72  CHAPTER
Urologic Surgery
Thomas Gillispie Smith III, Michael Coburn
OUTLINE
Urologic Anatomy for the General Surgeon
Endoscopic Urologic Surgery
Urologic Infectious Disease
Voiding Dysfunction, Neurogenic Bladder, Incontinence, and Benign Prostatic Hyperplasia
Male Reproductive Medicine and Sexual Dysfunction
Urolithiasis
Urologic Trauma
Nontraumatic Urologic Emergencies
Urologic Oncology
Urology is the study, treatment, and surgery of diseases of the
retroperitoneum, pelvis, and male genitalia. Of the subspecialties,
urology shares the most in common with general surgery because
of our operative approaches and techniques (both open and mini-
mally invasive) in the abdomen, retroperitoneum, and pelvis. Like
general surgeons, urologists treat patients with open, laparoscopic,
robotic, and endoscopic techniques. Frequently, urologists and
general surgeons collaborate in care of patients across our many
interdisciplinary subspecialties. Examples of this include the stress
of major trauma surgery, complexity of exenterative surgery for
advanced pelvic malignant neoplasms, management of iatrogenic
urologic and surgical injury, and challenges of necrotizing infec-
tions of the genitalia and perineum.
General surgeons will encounter patients with urologic condi-
tions as either presenting symptoms of or comorbidities to their
general surgical diseases. Urology itself has multiple subspecialties
and treats a wide range of patients and diseases spanning pediat-
rics, stone disease, and oncology. The intent of this chapter is to
give the practicing surgeon and trainee a broad overview of the
field of urology and to impart a fundamental knowledge of our
field to assist in our common goal of surgical care of the patient.
UROLOGIC ANATOMY FOR
THE GENERAL SURGEON
The organs of the genitourinary system span the entire retroperi-
toneum, pelvis, inguinal region, and genital region. Because of the
close anatomic relationships of the organs in the abdomen and
retroperitoneum, general surgeons must be familiar with all of the
urologic organ systems to prevent iatrogenic injury and to deal
with variations in normal anatomy. These challenges arise in many
fields of surgery, including vascular, oncology, and colorectal
surgery.
2068
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Upper Abdomen and Retroperitoneum
Adrenal
Beginning at the most superior aspect of the retroperitoneum lie
the adrenal glands. These small, paired organs have two different
embryologic origins and serve a primary endocrine function. The
adrenal glands are composed of the cortex and medulla and are
fused after development. The cortex is the outer layer of the
adrenal gland and is derived from mesoderm.1 On cross section,
the layers, from external to internal, are the zona glomerulosa,
zona fasciculata, and zona reticularis. The different zones secrete
various steroid-derived hormones including mineralocorticoids
(glomerulosa), glucocorticoids (fasciculata), and sex steroids
(reticularis).2 The adrenal medulla is derived from neural crest cells
and is directly innervated by presynaptic sympathetic fibers.1 The
medulla is responsible for secreting catecholamines in response to
sympathetic stimulation. The adrenal glands lie within Gerota
fascia and have an orange-yellow appearance and an area of usually
3 to 5 cm in transverse diameter.1 The arterial supply is through
three sources: superior—inferior phrenic; medial—abdominal
aorta; and inferior—ipsilateral renal artery. The venous drainage
does not mirror the arterial supply; on the right, the single adrenal
vein drains to the vena cava, whereas on the left, the adrenal vein
drains into the left renal vein. Supernumerary veins can exist on
either side because of anatomic variation. The adrenal glands are
anatomically distinct from the kidney, although there are ventral
and dorsal fascial investments that connect it to the kidney. The
anatomic relations to the right adrenal gland are the vena cava on
the anteromedial aspect and the liver and duodenum on the
anterior aspect of portions of the adrenal gland. On the left, the
pancreas and splenic vein are anterior to the cortical surface.
Kidney
The kidneys are the next paired organs just inferior to the
adrenal glands. These organs are completely enveloped within the

perirenal fascia (Gerota fascia) and are mobile structures sup-
ported only by the perirenal fat, renal vasculature, and abdominal
muscles and viscera. Although Gerota fascia separates the kidney
capsule and parenchyma from these adjacent organs and reduces
the risk of renal injury with local dissection, renal parenchymal
injury is possible with abnormal anatomy. The kidneys are approx-
imately the size of a closed fist, measuring 10 to 12 cm in length
and 5 to 7 cm in width. The right kidney lies more inferiorly than
the left kidney because of the liver. Despite being located in the
retroperitoneum, the kidney is well protected from external injury.
Posteriorly, each kidney is covered by the diaphragm on the upper
third of its surface and is crossed by the twelfth rib. The inferior
aspect of the kidney is adjacent to the psoas muscle medially and
the quadratus lumborum and transversus abdominis laterally.1
The anterior surfaces of the kidneys are intimately related to
several intraperitoneal structures. On the right, the liver is attached
to the kidney by the hepatorenal ligament, and the anterior upper
pole is adjacent to the peritoneal surface of the liver.1 The duode-
num lies on the medial aspect of the anterior right kidney, typi-
cally on the hilar structures. The hepatic flexure of the colon
crosses anterior to the inferior pole of the right kidney. On the
left, the superior pole of the kidney lies posterior to the tail of the
pancreas and the splenic vessels and hilum. The spleen is situated
anteromedial to the kidney and is directly attached to the kidney
by the lienorenal ligament. The splenic flexure of the colon is
draped over the caudal aspect of the anterior left kidney.
The renal vasculature has significant variability occurring in
25% to 40% of kidneys.3 The typical vasculature is based on a
paired artery and vein supplying the kidney as direct branches of
the aorta and vena cava, respectively. The renal artery branches
from the aorta inferior to the superior mesenteric artery at the
level of the second lumbar vertebra. The renal artery then branches
into four or five segments, each being an end artery.3 The renal
arteries are located posterior and slightly superior to the renal
veins. The artery initially branches posteriorly into the posterior
segmental artery. The anterior branches are variable but include
the apical, upper, middle, and lower segmental arteries. These
arteries branch multiple times within the cortical kidney, creating
a complex filtration mechanism at the capillary level. The venous
capillary branches coalesce to mirror the parenchymal arterial
system. Renal segmental veins are not end vascular structures and
collateralize extensively. The renal vein on the right is short, typi-
cally 2 to 4 cm in length, and enters the posterolateral inferior
vena cava.3 The left renal vein is longer, 6 to 10 cm, and travels
anterior to the aorta and inferior to the superior mesenteric artery
and enters the left lateral vena cava.3 The left renal vein also is the
common entry point for the left adrenal vein, gonadal vein, and
a lumbar vein. Renal ectopia is accompanied by markedly variable
and unpredictable renal vasculature, with multiple branches
arising from the iliac arteries or aortic bifurcation.
Ureter
The upper collecting system begins within the renal parenchyma
at the level of the papilla. The papillae coalesce to become the
minor calyces which, in turn, become the major calyces. The major
calyces converge to form the renal pelvis. The ureter begins at the
inferior aspect of the renal pelvis, where it narrows to become the
ureteropelvic junction posterior to the renal artery.2 Each ureter is
typically 22 to 30 cm in length, depending on height, and courses
through the retroperitoneum into the pelvis, where it connects to
the urinary bladder at the ureterovesical junction.4 At its origin,
the ureter courses along the anterior psoas major muscle and is
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CHAPTER 72  Urologic Surgery 2069
crossed by the gonadal vessels bilaterally. The ureters cross over the
iliac vessels to enter the pelvis, just superior to the bifurcation of
the iliac vessels into the internal and external segments. Once in
the pelvis, the ureters course medially to enter the bladder. The
ureters are divided into three segments, upper, middle, and lower,
using this anatomic landmark as a junction point.4 The upper
segment runs from the ureteropelvic junction to the superior
margin of the sacrum. The middle segment runs over the bony
pelvis. The lower segment begins at the inferior margin of the
sacrum and continues into the bladder. The ureteral lumen is not
uniform throughout its length and has three distinct narrowing
points: the ureteropelvic junction, crossing the iliac vessels, and the
ureterovesical junction. The right and left ureters have separate
anatomic relationships (peritoneal and retroperitoneal structures).
On the right, the ureter is posterior to the ascending colon, cecum,
and appendix. The left ureter is posterior to the descending and
sigmoid colon. In the male, the ureters are crossed by the vasa
deferentia as they emerge from the internal ring before turning
medially to join the prostate. The ureteral blood is drawn from
multiple vessels throughout its course and within the adventitia;
the arterial vessels create an anastomosing plexus. In general, the
upper ureteral segments have a medial vascular supply (i.e., renal
artery and aorta), and the lower ureteral segments have a lateral
vascular supply (i.e., internal iliac and various branches). This
unique collateral blood flow allows extensive mobilization of the
ureter, outside of its adventitia, without loss of its blood supply.4
The ureter is best identified, intraoperatively, in an area of
normal anatomy and then followed to the area of concern. This
is readily accomplished medial to the lower pole of the kidney or
at the iliac bifurcation. After prior surgery or retroperitoneal
disease processes, any of these rich collateral blood supply sources
may not be contributory; thus, it is critical to avoid unnecessary
extensive circumferential dissection of the ureter.
Pelvis
Bladder and Prostate
The bladder, the end reservoir for urine, is located within the
inferior pelvis. The bladder, when empty, is located behind the
pubic rami; but as the bladder becomes distended, the superior
aspect of the bladder extends out of the pelvis and into the lower
anterior abdomen.5 The bladder can be injured on entering of the
abdomen through a midline incision in the retropubic space (of
Retzius) if the bladder is not displaced posteriorly when the
midline rectus fascial incision is extended to the pubis. Superiorly,
the bladder is covered by the parietal peritoneum of the pelvis as
the peritoneum reflects off the anterior and lateral abdominal
walls. The anterior and lateral bladder walls do not have a perito-
neal surface but reside within pelvic fat and lie along the muscu-
lature of the pelvic side wall or pubis anteriorly. Prior lower
abdominal or pelvic surgery can change the anatomic relations of
the bladder and cause it to be affixed abnormally within the pelvis.
The bladder has a unique cross section with a urothelial lining
creating a tight barrier from urine and a central muscular detrusor
layer involved in the excretory function of the bladder.6 Branches
of the internal iliac artery, the superior and inferior vesical arteries,
supply blood to the bladder. Similar to the ureter, the bladder has
a rich collateral vascular network, so ligation or damage to an
artery is not detrimental to the bladder. The innervation of the
bladder is important because of the excretory function of the
bladder. The bladder has autonomic and somatic innervation with
a dense neural network to the brain. The sympathetic innervation
to the bladder is through the hypogastric nerve, and the
2070 SECTION XIII  Specialties in General Surgery
parasympathetic supply is through the sacral cord and pelvic
nerve.5 The anatomic relationships of the bladder differ between
male and female patients. In the male patient, the posterior
bladder wall is adjacent to the anterior sigmoid colon and rectum.
Prior pelvic surgery, irradiation, or pelvic trauma can make the
plane between these structures difficult to define, resulting in
inadvertent injury. In the female patient, the parietal peritoneum
becomes contiguous with the anterior uterus, and the superior
bladder lies against the lower uterus while the bladder base sits
adjacent to the anterior vaginal wall. The spherical bladder funnels
caudally into the bladder neck, and this becomes the tubular
urethra inferiorly.
In the male patient, the first segment of the urethra is sur-
rounded by and integrated into the prostate. The prostate, an
endocrine gland involved with male reproductive function, is
located immediately inferior to the bladder and invested in the
circular fibers of the bladder neck. The prostate is surrounded by
the lateral pelvic fascia on its anterior surface, by endopelvic fascia
on its lateral surface, and by Denonvilliers fascia posteriorly.7 The
rectum sits immediately posterior to the prostate and is separated
by a second layer of Denonvilliers fascia. This fascia also extends
superiorly on the posterior prostate to encompass the seminal
vesicles. The seminal vesicles are the reservoirs for seminal fluid
that makes up the majority of the ejaculatory fluid. The arterial
supply to both structures is through branches of the inferior
vesical artery. The venous drainage mirrors the arterial supply,
draining through the inferior vesical veins and subsequently into
the internal iliac veins. In addition to the rectum, the other major
anatomic relationship of the prostate is Santorini plexus, a network
of veins derived from the dorsal venous complex of the penis.7
Urethra, Male Genitalia, and Perineum
The drainage of urine from the bladder is through the tubular
urethra, which begins at the level of the bladder neck. In male
patients, the urethra has five distinct segments: prostatic, mem-
branous, penile, bulbar, and glandular (also known as the fossa
navicularis). The prostatic and membranous urethra is surrounded
by striated muscle, and when the urethra penetrates the genito-
urinary diaphragm in the perineum, the outer layer becomes
spongy vascular tissue. Within the prostate, the ejaculatory duct
opens into the urethra and serves as the exit point for seminal
emission. The blood supply of the extraprostatic urethra is through
the common penile artery, which is a branch of the internal
pudendal artery.5 The venous drainage of the urethra is through
the circumflex penile veins and ultimately into the deep dorsal
vein of the penis. The major surrounding structure in the proximal
male urethra is the rectum, which sits posterior to the proximal
bulbar segment. The female urethra is more regular in length and
is approximately 4 cm long.5 The female urethra contains three
distinct layers as opposed to the male urethra. The proximal
urethra is surrounded by smooth and striated musculature, which
forms the urinary sphincter. The arterial and venous blood supply
are through the internal pudendal, vaginal, and inferior vesical
veins. The only structure adjacent to the female urethra is the
anterior vaginal wall.
The male external genitalia consist of the penis, scrotum, and
paired testes. The penis consists of three circular erectile bodies:
the two dorsal corpora cavernosa and the ventral corpus spongio-
sum. The corpora cavernosa are responsible for penile erection;
the corpus spongiosum provides support and structure to the
urethra. Blood supply of the penis is through the external and
internal pudendal arteries. The external pudendal artery supplies
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the penile skin; the internal pudendal artery supplies the urethra
and the paired erectile bodies. The venous drainage of the penis
is through the superficial and deep dorsal veins and the cavernosal
veins. The penis is entirely an external structure, with all three
erectile bodies terminating in the perineum. The scrotum is a
surprisingly complex structure consisting of a muscular sac covered
with a unique epidermal layer with no fat but many sebaceous
and sweat glands. The sac is divided into two halves by a midline
septum of dartos muscle. The blood supply to the scrotum is
through the external pudendal arteries anteriorly and branches of
perineal vessels posteriorly. Within the scrotum are the right and
left testicles. The testicles have both endocrine and reproductive
function in men. Typically, the testes are 4 to 5 cm long and 3 cm
wide.5 The vascular and genital ductal structures leave the testis
from the mediastinum in the posterosuperior portion and travel
through the scrotal neck into the inguinal canal. The spermatic
cord is invested by the internal spermatic fascia, cremaster muscle,
and external spermatic fascia, which are derived from the trans-
versalis fascia, internal oblique, and external oblique, respectively.
Arterial blood supply is primarily through the testicular or gonadal
artery, which is a direct branch from the aorta inferior to the renal
artery. Secondary blood supply to the testicle is through the cre­
masteric and vasal arteries. The venous drainage of the testicle
initially begins as a pampiniform plexus coalescing into the
gonadal or testicular veins. On the right, the vein drains directly
into the vena cava; on the left, the vein drains into the left renal
vein. The testicles are also responsible for spermatogenesis. After
production, the spermatozoa exit through a series of ductal struc-
tures that emerge into the epididymis and ultimately the vas
deferens. The epididymis is located posteriorly and slightly lateral
to the testis. The spermatic artery, vein, and vas deferens are in-
vested together in the fascial structures of the spermatic cord. The
spermatic cord travels through the external inguinal ring through
the inguinal canal and then into the pelvis through the internal
inguinal ring. The spermatic cord is susceptible to injury during
inguinal dissection for hernia repair, especially in redo cases, when
it may be encased in fibrosis and injured without recognition.
Significant injury to the spermatic cord may put the viability of
the testis at risk, even though it is supported by three collateral
arteries. The perineum is divided into an anterior and posterior
triangle in the male by a line connecting the ischial tuberosities.5
The posterior perineal triangle contains the anus and internal and
external sphincters. The anterior triangle (or urogenital triangle)
contains the corpus spongiosum and proximal aspect of the paired
erectile bodies, the corpora cavernosa. The layers to the corpus
spongiosum consist of the skin, subcutaneous fat, Colles fascia,
and bulbospongiosus muscle (surrounding the corpus spongio-
sum) and ischiocavernosus muscles (surrounding the corpora cav-
ernosa). The blood supply to this region is based on branches of
the internal pudendal artery, and drainage is through the internal
pudendal vein. The presence of a urethral catheter is helpful in
palpating the location of the urethra, but the corpus spongiosum
surrounding the bulbar urethra is still vulnerable to injury with
dissection in an inflamed or obliterated anatomic plane.
ENDOSCOPIC UROLOGIC SURGERY
Urologists were early adopters of endoscopic surgery and began
evaluating the urethra and bladder with cystoscopy in the early
part of the 20th century. The first diagnostic and therapeutic
endoscopic procedures were performed for treatment of urologic

