonly occurs with blunt injuries when the testicle is forcibly compressed against the thigh or pubic bone with enough force to rupture the tunica albuginea. For patients with scrotal trauma, ultrasound is the preferred modality for staging the extent of injury. Ultrasound can evaluate the testicular blood flow, the presence of testicular contusions, intratesticular hematomas, hematoceles, or a disrupted tunica albuginea. The presence of a hematocele should increase suspicion for testicular rupture because ultrasound may not detect the tunical defect in this setting.²⁵

The goal of surgery is to salvage as much parenchyma as possible and to avoid delayed complications such as ischemic atrophy or abscess formation. A large hematocele, if not evacuated, could lead to ischemic atrophy, and drainage should be considered. A ruptured tunica albuginea can be repaired primarily, and nonviable parenchyma may need to be débrided. For penetrating trauma, immediate exploration is recommended for accurate staging and repair. Frequently, these injuries result in major devascularization and nonviable tissue (especially gunshot wounds). Although salvage may be possible, an orchiectomy usually is required.

Penis

Penile fractures are injuries that involve a traumatic rupture of the tunica albuginea, usually occurring during sexual intercourse—usually with the female partner on top. The engorged penile corporal bodies can rupture if sufficient force is generated against the partner’s pubic symphysis or perineum (Fig. 40-7). Men may notice an immediate audible “pop” and experience rapid penile detumescence. Immediate swelling develops. If Buck’s fascia is disrupted, swelling and ecchymosis can be noted throughout the perineum ("butterfly sign"). At presentation, a classic “eggplant” appearance of the penis is often, although not always, seen. Exploration by a circumcising (de-gloving) incision and repair of the defect offers the best chance at avoiding permanent ED and penile deformity while also minimizing the risk of infection.²⁶ A retrograde urethrogram should be performed to rule out urethral injury at the time of surgery. Alternatively, the urethra can be manually occluded intraoperatively at the penoscrotal junction and a dilute methylene blue solution injected under pressure into the urethral meatus with a catheter-tip syringe. Leakage should be visualized if there is a urethral disruption. If present, the urethra should be repaired, taking care not to significantly narrow the lumen. A Foley catheter is left in place for several days after surgery. Any penetrating injury to the penis must undergo exploration to repair any injuries to the corporal bodies or the urethra.

Acute Urinary Retention

Acute urinary retention (AUR) can happen in men or women and results from a variety of causes, although it most commonly occurs in men with benign prostatic hyperplasia (BPH). Other chronic causes of poor bladder emptying, such as diabetic neuropathy, urethral stricture, multiple sclerosis, or Parkinson’s disease, can result in episodes of complete urinary retention, often when the bladder becomes overdistended. This frequently occurs in the hospital setting when patients have limited mobility and are receiving medications that decrease bladder contractility, including opiates or anticholinergics. Constipation, a common side effect of those medications, can itself worsen urinary retention. Significant hematuria can result in the formation of blood clots, which may block the urethra and cause retention.

Although some patients receiving large doses of narcotics or those with chronically decompensated bladders may not experience discomfort, most patients with AUR have significant pain. If the urinary retention has lasted several days (often accompanied by overflow incontinence), patients may develop acute renal failure. Treatment should include placement of a urethral catheter as quickly as possible. However, BPH or urethral strictures often make the placement of a catheter difficult. For men with BPH, a coude (French for curved) catheter is helpful in negotiating past the angulation in the prostatic urethra (Fig. 40-8A). The curved portion (which is angled in line with the balloon port) is maintained at the 12 o’clock position as it is passed through the urethra (Fig. 40-8B). A common mistake is to use a smaller catheter to bypass the enlarged prostate. However, a larger (18F to 20F) catheter is less flexible and is more likely to push into the bladder rather than curl in the prostatic urethra. Smaller catheters are useful for bypassing a urethral stricture. A urethral stricture should be suspected when the catheter meets resistance closer to the meatus, as many strictures occur in the distal urethra, which is narrower than the proximal portion. Using a 12F or 14F catheter often will allow the passage of the catheter into the bladder. If catheter placement is not successful, a urologic consultation should be requested. The urologist can either choose to (a) use a cystoscope, guidewire, and urethral dilators to dilate the stricture and place a Counsel-tip catheter via Seldinger technique; or (b) place a suprapubic tube approximately two fingerbreadths above the pubic symphysis. With regard to the suprapubic tube, aspiration with a finder needle should be used first to localize the bladder and avoid intra-abdominal contents, although bowel injury is unlikely with a distended bladder filling the pelvis. If hematuria is the cause of retention, continuous bladder irrigation often is necessary to prevent clot formation. This is done through a large three-way catheter that has an additional port for fluid inflow. Fluid is infused by gravity only because the use of higher pressure may result in bladder rupture if outflow is occluded.

