Surgeries

Question 1

Walk me through an open cystolithotomy.

Answer 1

1. Supine position
2. Foley catheter placement
3. Lower midline incision
4. Place retractors, dissect down to bladder
5. Stay sutures, and then incise detrusor muscle (avoid bowel segment if augmented patient)
6. Remove bladder stones
7. Close in two layers with absorbable sutures
8. Leave SPT (optional), Foley catheter, and JP drain

Question 2

Walk me through an AUS

Answer 2

1. Place the patient in dorsal lithotomy position.
2. Prep patient with alcohol based scrub.
3. Perform cystoscopy if not done prior to check coaptation.
4. Place Foley catheter.
5. Make a Mercedes-benz incision along the perineal body.
6. Dissect down to the urethra, and mobilize circumferentially.
7. Take the urethral measurement tool, and measure for snug fit.
8. Cut the cuff to that length, and then place it around the urethra.
9. Make a counter incision just medial to he midline within the rectus muscle, and dissect down through the external oblique fascia.
10. Place the pressure reservoir, as well as the pump into the dependent part of the scrotum.
11. Connect the tubing
12. Repeat cystoscopy.
13. Deactivate.
14. Leave 14 fr catheter in place.

Question 3

Walk me through a distal ureterectomy for UTUC.

Answer 3

Must discuss about postoperative mitomycin C prior to surgery.

1. Robotic approach - appropriate insufflation with port placements
2. Identify ureter as it crosses the iliac artery.
3. Mobilize the ureter to UVJ.
4. Create bladder cuff by wide excision around UO. Ligate ureter proximal to lesion. Check bladder and ureteral margins.
5. Anastamosis - spatulate ureter, insert stent
6. Close bladder
7. Perform LND if warranted
8. Leave foley and JP drain

Question 4

Walk me through a nephroureterectomy.

Answer 4

Must discuss postoperative mitomycin C prior to surgery.

1. Robotic approach - appropriate insufflation, place ports
2. Mobilize the colon. If on right, identical gonadal and ureter. Ligate gonadal. Perform kocher maneuver to reflect duodenum. if on left, identify gonadal and ureter. Ligate gonadal.
3. Dissect renal hilum, ligate renal artery, followed by renal vein.
4. Mobilize the kidney.
5. Mobilize ureter down to UVJ.
6. Create bladder cuff by wide excision around UO. Ligate ureter.
7. Close bladder in two layers
8. Remove the specimen via Gibson incision.
9. Leave a JP drain and Foley catheter.

Perform LND.

Question 5

Talk me through a posterior urethroplasty.

Answer 5

1. Obtain informed consent.
2. Place patient in extended dorsal lithotomy position.
3. Lambda incision
4. Open up the hulbispongious muscle.
5. Mobilize the urethra circumferentially.
6. Excise the scar tissue segment.
7. Re anastamose, must be tension-free.
8. Close and place catheter.
9. Peri catheter rug in 2-4 weeks.

If cannot reach, separate crura of corpora, pubectomy, or route under one of corpora’s.

Question 6

Walk me through a distal reimplant with boari flap.

Answer 6

1. Place patient in supine position.
2. Place Foley catheter.
3. Lower midline incision.
4. Identify the left ureter over the crossing vessel, and mobilize it down to the area of the stricture. Can use ureteroscopy if needed.
5. (perform cystostomy and anastmaosis here if tension free). Otherwise mobilize the bladder by ligating the contralateral bladder pedicle.
6. Create a bladder flap - try to utilize superior vesicle artery flap distribution
7. Pex the bladder flap end to the psoas muscle with a vicryl suture.
8. spatulate the ureter, and then anastomose to end of bladder flap. Tubulurize the remaining bladder muscle.
9. Place JJ stent.
10. Place pelvic drain.

Question 7

Walk me through a cystectomy with ideal conduit.

Answer 7

Mark patient’s stoma site
1. Midline incision
2. Mobilize the bladder and ureters. Ligate ureters distally.
3. Take down lateral pedicles of the bladder and prostate.
4. ligate DVC and divide prostatic urethra, deliver specimen.

For ileal conduit:
Mark 15 cm from the ilealcecal junction, and then harvest the 15 cm proximally. re-anastamose the ileum with a GIA stapler, and oversew.
- maintain vascular supply,
- close the mesenteric trap
- close the butt end of the loop
- swing left ureter under the sigmoid
- Create bricker anastamosis
- insert stents
- create rose bud stoma
- leave JP drain.

For neobladder:
-harvest 50cm of ileum
- Prox 10 cm will be used for ureteral anastamosis, place stents and anastamsose ureters
- open anti mesenteric side of distal 40cm
- fold into sphere, and close
- anastamsose to prostatic urethra
- place JP drain
- SPT is optional

Question 8

Walk me through an anterior exoneration.

Answer 8

• Midline incision
• divid urachus
• mobilize bladder, ligate lateral pedicles
• ligate superior vesical artery
• divide ovarian vessels
• divide cardinal and uterosacral ligaments
• incise peritoneum and pouch of Douglas
  -divide ureters at level of bladder
• divide urethra, send for margin

LOOK AT A PHOTO

Question 9

Important points in performing a vesicostomy.

Answer 9

Infraumblical transverse incision
Mobilize the dome of bladder
Resect out the urachal remnant
Secure the bladder to the fascia level
Create a large stoma of at least 22 Fr

Question 10

Walk me through a PCNL.

Answer 10

Prone position.
Place 2 wire down utilizing nephrostomy tube tract.
Dilate over working wire with amplatz.
Perform lithotripsy (lithoclast)
Perform flex nephroscope + nephrostogram
Antegrade stent
Nephrostomy tube

Get a CXR postop
Antegrade nephrostogram if urine clear
remove nephrostomy tube
remove JJ as outpatient

Question 11

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