disease processes. Endoscopic procedures are divided on the basis
of intervention or evaluation of the lower or upper urinary tract
as each has specialized procedure-specific equipment.
Cystoscopy, or cystourethroscopy as it is formally called, is
used for evaluation of the urethra, both anteriorly and posteriorly,
and the bladder. Cystoscopic procedures are typically performed
to evaluate the lower urinary tract in the setting of hematuria,
voiding symptoms, or bladder obstruction; for surveillance in the
setting of malignant neoplasms; and for removal of genitourinary
foreign bodies. Furthermore, cystoscopy can be used to perform
diagnostic evaluation of the upper urinary tract with use of ure-
teral catheters and instillation of contrast material, which is visual-
ized within the collecting system by fluoroscopy. Cystoscopy can
be performed with both rigid and flexible endoscopes, each with
certain benefits and advantages. Endoscopes are sized with the
French size system, which refers to the outer circumference of the
instrument in millimeters. The rigid endoscope uses optical lens
systems, similar to laparoscopes, and has excellent resolution. The
inflexible structure is intuitive and easy to orient. Rigid cysto-
scopes have a range of sizes typically from 16 Fr to 26 Fr; surgical
endoscopes, or resectoscopes, have the largest size of 25 Fr or
26 Fr.8 Rigid endoscopes have larger luminal diameter, which
allows greater irrigation flow, improving visualization, and passage
of a number of working instruments. Rigid lower tract endoscopy
is more difficult to perform in the awake patient, although it is
much better tolerated in the female patient than in the male
patient because of the short, straight female urethra. Flexible
endoscopes are smaller, 15 Fr or 16 Fr, and better tolerated by
patients for examination. Both male and female patients can be
examined with local anesthetic. The flexible endoscope does not
require any specific patient positioning and can be used supine
and at the bedside. Finally, because of the large deflection radius,
the bladder is easily evaluated without changing lens or patient
position. The optics of flexible endoscopes continue to improve
by advancements in camera chip capability, with new digital plat-
forms approaching the resolution of optical lens systems. Pediatric
endoscopes are smaller, 8 Fr to 12 Fr, and are typically used in
the operating room.
Upper tract evaluation is performed with either a ureteroscope
or a nephroscope. The most common reason for either procedure
is management of calculous disease, both ureteral and renal. Ure-
teroscopy can also be used to visualize and to inspect the upper
collecting system, ureter, and renal pelvis; for hematuria originat-
ing from the upper urinary tract; for surveillance of urothelial
carcinoma; and for treatment or biopsy of abnormal findings.
Ureteroscopy is performed with both flexible and semirigid endo-
scopes, each with different benefits and purposes. Semirigid endo-
scopes are 6 Fr to 7.5 Fr at the tip and gradually enlarge to 8 Fr
to 9.5 Fr.8 The taper at the tip allows introduction into the ure-
teral orifice at the trigone of the bladder. These endoscopes have
larger working channels that allow greater irrigation flow and a
larger field of view. Because semirigid ureteroscopes are fairly
inflexible, they are used to evaluate and to treat conditions below
the level of iliac vessels and mid and distal ureter. Flexible ure-
teroscopes are 5.3 Fr to 8.5 Fr at the tip and gradually enlarge to
8.4 Fr to 10.1 Fr.8 The major advantage of flexible ureteroscopes
is the deflection of the tip, which ranges from 130 to 250 degrees
in one direction and 160 to 275 degrees in the opposite direction,
with newer endoscopes approaching 360-degree deflection. In
addition, these endoscopes can be advanced through ureteral tor-
tuosity and over external compression, such as the psoas muscle.
The working channel on the flexible ureteroscope is typically
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CHAPTER 72  Urologic Surgery 2071
smaller because of the fiberoptic system, and introduction of
instruments, such as baskets or laser fibers, reduces irrigation flow.
These flexible endoscopes can be used throughout the upper
urinary tract but are most useful in the proximal ureter and renal
pelvis and calyceal system.
The other method of upper tract endoscopy is through direct
percutaneous access into the renal collecting system. Similar to
retrograde ureteroscopy, nephroscopy is most commonly used to
treat large renal calculi. More recently, consideration has been
given to management of upper tract urothelial tumors with ful-
guration and resection. Nephroscopy is performed with both rigid
and flexible nephroscopes; however, most intervention is per-
formed with the rigid system. The rigid nephroscope is placed
through a percutaneous working access sheath, similar to a lapa-
roscopic trocar, to visualize the stone or tumor. Rigid nephro-
scopes are usually 25 Fr to 28 Fr, and their appearance is similar
to a rigid cystoscope, although they have a fixed lens system rather
than an exchangeable lens. Newer rigid nephroscopes are built on
a digital platform that allows a larger working channel with com-
parable optics to a standard endoscope. Various intracorporeal
lithotripters are placed through the working channel to fragment
large stones into manageable pieces. Flexible nephroscopes are
essentially flexible cystoscopes that are dual purposed for evalua-
tion of the kidney. Flexible endoscopy of the upper tract is advan-
tageous because all areas of the upper collecting system (upper,
mid, and lower pole calyces) can be inspected regardless of angle
or direction of the internal infundibula.
Numerous working elements are used in both upper and lower
tract endoscopy. Guidewires are commonly used to access the
upper urinary tract collecting system or the bladder and serve as
guides to pass catheters, stents, and sheaths. Most guidewires have
a flexible tip and a rigid shaft and are constructed of inner core
and outer covering, which may hydrophilic or neutral (polytetra-
fluoroethylene). Guidewires range in size from 0.018 to 0.038
inch and have various lengths. Urethral catheters and ureteral
catheters may be placed over wires to assist with direct placement
into the lower or upper urinary system, respectively. Ureteral
stents are hollow catheters with flexible ends that form a coil on
the proximal and distal ends to maintain position within the col-
lecting systems. Stents are placed to ensure drainage of the kidney
and to bypass blockages of the ureter from inflammation, stones,
or tumors. Most stents are composed of thermodynamic material,
which becomes softer at higher body temperatures. Stents range
in size from 4.8 Fr to 10 Fr and have various lengths to accom-
modate variable ureteral lengths. Ureteroscopic baskets are used
to remove ureteral and renal calculi and to perform extraction and
biopsy of tumors. These range in size from 1.3 Fr to 3.2 Fr and
are constructed of flexible material to allow placement into various
calyceal locations within the kidney.
UROLOGIC INFECTIOUS DISEASE
Urinary tract infections (UTIs) are a common medical problem,
although patients with UTI evaluated and treated by urologists
have a complicated or unusual element to their diagnosis. Other
infections treated by urologists include infections of the genital
skin, a spectrum of disease from cellulitis to necrotizing fasciitis,
and reproduction organs in men (i.e., orchitis, epididymitis, or
prostatitis). Furthermore, these infections may require simple
antibiotic therapy or multimodal treatment with surgical drainage
or débridement and management in an intensive care setting.
2072 SECTION XIII  Specialties in General Surgery
Urinary tract obstruction with proximal infection may result in
sepsis, challenging the skills of the urologist and surgical critical
care specialist.
Uncomplicated Urinary Tract Infection
Between the years of 2002 and 2007, UTIs in adult women and
men accounted for 39 million office visits and 6 million emer-
gency department visits.9 In adult patients, more than 50% of
women and 12% of men will develop a UTI during their life-
time.9 Urinary infection is considered uncomplicated when it
occurs in the immunocompetent host, without underlying ana-
tomic or physiologic abnormalities of the urinary tract in women.
UTI diagnosed in men is always considered complicated. For
diagnosis of a UTI, a clean catch, midstream urine specimen is
preferred, and on culture, 105 colony-forming units must be dem-
onstrated. In catheterized specimens, UTI can be diagnosed with
as little as 103 colony-forming units. The typical symptoms associ-
ated with UTI are dysuria, frequency, urgency to void, and mal-
odorous urine. Because of the inherent differences in etiology,
evaluation, and treatment, uncomplicated UTIs are divided into
those occurring in premenopausal and postmenopausal women.
A third category of uncomplicated UTI, that occurring in preg-
nant patients, is beyond the scope of this overview. In general,
risk factors include genetic, biologic, and behavioral; specific
aspects are discussed with each group.
Premenopausal Patients
History and physical examination of patients in this age group
presenting with symptoms of UTI are particularly important
because of overlapping disease processes. In patients without
vaginal discharge, the majority can be expected to have a UTI as
the diagnosis. However, in sexually active women, sexually trans-
mitted infections (STIs) must be considered, especially in the
setting of a negative urine culture. Furthermore, in patients with
vaginal discharge, vaginitis caused by yeast, trichomoniasis, and
bacterial vaginosis are possible causes. Risk factors for UTI in this
population of patients include frequent sexual intercourse, initial
UTI at a young age, maternal history of UTI, and number of
pregnancies and deliveries.10 Important aspects of the physical
examination in these patients include palpation of costovertebral
tenderness (assessing for ascending infection) and pelvic examina-
tion to evaluate for STI. The most common cause of infection in
these patients is Escherichia coli (80% to 85%), followed by Staph-
ylococcus saprophyticus (10% to 15%) and Klebsiella pneumoniae
and Proteus mirabilis (4% each).10 Empirical therapy is acceptable,
although confirmatory urine cultures are useful as the incidence
of antibiotic resistance continues to rise. Prevention includes
increased hydration and evaluation of hygiene practices.
Postmenopausal Patients
As in younger patients, history and physical examination are
important aspects of UTI evaluation in this group of patients.
Presenting symptoms are similar in this group, although some
elderly patients may simply present with altered mental status.
Furthermore, an important component in diagnosis and treat-
ment of postmenopausal women is the change in the vaginal pH
levels and change or reduction in lactobacillus in the vaginal flora.
The physical examination findings may differ in these patients as
STIs are less likely but physical changes, such as pelvic organ
prolapse and incomplete bladder emptying, become causative
factors. In addition, the pathologic bacterial species are different.
E. coli continues to be the predominant organism but in this age
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group, P. mirabilis, K. pneumoniae, and Enterobacter species
become more prevalent pathogens.10 Again, empirical therapy is
acceptable, but urine cultures are important because of increasing
antibiotic resistance patterns and differing organisms. Prevention
includes increased hydration and evaluation of hygiene practices.
Complicated Urinary Tract Infection
Complicated UTIs require more vigilance on the part of the treat-
ing physician because of patient factors that may lead to a more
rapid progression or worsening of the infection. By definition,
complicated UTIs occur in men and in patients with diabetes,
immunosuppression, upper tract infection, resistant organisms,
urinary tract anatomic abnormalities, prior surgery, calculous
disease, spinal cord injury, or recent or current indwelling Foley
catheter. In these patients, similar evaluation is warranted, but the
evaluation should not be limited to simply history and physical
examination. Empirical treatment of complicated UTI alone is
not appropriate, and urine cultures should be performed on all
patients with suspected complicated UTI before initiation of anti-
biotic therapy. In addition, imaging is indicated in these patients
because of concern for calculous disease and urinary stasis, so at
a minimum, a kidney, ureter, and bladder study and renal ultra-
sound with cross-sectional imaging should be performed in all
patients with equivocal or concerning findings. Finally, antibiotic
therapy alone may not be adequate, and these patients may require
surgical drainage of obstructed urinary systems or later surgical
correction of anatomic abnormalities or removal of urinary stones
(once infections are treated) to prevent recurrent UTIs. Consulta-
tion with infectious disease specialists may also be indicated in
patients with urologic anatomic abnormalities and recurrent UTIs
with resistant organisms.
Urinary Tract Infection in Men
Because of the lower incidence of UTI in men, when men present
with symptoms of infection, it is always considered complicated,
regardless of other patient factors. As in women, younger men
(younger than 50 years) and older men (older than 50 years) have
different causes of their UTI and symptoms. Common presenting
symptoms are urethritis, dysuria, hesitancy, frequency, and
urgency of urination. A history and physical examination in these
patients are important to delineate different sources of symptoms
or UTI. Men can present with these symptoms and have different
diagnoses, including UTI, STI, urethritis, and chronic pelvic
pain. Furthermore, bacterial infections can extend to other proxi-
mal areas of the genitourinary system, such as the prostate and
testicle. Men younger than 50 years are more likely to have STI
as the cause rather than UTI. These men should have a thorough
sexual history, genital examination, and microscopic urinalysis
performed. Urethral swab or urine tests for STI should be per-
formed as well. Men older than 50 years often have underlying
lower urinary tract symptoms (LUTS), and this can be a contrib-
uting factor. Men in this age group more frequently will have UTI
as a source of their symptoms, and common urinary pathogens,
as in women, should be considered. Furthermore, older men
should be questioned about recent surgical procedures, catheter-
ization, or hospitalization. Elderly men can also present with
mental status changes as their only symptom of UTI, and this
diagnosis must be ruled out in these patients. A lower threshold
for imaging and hospital admission is necessary in men with UTI
as they may present with more systemic symptoms. Patients who
cannot tolerate oral intake, are immunocompromised, or have
medical comorbidities should be admitted with cross-sectional
 CHAPTER 72  Urologic Surgery 2073

imaging performed. Broad-spectrum intravenous antibiotics,
based on local resistance patterns, and fluid resuscitation should
be initiated in these patients while the initial workup and evalu-
ation are completed. Urinary obstruction or stone disease in these
patients constitutes a urologic emergency and must be addressed
rapidly.
Specific Complicated Genitourinary Infectious States
Pyelonephritis
Pyelonephritis is a spectrum of infectious or inflammatory pro-
cesses that involve the kidney collecting system or parenchyma.
Pyelonephritis results from a UTI moving proximally upward
from the lower urinary tract. In the simple form, pyelonephritis
may be treated on an outpatient basis with oral antibiotics for 1
to 2 weeks. In this group of patients, urine culture is necessary to
identify the causative organism. If the patient appears more
acutely infected, hospitalization may be warranted for broad-
spectrum intravenous antibiotic therapy, fluid resuscitation, and
cross-sectional imaging. Emphysematous pyelonephritis represents
an advanced form of pyelonephritis and is considered a urologic
emergency. These patients have a significant necrotizing infection
of the kidney with gas-forming organisms, with pockets of gas
within the parenchyma apparent on imaging (Fig. 72-1). The
common bacterial pathogens include E. coli, P. mirabilis, and K.
pneumoniae.11 These patients require either prompt percutaneous
drainage of the infection or rapid nephrectomy. Most patients
who present with this condition are diabetic or have significant
medical comorbidities, and control of the metabolic abnormali-
ties, aggressive broad-spectrum antibiotic therapy, and supportive
critical care are essential. Xanthogranulomatous pyelonephritis is a
chronic infectious process resulting from renal obstruction, recur-
rent infection, and renal calculous disease. The disease presents in
three forms, focal, segmental, or diffuse, and each is treated in a
different manner. The underlying histologic process involves a
foamy, lipid-laden, macrophage infiltrate in the renal parenchyma,
with extensive inflammation, fibrosis, and loss of renal function.
On imaging, there may be indications of collecting system dila-
tion; however, drainage attempts often are unproductive because
the material is often solid or too viscous to drain. Patients with
focal or segmental disease may be treated with antibiotics, but
those with diffuse disease frequently require nephrectomy. The
risk of iatrogenic adjacent organ injury is high in these nephrec-
tomies, and the renal hilum may be so inflamed and fibrotic that
the renal vessels cannot be individually dissected. These cases may
require placement of a vascular pedicle clamp with renal excision
and oversewing of the pedicle.
Male Genital Organ Infection
UTIs may ascend into the genital ducts, resulting in infection of
the prostate, epididymis, or testicle. Beginning in the urethra, the
verumontanum is the exit point of the seminal vesicles and vas
deferens into the urinary tract. Prostatitis refers to any inflamma-
tory process affecting the prostate, but the general surgeon more
commonly may encounter acute bacterial prostatitis, which results

FIGURE 72-1  Emphysematous Pyelonephritis. This CT scan demonstrates extensive destruction of the
right kidney with intraparenchymal gas on the right, obliterating the renal architecture. The left kidney is
normal.

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2074 SECTION XIII  Specialties in General Surgery

A B
FIGURE 72-2  Fournier Gangrene. A, Skin necrosis, purulence, and edema of the scrotum. The skin can
also appear normal, with much more subtle physical findings in some cases. B, Appearance after extensive
débridement of scrotal skin and underlying tissues. The base of the penis is visible centrally; the testes are
elevated out of the field, and the spermatic cords are visible anteriorly.

from bacterial infiltration into the prostatic parenchyma. Most
infections of the prostate are secondary to gram-negative bacterial
infection and typically are associated with UTI. Two important
considerations in these patients are physical examination and
disease extent. Although a full history and physical examination
are warranted, elimination of digital rectal examination (DRE)
should be considered as pressure exerted on an infected prostate
may lead to hematogenous spread of the bacteria. In addition,
patients who do not have reasonably rapid resolution of their
symptoms should be evaluated for prostatic abscess. Prostatic
abscesses typically do not respond to antibiotic therapy and
require transurethral unroofing to allow adequate drainage.
Epididymitis-orchitis results when the UTI ascends through
the vas deferens into the epididymis or testicle. Again, the cause
is different according to the patient’s age; men younger than 35
years typically have an STI as a source, commonly Chlamydia
trachomatis, whereas men older than 35 years will often have
infections related to E. coli. Examination of these patients is often
difficult because of significant swelling of the affected epididymis
or testicle; scrotal ultrasound is useful diagnostically, especially to
rule out associated abscess. When infection is advanced, the entire
ipsilateral scrotal contents become involved, with overlying skin
fixation and edema. It may be difficult to distinguish this entity
from late torsion, incarcerated inguinal hernia, or testicular tumor
with necrosis and inflammation. Patients without abscess may be
managed with antibiotic therapy, rest, and scrotal elevation;
however, recovery is slow, with eventual resolution of edema and
discomfort. If abscess is present, surgical drainage and often orchi-
ectomy are indicated. A subset of patients may have persistent
pain or mass, and on repeated Doppler imaging, signs of testicular
ischemia or persistent inflammation may be noted. These patients
require exploration and possible orchiectomy to resolve the
process.
Fournier Gangrene
Fournier gangrene is a necrotizing infection of the male genitalia
and perineum similar to other progressive fasciitis and soft tissue
infections (Fig. 72-2). When the genitalia are involved, patients
typically present with significant pain and tenderness, scrotal and
genital swelling, discoloration or frank necrosis, crepitus, and, at
times, foul-smelling discharge. Fournier gangrene is usually a
polymicrobial infection with microaerobes, anaerobes, and gram-
positive and gram-negative organisms.12 Risk factors for develop-
ment include peripheral vascular disease, diabetes mellitus,
malnutrition, alcoholism, and other immunocompromised states.
This disease represents a urologic emergency. Treatment requires
urgent surgical drainage with aggressive débridement of the
necrotic tissue, broad-spectrum intravenous antibiotics, and
intensive monitoring with supportive care. The magnitude of the
débridement depends entirely on the degree of progression of the
process. It is rare for the process to involve the testicles or deep
tissues of the penis because of the tunica vaginalis and Buck fascia,
respectively, so these structures should be preserved. It is uncom-
mon for the urethra to be involved, although a defined urinary
tract source may be evident, such as a urethral stricture, with
perforation and local infection. Suprapubic tube diversion is gen-
erally not necessary; urethral catheter drainage is generally suffi-
cient. Once the active infection is controlled, the predominant
management issues become wound care and reconstruction,
which may require delayed skin grafting for tissue coverage.
Atypical Urinary Tract Infections
Fungal Infection
Fungal infections in the urinary system are most common in
specific populations of patients: diabetics, immunocompromised
patients, and the elderly. Fungal infections may not be symptom-
atic and in an outpatient setting may not require therapy. Most