A urinalysis should be checked because a poorly emptying bladder is prone to infection. Renal function also should be assessed for those in AUR by checking the creatinine level. An elevated creatinine level suggests that AUR has resulted in renal dysfunction, and these patients are at risk for postobstructive diuresis. These patients must be closely watched for excessive urine output, often caused by an osmotic diuresis due to retained nitrogenous waste products or a temporary renal concentrating defect. Fluid and electrolytes must be replaced if the urine output exceeds 200 mL/h, especially if hemodynamic instability or electrolyte imbalances are seen. Fluid replacement typically is 0.5 mL of 0.45 normal saline for every 1 mL of urine output above 200 mL in 1 hour, although sodium and potassium supplementation requirements depend on the electrolyte status of the patient.

Once the bladder is adequately drained, the cause of AUR should be addressed. For men with suspected BPH, an α-blocker such as tamsulosin should be started. Although finasteride and dutasteride (5α-reductase inhibitors) have been shown to reduce the incidence of urinary retention by 50%, they require a few months to take effect and, hence, will not provide significant benefit in the short term. Narcotics should be tapered as tolerated, and constipation should be treated. Acute spinal cord compression, which is accompanied by saddle paresthesias, is a neurologic emergency that requires neurosurgical or orthopedic consultation. In most cases, except severe neurologic injuries, patients will be able to resume voiding, and the catheter can be removed after 1 to 2 days. Postvoid residuals should be checked with a portable ultrasound device (bladder scanner) or by “straight” catheterization to determine the residual amount of urine left after the patient tries to empty his or her bladder. In patients with severe liver dysfunction, the bladder scanner may inadvertently misinterpret ascites for urine. The inability to void or the presence of a postvoid residual over 200 mL is concerning for development of another episode of AUR. Patients may be given the option of an indwelling catheter for another few days with a subsequent voiding trial, or learning to clean intermittent catheterization (CIC), whereby, after predetermined intervals (4–6 hours) or after voiding attempts, the patient passes a catheter into the bladder and empties it. This is the preferred method, because it reduces the likelihood of infections from indwelling catheters and may improve bladder functionality. However, most patients are resistant to this approach.

Testicular Torsion

The differential diagnosis of acute scrotal pain includes testicular torsion. This usually occurs in neonates or adolescent males but may be observed in other age groups. The blood supply to the testicle is compromised due to twisting of the spermatic cord within the tunica vaginalis, resulting in ischemia to the epididymis and the testis. In newborns, an extravaginal torsion also can occur with twisting of the tunica vaginalis and spermatic cord together. Risk factors for torsion include undescended testis, testicular tumor, and a “bell-clapper” deformity—poor gubernacular fixation of the testicles to the scrotal wall.

Clinical history is vital for diagnosis. Patients describe a sudden onset of pain at a distinct point in time, with subsequent swelling. Physical examination may demonstrate a swollen, asymmetric scrotum with a tender, high-riding testicle. Children normally have a brisk cremasteric reflex that usually is lost in the setting of torsion. The diagnosis is made by clinical history and examination, but can be supported by a Doppler ultrasound, which typically shows decreased intratesticular blood flow relative to the contralateral testis. If an ultrasound is not promptly available, timely surgical exploration should ensue if there is reasonable suspicion of torsion. However, besides ruling out other pathologies, an ultrasound can rule out an associated testicular neoplasm that would necessitate tumor serum marker evaluation and an inguinal, rather than a scrotal, incision.

