Procedures (circumcision, dialysis, nephrostomy& ureteric stenting, orchidectomy, prostatectomy, transplant, TURBT, vasectomy) Flashcards
Define circumcision.
Removal of the penil prepuse (foreskin)
What are the indications for circumcision?
- Phimosis/paraphimosis
- Balanitis and balanoposthitis
- Lichen sclerosis
- UTI and prostatitis
- Zoon balanitis
- Genital condyloma
- Malignant lesions of the foreskin
- Prevention of STI, HIV, penile carcinoma
- Personal preference - e.g. Judaism, Islam, sociocultural reasons
What are the complications of circumcision?
Acute:
- Bleeding
- Infection
- Wound dehiscence - post-op erections may cause excessive strain on suture line
- Overzealous or incomplete circumcision - causes skin thethering, penile length loss and rarely buried penis
Long term:
- Glans hyperesthesia
- Skin bridges and meatal stenosis - more common in lichen sclerosus
- Patient dissatisfaction
NB: mostly done under local anaesthesia
Define dialysis.
A type of renal replacement therapy in patients with AKI or CKS to prevent uraemia and death from adverse complication of kidney failure.
What are the types of dialysis?
Peritoneal dialysis (Tenchhoff catheter) 3-5 fluid exchanges per day needed done by the patient.
Haemodialysis - Peripheral (AV fistula or graft) or Central (Tesio) access. 3 times a week for 3-5hrs per session.
What are the indications for dialysis?
- intractable hyperkalaemia;
- acidosis;
- uraemic symptoms (nausea, pruritus, malaise);
- therapy-resistant fluid overload;
- chronic kidney disease (CKD) stage 5.
What are the costs of dialysis vs kidney transplant?
Dialysis - £30,000 per patient per year
Transplant - £20,000 per patient per transplant with immunosuppression costs of £6,500 per year thereafter
What is the overall mortality in dialysis patients?
20% anually
Commonest cause is CVD which is x30 more common in dialysis patients than age-matched controls
What are the complications of dialysis?
What are the complications with the different types of vascular access in dialysis?
AV graft - infection as prosthetic material
AV fistula - infection, thrombosis, bleeding, failure to mature, pseudoaneurysm, venous HTN, steal syndrome.
Central venous catheter - infection, SVC syndrome, failure
Define nephrostomy and ureteric stenting.
Ureteral stents used to relieve ureteral obstruction.
What are the indications for ureteral stenting/nephrostomy?
- Ureteral obstruction - e.g. stones, malignancy
- High stone burden or inability to place stent endoscopically -> nephrostomy tube
- Ureteral anastomosis - e.g. after renal transplant
- Prophylactic e.g. before ESWL if patient has large stones
What are the complications of nephrostomy and ureteral stenting?
- Haematuria
- UTI - prosthetic so prone to infection
- Stent migration
- Stent encrustation
Define orchidectomy.
Orchidectomy is the surgical removal of the testes.
What are the indications for orchidectomy?
- Maligancy
- Treatment of prostatic cancer - considered a form of hormonal manipulation
- Gender reassignment surgery
- Necrosis after testicular torsion
- Wasting of testes after trauma
How long after orchidectomy can the patient return to work?
2 weeks
What are the complications of orchidectomy?
- Reduced fertility or infertility
- Scrotal haematoma
- Infection
- Post-operative pain
- Phantom testis syndrome - pain like from the trauma they had there before
- Inguinal hernia
- Ilioinguinal nerve injury
- Risks for complications with prostheses are low but include infection and rotation.
- Reduced testosterone levels (in bilateral orchidectomy onlu) -> ED, gynaecomastia, loss of muscle mass, osteoporosis
Define prostatectomy.
Surgical removal of all or part of the prostate gland - subototal or radical prostatectomy.
What are the methods for prostatectomy?
What are the indications for prostatectomy?
Benign conditions: BPH, retention, recurrent UTI, uncontrollable haematuria, bladder stones from bladder outlet obstruction
Malignancy: intermediate and high risk prostate cancer
What are the complications of prostatectomy?
Acute: bleeding, infection, damage to surrounding organs, VTE.
Long term:
- sexual dysfunction - may no longer be able to ejaculate semen; avioded in TURP
- retrograde ejaculation
- incontinence
- urethral stricture
What are the types of transplant?
DBD - donation after brain death
DCD - donation after circulator death
Live donor
What are the most important antigens that give rise to rejection?
ABO blood group - DR>B>A. Maximum is 2 mismatches in each = 6.
HLA - done with PCR
Minor histocompatibility antigens
What are the types of organ rejection?
Hyperacute. This occurs immediately through presence of pre formed antibodies (such as ABO incompatibility).
Acute. Occurs during the first 6 months and is usually T cell mediated. Usually tissue infiltrates and vascular lesions.
Chronic. Occurs after the first 6 months. Vascular changes predominate.
What type of incision may be used in renal transplants?
A Rutherford-Morrison incision is made on the preferred sid
Define TURBT.
Transurethral resection of a bladder tumour
What are the indications for TURBT?
Treatment and diagnosis of:
- Non-invasive papillary carcinoma (Ta)
- Urothelial carcinoma in situ (Tis)
- Tumour invading the lamina propria only (T1)
Radical cystectomy is used for muscle-invasive tumours.
What are the complications of TURBT?
- Bleeding, infection, VTE, perforation of the bladder wall.
- Anaesthetic complications
- Haematuria
- Dysuria
- Recurrence of tumour
Define vasectomy.
Interruption or occlusion of the vas deferens for permanent male contraception.
Describe the process for vasectomy.
Done as an outpatient procedure
Puncture wound is made in the skin of the scrotum under local anaesthesia
Vas deferens is accessed, divided and occluded using cautery
Takes ~15mins and can be done in clinic, hospital or some GPs
What follow up is needed post-vasectomy?
Postvasectomy semen analysis is conducted at 12 weeks to confirm absence of spermatozoa in the ejaculate
Alternative contraception is required until azoospermia is confirmed
What are the complications of vasectomy?
- scrotal haematoma
- sperm granulomas - caused by sperm leaking from the tubes, may form a tender mass but usually asymptomatic
- infection
- epididymitis
- persistent post-vasectomy pain (may need further surgery to reverse vasectomy or complete epididymectomy
- failure