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fungal infections are related to the Candida species, and it is
incumbent on the treating physician to determine which infec-
tions require treatment and which represent contamination.
Patients who require careful evaluation and treatment include
neutropenic patients and intensive care patients, who may need
evaluation for an internal source, such as a fungus deposit (ball)
in the bladder or kidney. Infectious disease consultation is valu-
able in these cases because the organisms are atypical and selection
of treatment agents may not be straightforward. Renal and bladder
imaging with ultrasound may demonstrate a treatable source.
These patients may need antifungal bladder or kidney irrigation
or occasionally endoscopic removal.
Tuberculosis
The genitourinary tract is the third most common extrapulmo-
nary site for tuberculosis infection. This disease is spread hema-
togenously from the lungs and into the affected organ system.
Most patients with genitourinary tuberculosis are immunocom-
promised, so assessment of HIV infection status is important.
Patients present with various symptoms that include voiding
symptoms, sterile pyuria or hematuria, and chronic kidney disease.
Not all patients will have a positive PPD test result, and diagnosis
is confirmed with acid-fast bacilli smears of urine and mycobacte-
rial culture with sterile pyuria, chest radiograph, and imaging of
the genitourinary system to look for anatomic abnormalities.
Tuberculosis affecting the kidney may result in segmental or
global glomerular dysfunction, and progression antegrade down
the urinary system may result in ureteral strictures. Tuberculosis
of the epididymis may result in chronic epididymitis or mass.
Antibiotic therapy consists of 2 months of a four-drug regimen
with a subsequent 7-month treatment with isoniazid and rifampin.
Infectious disease consultation is mandatory in treating these
patients because of public health concerns. Significant anatomic
infection or functional change or loss may ultimately require
surgical excision.
Parasitic Infection
With the ease of global transportation and a mobile global popu-
lation, parasitic infections are considerations in patients with
recent travel histories. The main parasitic infections of the geni-
tourinary system are schistosomiasis, echinococcal infection, and
filariasis. Each parasite has a different point of entry, systemic
spread, and organ infestation. Typically, in schistosomiasis, the
parasite enters the body percutaneously and spreads through
the venous and lymphatic system. Most infestations affect the
bladder, resulting in chronic inflammation and granulomas. These
patients present with LUTS or hematuria. Medical therapy (pra-
ziquantel) can be used to treat granulomatous disease; however,
untreated infections can result in squamous cell carcinoma of the
bladder. Echinococcal infections are spread through ingestion of
contaminated food, and the parasite penetrates the intestinal walls
and infests the liver. On occasion, renal infestation can occur, with
the parasite becoming encysted in the parenchyma. Medical
therapy can shrink the cysts, but surgical removal by partial or
total nephrectomy is required for cure. These cysts must be
removed intact as rupture or spillage of internal contents can
result in severe anaphylaxis. Filariasis results from direct infection
of the lymphatic system through percutaneous entry. The parasite
creates noticeable symptoms when it dies, resulting in obstruction
of the lymphatics. Only mild infestation can be treated with oral
therapy (albendazole); advanced disease requires excision and
reconstruction.
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CHAPTER 72  Urologic Surgery 2075
VOIDING DYSFUNCTION, NEUROGENIC
BLADDER, INCONTINENCE, AND BENIGN
PROSTATIC HYPERPLASIA
A central aspect of urology is management of bladder function
and evaluation and treatment of bladder dysfunction. The bladder
is a large muscular sac responsible for storing and eliminating
urine. Common dysfunctions of the bladder include neurogenic
problems with bladder function, storage problems, incontinence,
and outflow issues related to benign prostatic hyperplasia (BPH)
or enlargement. Changes in these functional areas are one of the
most common reasons for urologic consultation. Although this is
a broad area of urology, concentrating on these core divisions will
give the general surgeon an understanding of the complex dynam-
ics of bladder function.
Neurogenic Bladder
Patients with neurogenic bladder dysfunction present with a wide
spectrum of neurologic diseases or injuries that affect bladder
function on the basis of the location of the injury or disease
process. There is a complex interaction between the bladder and
brain that primarily regulates bladder storage and bladder empty-
ing. Bladder storage is driven by the sympathetic nervous system,
specifically at the level of the adrenergic receptor. α-Adrenergic
receptors are the most common adrenergic receptors in the
bladder, prostate, and urethra; most are α1 and α2, with three
subtypes of α1 identified: α1a, α1b, and α1d.13 The α1 receptor is
the most common subtype in the lower urinary system. Bladder
emptying is driven by the parasympathetic stimulation of cholin-
ergic receptors, specifically the muscarinic receptors. The pre-
dominant muscarinic receptors in the bladder are M2 and M3.13
Sensory information is carried away from the bladder by myelin-
ated and unmyelinated afferent nerve fibers traveling through the
pelvic and pudendal nerves. Any interruption in the sympathetic
or parasympathetic nervous system and its communication with
the bladder can result in neurogenic dysfunction. In addition,
several centers within the pons, midbrain, and cerebral cortex have
direct effect on the storage and emptying of the bladder.13 Voiding
is initiated at the level of the pontine micturition center, which
sends out a parasympathetic signal to the bladder to initiate
voiding. The pontine micturition center is inhibited by the peri-
aqueductal gray located in the midbrain, and this is connected to
the afferent signaling pathways from the bladder. Based on this
standard sensory function, specific voiding symptoms or LUTS
can be predicted by the location of neurologic disease or injury.
Basic evaluation of these patients includes a through history
with neurologic and urologic historical focus, physical examina-
tion (focusing on the abdomen, pelvis, and peripheral and central
nervous system), and urinalysis. Additional evaluation is tailored
to location of injury. Cortical brain disease and injury, such as
cerebrovascular accident, are evaluated by history, physical exami-
nation, and urinalysis. These disease processes do not directly
affect the bladder function, and patients are treated on the basis
of symptoms alone. Spinal cord lesions are divided into suprasa-
cral spinal lesions (spinal cord injury, infarcts) and sacral or
peripheral spinal cord lesions (pelvic plexus damage from surgery,
diabetic neuropathy). Patients with lesions of the suprasacral
spinal cord tend to have increased bladder muscle tension, which
results in abnormal elasticity of the bladder (poor bladder compli-
ance).14 In addition, these patients have incoordination of the
bladder and urinary sphincter, resulting in detrusor-sphincter dys-
synergia. Patients with sacral or peripheral nerve lesions tend to
2076 SECTION XIII  Specialties in General Surgery
have variable LUTS but typically do not have changes in bladder
elasticity.14 The detrusor muscle is often partially or completely
nonfunctional, and the urinary sphincter remains closed. Special-
ized evaluation of the patients with spinal cord lesions includes
upper tract ultrasonography to monitor for evidence of hydrone-
phrosis and urodynamic evaluation. Urodynamic evaluation
involves measuring the elasticity of the bladder on filling (compli-
ance), the pressure generated on emptying (detrusor function) by
recording the abdominal pressure, and the intraluminal bladder
pressure with specialized catheters. Surveillance cystoscopy is indi-
cated in chronic patients to rule out the development of intravesi-
cal disease. Treatment for neurogenic bladder has recently been
revolutionized by the introduction of onabotulinum toxin. In the
past, these patients required complex regimens of antimuscarinic
agents and reconstructive surgery. Now, with the use of onabotu-
linum toxin, most patients are treated with periodic cystoscopic
injections and intermittent catheterization.
Problems With Bladder Storage
Overactive bladder (OAB) is the most common storage-related
problem of the bladder. It is defined as urinary urgency with or
without urgency urinary incontinence in the absence of UTI or
other obvious disease.15 Typical symptoms of this problem include
urgency, urinary frequency, nocturia, and urgency urinary incon-
tinence. Urgency refers to the sudden, compelling desire to pass
urine that is difficult to defer and replaces the normal urge.15
Urinary frequency is the complaint of micturition occurring more
frequently than previously deemed normal and characterized by
daytime and nocturnal voids.15 Nocturia is the complaint of inter-
ruption of sleep one or more times because of the need to urinate.15
Finally, urgency urinary incontinence is the involuntary loss of
urine associated with urgency.15 A difficult aspect of this disease
process is that it occurs in the spectrum of other LUTS and may
be the result of long-term bladder outflow obstruction. Other
conditions to consider in patients who present with OAB and
LUTS are UTI, urinary calculi, diabetes, polydipsia, neurogenic
bladder, and malignant disease. OAB has a worldwide prevalence
of 11%, and with the aging population, this is presumed to
increase over time.16
All patients who present with OAB should undergo a thorough
evaluation. At the basic level, this includes a thorough history to
fully disclose the symptoms and to rule out other causes. Histori-
cal elements that may be contributory include caffeine intake,
constipation, recurrent UTI, pelvic organ prolapse in women
and prostatic enlargement in men, and excessive fluid intake.
Physical examination should be directed toward evaluation of the
abdomen, pelvis, and neurologic systems. Other findings may
include decreased mental status or cognitive function and periph-
eral edema. The last absolute examination element is urinalysis,
which can reveal infection, inflammation, or hematuria that may
indicate more serious disease. Simple adjunctive tests that can be
performed in the office include measurement of post-void residual
urine volume, noninvasive flow test, validated symptom question-
naires, and voiding diaries. Specialized tests and evaluation per-
formed by the urologist may include cystoscopy, ultrasound, and
urodynamic testing as appropriate. However, current guidelines
do not require any of these specialized tests for initiation of
treatment.17
Treatment of OAB is directed toward therapy, symptoms, and
motivation of the individual patient (Fig. 72-3). As many patients
suffering from this problem take multiple medications, pharma-
cologic therapy is not always offered as an initial treatment.
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Behavioral therapies are the first-line treatment for all patients.
Behavioral therapies may include lifestyle modifications or specific
physical therapies. Typically, this includes fluid intake manage-
ment and modification with particular attention paid to timing
of fluid intake and amounts. For example, in patients who
complain of nocturia, limiting nighttime fluid intake can be ben-
eficial. Bladder training is a noninvasive method of physical
therapy whereby the patient postpones voiding to lengthen the
time intervals between voids. This may be coupled with urgency
suppression and timed voids to reinforce retraining of the sensory
output from the bladder. Finally, voiding diaries are important to
help the patient and urologist quantify the number of voids and
voided amount to better target improvement goals and to tailor
therapy. Pharmacologic management continues to be a mainstay
of treatment and is indicated for patients as an adjunct to behavior
therapies or for patients unresponsive to first-line therapy. Classic
pharmacologic therapy is antimuscarinic agents that target the
parasympathetic muscarinic cholinergic receptors, primarily M2
and M3, and block the action of these receptors. Most of the drugs
in this category are administered daily and have the common side
effects of dry mouth, dry eyes, and constipation. A newer phar-
macologic agent, beta agonists (β3), targets receptors in the detru-
sor muscle to stimulate bladder relaxation. Treatment options for
patients who fail to respond to these therapies fall into the special-
ized third-line treatments, which include neuromodulation (either
peripheral or central), onabotulinum toxin, chronic indwelling
catheters, and augmentation cystoplasty.
Urinary Incontinence
Urinary incontinence is the involuntary loss of urine; it can be
divided into stress urinary incontinence, urge urinary inconti-
nence, and mixed urinary incontinence.15 National data indicate
that the prevalence of urinary incontinence in America is 49.6%
in women older than 20 years.18 Men are typically affected after
the age of 50 years, and incontinence develops as a symptom of
LUTS or other problems rather than as a primary complaint as
in women. Stress urinary incontinence is defined as the involun-
tary loss of urine with Valsalva maneuver.15 Urge urinary incon-
tinence is the involuntary loss of urine associated with a strong
urge to void.15 Mixed urinary incontinence is any combination of
these two causes.
Evaluation of these patients includes history, physical examina-
tion (including pelvic examination), urinalysis, post-void residual
volume measurement, and voiding diaries. The history and physi-
cal examination are important to rule out any complicating factors
including neurogenic source, anatomic changes (pelvic organ pro-
lapse in the female patient and prostatic enlargement in the male
patient), and prior surgical intervention (radical prostatectomy in
the male patient or hysterectomy in the female patient) that might
affect evaluation and the treatment decision. In the neurologically
normal patient with no confounding factors, nonsurgical manage-
ment is the first step in treatment before any surgical intervention.
As with OAB, behavior modification and bladder training are the
initial steps. Dietary modification is important for management
of urinary incontinence. Patients are counseled to limit fluid
intake to around 2 liters per day, depending on body size and
activity level. In addition, patients should limit caffeine intake and
other bladder irritants including alcohol, carbonated beverages,
spicy foods, and citrus juices and fruits. Furthermore, bowel pro-
grams should be initiated to ensure that the patient has normal
bowel function and is not constipated. Other nonsurgical treat-
ment includes weight loss to a normal body mass index and
 CHAPTER 72  Urologic Surgery 2077

DIAGNOSIS & TREATMENT ALGORITHM:

AUA/SUFU GUIDELINE ON NON-NEUROGENIC OVERACTIVE BLADDER IN ADULTS

Consider urine culture, post-void

Not OAB or complicated
History and physical; urinalysis residual, bladder diary, and/or
OAB; treat or refer
symptom questionnaires

Patient education:
• Normal urinary tract function
• Benefits/risks of treatment alternatives
• Agree on treatment goals Follow-up for efficacy
and adverse events

Behavioral treatments Standard In extremely rare cases,

(consider adding pharmacologic management consider urinary
Treatment goals met
if partially effective) diversion or
augmentation cystoplasty

Pharmacologic management Standard

With active management of adverse events; Consider in carefully-selected and
consider dose modification or alternate thoroughly-counseled patients with moderate
medication if initial treatment is effective but to severe symptoms
adverse events or other considerations preclude • Intradetrusor onabotulinum toxin A
continuation Standard
(patients must be willing to perform CISC)
OR
• Peripheral tibial nerve stimulation (PTNS)
Recommendation
(patients must be willing and able to make
frequent office visits)
Reassess and/or refer;
consider urine culture, post-void residual, bladder OR
diary, symptom questionnaires, other diagnostic • Sacral neuromodulation (SNS)
procedures as necessary for differentiation Recommendation

FIGURE 72-3  Algorithm for diagnosis and management of overactive bladder (OAB). (Adapted from Gormley
EA, Lightner DJ, Burgio KL, et al: Diagnosis and treatment of overactive bladder [non-neurogenic] in adults:
AUA/SUFU guideline. J Urol 188:2455–2463, 2012.)

exercise, particularly core muscle exercises. Pelvic floor muscle
training and biofeedback have been shown to have acceptable
rates in helping patients achieve satisfactory management of their
urinary incontinence.
Surgical treatment options for women and men differ because
of the inherent mechanism causing the incontinence, typically
poor pelvic anatomic support in women and sphincteric in men.
In women, treatment options progress from less to more invasive.
The simplest treatment is injection of a urethral bulking agent
through a cystoscopy. The objective of this treatment is to improve
coaptation of the urinary sphincter and to increase the urethral
wall volume. Unfortunately, this treatment is not likely to produce
long-term cure, and re-treatment or progression to other options
is often necessary. The next option is placement of a midurethral
sling to resupport the central hammock of the urethra and to
provide backing to the urethra during stress maneuvers. These
approaches have a higher success rate, and long-term data show
cure rates of approximately 90%.19 With the success and ease of
the midurethral sling, fewer open retropubic suspensions are per-
formed. These procedures also work to improve the support of
the urethra and to reduce urethral hypermobility. In men, surgical
therapy is designed to reinforce the urinary sphincter to increase
bladder outlet resistance. Typically, treatments are divided into
male urethral slings, which have a larger surface area for the mesh
suspension material, and artificial urinary sphincters. An artificial
sphincter is a complex device that is implanted in the patient and
opened through a one-way valve contained in the scrotum.
Benign Prostatic Hyperplasia
BPH is the development of nodules within the prostate gland as
a result of enlargement of the stromal and epithelial components
of the gland.20 As the BPH progresses, the entire prostate enlarges
in a process called benign prostatic enlargement, resulting in
compression of the prostatic urethra and development of bladder
outflow obstruction (Fig. 72-4).20 As part of the bladder outflow
obstruction, patients can develop LUTS requiring evaluation and
treatment by a urologist. BPH is prevalent, affecting approxi-
mately 70% of men between the ages of 60 and 69 years, making
it one of the most common conditions treated by urologists.20 The
LUTS that result from BPH can be divided into storage, voiding,
and post-void symptoms. Interestingly, there is little correlation
between the measured volume of the prostate and the symptoms
that result. In addition, the degree of bladder outflow obstruction
does not necessarily correlate with the severity of LUTS.

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2078 SECTION XIII  Specialties in General Surgery

Prostatic urethra BPH: lateral lobes,

equal enlargement

A B C
FIGURE 72-4  BPH. A, Normal cystoscopic appearance of the prostate in a young man. B, Moderate BPH,
viewed cystoscopically. The size of the prostate correlates poorly with the magnitude of voiding symptoms.
C, Prostatic adenoma after simple open prostatectomy. Note the small medial lobe (arrow, top center), with
large lateral lobes (130-g specimen).

As with all conditions, evaluation of the patients is centered
on the history and physical examination. Key elements of the
physical examination include DRE and a focused neurologic
examination. Laboratory evaluation includes urinalysis and
prostate-specific antigen (PSA) testing in appropriate patients
with a life expectancy of more than 10 years. Further evaluation
of these patients includes the use of disease-specific validated
questionnaires (International Prostate Symptom Score), measure-
ment of post-void residual urine volumes, and noninvasive urinary
flow testing.20 Depending on initial evaluation findings, cystos-
copy and urodynamic studies may be appropriate adjunct tests.
Practice guidelines for BPH have been produced by the American
Urological Association (AUA) to guide providers in the diagnosis
and management of BPH (Figs. 72-5 and 72-6).20 Similar to all
voiding-related conditions, behavior and dietary modifications are
appropriate first-step treatment measures in all patients. Medical
therapy can be used in conjunction with the initial behavior
modifications or added subsequently.
The mainstay of treatment for LUTS due to BPH is α1-
adrenergic receptor blockers.20 As previously discussed, α-adrenergic
receptors are the most common adrenergic receptors in the bladder,
and α1 is the most common subtype in the lower urinary system,
prostate, and urethra. The action of α1 blockers is to relax the
smooth muscle in the bladder neck and prostate and to reduce
outflow resistance. This class of drugs has become progressively
more selective to the α1 subtypes, and many now target the α1a
subtype receptor specifically. The most common side effects of
these drugs are dizziness related to orthostasis, retrograde ejacula-
tion, and rhinitis. A second category of pharmacologic therapy is
the 5α-reductase inhibitors that target the glandular component
of the prostate. These drugs block the conversion of testosterone
to dihydrotestosterone in the prostate and subsequently reduce
the prostate volume, thereby reducing outflow resistance. This
class of drugs also alters the serum PSA level (reduces it about
50%), which must be kept in mind with regard to prostate cancer
screening. In addition, these drugs can be used in combination
because of their differing mechanism of action, and studies show
superior results to either drug used independently.
When medical therapy is ineffective, symptoms remain bother-
some, or an objective surgical indication arises (e.g., acute urinary
retention, bladder calculi, azotemia, recurrent UTI, or recurrent
hematuria), surgical intervention is considered. The standard
approach to surgical treatment of BPH is transurethral resection
of the prostate (TURP) using various electrosurgical options
(monopolar, bipolar, or laser). Minimally invasive treatment
options, such as microwave thermotherapy and radiofrequency
ablation, can be performed in an office setting but do not have
equivalent long term outcomes compared to standard surgical
procedures. When the adenomatous growth is particularly large,
open simple prostatectomy is performed to enucleate the adenoma
surgically. Outcomes of the transurethral procedures show dra-
matic improvement in International Prostate Symptom Score
numbers, urinary flow rates, and post-void residual volumes. Pro-
cedures such as simple prostatectomy have such a long historical
use that objective data have not been measured or compiled, but
outcomes are similar to those of TURP. Complications of TURP
procedures include persistent bleeding, dilutional hyponatremia
from fluid absorption of the glycine irrigation, UTI, urinary
incontinence, and urethral stricture. With newer electrosurgical
systems (bipolar and laser), normal saline irrigation is used and
dilutional hyponatremia has been eliminated. In addition, visual-
ization is improved, with a significant reduction in bleeding com-
plications and a lower incidence of urinary incontinence.
MALE REPRODUCTIVE MEDICINE
AND SEXUAL DYSFUNCTION
Male infertility and sexual dysfunction are a specialized area of
urologic practice. Diagnostic evaluation, medical treatment, and
surgical therapy of male infertility represent sophisticated aspects
of urologic care. Male sexual dysfunction is becoming more prom-
inent as the field of men’s health continues to evolve. Many
patients seen and evaluated by general surgeons may be receiving
specific medical therapy or have undergone prosthetic surgical
implants for sexual dysfunction management. A basic familiarity

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 CHAPTER 72  Urologic Surgery 2079

Basic management of LUTS in men

LUTS Recommended tests: Complicated LUTS:

Cause little or
no bother • Relevant medical history • Suspicious DRE
• Assessment of LUTS • Hematuria
• Severity and bother (i.e., AUA-SI) • Abnormal PSA
• Physical examination including DRE • Pain
• Urinalysis • Infection3
• Serum PSA1 • Palpable bladder
• Frequency/volume chart2 • Neurological disease
Reassurance
and follow-up

Predominant
significant nocturia
Bothersome LUTS
Frequency-volume chart

No polyuria

Polyuria

Standard treatment
1 Polyuria
24-hour output  3 liters • Alter modifiable factors
· drugs
Lifestyle and fluid intake · fluid & food intake
is to be reduced5 • Lifestyle advice
Drug treatment5

2 Nocturnal polyuria
 33% output at night
Fluid intake to be reduced
• Consider other causes
FAILURE Success in
relieving
bothersome
LUTS:
1. When life expectancy is >10 years and if the
diagnosis of prostate cancer can modify the
management 1. For the AUA PSA Best Practice
Statement: 2009 Update, see: www.auanet.org. Continue
2. When significant nocturia is a predominant treatment
symptom.
3. Assess and start treatment before referral.
4. In practice, advise patients with symptoms to
aim for a urine output of about 1 liter/24 hours.
5. See Figure 2.
DETAILED MANAGEMENT

FIGURE 72-5  Algorithm for initial diagnosis and management of BPH. (Adapted from McVary KT, Roehrborn
CG, Avins AL, et al: Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol
185:1793–1803, 2011.)

with these specialized areas is beneficial to general surgeons in
their surgical practice.
Male Infertility: Evaluation and Treatment
Infertility affects approximately 8% to 14% of couples; the male
factor is the primary or sole factor in 36% to 75% of these cases.21
Couples are often referred to the urologist after a period of infertil-
ity, and referrals are generally from a primary care physician or
from the evaluating gynecologic reproductive endocrinologist.
Infertility is defined as a couple’s inability to achieve pregnancy
after 1 year of unprotected intercourse.21
The standard male factor evaluation involves a detailed history,
physical examination, and basic laboratory and imaging evalua-
tion. The AUA has produced a series of best practice statements on
the evaluation of the infertile man with the following objectives:
to recognize and to treat reversible conditions, to categorize disor-
ders potentially amenable to assisted reproductive techniques, to
identify syndromes and conditions that may be detrimental to the
patient’s health, and to distinguish genetic abnormalities that can
be transmitted to or affect the health of offspring.22
The causes of infertility can be divided into anatomic, behav-
ioral and environmental, and iatrogenic. Anatomic causes of male

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2080 SECTION XIII  Specialties in General Surgery

Detailed management for persistent bothersome LUTS after basic management

OAB Recommended tests: Optional tests:

(storage symptoms)
no evidence of BOO • Validated questionnaires • Flow rate recording
• FVC (frequency/volume chart) • Residual urine

• Lifestyle intervention
Evidence of BOO MIST
• Behavioral therapy
• Antimuscarinics1 Discuss RX options OR
shared decision Surgery options
flow rate
(if not previously used)

Medical therapy
option
Mixed OAB
FAILURE
and BOO
Predominant BOO

Reassess and Antimuscarinics1 Small gland/ Larger gland

consider invasive and and/or low PSA2 and/or higher PSA3
therapy of OAB -blocker -blocker -blocker and/or
(i.e., neuromodulation) 5-reductase
inhibitor

FAILURE

BOO: Bladder Outlet Obstruction

MIST: Minimally Invasive Surgical Treatment Offer MIST or surgery to patient
OAB: Overactive Bladder
PSA: Prostate-specific Antigen
PVR: Post Void Residual
Rx: Treatment Evaluation clearly suggestive
of obstruction? (OMAX <10 ML/S) YES
1 Consider checking PVR prior to initlation
2 PSA <1.5 ng/ml
3 PSA >1.5 ng/ml

NO

Pressure-flow studies

NO Obstruction?