Immediate surgical exploration can salvage an ischemic testis. More than 80% of testes can be salvaged if surgery is performed within 6 hours; this rate decreases to <20% as time lapses beyond 12 hours.²⁷ At the time of surgery, the contralateral testes also must be explored and fixed to the dartos fascia due to the possibility that the same anatomic defect allowing torsion exists on the contralateral side. Midline (along the median raphe) or bilateral transverse scrotal incisions are made. Once the testis is detorsed, it should be assessed for viability after being given time for normal blood flow to resume. One can assess for blood flow by intraoperative Doppler or by incising the tunica vaginalis and examining for blood. The testes are fixed to the dartos fascia with a small, nonabsorbable suture on their medial, lateral, and dependent aspects, taking care to ensure that the spermatic cord is not twisted before doing so. An orchiectomy should be performed to avoid later risk of abscess formation only if the testis is clearly necrotic because overall testicular function may be improved with testicular preservation in cases of moderately delayed (15 hours) presentation.²⁸

Fournier’s Gangrene

Fournier’s gangrene is a necrotizing fasciitis of the male genitalia and perineum that can be rapidly progressing and fatal if not treated promptly (Fig. 40-9A). The mortality rate has been reported to be as high as 30% to 40%.²⁹ Risk factors for Fournier’s gangrene include urethral strictures, perirectal abscesses, poor perineal hygiene, diabetes, cancer, human immunodeficiency virus (HIV), and other immunocompromised states.³⁰ The infection spreads along the dartos, Scarpa’s, and Colles’ fascias. Clinical signs include fevers, perineal and scrotal pain, and associated indurated tissue. Cellulitis, eschars, necrosis, flaking skin, and crepitus may all be observed. The diagnosis is largely made on clinical suspicion, and significantly less often made on laboratory or radiographic findings. Classically, the patient describes pain out of proportion to the physical findings.

Prompt débridement of nonviable tissue and broad-spectrum antibiotics are necessary to prevent further spread (Fig. 40-9B). If there is damage to the external anal sphincter, patients may require a colostomy.³⁰ Because the testes have a separate blood supply, they are usually not threatened and do not need to be removed. They may be tucked subcutaneously into the thigh ("thigh pouch") to ease postoperative management. Patients frequently require return trips to the operating room for further débridement. Tight glucose control and adequate nutrition are necessary to facilitate wound healing. The large tissue defect should be initially treated with frequent dressing changes. Reconstructive strategies involving skin grafting are needed when large tissue defects result from extensive tissue damage.

Priapism

Priapism is a persistent erection for greater than 4 hours unrelated to sexual stimulation. Priapism is divided into two types, based on the underlying pathophysiology. The most common type—low-flow/ischemic priapism—is a medical emergency. On examination, the penis is very tender, and both cavernosal bodies will be rigid while the glans will be flaccid. Decreased venous outflow with persistent inflow results in increased intracorporeal pressure and tumescence, which is the normal process of erection. Diminished arterial inflow due to elevated intrapenile pressure usually is brief under normal circumstances. Priapism is essentially a compartment syndrome.³⁰ With prolonged erection (priapism), the sustained decrease in arterial inflow ultimately causes tissue hypoxia, acidosis, and edema and results in long-term fibrosis and impotence, and sometimes frank necrosis. Risk factors include sickle cell disease or trait, malignancy, medications, cocaine abuse, certain antidepressants, and total parenteral nutrition.^32,33,34 If a cause is not identified, a hematologic workup is necessary to rule out malignancy or blood dyscrasias.

The management of priapism is rapid detumescence with the goal of preservation of future erectile function. The ability to achieve normal erections is directly related to length of the episode of priapism.³⁰ Low-flow priapism can be confirmed with a penile blood gas of the cavernosal bodies demonstrating hypoxic, acidotic blood. Initial management can include oral agents such as pseudoephedrine or baclofen, but more aggressive measures usually are necessary to achieve rapid detumescence. Insertion of a large-gauge needle (18-gauge) into the lateral aspect of one corporal body allows thorough aspiration and irrigation of both corporal bodies because of widely communicating channels. Injection of phenylephrine (up to 200 mg in 20 mL normal saline) into the corporal bodies may be required. For those with sickle cell disease, hydration and oxygen administration should be performed first, because these are sometimes successful in this group.³⁵

A surgical shunt is sometimes necessary to resolve the episode. Distal shunts should be performed first, because they can be done quickly in the emergency room with a True-Cut needle (Winter shunt). If this fails, an operative distal shunt can be performed (Al-Ghorab). Proximal shunts such as Grayhack (corporal-saphenous vein) or Quackel (proximal cavernosum-spongiosum) shunts may be required in refractory cases.

The other form, high-flow/traumatic priapism, is rare and is related to penile or perineal trauma resulting in a cavernous artery–corporal body fistula. This form is not painful because it is not related to ischemia and can be managed conservatively. Many cases will resolve with time; those that do not can undergo selective arterial embolization.³⁶

Paraphimosis

Foreskin emergencies occur in uncircumcised men. Paraphimosis is a common problem that represents a true medical emergency. When foreskin is retracted for prolonged periods, constriction of the glans penis may ensue. This is particularly likely in hospitalized patients who are confined to bed or who have altered mentation. Edema often forms in the genitals of supine patients due to the dependent position of that area. Patients with diminished consciousness will not be aware of the penile pain from paraphimosis, which may delay recognition of the problem until too late. Delay can be catastrophic as penile necrosis may occur due to ischemia.³⁷ Penile blocks, pain medication, and sedation are sometimes necessary before manual reduction. It is useful to apply firm pressure to the edematous distal penis for several minutes. Although painful, this reduction in penile edema can be the key to success. With the fingers pulling the constricting band distally, the thumbs can push the glans penis back into normal location. If the foreskin cannot be manually reduced, surgical intervention is required.

Emphysematous Pyelonephritis

Emphysematous pyelonephritis is a life-threatening infection that results from complicated pyelonephritis by gas-producing organisms. It is an acute necrotizing infection of the kidney that occurs predominantly in diabetic patients.³⁸ Patients frequently present with sepsis and ketoacidosis. Escherichia coli appears to be the most frequent organism responsible for this infection.³⁹

Patients require supportive care, intravenous (IV) antibiotics, and relief of any urinary tract obstruction. Emphysematous pyelonephritis can be subdivided based on extent of infection. Those with gas confined to the parenchyma frequently can be managed conservatively with placement of a nephrostomy tube to allow drainage of purulent material. Patients with extensive involvement of the perirenal tissue may not respond to conservative management, and strong consideration should be given to expeditious nephrectomy, particularly if the patient is displaying signs of sepsis.⁴⁰

Cystitis

Cystitis is an infection in the bladder with common symptoms of dysuria, urinary frequency, and urgency. Urinary culture (10⁵ colony-forming units) is necessary to make a definitive diagnosis, although lower thresholds are meaningful if clinical suspicion is high. Urinalysis can assist with the diagnosis, as leukocyte esterase is a marker of inflammation, and nitrites are formed from bacterial reduction of nitrates. Risk factors include female gender, urinary instrumentation, urinary obstruction, diabetes, and neurologic bladder dysfunction.

An uncomplicated episode of cystitis requires a 3-day course of antibiotics. Those with complicated cystitis require 7 days of antibiotics and possible imaging studies. Asymptomatic bacteriuria does not necessarily need to be treated except if found in a pregnant woman, before a planned urinary tract surgery, or with associated urinary tract obstruction. Patients undergoing nonurologic surgery also should be considered for treatment, especially in surgery involving cardiac valves or orthopedic hardware.

Pyelonephritis

Pyelonephritis is a bacterial infection of the kidney that usually manifests itself by fevers and flank tenderness. It is frequently attributed to ascending bacteria along the path of the ureters and is rarely due to hematogenous bacterial spread. Patients typically present with flank pain and fevers. However, very young or elderly patients may not demonstrate these symptoms but rather irritability, poor appetite, or altered mental status. Urinary tract imaging is not required unless urinary obstruction or stones are suspected or the patient is not responding to antibiotics. Patients who are not septic and can tolerate fluids can be discharged home on a 2-week course of oral antibiotics. Otherwise, they should be hospitalized for IV antibiotics. Fevers from pyelonephritis may take 24 to 48 hours to subside in the setting of effective antibiotic therapy. Pyelonephritis can result in renal scarring that is accelerated in the setting of urinary obstruction. Emphysematous pyelonephritis can be a life-threatening condition with a mortality of up to 30% (see Emphysematous Pyelonephritis in the Emergencies section).

Occasionally, pyelonephritis can develop into an abscess that can be located within the renal parenchyma (renal abscess) or between the capsule and Gerota’s fascia (perinephric abscess). Any patient who is not properly responding to antibiotic therapy after 72 hours should undergo CT imaging to rule out an abscess or obstruction. Treatment consists of broad-spectrum IV antibiotics and percutaneous drainage.