Treat appropriately. YES

If interventional therapy
is pursued, patients need
to be informed of possibly Proceed with selected
higher failure rates. techniques

FIGURE 72-6  Algorithm for secondary management of BPH. (Adapted from McVary KT, Roehrborn CG,
Avins AL, et al: Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol
185:1793–1803, 2011.)

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FIGURE 72-7  Varicocele. The bag of worms appearance is visible
and palpable through the scrotal skin, representing the dilated branches
of the internal spermatic venous system.
infertility are either congenital or acquired.21 The most significant
anatomic cause is congenital absence of the vas deferens, which is
a partial or complete agenesis of the vas deferens. Although
uncommon, the finding is associated with a cystic fibrosis trans-
membrane conductance regulator (CFTR) gene mutation, making
these patients carriers for cystic fibrosis.22 Other anatomic findings
include cryptorchidism, ejaculatory duct obstruction (at the level
of the prostate), and varicocele (Fig. 72-7). Behavioral and envi-
ronmental sources of infertility are more common and easier to
reverse than anatomic causes of male infertility. These include
obesity, environmental exposures, substance abuse (including
exogenous testosterone), and vitamin deficiency. Finally, iatro-
genic causes to be considered include prior chemotherapy or
radiation therapy, prior inguinal or genital surgery, and current
medical treatments. Surgeons must be aware of iatrogenic causes
of infertility in groin and pelvic surgical procedures from damage
to the spermatic cord vasculature, vas deferens, and ejaculatory
duct region or vasal entrapment from mesh used for inguinal
hernia repair. The blood supply to the vas deferens or testicle is
vulnerable to injury when the groin is explored in reoperative
surgery or when the anatomy is obscured because of inguinal
trauma as identification of these structures is challenging.
The history should include a discussion of sexual and reproduc-
tive history. This includes potential gonadotoxic exposure; uro-
logic infections and STIs; trauma and prior surgery involving the
pelvis, groin, and genitalia; and family history of infertility. Physi-
cal assessment should include a general evaluation of masculiniza-
tion and genital findings, including normal meatal location,
testicular size and consistency, presence and normalcy of the epi-
didymis and vas deferens, and possible presence of a varicocele.
Perineal and rectal examinations are routine parts of this
assessment.
Basic Laboratory Assessment
Laboratory evaluation of these patients includes two semen analy-
ses and serum hormone studies. The semen analyses should be
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CHAPTER 72  Urologic Surgery 2081
separated by 1 month and preceded by 2 to 3 days of abstinence.
Semen analysis parameters of importance include semen volume,
pH, sperm concentration and total count, total motility, progres-
sive motility, quality of sperm movement, morphology, and pres-
ence of red and white blood cells or bacteria.21 The World Health
Organization has defined parameters of normal for routine semen
analyses.21 Semen analysis abnormalities fall into two main catego-
ries: azoospermia—the complete absence of sperm from the
semen; and abnormal semen parameters—reduced concentration,
motility, or morphology and abnormal function. Azoospermia can
roughly be divided into three categories: pretesticular, testicular,
and post-testicular. Pretesticular azoospermia results from endo-
crine causes, such as hypogonadotropic hypogonadism, or con-
genital causes. Testicular causes are the result of primary testicular
failure of germinal epithelium of the testis to produce mature
sperm. This is often accompanied by normal semen volume and
by a markedly elevated serum follicle-stimulating hormone (FSH)
level. Post-testicular causes, such as ejaculatory dysfunction and
obstruction, account for 40% of cases of azoospermia.22 Abnormal
semen parameters may be indicative of a wide range of disorders
that may cause reduced sperm numbers, motility, or morphology,
including varicocele, antisperm antibodies, genital duct infection
with pyospermia, and prior or current gonadotoxic exposure.
Reduced semen volume may be artifactual, indicating incomplete
ejaculation or specimen collection, or it may represent true disease,
including, for example, congenital absence of the seminal vesicle,
ejaculatory duct obstruction, or retrograde ejaculation caused by
diabetes or neurologic injury or prior bladder neck surgery or
medications.
Serum hormone testing includes determination of levels of
FSH, luteinizing hormone, testosterone, free testosterone, and
prolactin. Hypogonadotropic hypogonadism may be diagnosed
on the basis of serum hormone studies or elevation in the FSH
level. A patient with a low testosterone level should have follow-up
prolactin levels measured to rule out a prolactinoma of the pitu-
itary gland.
Ultrasound of the scrotum is useful to measure testicular
volume and symmetry, to exclude the possibility of testicular
neoplasm, to identify epididymal anatomy, and to define or to
confirm the presence of a varicocele, which is an abnormal dila-
tion of the pampiniform venous plexus of the internal spermatic
venous system (Fig. 72-7). Transrectal ultrasound (TRUS) of the
prostate may provide evidence of ejaculatory duct obstruction
with seminal vesicle dilation or congenital absence of the seminal
vesicle, which may accompany congenital absence of the vas
deferens.
Treatment
Treatment of male infertility depends on the identified cause and
on the availability and affordability of assisted reproductive tech-
nology support options for specific or empirical treatment of
failure to conceive. Medical therapy is used to treat hormone
deficiencies, hormone excess, thyroid hormone excess, and pro-
lactin excess. The most common medical therapies include hor-
monal stimulation of spermatogenesis, such as gonadotropin
agents and antiestrogen agents, which have been met with mixed
results. Anti-inflammatory or antibiotic therapy can be used in
patients with findings of pyospermia or concern for genital duct
infection. Surgical therapies may include microsurgical recon-
struction for vasal or epididymal occlusion (including vasectomy
reversal), transurethral resection of the ejaculatory duct for
obstructive lesions, and varicocele repair.
2082 SECTION XIII  Specialties in General Surgery

Male Sexual Dysfunction and Treatment

Sexual dysfunction in men refers to a range of disorders, including
erectile dysfunction (ED), diminished libido, hypogonadism, and
ejaculatory dysfunction. Because of the numerous organ system
interactions, patients with these conditions may have associated
neuropathy, endocrinopathy, vasculopathy, and psychological dis-
orders, and these abnormalities may affect nonurologic patient
management and surgery.
Normal erectile function is a complex interaction between the
nervous and vascular systems, with unique molecular actions
occurring in penile vascular structures. Many medical comorbidi-
ties and lifestyle choices can contribute to ED, including age,
coronary artery disease, smoking, hypertension, dyslipidemia,
atherosclerosis, peripheral vascular disease, obesity, diabetes,
spinal cord injury and degenerative neurologic conditions, treat-
ment of pelvic malignant neoplasms, and chronic kidney
disease.23 The causes of ED can be divided into neurologic, vas-
cular, metabolic, medication induced, endocrine, and psycho-
logical; importantly, it can be an early marker for coronary artery
disease.23 The initial evaluation of the ED patient centers on the
history and physical examination. The history is focused on
sexual performance and erectile function; the nonsexual histori-
cal aspects center on possible medical and surgical conditions.
Social aspects, such as smoking, recreational drug use, and
diet, are also important considerations. Validated questionnaires FIGURE 72-8  Inflatable Penile Prosthesis. A three-component
provide objective historical data both for initial treatment and device is shown. The reservoir (top) is placed retropubically in an extra-
for evaluation of therapy outcomes. The physical examination peritoneal position. The paired cylinders (right) are placed within the
centers on the genitalia and evaluation of male secondary sexual corpora cavernosa. The pump (left) is placed in the scrotum, adjacent
to the testes.
characteristics. Basic laboratory studies in these patients include
morning total testosterone concentration, fasting lipid levels, and
hemoglobin A1c level. Important consideration should be given through erosion through the peritoneal membrane, and the res-
to assessment of cardiovascular function in younger patients ervoir or system tubing may be encountered during nonurologic
because this disease process is considered an early marker for abdominopelvic surgery. Care should be taken not to contaminate
cardiovascular disease, especially in younger patients. Further any of the implant components or inadvertently injure the tubing
evaluation is specialized but may include neurologic testing (e.g., or device components. If it is known that an implant is in place
biothesiometry) and vascular testing (e.g., penile duplex Doppler and pelvic or inguinal surgery is planned, urologic consultation
ultrasound studies). may be helpful in handling any issues that arise with the implant.
Most treatments of ED are based on restoring penile arterial Revascularization of the penis to restore erectile function, follow-
blood flow to achieve or to maintain a satisfactory erection. Life- ing arteriography for anatomic documentation, is usually achieved
style modifications are an important component of this, and using an inferior epigastric artery pedicle flap, whereby new arte-
dietary changes and increased regular cardiovascular exercise have rial inflow is brought to the corpora cavernosa. This has limited
been shown to independently improve erectile function. Evalua- indications, most relevant in younger patients with traumatic
tion and adjustment of offending medications should be consid- injury to the pelvic blood supply, and national practice guidelines
ered as well. The basis of medical therapy for ED is phosphodiesterase consider this to be controversial.
type 5 inhibitors. These medications improve penile blood flow The other area of male sexual medicine affecting a significant
by limiting the breakdown of cyclic guanosine monophosphate number of patients is testosterone deficiency or hypogonadism.
and potentiating penile blood flow. These drugs should be limited Serum testosterone is produced in the Leydig cells of the testes
in their use in men with known cardiovascular disease, especially (90%) and adrenal glands (10%). Testicular synthesis of testoster-
those taking oral nitrates. Other forms of nonsurgical treatment one is controlled by the hypothalamus and anterior pituitary. This
include vacuum erection devices, intraurethral suppository therapy is a condition in which serum testosterone levels decline and are
with prostaglandin compounds, intracavernosal self-injection, associated with symptoms of fatigue, lack of energy, depressed
and occasionally psychotherapy. Surgery for ED includes primar- mood, irritability, reduced motivation, decreased cognitive acuity,
ily placement of a penile prosthesis and limited vascular recon- decreased strength and stamina, reduced muscle mass and
struction. Penile implant surgery may involve malleable implants, increased fat, and sexual side effects including decreased libido
which have a flexible wire core inside a silicone sleeve, implanted and ED. There is a normal age-related decline in testosterone as
bilaterally in the corpora, or, more commonly, inflatable penile men age, and total testosterone declines by 1%, on average, each
implants. These are fluid-containing, completely internalized year after the age of 40 years. The prevalence of this condition is
systems that may include paired corporal cylinders, a scrotal between 2.1% and 39% of men older than 40 years, depending
pumping device, and a fluid reservoir, which is typically posi- on the criteria used and association of symptoms.24 The patient’s
tioned in the retropubic space or extraperitoneal lower abdominal history should elicit information on the specific symptoms of
quadrant (Fig. 72-8). The general surgeon should be aware that testosterone deficiency, and physical examination is similar to that
intraperitoneal positioning may also occur, intentionally or for ED with evaluation of the genitalia and secondary sexual

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characteristics. Validated questionnaires are useful to assess and to
monitor therapy. Laboratory studies should include free and total
morning testosterone, luteinizing hormone, prolactin, hemato-
crit, and hemoglobin levels.25 Therapy for testosterone deficiency
is based on lifestyle modifications and testosterone supplementa-
tion.25 Many men who suffer from this condition are either obese
or have metabolic syndrome. Dietary changes to improve nutri-
tional status and to result in weight loss have been shown to
improve not only baseline medical conditions but also serum
testosterone levels. Furthermore, moderate-intensity exercise has
been shown to improve serum testosterone levels. In addition to
lifestyle modifications, many patients are treated with supplemen-
tal testosterone. Synthetic testosterone may be administered orally,
transdermally, through intramuscular injections, and by subcuta-
neous pellets. The goal of therapy is maintenance of testosterone
levels between 400 and 700 ng/dL and resolution or improve-
ment of presenting symptoms.25 Whereas there are few absolute
contraindications to testosterone administration, many potential
adverse side effects exist and should be discussed before adminis-
tration of these medications as this is the area of greatest contro-
versy with testosterone supplementation. Potential adverse effects
include cardiovascular events and mortality, dermatologic changes,
polycythemia, diminished spermatogenesis, gynecomastia, LUTS,
prostate cancer, and sleep apnea.25
UROLITHIASIS
Urinary tract stones are a common cause of visits to the emergency
department. The prevalence of renal calculous disease in the
United States is increasing, with a lifetime risk of forming a renal
stone at 5% in 1994 and 9% in 2010.26 The incidence of stone
disease peaks in the fourth to sixth decades of life and is more
common in men than in women by a 2 : 1 margin.26 Renal calcu-
lous disease has several aspects of management and evaluation,
including acute stone presentation, metabolic evaluation, and
medical and surgical therapy. As most general surgeons will
encounter patients either in the acute presentation or around the
time of surgical intervention, this section focuses on these areas.
Background
The pathogenesis of calculus formation is governed by the physical
chemistry characteristics of the urine in the upper collecting
system. Most stones are formed by minerals or stone-forming salts
and begin to crystallize when their concentration becomes super-
saturated in the urine. Just as certain minerals or salts promote
calculus formation, there are many inhibitors of calculus forma-
tion, including citrate, phosphate, and magnesium. There are
many theories to stone formation, none of which are definitively
proven, such as Randall plaque formation, stasis, bacteria, and
reactive oxygen species from oxalate excretion.27 Kidney stones are
classified by the stone composition, and the mineral composition
directs evaluation, treatment, and nonsurgical management.
Kidney stones can be generally classified as calcium based, uric
acid stones, struvite stones, and cystine stones.27 Calcium stones
are usually composed of two calcium salts, calcium phosphate and
calcium oxalate, and are the most common renal calculi. Risk
factors for calcium stone formation include abnormal urine pH;
high urine concentration of calcium, oxalate, or uric acid; and low
urine concentration of the stone inhibitor citrate. Uric acid stones
form in a low pH urine in patients with hyperuricosuria and can
be the result of purine metabolism from cellular breakdown
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CHAPTER 72  Urologic Surgery 2083
(tumor lysis) or excessive protein intake. These stones are often
radiolucent. Struvite stones, also called infection stones or mag-
nesium ammonium phosphate, result from specific bacterial infec-
tions (P. mirabilis, K. pneumoniae, Staphylococcus aureus, and
Staphylococcus epidermidis) that contain urease, which converts
urea into ammonia. The base properties of ammonia lead to
higher urine pH and crystallization with phosphate. Cystine
stones are formed from an autosomal recessive defect in the
metabolism of the COLA amino acids (cystine, ornithine, lysine,
and arginine), which results in elevated urine cystine levels.27 The
other rare cause of calculi is pharmacologically induced, resulting
from poor drug metabolite urine solubility and precipitation in
the urine. The most notable of these are protease inhibitors (indi-
navir and ritonavir), which are not visible on noncontrast com-
puted tomography (CT) scans.
Acute Presentation and Management
Patients presenting with an acute stone episode or renal colic
typically have characteristic complaints of abdominal, flank, or
back pain that waxes and wanes but cannot be resolved with posi-
tion changes. Often, these patients can localize the most intense
center of the pain, giving some indication of stone location. When
the ureter is obstructed by a stone, the pressure in the proximal
collecting system rises, and with progressive distention, the patient
may experience visceral symptoms, including nausea, vomiting,
and ileus. Physical examination in these patients should be focused
on the back, flank, abdomen, and genitalia. Patients who have
specific vital sign findings in combination (temperature higher
than 101.5° F, hypotension, or tachycardia) should be assessed for
obstructive upper tract UTI with the potential for sepsis. Basic
laboratory evaluation should include complete blood count, met-
abolic panel, and urinalysis with microscopy. Significant findings
of leukocytosis or acute kidney injury may direct urgency of
therapy and type of intervention. A non–contrast-enhanced CT
scan of the abdomen and pelvis is the preferred imaging study
because of its superior sensitivity and specificity compared with
intravenous urography and plain radiography. Patients with ure-
teral calculi may benefit from a plain radiograph, as 85% of calculi
are radiopaque, to observe for stone passage.
Once the stone is identified and the location established, pain
management is the next step. Patients who are diagnosed with
renal or ureteral calculi should receive intravenous nonsteroidal
anti-inflammatory drugs (ketorolac) or opioid analgesics as initial
therapy. A successful attempt at pain control with oral agents
determines if the otherwise hemodynamically stable patient can
be discharged or requires inpatient treatment for the stone. Those
patients who present with upper tract UTI and obstruction should
undergo expeditious drainage with either cystoscopic ureteral
stent placement or percutaneous nephrostomy tube placement. If
one upper tract is totally obstructed by stone, the patient could
have a serious infection with pyonephrosis, and the voided urine
would be deceptively normal. Patients who are suitable for hos-
pital discharge include those with no evidence of UTI, hemody-
namic stability, good oral intake, pain well controlled on oral
analgesics, and a stone size with reasonable chance of spontaneous
passage. In patients who are discharged from the hospital, medical
expulsive therapy, with agents to promote spontaneous stone
passage, is the recommended management.28 The most common
drug used is tamsulosin, the α1a blocker that relaxes ureteral
smooth muscle.28 If a patient is discharged for outpatient manage-
ment, she or he should be observed closely to determine whether
the stone has passed. It should not be assumed that because the
2084 SECTION XIII  Specialties in General Surgery

pain has resolved, the stone has passed. With persistent upper tract
obstruction, the pressure in the collecting system eventually
declines as renal blood flow diminishes and urine output drops.
The patient’s pain can disappear and the kidney can remain
obstructed, undergoing silent destruction in the weeks and
months that follow. Reimaging is necessary if there is no definitive
evidence that the stone has been passed (e.g., the patient brings
it in for analysis).
Elective Diagnostic Evaluation and Management
Patients who are diagnosed with asymptomatic renal calculi, such
as nonobstructing renal calyceal stones found incidentally during
a hematuria evaluation, and patients who have convalesced after
an acute presentation undergo a basic metabolic screening evalu-
ation. Important historical aspects to obtain include prior stone
passage or treatment, family history, bowel disease or malabsorp-
tion, gout, hyperthyroidism, obesity, and dietary supplements.29
Routine laboratory work includes urinalysis, basic metabolic
panel with determination of calcium and uric acid levels, urine
culture, and stone analysis (if available). A 24-hour urine speci-
men is also collected to evaluate the urine for specific chemical
and mineral content: volume, pH, creatinine, calcium, oxalate,
uric acid, citrate, sodium, and potassium.29 Specific dietary
changes and medical therapy can be used for prevention of stone
formation in specific populations. These dietary modifications
and pharmacologic treatments are based on stone composition
and findings on 24-hour urinalysis. The two most common stone
types, calcium and uric acid, are discussed.
In patients with calcium-based stone disease (oxalate or phos-
phate), the single most important treatment or dietary modifica-
tion is increased fluid intake to achieve more than 2 liters of urine
output daily. In addition, there should be no changes in calcium
consumption, and patients, in general, should consume the rec-
ommended daily allowance of dietary calcium. Dietary levels of
sodium, foods high in oxalate, and animal protein should be
reduced as each of these can affect urinary oxalate and citrate
levels. Pharmacologic therapy is typically based on three different
agents—thiazide diuretics, potassium citrate, and allopurinol—
each of which has separate effects on calcium urine levels and
calcium stone formation. Patients with uric acid stones are treated
with drug therapy.29 There are no dietary recommendations other
than to increase fluid intake to raise urine output to 2 liters per
day. Pharmacologic therapy in this group consists of potassium
citrate and allopurinol. Many uric acid stones can be dissolved by
raising urinary pH levels with use of alkalinizing agents.
Elective Surgical Management
Patients who have large stone burdens or continue to have symp-
tomatic stones require surgical treatment of their calculous disease.
Surgical treatment of renal and ureteral calculi varies from com-
pletely noninvasive, shock wave lithotripsy (SWL), to minimally
invasive, percutaneous nephrolithotomy (PCNL). SWL is a trans-
cutaneous procedure using generated shock waves to fragment
stones. Shock waves create positive and negative pressure compo-
nents that are focused on the stone and create fractures in the
targeted stones, ultimately resulting in stone fragmentation.30 The
progress of stone fragmentation is monitored during SWL, typi-
cally with fluoroscopy, to direct treatment length and location.
Nonradiopaque stones, stones larger than 2 cm, and certain ure-
teral calculi should not be treated with this method. Complica-
tions from SWL include renal injury, steinstrasse (street of stones),
hypertension, and chronic kidney disease.30
Smaller renal stones and ureteral calculi can be managed in an
endoscopic fashion using ureteroscopes (Fig. 72-9). As previously
mentioned, ureteroscopes are both semirigid and flexible, allow-
ing full upper tract collecting system access. Through the working
channel of ureteroscopes, a variety of working instruments can be
placed to fragment or to remove stones. The most common stone
treatment is laser lithotripsy to completely fragment the symp-
tomatic calculus. Smaller fragments can be removed using differ-
ent basket and grasping systems to render the patient stone free.
Complications of ureteroscopy include acute ureteral perforation
or avulsion, UTI, and late ureteral stricture formation.
For larger renal stones or select proximal ureteral stones, PCNL
is preferred because of the larger working endoscopes and better
instrumentation for stone fragmentation. The basic steps of
PCNL are percutaneous renal access, dilation of the nephrostomy
track, placement of the working sheath for stone fragmentation
and extraction, and postoperative renal drainage. The advantage
of PCNL is that numerous intracorporeal lithotripsy devices are
available, and large stones can be rapidly fragmented. Flexible
nephroscopes can be used as well in this setting. Complications
of PCNL are most significant because of the more invasive nature
of the procedure; these include sepsis, renal hemorrhage, renal

GYRUS ACMI GYRUS ACMI

A B
FIGURE 72-9  Ureteral Stone. A, An obstructing calculus is shown crowning within the right ureteral
orifice. B, Cystoscopic extraction performed with a grasping forceps.

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 CHAPTER 72  Urologic Surgery 2085

collecting system injury, and damage to adjacent organs and TABLE 72-1  Organ Injury Scaling
viscera. PCNL may result in hydrothorax or pneumothorax from
System: Kidney
transpleural or peripleural access tracks that requires evacuation.
With the refinement of PCNL, open stone surgery is rarely indi- GRADE INJURY DESCRIPTION AIS-90
cated even for the most complex intrarenal calculi. Laparoscopic I Contusion Microscopic or gross hematuria, 2
and robotic procedures for specific renal calculi have been urologic studies normal
described. Hematoma Subcapsular, nonexpanding, without 2
parenchymal laceration
II Hematoma Nonexpanding perirenal hematoma 2
UROLOGIC TRAUMA confined to renal retroperitoneum
Laceration <1 cm parenchymal depth of renal 2
Urologic injury is present in approximately 15% of all abdominal cortex without urinary extravasation
and pelvic trauma patients regardless of mechanism, blunt or III Laceration >1 cm depth of renal cortex, without 3
penetrating.31 Renal injuries, for example, are reported to occur collecting system rupture or urinary
in 0.3% to 1.2% of all trauma patients; however, the kidneys are extravasation
the second most common visceral organ injured, accounting for IV Laceration Parenchymal laceration extending 4
approximately 24% of injuries.31 In many trauma centers, injuries through the renal cortex, medulla,
are typically initially assessed by an emergency physician or general and collecting system
surgeon and may be addressed without urologic consultation, Vascular Main renal artery or vein injury, with 5
although, for complex urologic injuries, the input of a urologist contained hemorrhage
can be essential. For example, high-grade, nonreconstructible V Laceration Completely shattered kidney 5
renal injury can be managed with an expeditious nephrectomy; Vascular Avulsion of renal hilum, which 5
however, most renal injuries, such as an extensive parenchymal devascularizes kidney
and collecting system laceration, should be repaired with renor-
rhaphy. Management of trauma patients is the greatest overlap Adapted from Moore EE, Shackford SR, Pachter HL, et al: Organ
between urology and general surgery and allows numerous areas injury scaling: Spleen, liver, and kidney. J Trauma 29:1664–1666,
for collaboration; urologic expertise can enhance the quality of 1989.
care provided for all urologic injuries, whether they are managed
operatively or nonoperatively. discussed in the retroperitoneal anatomy section, the kidneys are
The focus of the following section on urologic trauma is the well protected in the retroperitoneum but are close to intraperi-
practical management of a variety of acute urologic injuries and toneal structures. The key points in evaluation, as with any trauma
the optimal interaction between the urologist and general trauma patient, are the ABCs: airway, breathing, and circulation. In
surgeon. The management of common injuries throughout the patients with a history of blunt trauma, key findings include loca-
urinary tract, the optimal timing of such interventions, and the tion of impact, flank ecchymosis, and gross or microscopic hema-
role of damage control techniques are discussed. turia. Other relevant historical information is concomitant injury
and mechanism of injury. Close attention to the entry and exit
points in penetrating injuries are also important to estimate the
Core Guideline and Consensus Statements trajectory of the missile.
for Urologic Trauma Management
The Organ Injury Scaling system of the American Association for Imaging
the Surgery of Trauma describes an objective grading system for There are many well-established indications for renal imaging after
urologic injuries (Table 72-1 and Fig. 72-10).32 The staging system blunt or penetrating injury. In patients with blunt trauma, the
for renal trauma has become well established in the urologic lit- criteria for imaging include gross hematuria, hemodynamic insta-
erature and has been externally validated. The Organ Injury Scaling bility (systolic blood pressure < 90 mm Hg), microscopic hema-
system also describes staging for other urologic injuries; however, turia (>5 red blood cells/high-power field), a traumatic mechanism,
the subjective criteria applied to these divisions do not practically and suspicion of injury on screening radiographs (Fig. 72-11). In
affect management decisions and treatment (Fig. 72-10). patients with penetrating injury who are hemodynamically stable,
In 2002, a consensus conference for the diagnosis and treat- imaging is indicated for any degree of hematuria, microscopic or
ment of urologic injuries was convened by the World Health gross (Fig. 72-12).38 The relevance of imaging to detect and to
Organization and the Société Internationale d’Urologie. The stage urinary tract injury before abdominal trauma surgery has
resulting consensus statements were divided by organ site: kidney, been debated in the general surgical and urologic literature. Cross-
ureter, bladder, urethra, and external genitalia.33-37 These reports sectional imaging, specifically contrast-enhanced CT scan, is the
still constitute the centerpiece of urologic trauma management. preferred study to evaluate the renal injuries. Proper imaging
Management guidelines have subsequently been produced by the should include arteriovenous phases with delayed imaging to
European Association of Urology and the AUA to create core evaluate the urinary collecting structures. In those patients who
documents to guide the management of urologic injuries.38 proceed directly to surgery, the “one-shot” intravenous urogram
(intravenous administration of 2 mL/kg contrast material fol-
Renal Injuries lowed by a single abdominal radiograph) can provide information
The majority of renal injuries are the result of blunt trauma concerning the presence or absence of a contralateral kidney.
(80%); the remainder are the result of penetrating injury (20%).33 Ultrasound, intravenous urography, and magnetic resonance
Approximately 70% of all patients who sustain renal injury are imaging (MRI) have a limited role in renal imaging for injury
male, and most of these patients are younger than 50 years. As staging.

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2086 SECTION XIII  Specialties in General Surgery

Grade I Grade II Grade III

Grade V Grade IV
FIGURE 72-10  Illustrative diagram showing grade I-V renal injuries from the AAST organ injury scaling
system. (From Moore EE, Shackford SR, Pachter HL, et al: Organ injury scaling: Spleen, liver, and kidney. J
Trauma 29:1664–1666, 1989.)

Management: Operative versus Nonoperative
With better staging of renal injury, management paradigms have
changed over time (Figs. 72-11 and 72-12). Furthermore, as
urologists learned more from general trauma surgeons in the
management of solid organ injury, nonoperative management of
renal injuries has become more commonplace. The basis of non-
operative management centers around a properly staged injury
with contrast-enhanced cross-sectional imaging (Fig. 72-13). In
general, lower grade injuries, grades I to III, in hemodynamically
stable patients are managed nonoperatively. Grade IV injuries
are more controversial, and many are managed nonoperatively.
High-grade injuries, grades IV and V, particularly in patients
with concomitant intraperitoneal injuries, may undergo surgical
exploration.
In hemodynamically unstable patients who proceed directly to
the operating room, there are absolute and relative criteria for
operative exploration. The absolute criteria for exploration are
expanding hematoma, pulsatile hematoma, and persistent renal
bleeding. Any of these findings are concerning for possible renal
pedicle injury.39 The relative criteria for renal exploration include
persistent urinary extravasation, nonviable renal parenchyma,
arterial injury, and incomplete renal staging.39 In the absence of

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 CHAPTER 72  Urologic Surgery 2087

Blunt renal injury

Determine haemodynamic stability

Stable Unstable-any haematuria

Child <50 RBC/hpf Gross haematuria

adult microhaematuria
SBP >90 mm HGS
child >50 RBC/hpf
adult microhaematuria
SBP <90 mmHg
high index of suspicion
On table IVP
for renal injury

Observe Contrast enhanced

F/U UA in 3 weeks spinal CT scan with Normal IVP Abnormal IVP
10 minute delayed cuts expanding/pulsatile
haematuria
Observe

Grade 1 and 2 Grade 3 & 4 lacerations Grade 4 vascular &

Grade 5 renal pedicle trauma
shattered destroyed kidney

Observe No intraperitoneal Intraperitoneal injuries Renal exploration*

injuries requiring exploration reconstruction
or nephrectomy

Observe bedrest
serial HCT
*except isolated renal artery thrombosis
in patient with normal contralateral kidney
and no other associated injuries
Selective reimaging
angiography/embolization?
ureteral stenting?

FIGURE 72-11  Algorithm for management of blunt renal injuries. (Adapted from Santucci RA, Wessells H,
Bartsch G, et al: Evaluation and management of renal injuries: Consensus statement of the renal trauma
subcommittee. BJU Int 93:937–954, 2004.)

such findings or in patients in whom a damage control approach
is to be implemented, exploration may be avoided if the surgeon
is uncomfortable with the potential requirements for reconstruc-
tive renal surgery.
Renal vascular injury is uncommon, and the radiologic presen-
tation is variable. On CT imaging, these patients may have either
large perinephric hematomas with intravascular extravasation of
contrast material (indicating possible renal pedicle injury) or
absent renal perfusion (indicating renal artery thrombosis). Seg-
mental renal vascular injuries are usually the result of blunt renal
trauma and appear as wedge-shaped defects in the renal paren-
chyma. These injuries rarely require intervention.
With an increase in nonoperative management of renal inju-
ries, renal arteriography and selective angioembolization have
been used with increasing frequency in management of renal
trauma (Fig. 72-14). However, only select patients have been
shown to benefit from this intervention: those with intravascular
extravasation of contrast material, perirenal hematoma rim dis-
tance of more than 25 mm, and medial hematomas.40 In addition,
patients who are assigned to a nonoperative management protocol
and have received more than 2 units of red blood cell transfusion
should undergo angiography.
Surgical Exploration and Operative Approach
Strict criteria exist for renal exploration. In those patients who
proceed directly to the operating room, renal exploration is indi-
cated with an expanding, pulsatile, uncontrolled retroperitoneal
hematoma or renal pedicle avulsion. Patients with persistent renal
bleeding but who require damage control management may
require nephrectomy for hemodynamic stability. Patients with
certain intraperitoneal injuries require surgical exploration and
repair of renal injuries, including patients with concomitant
bowel or pancreatic injury. Patients with renal pelvic laceration or
persistent urinary extravasation of contrast material may require

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2088 SECTION XIII  Specialties in General Surgery

Penetrating renal injury

Determine haemodynamic stability

Stable – any degree of haematuria Unstable-needs laparotomy

high index of suspicion for renal injury Any haematuria
Retroperitoneal haematoma

Contrast enhanced spiral CT scan On table IVP

with 10 minute delayed imaging

Normal IVP Abnormal IVP

Expanding/pulsatile
haematoma
Observe

Grade 1 and 2 Grade 3 & 4 lacerations Grade 4 vascular &

Grade 5 injuries
Renal pedicle trauma
Shattered destroyed kidney

Observe No intraperitoneal Intraperitoneal injuries Renal exploration &

injuries requiring exploration reconstruction
or nephrectomy

Observe
Bedrest serial HCT

Selective reimaging
Angiography/embolization?
Ureteral stenting?

FIGURE 72-12  Algorithm for management of penetrating renal injuries. (Adapted from Santucci RA, Wes-
sells H, Bartsch G, et al: Evaluation and management of renal injuries: Consensus statement of the renal
trauma subcommittee. BJU Int 93:937–954, 2004.)

surgical repair of the collecting system. Patients with large seg-
ments of devitalized renal parenchyma and urinary extravasation
may need early partial or total nephrectomy to prevent long-term
complications. Trauma patients who have continued urinary
extravasation despite percutaneous or endoscopic urinary diver-
sion may require renal exploration and repair, although this may
result in nephrectomy.
There are conflicting data concerning early vascular control
before renal exploration, although the guidelines recommend vas-
cular control.33 Urologists are typically trained to approach the
injured kidney anteriorly through a midline incision and to obtain
vascular control of the renal vessels, before opening Gerota fascia
and exposing the kidney, to avoid severe renal bleeding that may
necessitate an urgent nephrectomy. In significant anatomic distor-
tion, which may occur in the trauma setting, renal pedicle control
can be obtained by bluntly creating a window medial to the lower
pole of the kidney and lateral to the aorta (left) or vena cava (right),
down to the psoas muscle fascia, which allows a vascular pedicle
clamp to be placed if bleeding is encountered on renal exposure
(Fig. 72-15). Once vascular access is achieved, the kidney is exposed
through an anterior vertical incision in Gerota fascia, which
extends from the upper to the lower pole of the kidney. If there
is parenchymal injury, care must be taken to identify the renal
capsule in exposing and mobilizing the kidney to avoid stripping
the entire capsule from the renal parenchyma and affecting kidney
closure after renal reconstruction. The entire kidney should be
exposed to reveal any lacerations, to evacuate hematoma, and to
facilitate full mobility for repair. In general, if half the kidney can
be preserved, renal reconstruction has benefit; however, if there is
extensive destruction of the hilar region, successful reconstruction
is unlikely. The preferred surgical management is renorrhaphy with
suture ligation of bleeding vessels and closure of the collecting
system with fine absorbable suture followed by parenchyma and
capsular approximation with absorbable suture. For renal recon-
struction in the trauma setting, pedicle clamping with a warm
ischemia time of less than 30 minutes generally will not have a
permanent adverse impact on renal function. The use of hemostatic
agents and tissue sealants may aid in the reconstructive effort, and

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 CHAPTER 72  Urologic Surgery 2089

A B

C D
FIGURE 72-13  CT Scans Depicting Renal Trauma. A, Left renal contusion with heterogeneous contrast
enhancement. B, Small right posterior pericapsular renal hematoma. C, Nonperfused left kidney after decel-
eration trauma and intimal disruption, with thrombosis of the renal artery. Vessel cutoff sign and some
pericapsular enhancement are demonstrated. D, Grade IV laceration to the posterolateral right kidney, with
posterolateral extravasation of contrast material.

closed suction drainage is beneficial in the instance of a collecting Management

system injury or significant bleeding.
Ureteral Injuries
Ureteral injuries are uncommon (1% to 2.5% of all urologic
injuries) and are rarely life-threatening but occur in the context
of complex polytrauma.39 Ureteral injuries due to external vio-
lence are most often the result of penetrating injuries; blunt inju-
ries are the result of injuries with high-energy transfer, such as
motor vehicle collision. Up to 5% to 10% of penetrating abdomi-
nal or pelvic injuries have ureteral involvement.39 Management of
ureteral injuries is dependent on mechanism of injury, anatomic
location, and overall condition of the patient. The ureter is infre-
quently injured because of its mobility and location in the retro-
peritoneum protected by large muscle groups and the spine and
bony pelvis. Ureteral injuries do not present with specific signs
and symptoms, and their diagnosis requires heightened suspicion
for injury based on mechanism and injury location.38 Evaluation
of ureteral injuries should be performed in the context of evalu-
ation for more serious or life-threatening injuries.
Imaging
Ureteral imaging should be performed with contrast-enhanced,
cross-sectional imaging, preferably CT scan, and must include
delayed imaging to evaluate urinary excretion.38 Findings suggest-
ing ureteral injury include extravasation of contrast material,
absence of contrast material distal to the suspected injury, and
ipsilateral hydronephrosis. Other forms of imaging, including
retrograde pyelography and intravenous urography, are difficult in
the acute setting and often of lower quality.
As a general principle, injuries to the ureter are best managed by
surgical repair. Endoscopic ureteral stents or percutaneous diver-
sion is generally reserved for missed injuries and for patients for
whom reoperation is prohibitively morbid or the timing would
make a successful repair unlikely. Ureteral contusions from adja-
cent penetrating trauma may benefit from ureteral stent place-
ment to reduce progressive edema, occlusion, and ischemia and
potentially to diminish the risk of delayed urinary extravasation.
Surgical Exploration and Operative Approach
When a ureteral injury is suspected, the ureter should be identi-
fied and directly inspected. The ureter can be approached surgi-
cally at any level by finding an area of normal anatomy and
proceeding expeditiously to the areas in question. While dissect-
ing around the ureter and mobilizing it from surrounding tissues,
it is important to avoid stripping the periureteral tissue, causing
devascularization. Ureteral injuries should be managed at the time
of initial injury to decrease the chance of complication, such as
urinoma, fistula, ureteral obstruction, and renal failure.34 Repair
usually involves minimal débridement of viable tissue. Lacerations
are closed perpendicular to the axis of incision and transections
with a spatulated, tension-free anastomosis. Injuries of the distal
ureter often require reimplantation into the bladder. Gunshot
wounds represent a particular concern as the viability of the ure-
teral stump may be compromised because of local tissue injury
from the blast effect of the missile.34 Fine absorbable suture is used
in a running or interrupted fashion. Stent placement is desirable
to allow low-pressure drainage, to minimize postoperative urinary
extravasation, and to prevent angulation of the healing ureter.

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2090 SECTION XIII  Specialties in General Surgery

The value of CT staging in case selection Options?

A B

2.2 mm – 3 cm coils

C D
FIGURE 72-14  CT Scans Depicting Penetrating Renal Injury. A, Superficial laceration to the lateral left
kidney from a stab wound. Note minimal hematoma and proximity of the posterior descending colon to the
track of injury. Nonoperative management was selected and was successful. B, Deep laceration to the right
kidney following a stab wound. Note the proximity to renal hilar structures and moderate-sized hematoma.
C, Renal angiography performed for significant postinjury hematuria with hemodynamic instability, demon-
strating pseudoaneurysm. D, Postembolization appearance of the right kidney showing a wedge-shaped
defect after coil placement, which was successful.