Prostatitis

Acute prostatitis is a bacterial infection in the prostate gland, most commonly by urinary pathogens. Patients present with fevers, dysuria, and perineal or back discomfort. A digital rectal examination may indicate an indurated and tender gland. However, a brisk digital rectal examination should be avoided, as it is extremely uncomfortable for patients and is thought to cause bacteremia. Patients require a 4- to 6-week course of antibiotic therapy, typically a quinolone. Those who continue to have no improvement after 48 hours should be considered for imaging to rule out a prostatic abscess. If present, large abscesses can be managed with transurethral unroofing or percutaneous drainage.

Chronic prostatitis presents with continued lower urinary tract symptoms and pelvic pain. Chronic prostatitis may be bacterial or nonbacterial, which can be distinguished by culturing pre- and postprostatic massage urine. The bacterial form is a frequent cause of recurrent urinary tract infections in men and can be treated with a prolonged course of antibiotics. Chronic nonbacterial prostatitis does not respond to antibiotics or most other medications. Biofeedback, physical therapy, and other non–prostate-specific treatments may be effective in the treatment of this challenging clinical entity.⁴¹

Epididymo-orchitis

Epididymo-orchitis is typically the result of bacterial infection originating in the urinary tract. However, most men will not show evidence of urinary tract infection. Symptoms consist of unilateral painful swelling of the epididymis and/or testis, often with fever. The scrotum may be erythematous on the side of involvement. The white blood cell (WBC) count often is elevated. The onset is fairly rapid, but not as sudden as torsion. An ultrasound may provide supporting evidence such as increased blood flow to the epididymis. A reactive hydrocele may be present. Intratesticular infection can result in ischemic orchitis, and reduced testicular blood flow can be seen on ultrasound. Although the clinical history of gradual onset may point to an infectious etiology, scrotal exploration is necessary when blood flow is reduced to rule out torsion unless other signs such as pyuria, elevated WBC count, or fevers are present.

Treatment is with oral antibiotics if the patient is not markedly febrile and is otherwise stable. Hospitalization and parenteral antibiotics are required if the patient has high fevers or significantly elevated WBC or is hemodynamic unstable, as sepsis from epididymo-orchitis is possible. Intratesticular abscesses may form and usually result in orchiectomy. The tunica albuginea of the testis is not compliant, so elevated pressures from intratesticular inflammation can result in ischemic necrosis of the parenchyma.

Benign Prostatic Hyperplasia

BPH is a clinical diagnosis describing urinary symptoms attributable to obstruction by the prostate, although some patients with BPH have minimally enlarged glands, and some with large prostates have no symptoms. The symptoms of BPH are urinary frequency, urgency, hesitancy, slow stream, and/or nocturia. These symptoms are not specific and may be caused by infection, urethral strictures, or neurologic dysfunction from diabetes, Parkinson’s disease, multiple sclerosis, stroke, or spinal cord injury. Besides voiding symptoms, consequences of BPH include gross hematuria, infections due to incomplete emptying, bladder calculi, and urinary retention. Over time, incomplete emptying may lead to chronic bladder overdistension that can result in a defunctionalized bladder.

Medical treatment of BPH is usually the first step. α-Blockers act on α receptors in the smooth muscle of the prostate and decrease its tone. 5α-Reductase inhibitors, which block the conversion of testosterone to the more potent Z, shrink the prostate over several months. Both are used either singly or in combination as medical therapy for BPH. If medications are ineffective at alleviating urinary symptoms or other consequences of BPH, surgical intervention is indicated. Transurethral resection of the prostate is the mainstay of endoscopic surgical BPH treatment. It is extremely effective at improving flow and decreasing residual urine. Complications are rare but include incontinence and excessive fluid absorption of the hypotonic irrigating solution used during resection, resulting in the transurethral resection syndrome. It is due to hyponatremia and fluid overload, and although rare, can result in death. Mental status changes and pulmonary edema are managed by diuresis and sodium supplementation with hypertonic saline in severe cases. Because of these rare, but potentially dangerous side effects, laser or electrovaporization of the prostate has grown popular. It is associated with very limited fluid absorption, and saline can be used because there is no monopolar electrocautery. There also is less bleeding. Urinary outcomes appear to be similar to transurethral resection of the prostate.⁴² When the prostate is very enlarged (>100 g), endoscopic management is less effective and open surgical procedures can be used. Suprapubic (simple) prostatectomy involves enucleation of the majority of the prostate, but the capsule is left so there is minimal effect on continence and erectile function.