Ureteral injuries are highly amenable to damage control approaches

when repair acutely is not appropriate because of the patient’s
condition or the need to prioritize the management of other, more
critical injuries.41

Bladder Injuries
The bladder is the second most commonly injured urologic struc-
ture and accounts for 10% of all urologic injuries. The most
common source of bladder injury is blunt trauma (80% to 85%)
from high-energy transfer, and it is often associated with pelvic
fracture (83% to 95%).35 The most common blunt sources of
trauma are motor vehicle collision, falls from height, and indus-
trial injuries. Patients with suspected bladder injuries often present
with multisystem trauma and should be evaluated in the context
of their presenting trauma. Most of the patients with bladder
injury will present with hematuria and pelvic fracture, and in
patients with gross hematuria and pelvic fracture, bladder injury
is associated in 13% to 55% of cases.38

Imaging
Patients with suspected bladder injury should be evaluated with
retrograde cystography. Both plain film cystography and CT cys-
tography are acceptable, although CT scan may provide more
FIGURE 72-15  Placement of a pedicle clamp across renal anatomic detail. A necessary component of appropriate cystogra-
vasculature. phy is adequate retrograde filling of the bladder with 300 to

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400 mL of contrast material.38 If plain film cystography is per-
formed, three anterior-posterior images must be obtained: scout,
full bladder, and after drainage. CT cystography requires a diluted
contrast agent of at least 1 : 6 concentration (Figs. 72-16 to 72-18).
In patients with penetrating bladder injuries, imaging should not
delay operative exploration as the bladder can be visually inspected
at the time of surgery.
Management: Operative versus Nonoperative
Management of bladder injuries is dependent on location of the
injury, extraperitoneal or intraperitoneal (Fig. 72-19). In general,
intraperitoneal bladder injuries should be surgically repaired at
the time of diagnosis. On the other hand, most extraperitoneal
bladder injuries can be managed in a nonoperative fashion with
simple catheter drainage. Extraperitoneal bladder injuries that
should be managed in an operative fashion include penetrating
bladder trauma, ongoing hematuria, concomitant pelvic organ
injury, foreign body or bone fragment in the bladder, and bladder
neck injuries.
FIGURE 72-16  Static cystogram in patient with pelvic fracture and
gross hematuria showing extraperitoneal extravasation of contrast
material on the right side.
FIGURE 72-17  Static cystogram in patient after blunt injury to the
lower abdomen showing the typical contrast material extravasation
pattern of intraperitoneal bladder rupture. Note contrast material outlin-
ing the left and right colic gutters and present within the peritoneal
cavity.
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CHAPTER 72  Urologic Surgery 2091
Surgical Exploration and Operative Approach
The operative repair of bladder injuries is through a lower midline
incision, often extending the midline incision from abdominal
exploration to the pubic symphysis. Intraperitoneal injuries are
often evident at the dome of the bladder within the overlying
peritoneum. The traumatic cystotomy should be extended, if nec-
essary, to fully evaluate the lumen of the bladder. In extraperito-
neal injuries, the bladder is often opened through an anterior
midline cystotomy to evaluate the lumen. This is especially true
in the case of pelvic fracture to avoid disturbing the associated
hematoma. If necessary, ureteral catheters can be inserted to
confirm efflux of urine and ureteral continuity. Defects in the
bladder wall are closed with absorbable 2-0 sutures in two layers
to enhance watertightness. Use of a tissue interposition flap (e.g.,
omental flap) at the time of bladder repair may be necessary in
cases of contiguous injuries to the rectum or vagina to prevent
fistula formation. Diversion with a large-bore Foley catheter (at
least 20 Fr to 24 Fr in the adult) allows bloody urine to drain and
manual catheter irrigation, if necessary. Suprapubic cystostomy
tubes are used for cases of extensive injuries requiring complex
repairs or if prolonged bladder drainage is anticipated, such as
with concomitant rectal or vaginal injury or traumatic brain
injury. In patients with significant multisystem trauma who are
hemodynamically unstable, definitive bladder repair may be
delayed as a damage control maneuver.
Urethral Injuries
The urethra is not a common source of urologic trauma, and
injury due to external violence accounts for approximately 4% of
all genitourinary injuries.36,42 Broadly, the urethra is divided into
the anterior and posterior segments. Each segment has a different
cause for injury and different management options based on the
mechanism of injury, the involvement of surrounding structures,
and the medical condition of the patient. The anterior segment
of the urethra most commonly injured is the bulbar urethra,
which accounts for 85% of urethral injuries.36 Approximately 3%
to 6% of posterior urethral injuries are associated with pelvic
fracture, the so-called pelvic fracture urethral injury. The male
anterior urethra may be injured at the time of penile injury, and
40% to 50% of penetrating wounds to the penis have urethral
FIGURE 72-18  CT cystogram demonstrating intraperitoneal contrast
material extravasation pattern of intraperitoneal bladder rupture. Note
contrast material in the colic gutters, within the deep pelvis, and outlin-
ing the ovaries.
2092 SECTION XIII  Specialties in General Surgery

• No blood at Gentle urethral Gross Stress Bladder

the meatus AND catheterization haematuria cystogram rupture
• Normal prostate
on DRE

Microhaematuria Normal Extra-

peritoneal
Failed Intra-
peritoneal
Normal
Urethrovesical
foley
Lower urinary
tract management Surgical
in the pelvic repair
fracture patient
Retrograde Partial
urethrogram urethral
rupture

• Blood at the meatus OR Total Suprapubic

• Ascended or impalpable urethral cystostomy
prostate on DRE rupture (consider stress
cystogram if gross
haematuria suspicion
of bladder injury)

FIGURE 72-19  Algorithm for management of bladder injuries. (Adapted from Chapple C, Barbagli G, Jordan
G, et al: Consensus statement on urethral trauma. BJU Int 93:1195–1202, 2004.)

involvement. The classic triad of physical examination findings

for urethral injury is blood at the urethral meatus, inability to
void, and a palpably distended bladder. Blood at the urethral
meatus occurs in 37% to 93% of patients with urethral injury.
The other physical finding that occurs in urethral trauma is peri-
neal or “butterfly” hematoma due to rupture of Buck fascia; this
can spread into the scrotum or up the abdomen along the layers
of dartos and Scarpa fascia (Fig. 72-20).

Imaging
In patients with suspected urethral injury, retrograde urethrogra-
phy should be performed before attempting the insertion of a
Foley catheter.38 Proper performance of retrograde urethrography
involves adequate filling of the entire urethra with passage of
contrast material into the bladder. Extravasation of contrast mate-
rial occurs when continuity of the urethra has been lost because
of the injury (Fig. 72-21).

Management
The immediate goal in managing urethral injury is to provide
urinary bladder drainage and to avoid further injury.36 Few ure-
thral injuries, barring those resulting in significant ongoing exter-
nal bleeding, such as with penetrating perineal trauma, require
acute operative reconstruction. A delayed approach can almost FIGURE 72-20  Butterfly hematoma due to rupture of Buck fascia after
always be implemented and often produces better outcomes. urethral injury.
The surgeon with limited experience with these injuries should
perform urinary diversion maneuvers for these cases. Urethral
reconstruction is a highly specialized area of urology; definitive

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 CHAPTER 72  Urologic Surgery 2093

Bladder
Prostatic
Membranous

Normal “cone”
of bulbar urethra
Penile urethra
Bulbar urethra

A Normal Retrograde Urethrogram B

FIGURE 72-21  Retrograde Urethrograms. A, Standard technique with patient in an oblique position and
complete filling of the anterior and posterior urethra with contrast material. B, Posterior urethral disruption
in patient with displaced pelvic fracture. Note the deformity of the right superior pubic ramus and extensive
extravasation of contrast material, extending above and below the urogenital diaphragm, on retrograde injec-
tion into the urethra. The bladder, which is greatly displaced cephalad, is filling with contrast material admin-
istered intravenously. The photograph demonstrates the so-called pie in the sky bladder resulting from
dramatic displacement by a large pelvic hematoma after the prostatomembranous disruption injury. (A from
Older RA, Hertz M: Cystourethrography. In Pollack HM, McClennan BL, Dyer R, Kenney PJ, editors: Clinical
urography, ed 2, Philadelphia, 2000, WB Saunders.)

reconstructive surgery can be performed in a subacute or delayed
fashion, with good results.36
Surgical Exploration and Operative Approach
Penetrating anterior urethral injuries should be explored and
repaired primarily unless the patient is hemodynamically unsta-
ble. Urethral repair should be performed in two layers with fine
absorbable suture over a catheter, creating a spatulated primary
repair. Other anterior and posterior urethral injuries should be
managed with suprapubic catheter insertion rather than by instru-
mentation of the traumatized urethra with risk of further injury.
If the bladder is palpably distended and there is no evidence of
prior lower abdominal surgery or the bladder can be clearly local-
ized with ultrasound, percutaneous tube placement is appropriate.
If these criteria are not met, open surgical cystostomy tube place-
ment is safer and can be accomplished through a small anterior
cystotomy. The drainage catheter should be anchored at the ante-
rior bladder wall with absorbable sutures and at the skin exit site.
Immediate operative repair of posterior urethral injuries is not
indicated, and management should consist of suprapubic tube
placement. Posterior urethral injuries are well suited to damage
control maneuvers.41 Although it is controversial, there has been
increased interest in early catheter realignment for posterior ure-
thral disruption in the setting of pelvic fracture within 7 to 10
days of injury (Fig. 72-22). This technique requires substantial
expertise in urologic endoscopic procedures, and the risk of creat-
ing further injury is substantial. Catheter realignment is per-
formed using the suprapubic access that has been established
acutely, so there is no need to feel a sense of urgency in doing this
on the day of injury. The outcomes of this procedure are unclear,
but much of the literature indicates that 30% to 50% of patients
can avoid urethral reconstruction, although strictures typically
develop and require at least endoscopic management.
Genital Injuries
Genital trauma involves a range of anatomic structures, creating
a difficulty in classification and standardization of treatment. The
injuries are often the result of blunt or penetrating trauma but
may include burns, bites, and avulsions and involve the penis,
testicles, or scrotum in the male patient and the vulva in the
female patient. Injuries to the external genitalia occur in 28% to
68% of patients with injuries to the genitourinary system; however,
the incidence of genital trauma varies because of few epidemio-
logic studies.43 The majority of external genital trauma is blunt in
nature, although 40% to 60% of penetrating injuries to the geni-
tourinary system involve the external genitalia.43 Genitalia injuries
may be the result of a variety of trauma, such as sexual excess in
penile fracture, blunt scrotal trauma in testicular injury, or indus-
trial accidents with skin avulsion in scrotal injuries.
Imaging
Imaging may be helpful in further diagnosing injuries in penile
and scrotal trauma. In most patients, the genital trauma diagnosis
is made on physical examination but can be confirmed with
ultrasonography. For equivocal cases of penile fracture injury that
results from sudden flexion of the erect penis during sexual

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2094 SECTION XIII  Specialties in General Surgery

A B
FIGURE 72-22  Posterior Urethral Disruption Injury. A, Patient with blood visible at penile meatus,
managed with percutaneously placed suprapubic cystostomy tube. B, Patient initially managed similarly has
undergone an endoscopic, fluoroscopically guided realignment procedure, with placement of urethral and
suprapubic Foley catheters.

activity, penile ultrasound can demonstrate interruption of the

corpora cavernosa. For blunt scrotal injuries, scrotal ultrasound
may be helpful in determining whether the testis is ruptured. Key
findings on ultrasound indicating testicular injury are loss of
testicular contour of the tunica albuginea and heterogeneous
echotexture of the testicular parenchyma.38,42 Retrograde ure-
thrography can be performed if there is concern for concomitant
urethral injury.

Management
Because of the normal flaccid nature of the penis, the only injury
that can occur is fracture of the erect penis. Management of these
injuries involves surgical exploration of the penis and identifica-
tion of the defect in the corporal body.38,42 This is closed with
slowly absorbing suture in a running fashion (Fig. 72-23). Blunt
testicular injuries should be explored if ultrasound confirms tes-
ticular rupture. Repair of the injury is performed by limited
débridement of the seminiferous tubules and closure of the tunica
albuginea (Fig. 72-24). Orchiectomy is reserved for those injuries
that thoroughly destroy the blood supply to the testis or those
parenchymal injuries in which there is no viable parenchyma
available to salvage.
Penetrating injuries to the external genitalia warrant surgical FIGURE 72-23  Penile Fracture. This patient was undergoing surgical
exploration in most cases. Functional and structural outcomes are exploration for a suspected penile fracture injury sustained during
greatly improved by early exploration and repair for penetrating sexual activity. A ventral midline penoscrotal incision is used to expose
penile, scrotal, and testicular injuries. For penile injuries, the goal the transverse laceration in the ventral right tunica albuginea of the
is to remove foreign material, to cleanse the wound, to obtain corpus cavernosum, shown centrally. The Penrose drain at the bottom
hemostasis, to identify any defects in the tunica albuginea or was used briefly as a tourniquet to control bleeding during suture repair
of the injury. The hook and ring retractor system shown is useful for
urethra, and to proceed with appropriate repair while exercising
genital surgery.
caution not to be excessively aggressive with débridement of
tissues of uncertain viability. For testicular injuries, débridement
of devitalized parenchyma, closure of the capsule (tunica albu-
ginea of the testis), and repair of the scrotum are key tasks.

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B and externalized to gravity drainage.
FIGURE 72-24  Testicular Rupture from Blunt Trauma. A, Intact
tunica albuginea with a large transverse laceration (left); the extruded
testicular parenchyma from the upper portion of the testis is also shown
(right). B, Appearance after repair with running absorbable sutures.
Damage Control Techniques for Urologic Injuries
Many urologic injuries are amenable to initial management by
applying damage control strategies. Damage control surgery refers
to the concept of limiting the initial operative interventions, in
the unstable trauma patient, to those maneuvers that are imme-
diately lifesaving (e.g., control of surgical hemorrhage, control of
continued fecal contamination). More time-consuming, definitive
reconstructive efforts are delayed until later, after resuscitation,
when the patient is more stable and can tolerate such reconstruc-
tive efforts. The physiologic rationale for damage control surgery
relates to the metabolic consequences of extensive blood loss and
blood and fluid replacement. These patients develop progressive
hypothermia, acidosis, and coagulopathy (the so-called lethal
triad), which can be corrected only when the patient can be
brought to the intensive care unit with appropriate warming, fluid
resuscitation, and other critical care interventions performed.41
Initially described in the military trauma literature, then
applied to civilian penetrating abdominal trauma, these principles
have now been successfully applied to a wide range of penetrating
and blunt injuries. Extensive studies now support the view that
appropriately selected patients managed by damage control strate-
gies demonstrate improved survival compared with patients who
undergo prolonged surgical efforts during the initial operative
period. With the exception of patients with severe renal or bladder
bleeding, urinary tract injuries do not directly result in early
mortality. In the surgeon’s judgment, when the patient would not
tolerate the extended reconstructive effort needed to deal defini-
tively with a urologic injury at initial laparotomy—because of
pattern of injury, hypothermia, acidosis, coagulopathy, or other
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CHAPTER 72  Urologic Surgery 2095
FIGURE 72-25  Damage control management of gunshot wound to
right ureter. A diversion stent has been secured into the right ureter
parameters that mandate a damage control approach—certain
temporary solutions may be used. The complexity of patient selec-
tion for damage control surgery requires a multidisciplinary inter-
action, with the trauma surgeon and surgical specialists involved,
to determine which injuries must be addressed initially and which
can be definitively handled in a delayed fashion. Earlier selection
of damage control surgery candidates, based on patterns of injury
and response to initial resuscitative efforts, results in improved
survival when the initial operative procedure can be concluded
before significant metabolic deterioration occurs.41
Renal injuries that are incompletely staged or unstaged may be
approached with delayed assessment and exploration, as long as a
determination is made that life-threatening bleeding from the
injury is unlikely to occur. In the absence of significant bleeding
from the renal fossa into the peritoneal cavity, a large midline
hematoma, or an expanding or pulsatile renal hematoma, one can
elect to leave the perinephric hematoma undisturbed and fully
resuscitate the patient.41 Appropriate staging studies can be per-
formed and delayed exploration and reconstruction completed at
the time of a second-look procedure. If a major reconstructive
effort is still needed in the unstable patient, packing the kidney
and returning for reconstructive interventions later is also an
option.
Ureteral injuries may be managed initially with externalized
stents, ligation, or simple local drainage. Of these options, exter-
nalized stents are preferred as they allow control of the urinary
output, minimize ongoing urinary extravasation, and can be
maintained until the patient is stable enough to return to surgery
for definitive reconstruction. Any number of medical tubes or
catheters can be used, but the ideal solution is a 7 Fr or 8.5 Fr
single-J urinary diversion stent placed into the ureter through the
injury site, advanced proximally into the kidney, and then exter-
nalized through the abdominal wall (Fig. 72-25). The catheter
should be tied to the very end of the injured ureter at the injury
2096 SECTION XIII  Specialties in General Surgery
site so as not to lose ureteral length by ligating it more proximally
and making later reconstruction more challenging. The distal
ureteral limb is best left undisturbed; ligating it requires subse-
quent débridement and causes further tissue loss.
A similar approach can be used for extensive bladder injuries;
the ureteral orifices can be catheterized, the catheters externalized,
and the pelvis packed, leaving bladder reconstruction to be per-
formed at a more suitable time, after appropriate resuscitation.
Urethral and genital injuries are also amenable to damage control
approaches, generally involving tube diversion, placement of
moistened dressings, and tissue preservation until definitive
reconstruction after appropriate resuscitation.
NONTRAUMATIC UROLOGIC EMERGENCIES
Within the field of urology are several emergent conditions,
although not due to external violence, that represent true emer-
gencies, some of which are life-threatening. These urologic emer-
gencies include obstructed upper tract UTI, hematuria with
urinary retention due to blood clots, and the acute scrotum—
specifically testicular torsion, priapism, and Fournier gangrene.
Some of these conditions have been discussed in other sections of
this chapter (Fournier gangrene and obstructed upper tract UTI);
the remainder are covered in this discussion.
Testicular Torsion
The most urgent cause of the acute scrotum is testicular torsion.
Testicular torsion occurs when arterial blood supply is compro-
mised by a twist of the spermatic cord, creating occlusion of the
spermatic cord and loss of vascular supply. In the normal anatomic
arrangement, the inferior aspect of the testicle is attached to the
scrotum by the gubernaculum, preventing rotation of the testicle
within the scrotum. When torsion occurs, the testicle is subjected
to warm ischemia; without reversal of the occluded blood supply,
irreversible damage begins as soon as 4 hours and is complete by
8 to 12 hours. Although testicular torsion is most common in
adolescent males, it may occur in any age group from neonate to
adult men. As many other conditions may result in the so-called
acute scrotum, a high index of suspicion is necessary on the part
of the treating physician to ensure rapid diagnosis and treatment.
Differential diagnosis includes trauma, epididymitis, incarcerated
hernia, and torsion of the appendix testis or appendix epididymis.
Diagnosis is strongly suspected on the basis of history and physical
examination. Classic historical findings include sudden onset of
intense unilateral scrotal pain, unrelated to trauma, that may be
associated with nausea and vomiting. The most consistent physical
examination finding is loss of the cremasteric reflex of the testicle;
however, in an acute setting, this may be difficult to elicit. The
best confirmatory radiologic study is color Doppler ultrasound of
the scrotum, which shows absence of arterial flow to the testis in
torsion. In patients with suspected testicular torsion, there is no
need to delay scrotal exploration to obtain imaging or further
laboratory evaluation.
Treatment of testicular torsion involves surgical exploration
through a midline or transverse scrotal incision with inspection
of the testis with detorsion, if present, of the spermatic cord (Fig.
72-26). For testes that are deemed to be viable, suture orchiopexy
or fixation to the interior scrotal wall is performed, followed by a
similar orchiopexy on the contralateral side at the same setting to
prevent contralateral torsion. Because of the important medicole-
gal considerations in these cases, urgent exploration is still
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FIGURE 72-26  Testicular Torsion. Exploration through a transverse
scrotal incision demonstrates the twisted cord (top). Note the degree
of edema, erythema, and ecchymosis present after several hours of
torsion.
indicated even in patients who present with a suspected late
torsion (e.g., several days of fixed swelling, firmness). Many times,
it is difficult to know exactly how long complete ischemia has
been present and whether there is still a potentially viable
testicle.
Gross Hematuria With Urinary Retention
from Blood Clots
Most patients who have hematuria present with either micro-
scopic hematuria or episodic gross hematuria. However, in a
subset of patients, onset of gross hematuria is rapid with signifi-
cant blood loss and development of blood clots within the bladder.
This problem is exacerbated in patients who are receiving chronic
anticoagulation for underlying cardiovascular disease processes.
The blood clots are organized into larger masses; the patient may
not be able to expel the clot, leading to urinary retention and a
potential surgical emergency (Fig. 72-27). Other causes of signifi-
cant vesical hemorrhage include postoperative bleeding after
TURP or transurethral resection of bladder tumor (TURBT),
radiation cystitis, pelvic trauma, upper tract arteriovenous fistula,
and iliac arterial fistula to the ureter.
It is difficult to judge the amount of blood that is being lost
from the urinary tract with gross hematuria because only a small
amount of blood mixed with urine will darken the bladder efflux.
If, however, copious amounts of clot are evacuated from the
bladder, one should suspect at least moderate blood loss and
monitor the patient with vital signs and hemoglobin measure-
ments. If bleeding from these events causes symptomatic anemia,
the patient may require multiple urgent blood transfusions. In the
patient with a significant amount of blood clot in the bladder, it
will be necessary to place a large-bore irrigation catheter (in the
adult, often 20 Fr to 26 Fr) and adequately irrigate the clots from
the bladder using normal saline irrigation. Special hematuria cath-
eters are designed to allow large-volume irrigation and clot
removal, but if this is unsuccessful, the patient may require urgent
operative cystoscopy to evacuate the clot and to identify and
fulgurate any bleeding source. Typically, this involves rigid cystos-
copy with a large working sheath or resectoscope sheath and
irrigation performed with a piston syringe or special evacuation
devices (Ellik evacuator). After clot evacuation and fulguration, a

FIGURE 72-27  CT scan of the pelvis with cystography in a patient with
urinary clot retention caused by chronic hemorrhagic cystitis after radia-
tion therapy for prostate cancer. A clot may be seen surrounding the
Foley catheter balloon, with instilled contrast material outlining the
balloon and intact bladder wall.
large three-way catheter is left in place to run continuous irriga-
tion to prevent a recurrent episode of clot retention. Upper tract
clot formation may produce a so-called clot colic, with renal pain
similar to that experienced from passage of a renal calculus. Sup-
portive care and, in some cases, stent insertion may be helpful to
address the underlying problem. If unexplained, significant, gross
hematuria occurs after minor trauma, one should suspect an
underlying abnormality of the urinary tract, such as a neoplasm,
congenital anomaly, or arteriovenous malformation.
Priapism
Priapism is a prolonged, painful penile erection that occurs in the
absence of sexual arousal or stimulation. Priapism is typically
divided into ischemic and nonischemic priapism. Important
causes of ischemic priapism include sickle cell disease or other
blood dyscrasias and certain types of drug or medication use,
especially drugs for penile erection and hematologic malignant
disease. Nonischemic priapism is the pelvic or genital trauma that
results in arteriovenous fistula of the penile circulation. Priapism
may resolve spontaneously, but if it persists longer than 4 hours,
measures should be taken to reverse the process in most cases.
Patients with priapism that lasts longer than 12 hours may develop
irreversible damage to the penile vascular structure and long-term
ED.
Evaluation in cases of ischemic priapism is centered on detailed
history for risk factors, corporal blood gas analysis, and color
Doppler ultrasound of the corpora cavernosa. Nonischemic pria-
pism is evaluated similarly; however, aspirated blood has an arte-
rial appearance and arterial blood gas parameters.
Ischemic priapism is managed with initial needle aspiration of
the corpora cavernosa and irrigation with saline. In patients who
do not respond to this step, needle aspiration is repeated with the
injection of small, dilute doses of an α-adrenergic agonist sub-
stance, such as dilute phenylephrine. For patients who fail to
respond to these measures, various shunting procedures can be
performed to create shunts between the corpus cavernosum and
other vascular structures, like the corpus spongiosum, to induce
blood flow. For priapism related to sickle cell disease, medical
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CHAPTER 72  Urologic Surgery 2097
treatment of the sickle crisis (e.g., hydration, oxygenation, pain
management, and addressing hemoglobin and transfusion status)
with hematology support is a mainstay of therapy to resolve pria-
pism. For nonischemic priapism, there is no role for aspiration or
irrigation of the erection as this is the result of an abnormality of
the vascular system. Compression of the perineum or other injury
site can be performed as an initial maneuver. If this fails, the next
treatment step is usually superselective angioembolization to
occlude the arteriovenous fistula with reversible agents, such as
autologous blood clots or Gelfoam. It is important that the general
surgeon consult with the urologist about treatment because cor-
poral fibrosis and loss of erectile function are risks that increase
with significant delays in therapy.
UROLOGIC ONCOLOGY
Urologic malignant neoplasms account for a significant disease
burden in adults in the United States. Cancers of the genitouri-
nary system encompass the full spectrum of malignant neoplasms
and are of some of the most common (prostate) and rare (penile)
cancers in the United States. Of the 12 most common cancers
diagnosed annually in the United States, three are urologic in
origin: prostate, bladder, and kidney. Low-stage cancers are typi-
cally managed with extirpative surgery or therapeutic radiation.
Urologic cancers may involve adjacent viscera, vasculature, and
soft tissue and body wall structures so that additional surgical
expertise is necessary to complete the extirpative surgery and to
support reconstructive efforts. As is the case with other malignant
neoplasms, cancers of the genitourinary system are often managed
with a multidisciplinary approach. The major anatomic types of
urologic cancers are discussed in this section, with a focus on the
essential basic background knowledge, the fundamental therapeu-
tic approaches for various stages of cancer presentation, and the
basic outcomes for different tumor types.
Renal Tumors
Renal cell carcinoma, the most common type of renal malignant
disease, accounts for 2% to 3% of all adult malignant neoplasms.44
The majority of renal malignant neoplasms are now diagnosed
incidentally by cross-sectional imaging or ultrasound evaluation
of other nonspecific complaints. Historically, renal cell carcinoma
was diagnosed only at an advanced stage because of its location
within the retroperitoneum. The classic triad of renal cell carci-
noma (flank pain, gross hematuria, and palpable abdominal mass)
is now seen in less than 10% of patients. Despite this increase in
asymptomatic diagnoses, 30% of patients present with metastatic
disease.45 Other symptoms on advanced presentation include
hemorrhage, paraneoplastic syndrome, and symptoms of metas-
tasis, such as pathologic fracture. Paraneoplastic syndromes are
present in 20% of patients at diagnosis and include Stauffer
syndrome (reversible hepatitis without liver metastasis), con­
stitutional symptoms, polycythemia, and elevated inflammatory
markers (erythrocyte sedimentation rate and C-reactive protein).45
Renal cell carcinoma typically presents in the sixth to eighth
decade of life and is more common in men. Risk factors for renal
cell carcinoma include smoking, hypertension, obesity, acquired
renal cystic disease (in patients with end-stage renal disease),
and occupational exposures (aromatic hydrocarbons, asbestos,
cadmium, and chemical and rubber industries).44 These tumors
typically arise in the proximal convoluted tubule or collecting
duct within the renal parenchyma.44
2098 SECTION XIII  Specialties in General Surgery

Renal cell carcinoma is classified as follows: clear cell carci- TABLE 72-2  Staging of Kidney Cancer
noma, papillary renal cell carcinoma, chromophobe renal cell
carcinoma, collecting duct carcinoma, and renal medullary carci- Primary
noma; this classification is based on microscopic appearance and TX
cell of origin.45 The genetics of these malignant neoplasms is fairly T0
well described. The most common tumor, clear cell carcinoma, is T1
the result of chromosome 3 abnormalities; papillary carcinoma is T1a
the result of aberrations of chromosome 7, 17, or Y.45 In addition, T1b
clear cell carcinoma and papillary carcinoma are responsible for
the two most common familial cancer syndromes, von Hippel– T2
Lindau and hereditary papillary renal cell carcinoma, respectively. T2a
Most renal masses are malignant, and only 15% to 20% are
benign; the two most common benign masses are oncocytoma T2b
and angiomyolipoma.45 T3
A final consideration with renal neoplasms is cystic renal
masses, which present diagnostic challenges. Depending on spe- T3a
cific characteristics of renal cystic lesions, the risk of these lesions
representing cystic malignant neoplasms must be considered. The
Bosniak classification system describes cystic renal masses accord- T3b
ing to their malignant risk and CT appearance, ranging from T3c
category I (simple cysts) to category IV (cysts associated with
enhancing or solid elements).45 Category III and IV cysts are T4
usually treated as representing cystic renal cell carcinomas.
Tumor (T)
Primary tumor cannot be assessed
No evidence of primary tumor
Tumor 7 cm or less in greatest dimension, limited to the kidney
Tumor 4 cm or less in greatest dimension, limited to the kidney
Tumor more than 4 cm but not more than 7 cm in greatest
dimension, limited to the kidney
Tumor >7 cm in greatest dimension, limited to the kidney
Tumor >7 cm and ≤10 cm in greatest dimension, limited to the
kidney
Tumor >10 cm in greatest dimension, limited to the kidney
Tumor extends into major veins or perinephric tissues but not
into the ipsilateral adrenal gland and not beyond Gerota fascia
Tumor grossly extends into the renal vein or its segmental
(muscle-containing) branches, or tumor invades perirenal and/
or renal sinus fat but not beyond Gerota fascia
Tumor grossly extends into the vena cava below the diaphragm
Tumor grossly extends into the vena cava above the diaphragm
or invades the wall of the vena cava
Tumor invades beyond Gerota fascia (including contiguous
extension into the ipsilateral adrenal gland)

Staging Regional Lymph Nodes (N)

Outcomes in renal cell carcinoma are directly tied to clinical stage NX Regional lymph nodes cannot be assessed
at time of diagnosis. Evaluation and staging for renal cell carci- N0 No regional lymph node metastasis
noma include history, physical examination, and laboratory N1 Metastasis in regional lymph node(s)
testing. Evaluation for renal masses includes imaging of the
primary tumor, usually with a contrast-enhanced CT scan or MRI Distant Metastasis (M)
study of the abdomen and pelvis, as well as chest imaging, typi- M0 No distant metastasis
cally chest radiography. Also, based on clinical suspicion or abnor- M1 Distant metastasis
mal results of laboratory studies, bone and brain imaging is
Stage Grouping
performed. A key aspect of abdominal CT or MRI is evaluation
Stage I T1 N0 M0
of the renal vein and inferior vena cava as renal cell carcinoma
Stage II T2 N0 M0
commonly forms tumor thrombus in these structures, and this
Stage III T1 or T2 N1 M0, T3 N0 or N1 M0
finding is not necessarily correlated with tumor stage. The TNM
Stage IV T4 Any N M0
staging system is listed in Table 72-2. Histologic grading is based
on the Fuhrman nuclear grading system on a scale of I to IV.

Management
The management of renal cell carcinoma has evolved in recent
years. Historically, renal cell carcinoma was a surgical disease, and
patients diagnosed with any renal mass underwent total radical
nephrectomy. Now, select patients may undergo renal biopsy and
active surveillance protocols. In the past, renal biopsies were
fraught with high false-negative rates and low accuracy. Contem-
porary series show an accuracy rate of more than 90% in experi-
enced centers with low complications.45 Those patients who are
appropriate for renal biopsy are patients considered for either active
surveillance or renal ablation therapy. Active surveillance protocols
have been developed for patients with incidentally diagnosed, small
(<3 cm) renal masses and those patients who would not tolerate
extirpative or ablative therapy.45 The natural history of renal masses
is a tendency to grow slowly, on average 0.5 cm/yr, and they do
not metastasize. Patients assigned to surveillance protocols undergo
imaging every 3 to 6 months; once mass size stability is observed,
this interval is extended to 6 to 12 months.45 Small renal masses
(<5 cm) can be considered for percutaneous, laparoscopic, or open
ablation using cryotherapy or radiofrequency energy.44 This treat-
ment should be considered more for patients with significant
medical comorbidities and less often in healthy patients.
For renal tumors that are diagnosed in the absence of metas-
tases or for those with a solitary metastasis, extirpative surgery is
the standard approach. Resection of solitary synchronous meta-
static disease is performed when it is technically feasible. Renal
surgery has undergone a significant transformation in the past 10
years, and most renal surgery, both nephron sparing and radical
excision, is now performed through either a laparoscopic or robot-
ically assisted approach. The trend in extirpative surgery is to
perform nephron sparing or partial nephrectomy for most T1
tumors. Partial nephrectomy is equivalent to radical nephrectomy
in this tumor stage and should be considered for all patients with
a T1a tumor and most with T1b tumors. Partial nephrectomy
surgery may be straightforward in dealing with small, well-
encapsulated, superficial, exophytic lesions or complex in dealing
with larger, central lesions that involve the renal hilar structures.
For partial nephrectomy, a negative margin should be obtained
with the parenchymal resection, and only a few millimeters of
normal parenchyma around the tumor are considered necessary.
The general principles for partial nephrectomy include achieve-
ment of a negative surgical margin, identification and suturing of
significant segmental renal vessel branches, and collecting system
repair when the collecting system is entered or partially resected.

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 CHAPTER 72  Urologic Surgery 2099

To assist with blood loss, atraumatic vascular clamping of the renal TABLE 72-3  Staging of Urothelial Cancer
artery and surface cooling of the kidney with iced saline slush are
effective. When laparoscopic or robotic approaches are used for Primary Tumor (T)
partial nephrectomy, local hypothermia is more cumbersome, and TX Primary tumor cannot be assessed
rapid tumor resection and clamp times of less than 30 minutes T0 No evidence of primary tumor
are employed. Tissue sealants, hemostatic agents, and absorbable Ta Noninvasive papillary carcinoma
mesh reconstruction of the kidney are all useful techniques to aid Tis Carcinoma in situ: “flat tumor”
in hemostasis of a partial nephrectomy in the open surgical, lapa- T1 Tumor invades subepithelial connective tissue
roscopic, or robotic setting. T2 Tumor invades muscularis propria
Radical nephrectomy is performed in patients with large pT2a Tumor invades superficial muscularis propria (inner half)
tumors and those patients in whom a partial nephrectomy is not pT2b Tumor invades deep muscularis propria (outer half)
technically feasible. The primary long-term risk in this surgery is T3 Tumor invades perivesical tissue:
chronic kidney disease and loss of renal function. In comparison pT3a Microscopically
to partial nephrectomy, radical nephrectomy has a lower rate of pT3b Macroscopically (extravesical mass)
complications. The adrenal gland is no longer removed with T4 Tumor invades any of the following: prostatic stroma, seminal
radical nephrectomy except in cases of obvious tumor involve- vesicles, uterus, vagina, pelvic wall, abdominal wall
ment as the rate of synchronous involvement is less than 10%. T4a Tumor invades prostatic stroma, uterus, vagina
Typically, radical nephrectomy is performed by either a laparo- T4b Tumor invades pelvic wall, abdominal wall
scopic or open approach. Standard incisions for radical nephrec-
tomy include anterior subcostal, flank, chevron, and midline, Regional Lymph Nodes (N)
although the midline incision has the most difficult vascular Regional lymph nodes include both primary and secondary drainage regions.
access. Regardless of approach, dissection of the renal pedicle with All other nodes above the aortic bifurcation are considered distant lymph
ligation of a renal artery must precede vein ligation to prevent nodes.
swelling and dangerous bleeding from the kidney. The entire NX Lymph nodes cannot be assessed
Gerota fascial envelope, containing the perinephric fat as a margin N0 No lymph node metastasis
around the kidney parenchyma and tumor, is excised intact. The N1 Single regional lymph node metastasis in the true pelvis
ureter is ligated and divided where convenient. A regional lymph (hypogastric, obturator, external iliac, or presacral lymph node)
node dissection is often performed with a radical nephrectomy, N2 Multiple regional lymph node metastasis in the true pelvis
although, on the basis of most evidence, it is more helpful as a (hypogastric, obturator, external iliac, or presacral lymph node
staging and prognostic procedure than as a therapeutic one. For metastasis)
patients with locally advanced or metastatic disease, immuno- N3 Lymph node metastasis to the common iliac lymph nodes
therapy and targeted therapy (drugs with action on vascular endo-
thelial growth factor and mammalian target of rapamycin) are Distant Metastasis (M)
used in a neoadjuvant or adjuvant setting. Overall organ-confined M0 No distant metastasis
disease has an 80% to 100% 5-year survival in T1 tumors and a M1 Distant metastasis
50% to 80% 5-year survival in T2 disease.45 Advanced disease has
grim prognosis of 0% to 20% 5-year survival.45
survival. Ta disease refers to papillary tumors, with involvement
Bladder Cancer of only the mucosa. T1 tumors involve the lamina propria, and
Urothelial malignant disease can arise anywhere in the upper or T2 disease involves the detrusor muscle. Higher stages of the local
lower collecting system, but the most common site is the bladder. tumor reflect involvement of perivesical fat or adjacent organs.
The entire upper and lower urinary tracts, renal collecting system Tumors are graded on the basis of histologic appearance from
through the prostatic urethra, are lined with surface epithelium papilloma to high grade.
called urothelium. The urothelium has a variable thickness of
three to six cell layers, and transitional cell carcinoma arises from Non–Muscle Invasive Bladder Cancer
the basal cell layer. Bladder cancer is the fifth most common adult Urothelial tumors that have not invaded the detrusor muscle
malignant neoplasm diagnosed in the United States and is more are termed non–muscle invasive bladder cancers (NMIBCs).
common in men than in women.46 The tumor arises most fre- Approximately 70% of patients who present with bladder cancer
quently in the eighth decade of life, and men older than 70 years will be diagnosed with NMBIC, which includes T stages Tis
have a 3.7% probability for development of bladder cancer.46 The (carcinoma in situ), Ta, and T1.46 Patients who are suspected of
multiple risk factors for development of bladder cancer include having bladder cancer should undergo a thorough evaluation,
tobacco smoke, arsenic, chronic infections and inflammatory con- which includes history, physical examination, basic laboratory
ditions (e.g., schistosomiasis), and occupational exposures (such tests, upper urinary tract imaging (preferably contrast-enhanced
as arylamines and aromatic hydrocarbons). The most common cross-sectional imaging), and office cystoscopy. If bladder cancer
presenting symptom in bladder cancer is hematuria, microscopic is present, characteristic flat, papillary, or bizarre, aggressive-
in 1% to 11% and gross in 13% to 35%.46 The other presenting appearing masses will be present on the urothelial surface of the
symptom is irritative voiding—frequency, urgency, and dysuria. bladder. NMIBCs typically appear as flat (carcinoma in situ) or
Bladder cancer can be divided into non–muscle invasive and papillary (Ta or T1) lesions. An adjunct test for equivocal findings
muscle invasive, which have different treatments and outcomes. is urine cytology, which is either as voided or bladder wash at the
TNM staging is included in Table 72-3; the T stage at diagnosis, time of cystoscopy. Urine cytology is most sensitive for high-grade
specifically non–muscle invasive (T1 or less) or muscle invasive tumors and can be equivocal or nondiagnostic in the setting of
(T2 or greater), is highly predictive of long-term outcome and low-grade NMIBCs. Adjunct urine tumor markers exist but are

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2100 SECTION XIII  Specialties in General Surgery
not recommended on consensus guidelines because of cost and
low specificity.
Any tumor identified in the bladder should be fully resected
by TURBT. TURBT allows pathologic analysis, tumor staging
but identification (if present) of muscle invasion, and treatment
of noninvasive, low-grade disease. TURBT is performed through
a surgical endoscope, called a resectoscope, and uses either mono-
polar or bipolar energy to shave the tumor from the bladder wall.
At the time of TURBT, patients should undergo a bimanual
examination of the bladder to identify extravesical extension of
disease and palpable mass. Any patient identified with high-grade
T1 tumors or absence of muscle in the initial resection should
undergo repeated TURBT. All patients who undergo TURBT
should receive immediate intravesical chemotherapy within 6
hours of surgery; this treatment has been shown to reduce the
tumor recurrence rate by 35%.46 The agent most commonly used
for this purpose is mitomycin C. Six weeks after TURBT, patients
with carcinoma in situ or NMIBC with high risk for progression
or recurrence should receive intravesical therapy with either
immunotherapy or chemotherapeutic agents. Standard immuno-
therapy for NMIBC consists of serial bacille Calmette-Guérin
(BCG) intravesical instillations for induction and periodic main-
tenance therapy. Intravesical BCG significantly decreases the
invasion and progression rate for NMIBCs, compared with
transurethral resection alone. Patients with recurrent NMIBC
may require regimens of BCG plus interferon for salvage therapy.
Maintenance BCG instillations reduce the risk of recurrence and
progression and are given at variable intervals for periods of 1 to
3 years. Other salvage intravesical treatments include chemothera-
peutic agents such as mitomycin C and gemcitabine. Visual sur-
veillance by office cystoscopy is mandatory in these patients as
15% to 80% of these tumors recur, and in higher grade tumors,
25% to 50% progress to higher stage or muscle invasive tumors.46
Muscle Invasive Bladder Cancer
Muscle invasive bladder cancer (MIBC) includes stage T2 or
greater bladder cancer at diagnosis. The majority of patients who
present with MIBC have invasive disease at diagnosis; approxi-
mately 15% to 20% of patients who present with NMIBC pro­
gress to MIBC.46 MIBC is typically urothelial cell carcinoma, but
other histopathologic types occur, including squamous cell carci-
noma, adenocarcinoma, and small cell carcinoma. The last two
have the worst prognostic outcomes. MIBC should be staged in
a similar fashion to NMIBC, with cross-sectional imaging of the
abdomen and pelvis, but consideration should be given to chest
CT rather than plain radiography. Despite adequate staging, 40%
of patients are understaged at diagnosis and have extravesical
disease on the final pathologic specimen.
Management.  Standard management of MIBC is radical cys-
toprostatectomy. In the male patient, radical cystectomy involves
the removal of the entire urinary bladder en bloc with the perivesi-
cal fat, prostate, seminal vesicles, and pelvic lymph nodes. In the
female patient, radical cystectomy typically involves en bloc
removal of the female pelvic viscera, although salvage of these
structures may at times be considered, depending on the details
of the case. Extended lymph node dissection is performed at the
same setting and includes removal of the external and internal
iliac lymph nodes, common iliac lymph nodes to the aortic bifur-
cation, and presacral lymph nodes. Improved survival is associated
with extended pelvic lymph node dissection at the time of radical
cystectomy. Perioperative complication rates are high, and more
than 60% of patients undergoing radical cystectomy and extended
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pelvic lymph node dissection have at least one complication
within 90 days of surgery.46 Because of the high rate of extravesical
extension at the time of radical cystectomy, many patients are
treated with neoadjuvant chemotherapy. Typical regimens for
neoadjuvant chemotherapy include MVAC (methotrexate, vin-
blastine, doxorubicin [Adriamycin], and cisplatin) and GC (gem-
citabine and cisplatin). The use of neoadjuvant chemotherapy
improves overall survival by 5% to 7%.46
The selection of the type of urinary diversion after radical
cystectomy must take into account any history of pelvic irradia-
tion, presence of renal insufficiency, liver function abnormalities,
and mechanical tasks for which the patient will be responsible.
There are various options for urinary diversion, including ileal
conduit, orthotopic bladder substitution with anastomosis to the
native urethra, and more complex forms of cutaneous catheteriz-
able reservoirs with continence mechanisms. No randomized
study has shown one type of urinary diversion to be superior to
any other, and the decision is usually directed by the patient’s
preference or the surgeon’s choice. There is an extensive and
complex history involving the use of intestinal segments in the
urinary tract for urinary diversion after cystectomy and in other
reconstructive settings. The surgeon should be familiar with the
metabolic, mechanical, and other risk factors associated with the
use of intestinal segments in the reconstructed urinary tract,
including electrolyte abnormalities, bone demineralization, mucus
production, stone formation, chronic infection, diarrhea, vitamin
B12 deficiency, and increased cancer risk. Patients with organ-
confined, node-negative disease have the best overall disease-
specific survival at 5 and 10 years at 60% to 85%.46
Prostate Cancer
Prostate cancer is the most common cancer diagnosed in men and
the third most common cancer diagnosed in the United States,
behind breast and lung, with approximately 220,000 men diag-
nosed annually.47 Prostate cancer is an adenocarcinoma and arises
from the glandular structures within the prostatic parenchyma.
Most new prostate cancer cases are diagnosed in men 60 years of
age and older, are low grade and low stage, and are diagnosed by
routine screening.48 Screening for prostate cancer is performed
with the blood test PSA, a serine protease, and DRE. The most
controversial aspect of prostate cancer is screening and determin-
ing which patients require treatment. The goal of prostate cancer
screening is to detect potentially lethal cancer at an early, treatable
stage and to intervene with intent to cure. Because of the contro-
versy surrounding the recent U.S. Preventive Services Task Force
recommendation against screening for prostate cancer in 2012,
the AUA released its own guidelines for screening in 2013.49 These
recommendations are for screening in men aged 55 to 69 years
to be a joint decision between the physician and the patient, with
recognition that the mortality of prostate cancer is 1 in 1000 men
screened per decade, and a routine screening interval to occur
every 2 years.49 Routine screening is not routinely recommended
in men aged 40 to 54 years and in men older than 70 years or
younger than 40 years.49 Furthermore, screening should not be
performed in men with a life expectancy of less than 10 to 15
years.
Evaluation
Patients who have either an elevated total PSA level or abnormal
findings on DRE or both undergo TRUS-guided biopsy of the
prostate. In equivocal cases, other testing, including determina-
tion of free PSA level or calculation of PSA velocity, can help
 CHAPTER 72  Urologic Surgery 2101