Urethral Stricture

The voiding symptoms of urethral stricture are very similar to BPH. Strictures may result from scarring due to infectious urethritis, prior instrumentation, trauma, or cancer. Urethral carcinoma is very rare, particularly in males, so most strictures are due to benign causes. Diagnosis is by retrograde urethrogram or cystoscopy. They may be treated with dilation or transurethral incision, but they have a tendency to recur after treatment. Open surgical excision is preferred for long or recalcitrant strictures, and long-term success rates are excellent.⁴³

The hallmark of partial or complete upper urinary tract obstruction is hydroureteronephrosis (HN), with the ureteral dilation extending to the level of the obstruction (Fig. 40-10). HN may be seen on CT imaging or ultrasound, and it may range from very mild to severe, with associated parenchymal thinning in chronic cases. In the acute setting, the degree of HN does not necessarily correlate with the degree of obstruction, as it may take time for severe HN to develop. The obstruction may be intrinsic, as with calculi or ureteral tumors, or due to extrinsic compression due to varied causes, such as an intra-abdominal tumor, iliac aneurysm, or gravid uterus. Serum creatinine may be elevated, but the contralateral kidney will compensate so serum chemistries may not indicate renal impairment. Normal renal function makes intervention less urgent, but even partial obstruction may result in permanent loss of function on the affected side if not alleviated within several weeks.⁴⁴ Complete occlusion can cause permanent dysfunction within 2 weeks.⁴⁵

Treatment of ureteral obstruction is by endoscopic placement of a ureteral stent, which is a temporary plastic tube with curls on each end to prevent migration. Stents allow flow both through the lumen and around it. When chronic stenting is required, it must be changed every 3 months to prevent severe encrustation with urinary sediments. Stents commonly become colonized with bacteria, but symptomatic infections are less common.⁴⁶ Once a stent is in place, mild residual HN often will persist due to ureteral aperistalsis and urinary reflux, but unless severe, it does not represent residual obstruction.

When stent placement is unsuccessful or fails to provide adequate drainage due to severe extrinsic compression, a percutaneous nephrostomy (PCN) should be placed. This is the preferred approach when a patient is unstable because it requires less anesthesia and provides more rapid and reliable decompression of the renal collecting system.

Urolithiasis

Urolithiasis, or urinary calculus disease, may affect up to 10% of the population over the course of a lifetime.⁴⁷ Calculi are crystalline aggregates of one or more components, most commonly calcium oxalate. They also may contain calcium phosphate, magnesium ammonium phosphate (struvite), uric acid, or cystine. Calcium- and struvite-containing stones often are visible on plain radiographs, but CT scans will demonstrate all calculi except those composed of crystalline-excreted indinavir, an antiretroviral medication.⁴⁸ For this reason, noncontrast CT scans have become the study of choice to evaluate for urolithiasis.

Several underlying causes exist for the formation of urinary calculi. Hypercalciuria due to hyperparathyroidism, sarcoidosis, “renal leaks,” or idiopathic overabsorption can lead to calcium-containing stones. Patients often will develop calculi after gastric bypass, which has been attributed to increased oxalate excretion in the urine.⁴⁹ After bypass, dietary calcium is bound by unabsorbed dietary fats (saponification), preventing it from binding dietary oxalate, thereby making oxalate more available for intestinal absorption. Patients with gout are at risk for uric acid stones due to increased urinary uric acid and decreased urine pH, which diminishes uric acid solubility.

Urinary calculi may occur anywhere in the urinary tract. They usually are asymptomatic in the renal pelvis or bladder, but they are a very common cause of symptomatic ureteral obstruction. The obstruction may be partial or complete. Smaller stones (up to 6 mm) may cause severe symptoms, such as flank pain and nausea, but typically pass without intervention beyond supportive care.⁵⁰ α-Blockers, which relax the distal ureter, may be given to reduce renal colic.⁵¹ Calculi ≥7 mm are more likely to become impacted or to have a prolonged passage through the ureter. For this reason, intervention at the time of presentation is preferred for larger stones (except in cases where the calculus is in the very distal ureter) due to the likelihood of repeat emergency room visits for severe symptoms.

Several methods for treating urinary calculi are available, depending on location. Obstructing stones often are temporized with stent placement, which allows proximal collecting system decompression. When urinary infection coexists with an obstructing stone, a stent can be placed, but a PCN is preferable if the patient demonstrates any instability. Definitive treatment of renal or ureteral calculi (lithotripsy) is through ureteroscopy, percutaneous nephrostolithotomy (PCNL), or extracorporeal shock wave lithotripsy (ESWL). Ureteroscopy is performed with a flexible or semirigid device that is passed to the level of the calculus. Under direct visualization, a laser fiber is passed through the scope, and energy is delivered to fragment the calculus. Fragments are extracted, although they usually will pass spontaneously. PCNL is performed through a percutaneous tract into the kidney, where a larger scope and various energy sources (laser, ultrasound) are used to fragment and aspirate large renal calculi. This approach is well suited to staghorn calculi. ESWL is completely noninvasive and uses a device that delivers convergent shockwave energy to the calculus under fluoroscopic guidance. However, the lower efficacy rate of ESWL, when compared with ureteroscopy or PCNL, highlights the point that despite ESWL being less invasive, patients will often undergo multiple procedures to be rendered stone free.

Complications of lithotripsy are specific to the technique used. Ureteroscopy may occasionally lead to strictures due to scarring from trauma to the ureter. If performed in the setting of infection, endoscopic irrigation can force bacteria into the renal parenchyma and result in sepsis. PCNL can cause significant bleeding, and if the tract used to access the kidney traverses the lower aspect of the pleura, large amounts of irrigating fluid can result in a significant hydrothorax. ESWL can occasionally cause renal hematomas, and splenic rupture has been seen after the treatment of a left-sided stone.^52,53

Patients with recurrent stones will benefit from examination of stone composition and 24-hour urine metabolic workup to determine the underlying etiology. Better hydration is useful for all etiologies. Additionally, most patients will benefit from alkalization of the urine (e.g., potassium citrate). Patients with calcium-containing stones do not benefit from a reduction in dietary calcium unless they have absorptive hypercalciuria, which most do not. In fact, patients with higher dietary calcium have, on average, fewer episodes of urolithiasis.⁵⁴

Retroperitoneal Fibrosis

Retroperitoneal fibrosis is a process resulting in encasement of the ureters, along with the great vessels, in a dense fibrotic mass. Many patients present in acute renal failure, and imaging demonstrates medially displaced ureters with a homogeneous, plaque-like mass in the retroperitoneum. The cause may occasionally be a neoplastic process such as histiocytosis or lymphoma—which must be ruled out—but most are idiopathic.⁵⁵ Many medications such as the ergot derivative methysergide, methyldopa, and β-blockers have been implicated as precipitating factors for the inflammatory process.⁵⁶

Bilateral ureteral stent or PCN placement provides temporary relief of the obstruction. Corticosteroids may be given to reverse the inflammatory process, but surgical ureterolysis still usually is required to free the ureters from retroperitoneal encasement. They are brought into the peritoneum and wrapped in omentum to prevent re-entrapment.

Ureteropelvic Junction Obstruction

UPJ obstruction is the most common cause of hydronephrosis found on prenatal ultrasound. UPJ obstruction also is commonly observed in children and young adults. Intrinsic and extrinsic causes of UPJ obstruction exist and can be determined by presentation. Intrinsic UPJ obstruction occurs in neonates due to an adynamic or stenotic segment of proximal ureter. This impairs flow of urine into the ureter, particularly during times of high flow, and causes dilatation of the collecting system. Over time, elevated renal pelvic pressures and recurrent infections can injure renal parenchyma. Abnormal lower pole (i.e., accessory) renal arteries may be a secondary cause of UPJ obstruction by kinking the proximal ureter. Nuclear scans (mercaptoacetyltriglycine or ^99mTc diethylene-triamine-penta-acetic acid) have replaced the IVP as the diagnostic modality of choice. Delayed clearance of contrast or radiotracer implies obstruction. Invasive pressure-flow examinations (Whitaker test) rarely are performed.