guide the decision for biopsy or further evaluation. The standard Treatment
biopsy template involves 12 cores with a spring-loaded biopsy The treatment of prostate cancer has changed significantly during
instrument; tissue is obtained from the base, mid, and apex the past several years. As most prostate cancer, at diagnosis, is low
regions, medially and laterally from the left and right sides. Pro- risk, many patients are now treated with active surveillance rather
phylactic antibiotics are routinely administered, and cleansing than with active therapy. In general, men with cancer of low clini-
enemas are advised. When feasible, patients are asked to stop cal stage (T1c), low grade (Gleason sum ≤ 6), and low volume on
anticoagulants to help prevent bleeding complications. Common biopsy are candidates for active surveillance.48 Patients assigned to
adverse events that follow TRUS biopsy include rectal bleeding, active surveillance protocols undergo DRE and PSA monitoring
gross hematuria, and hematospermia, all of which are usually self- every 3 to 6 months, with repeated TRUS-guided prostate biop-
limited. Fever and urinary infection and retention occur in less sies every 1 to 3 years.48 Patients with increase in Gleason sum or
than 5% of patients; bacteremia occurs, but it is a rare occurrence increase in tumor volume on biopsy typically shift to an active
in less than 1% of patients. treatment plan.
Prostate cancer is diagnosed histologically by the Gleason Prostate cancer can be treated with either radical surgical exci-
grading system, which evaluates the level of abnormality in the sion or definitive radiation therapy. Radical prostatectomy involves
patterns of the glandular architecture of the prostate in compari- the surgical removal of the entire prostate and seminal vesicles
son to normal. The grading system is based on a scale of 1 to 5, with anastomosis of the urethral stump to the bladder neck. Pelvic
with 1 being the most differentiated and 5 being the least dif- lymph node dissection is controversial in the management of
ferentiated. Most prostate cancers have a Gleason grade of 3 with prostate cancer; some protocols recommend no lymph node dis-
a sum of 6 or 7. Patients diagnosed with prostate cancer are risk section for low-risk disease, and others recommend extended
stratified on the basis of PSA level at time of diagnosis, clinical pelvic lymph node dissection. For prostate cancer Gleason sum 7
stage based on DRE, and Gleason sum score on the prostate or higher, at a minimum, the external iliac and obturator lymph
biopsy. Patients with high-risk cancers should undergo cancer nodes should be removed. Radical prostatectomy can be per-
staging, which in prostate cancer may include radionuclide bone formed with an open, laparoscopic, or robotically assisted laparo-
scan to evaluate for bone metastasis and cross-sectional imaging scopic approach. The majority of radical prostatectomies in the
of the abdomen and pelvis to evaluate for nodal metastasis United States are now performed by a robotically assisted laparo-
(Table 72-4). scopic prostatectomy (RALP).47 The advantages of RALP appear
to be decreased blood loss, shorter hospital stay, and quicker
return to work. When it is technically feasible and oncologically
appropriate, a nerve-sparing approach is used, which avoids injury
TABLE 72-4  Staging of Prostate Cancer to the cavernous nerves that run posterolateral along the prostate
in the neurovascular bundle and mediate penile erection. Impor-
Primary Tumor (T)
tant landmarks for radical prostatectomy are the dorsal venous
TX Primary tumor cannot be assessed
plexus anteriorly, bladder neck cephalad, prostatomembranous
T0 No evidence of primary tumor
urethral junction distally, and rectal wall posteriorly. The correct
T1 Clinically inapparent tumor neither palpable nor visible by imaging
plane of posterior dissection in radical prostatectomy is just
T1a Tumor incidental histologic finding in 5% or less of tissue resected
posterior to the Denonvilliers fascia. The primary long-term risks
T1b Tumor incidental histologic finding in more than 5% of tissue
of radical prostatectomy are urinary incontinence and ED.
resected
Because of the recent introduction and adaptation of RALP,
T1c Tumor identified by needle biopsy (for example, because of
most long-term survival series are based on historical open radical
elevated PSA)
prostatectomy data. Ten-year cancer progression-free survival
T2 Tumor confined within prostate is approximately 85% for patients with organ-confined disease,
T2a Tumor involves one-half of one lobe or less approximately 60% to 70% for extracapsular extension, and
T2b Tumor involves more than one-half of one lobe but not both lobes approximately 50% for patients with positive surgical margins.
T2c Tumor involves both lobes Patients who do not desire surgical extirpation may undergo
T3 Tumor extends through the prostate capsule local therapy with either intensity-modulated radiation therapy
T3a Extracapsular extension (unilateral or bilateral) (IMRT) or brachytherapy. The typical treatment dose for IMRT-
T3b Tumor invades seminal vesicle(s) based prostate cancer therapy is 76 to 86 Gy. The most common
T4 Tumor is fixed or invades adjacent structures other than seminal form of brachytherapy is low-dose ultrasound-guided placement
vesicles, such as external sphincter, rectum, bladder, levator of iodine-125 or palladium-103 radioisotope sources into the
muscles, and/or pelvic wall prostate. Both treatments are commonly used for low-risk prostate
cancer. Intermediate- and high-risk prostate cancer is typically
Lymph Nodes (N)
treated with IMRT coupled with androgen deprivation therapy
NX Regional lymph nodes were not assessed
for up to 2 years. Low- and intermediate-risk prostate cancers have
N0 No regional lymph node metastasis
outcomes after radiation-based therapy similar to those of radical
N1 Metastasis in regional lymph node(s)
prostatectomy.47 In advanced prostate cancer, androgen depriva-
Distant Metastasis (M) tion therapy may become ineffective, with clinical or PSA progres-
M0 No distant metastasis sion observed in spite of appropriate hormonal therapy. In these
M1 Distant metastasis cases, second-line treatment includes antiandrogens, chemother-
M1a Nonregional lymph node(s) apy, and investigational agents. Other forms of treatment that can
M1b Bone(s) be considered for local treatment of prostate cancer include cryo-
M1c Other site(s) with or without bone disease therapy and proton beam therapy, although long-term results for
these modalities are still being reported.

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2102 SECTION XIII  Specialties in General Surgery

After prostate cancer therapy, patients are monitored for post-
treatment morbidities (e.g., continence, erectile function, voiding
adequacy) and possible cancer recurrence. The latter involves PSA
testing and potentially repeated metastatic evaluation, when indi-
cated. Long-term follow-up for prostate cancer patients should
continue at least 10 years, if not permanently, because very late
recurrences can occur. If the PSA level becomes significantly
detectable or is rising after definitive treatment, it may be appro-
priate to consider repeated TRUS of the anastomotic region,
possibly with biopsy, and repeated metastatic evaluation to decide
whether to proceed with local radiation therapy, androgen depri-
vation therapy, or observation.
Testicular Cancer
Testicular cancer is an uncommon malignant neoplasm; in the
United States, the incidence is 5/100,000 men.50 Most cases of
primary testicular cancer are germ cell origin (95%); the remain-
der are predominantly stromal (Leydig cell) or sex cord (Sertoli
cell) tumors.50 Any solid intratesticular mass is likely to represent
a malignant germ cell tumor and is typically treated as such unless
there is a strong suspicion to the contrary. Risk factors for testicu-
lar tumors include cryptorchidism, family history of testicular
cancer, and intratubular germ cell neoplasia.
Germ cell–derived testicular tumors can be broadly divided
into seminoma and nonseminoma germ cell tumors (NSGCTs);
the division is approximately 50% for each. The majority of
seminomas are classic (85%); the remainder are either anaplastic
or spermatocytic seminoma.50 NSGCTs can be divided into
numerous histologic types: embryonal carcinoma, yolk sac or
endodermal sinus tumors, choriocarcinoma, teratoma, and mixed
germ cell tumors. Testicular malignant neoplasms are the most
common tumors in men between the ages of 20 and 40 years.50
Seminomas, however, present in the fourth or fifth decade of life,
and spermatocytic seminomas may present in men older than 50
years.50 The most common presenting complaint in men with
testicular cancer is a painless testicular mass; however, it is not
uncommon for men to present with symptoms of metastatic
disease, including palpable abdominal mass, shortness of breath,
and hemoptysis. In patients who present with a painless testicular
mass, scrotal ultrasonography is the diagnostic study of choice. In
addition to history, physical examination, and ultrasonography,
patients with testicular tumors should have determination of spe-
cific tumor markers: α-fetoprotein, β-human chorionic gonado-
tropin, and lactate dehydrogenase. After treatment, these markers
have a characteristic half-life, and appropriate clearance has
important prognostic significance.
Treatment
Initial treatment of suspected testicular tumor is radical inguinal
orchiectomy, which involves removal of the testicle and spermatic
cord at the level of the inguinal ring (Fig. 72-28). Because of the
characteristic and well-described lymph drainage of the testicle,
there is no role for trans-scrotal biopsy or orchiectomy. If the
intrascrotal tissue planes are violated during orchiectomy, the
lymphatic drainage can be altered, affecting future treatment.
After radical inguinal orchiectomy, the patient should undergo
disease staging, including cross-sectional, contrast-enhanced
imaging of the abdomen and pelvis and chest imaging, either
chest radiography in low-risk patients or cross-sectional chest
imaging in patients with high-risk disease.
Clinical staging for testicular cancer includes primary tumor
pathology, lymph and metastatic staging on imaging, and postor-
chiectomy serum tumor markers (Tables 72-5 and 72-6). The
half-life of β-human chorionic gonadotropin is 24 to 36 hours,

A B C
FIGURE 72-28  Advanced Testicular Carcinoma. A, Preoperative appearance of the scrotum in a patient
with a large right testis tumor. The normal left testis is seen pushed cephalad by the right-sided mass.
B, Surgical exploration through right inguinal incision, showing the right testis that has been dissected from
the scrotum in an extravaginal plane, still attached by the spermatic cord pedicle to the right. C, Massive
retroperitoneal lymphadenopathy in the same patient. Note that the descending colon is opacified with
contrast material, but all other viscera are pushed cephalad so that no small intestine is seen in this image.
The patient was managed with primary chemotherapy followed by retroperitoneal lymphadenectomy for the
residual mass.

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 CHAPTER 72  Urologic Surgery 2103

TABLE 72-5  Staging of Testicular Cancer TABLE 72-6  Clinical Staging of

Primary Tumor (T)
Testicular Cancer
pTX Primary tumor cannot be assessed STAGE T N M S
pT0 No evidence of primary tumor Stage I pT1-4 N0 M0 SX
pTis Intratubular germ cell neoplasia IA pT1 N0 M0 S0
pT1 Tumor limited to the testis and epididymis without lymphovascular IB pT2 N0 M0 S0
invasion, may invade tunica albuginea but not tunica vaginalis
pT3 N0 M0 S0
pT2 Tumor limited to the testis and epididymis with lymphovascular
pT4 N0 M0 S0
invasion or tumor involving the tunica vaginalis
IS Any pT N0 M0 S1-3
pT3 Tumor invades the spermatic cord with or without lymphovascular
Stage II Any pT N1-3 M0 SX
invasion
IIA Any pT N1 M0 S0-1
pT4 Tumor invades the scrotum with or without lymphovascular invasion
IIB Any pT N2 M0 S0-1
Regional Lymph Nodes (Clinical) (N) IIC Any pT N3 M0 S0-1
NX Regional lymph nodes cannot be assessed Stage III Any pT Any N M1 SX
N0 No regional lymph node metastasis IIIA Any pT Any N M1a S0-1
N1 Metastasis within one or more lymph nodes less than 2 cm in size IIIB Any pT N1-3 M0 S2
N2 Metastasis within one or more lymph nodes greater than 2 cm but Any pT Any N M1a S2
less the 5 cm in size IIIC Any pT N1-3 M0 S3
N3 Metastasis within one or more lymph nodes greater than 5 cm in size Any pT Any N M1a S3
Any pT Any N M1b Any S
Regional Lymph Nodes (Pathologic) (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis within 1-5 lymph nodes; all node masses less than 2 cm distributions may be altered and the metastatic pattern may be
in size unpredictable, potentially leading to involvement of the inguinal
N2 Metastasis within a lymph node greater than 2 cm but not greater or pelvic nodes. Distant metastases are typically seen to the lung,
than 5 cm in size, or more than 5 lymph nodes involved, none liver, brain, bone, kidney, and adrenal gland.
greater than 5 cm and none demonstrating extranodal extension of Second-line treatment is directed by tumor histology and
tumor lymph node staging. Further treatment may consist of regular
N3 Metastasis within one or more lymph nodes greater than 5 cm in size surveillance, retroperitoneal radiation therapy, retroperitoneal
lymph node dissection (RPLND), systemic chemotherapy, or a
Distant Metastasis (M)
multimodal therapy approach. The treatment decisions are
MX Distant metastasis cannot be assessed
complex, often at the direction of an institutional tumor board,
M0 No distant metastasis
but several general principles apply:
M1 Distant metastasis
• For seminoma stage IA and IB disease, treatment options
M1a Nonregional nodal or pulmonary metastasis
include surveillance, radiotherapy to the regional lymph nodes
M1b Distant metastasis at site other than nonregional lymph nodes or
(20 Gy), and one or two cycles of carboplatin-based
lung
chemotherapy.50
Serum Tumor Markers (S) • For seminoma stage IIA and IIB, radiotherapy of the retroperi-
SX Tumor markers not available or performed toneal lymph nodes is standard therapy; for stage IIC or III,
S0 Tumor markers within normal limits platinum-based chemotherapy is standard therapy.50
S1 LDH <1.5× normal, hCG <5000 IU/L, AFP <1000 ng/mL • For NSGCT stage I disease, the options include surveillance,
S2 LDH 1.5-10× normal, hCG 5000-50,000 IU/L, AFP 1000-10,000 ng/mL RPLND, and cisplatin-based chemotherapy.50
S3 LDH >10× normal, hCG >50,000 IU/L, AFP >10,000 ng/mL • For NSGCT stage IIA, either primary RPLND (in patients
with normal levels of tumor markers) or three or four cycles
AFP, α-fetoprotein; hCG, human chorionic gonadotropin; LDH, lactate of cisplatin-based chemotherapy is standard; for stage IIB,
dehydrogenase. three or four cycles of cisplatin-based chemotherapy is stan-
dard, followed by RPLND or surveillance.50
RPLND involves removal of all lymph nodes in the retroperi-
and the half-life of α-fetoprotein is 5 to 7 days; these levels should toneum from the renal vessels to the aortic bifurcation. An appro-
normalize in the absence of metastatic disease. Metastatic disease priate RPLND should include the lymph tissue surrounding the
from testicular cancer typically follows a predictable retroperito- great vessels and division of the appropriate lumbar vessel to
neal lymphatic path, although choriocarcinoma is notorious for ensure thorough dissection, the split-and-roll technique. The most
hematogenous spread early to distant sites. From the right testis, challenging RPLNDs are after chemotherapy, when the retroperi-
initial lymph node metastasis is to the infrarenal interaortocaval toneal tissues may be fibrotic or desmoplastic and adherent to the
nodes, paracaval nodes, and para-aortic nodes; on the left, the inferior vena cava, aorta, bowel, and mesentery. RPLND is tem-
para-aortic nodes and then interaortocaval nodes. Retroperitoneal plate driven, and the appropriate levels and location of tissue
lymph nodes are the primary metastatic site in more than 70% excision are well described. Following the appropriate templates,
of patients with metastatic testicular cancer.50 If the patient the sympathetic nerve chain should be uninjured, allowing ante-
has had prior groin or pelvic surgery, the natural lymphatic grade ejaculation.

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2104 SECTION XIII  Specialties in General Surgery

Many patients undergoing RPLND will have been exposed to

This article is a classic reference from the first consensus
bleomycin chemotherapy, which requires meticulous intraopera-
panel discussing evaluation and management of bladder
tive anesthetic management because of the exquisite sensitivity of
injuries.
these patients to elevated oxygen exposure; often, the anesthetic
is run essentially on room air ventilation in these cases.
Gupta K, Hooton TM, Naber KG, et al: International clinical
After orchiectomy and before any additional therapy for tes-
practice guidelines for the treatment of acute uncomplicated cys-
ticular cancer, consideration should be given to preservation of
titis and pyelonephritis in women: A 2010 update by the Infec-
fertility. Patients should be made aware of the potential impact of
tious Diseases Society of America and the European Society for
radiation, chemotherapy, or RPLND on the ability to ejaculate
Microbiology and Infectious Diseases. Clin Infect Dis 52:e103–
and on spermatogenesis. It is essential that patients be offered
e120, 2011.
sperm cryopreservation before therapies that could adversely affect
their reproductive potential. In addition, patients should be made
This document represents the most current guideline for the
aware that radiation has the potential morbidity of delayed sec-
diagnosis and treatment of outpatient or uncomplicated
ondary malignant disease as high as 15% within 25 years of
urinary tract infection in women.
treatment.50
Curative treatment of testicular cancer is one of the great
Haylen BT, de Ridder D, Freeman RM, et al: An International
success stories of modern oncology. Overall, long-term survival
Urogynecological Association (IUGA)/International Continence
for testicular cancer ranges from 98% to 99% for stage I semi-
Society (ICS) joint report on the terminology for female pelvic
noma or NSGCT.50 In patients with stage II seminoma, radio-
floor dysfunction. Neurourol Urodyn 29:4–20, 2010.
therapy yields survival of up to 100%, and stage II NSGCT
standard treatments yield survival of 90% to 95%.50 Even advanced
This article is the most recent consensus guideline to stan-
disease, stage III seminoma, has an expected survival of more than
dardize terminology, diagnosis, and management of pelvic
90%, and NSGCTs have long-term survivals of 80% to 90%.50
floor dysfunction and incontinence.

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Smith TG, 3rd, Coburn M: Damage control maneuvers for uro-
logic trauma. Urol Clin North Am 40:343–350, 2013.
This reference represents the only literature on manage-
ment of traumatic urologic injuries using damage control
principles and organized by urologic organ systems.
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2106 SECTION XIII  Specialties in General Surgery
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