Not every case of UPJ obstruction requires operative intervention. Many children with hydronephrosis due to an apparent UPJ obstruction are not highly obstructed and will improve with time. However, patients with infections or impaired renal function require repair to improve drainage. Open dismembered pyeloplasty is considered the gold standard approach, especially in infants. In older children or adults, laparoscopic or robotic approaches for pyeloplasty can expedite convalescence and diminish postoperative pain. An endoscopic approach, endopyelotomy, is also an option in older children and adults. However, it is not as effective as a dismembered pyeloplasty. Surgery involves ureteroscopy and a full-thickness lateral incision into the affected ureteral segment with a laser or knife taking care not to injure the renal hilar vessels (or accessory vessels in cases of a crossing vessel).

Vesicoureteral Reflux

Vesicoureteral reflux (VUR) is the second most common cause of hydronephrosis after UPJ obstruction. Up to two thirds of infants presenting with urinary tract infections have VUR.⁵⁷ VUR is significantly more common among white children (10 times as common) than black children. Although VUR is more prevalent in male newborns, among children older than 1 year of age, girls are five to six times more likely to have VUR than boys. The incidence of VUR decreases with advancing age. Primary reflux is a congenital anomaly caused by insufficient intramural tunneling of the distal ureter, although bladder outlet obstruction may cause unilateral or bilateral secondary reflux when the ureters are anatomically normal. The primary danger of VUR is reflux of infected urine that results in recurrent episodes of pyelonephritis, which can cause scarring and cumulative renal damage.

Neonates with hydronephrosis detected on prenatal ultrasound or infants/children experiencing a urinary tract infection should be evaluated for VUR with a voiding cystourethrogram (VCUG). VUR is graded according to the International Classification System. Spontaneous resolution of VUR, which is the norm, is a function of the grade of VUR.⁵⁸ The large majority of low-grade (1–2) reflux cases will spontaneously resolve, whereas 30% to 50% of grade 3 and 4 reflux cases and 9% of grade 5 reflux cases will resolve.^58,59 The initial management of VUR is controversial, particularly for moderate degrees. Surgical repair with ureteral reimplantation is effective, but may be overtreatment for those destined to resolve spontaneously. However, conservative management, consisting of antibiotic prophylaxis, may result in breakthrough infections with resistant organisms. Submucosal injection of bulking agents at the ureteral orifice (Deflux¯) is being used with increasing frequency. Although patients with high-grade VUR still undergo ureteral reimplantation, those with low-grade VUR are increasingly more likely to undergo submucosal injection of bulking agents instead of being managed conservatively. It is a minimally invasive technique that may, in some patients, obviate the need for long-term suppressive antibiotics. Submucosal bulking is not effective in every case, and patients with severe reflux will likely need reimplantation.

Ureteroceles

A ureterocele is a cystic dilation of the terminal ureter thought to result from a persistent membrane between the ureteral bud and the urogenital sinus. Most patients will have associated genitourinary anomalies such as duplicated collecting systems or an ectopic ureteral location. Patients frequently present during childhood and can present in multiple ways depending on size and degree of obstruction. Patients may have hydronephrosis and pyelonephritis. A large, prolapsing ureterocele can cause bladder outlet obstruction, and rarely, a large ureterocele can present as an intralabial mass in a newborn child. Diagnosis can be confirmed with cystoscopy, VCUG, or IVP.

Patients with a functioning renal moiety can undergo endoscopic incision of the ureterocele; however, VUR is common postoperatively. A ureterocele in a nonfunctioning duplicated system may require a heminephrectomy to avoid infections.

Posterior Urethral Valve

Posterior urethral valves can be a particularly damaging cause of bilateral hydronephrosis in a newborn boy. The “valves,” which are tissue folds located in the prostatic urethra, cause bladder outlet obstruction. Diagnosis is established with a VCUG, which may show poor bladder emptying and a dilated posterior urethra. A Foley catheter should be placed in the bladder to decompress the urinary system in the hopes of facilitating recovery of renal function. Treatment involves cystoscopic ablation or resection of the valve. Even after ablation of the valves and elimination of the urethral obstruction, patients with posterior urethral valves are at significant risk of renal failure, depending on the degree of prenatal obstruction.⁶⁰ Bladders frequently suffer damage and become partially defunctionalized from prolonged prenatal obstruction, and normal voiding patterns often are not established. The most serious outcome of posterior urethral valves is pulmonary hypoplasia due to intrauterine oligohydramnios, and efforts have been made prenatally to transplacentally decompress the urinary bladder and prevent this dreaded development.