SachRana11 Operation spiels

Must know operations:

Endoscopy
1. Cystoscopy
2. Urethrotomy
3. Urethral dilation
4. BNI, TURP
5. TURBT
6. SPC
7. Litholopaxy
8. Ureterocoele
9. Ureteroscopy – flex, rigid
10.RPG and washings

Bladder/Prostate
11.Open prostatectomy – suprapubic, retropubic
12.Radical prostatectomy
13.Cystoprostatectomy
14.Diversion – continent, conduit
15.Diverticulectomy, partial cystectomy
16.Augmentation – autoaugment, enterocystoplasty
17.Cystolithotomy
18.Vesicostomy
19.Trauma – exploration, realignment
20.PLND

Ureter
21. Reimplantation – Cohen, Leadbetter
22. Psoas hitch, Boari flap
23. Ureteroureterostomy, TUU
24. Ureterolysis – RPF
25. Pyeloplasty – AH (open, lap), CDW, VY
26. Endopyelotomy, accusize
27. Ureterolithotomy – open, lap
28. Reduction ureteroplasty

Kidney
29. Nephrectomy
a. simple
b. radical (open, lap)
c. partial
30. nephrolithotomy – anatrophic
31. pyelolithotomy – extended (Gil-Vernet)
32. PCNL
33. Trauma exploration

Retroperitoneum
34.Templates for RPLND – primary, post chemo
Adrena. 35.Adrenalectomy
a. Open (transper, retrop, thorabdo)
b. Laparoscopic

Testis/Scrotum
36.Exploration/orchidopexy for torsion/UDT
a. Fowler Stephens
b. Standard
37.Orchidectomy
a. Inguinal
b. Scrotal (total, subcapsular)
38.Epididymal cysts, spermatocoeles
39.Epididymectomy
40.Hydrocoele
41.Varicocoele
a. High (open, lap)
b. Inguinal, subinguinal
42.Vasectomy and reversal

Penis
43. Partial penectomy
44. Total penectomy and perineal urethrostomy
45. Circumcision
46. Inguinal node dissection
47. Shunts
48. Chordee correction/ Peyronie’s operations
49. Implants

Female/Incontinence
50. Slings (TVT)
51. Sling (Advance)
52. AUS
53. Botox
54. SNM
Anatomy & Operative Surgery 1 and 2 (OPSA) – 25 minutes each

The Anatomy and Operative Surgery vivas consist of two separate segments of 25 minutes each. The candidate
will be questioned on a particular operative procedure and will also be questioned on the anatomy relevant to the
operative procedure. The candidate will usually be asked on segments of the operation and in particular will be
asked to deal with common complications that occur intra-operatively in that particular procedure. In each viva
there will be four 6 minute equally weighted segments which will focus on separate clinical cases with issues such
as consent, peri-operative specifics, operative steps, anatomical considerations and complications.

- CONSENT
o Aim
o Alternatives
o Operation
o Logistics (pre + post-op)
o Risks (intra-op, early, late)
o Qs
- PERI-OP SPECIFICS
o Contraindications
o Medically optimise
o Anticoagulation
- OPERATIVE STEPS
- ANATOMICAL CONSIDERATIONS
- COMPLICATIONS

Opening Spiel:
 I would ensure patient is appropriately consented with no contraindications, medically optimised patient with clear
urine, imaging available, pressure area cares taken with DVT and antibiotic prophylaxis
o Team time out with site and side marked and position he patient
 Goals of operation are -->
 IDC, bowel prep, shave, 10min scrub (optional)

General principals:
 Aim
 Preparation
 Exposure
 Identify
 Resect
 Protect
Endoscopic:
Cystoscopy
- Aim/Principals: Assess LUT. Urethra, Bladder (UOs, trabeculation, diverticuli, mucosal changes. 4 quadrant inspection)
- Steps:
o Clear urine MCS, lithotomy position
o 22Fr rigid cystoscopy (30/70 degree scopes)
Optical urethretomy
- Aim/Principals: Open stricture by incising it to healthy vascular tissue
- Indications: BNC
- Steps:
o 0 degree scope with urethrotome, place wire, cold knife
o Cut spongifibrotic tissue at 12 o’clock until bleeding.
o Assess lumen --> thickness, density. Finish cystoscopy examination
Urethral dilation: Done with s-cook dilators for bulbar urethral strictures. Similar evidence with optical urethrotomy vs dilation
Meatotomy:
- Aim/principals: Open meatal stricture
- Steps:
o Wire to bladder. Incision at 12 o’clock meatus with scalpel, suture open with 3.0 vicryl rapide
o Place IDC, leave in 3 says.
- Post-op: IDC for 2-3 days (depending on extent of fibrosis) + golf tee dilation with uroflow at 2/12
TURP
- Aim/Principles: Aim to unobstruct urinary flow by endoscopic resection of prostate from BN to verumonatum
- Steps:
o 22Fr rigid cystoscopy – delineate LUT, exclude malignancy, identify UOs
o Continuous flow irrigation via 26Fr resectoscope, with 60cmH20 pressure. Preference for bipolar
o Ordered resection of prostate gland to capsule from bladder neck to veru – middle lobe, left, right
o Meticulous care to avoid UO’s and veru. Removal of prostatic chips, meticulous haemostasis
o Bladder drainage via 22Fr 3-way IDC
- Complications:
o Bleeding  systematic. Rollerball. (BN or apex), IDC traction, legs down, re-look, IDC again
 Last resort  midline laparatomy, cystotyomy, pack + ICU, IDC over trac traction, re-look 24hrs
 Embolisation of Internal Illiacs
o TUR Syndrome  absorption of glycine/hypotonic fluid …
 Pathophys: Dilutional hyponatremia, glycine toxicity, fluid overload.
 Sx: Restlessness, confusion, visual changes, bradycardixa, seizures, coma
 Tx: Emergency, cease resection, haemostasis, IDC, anathesthesist – blood gas
 CCRISP, oxygen, ICU, Bloods, fluid restrict, Fluid balance, UEC Q6hrs
o Lasix. Tx seizures (phenytoin).
o Hypertonic saline. Be weary of pontine demylination
o Ureteric injury  attempt to stent.
 If unable  monitor progress. USS 48hrs. Nephrostomy if sx/hydro
o Sphincter  monitor. Betmiga for DO, PFE, assess at 3/12. Consider UDS, If severe, may need AUS
BNI
- Aims: Similar Similar to TURP (disobstruct)
o Incise at 5 and 7 o’clock from BN to proximal to veru opening (line up in direction of UO)
o Ensure incision to healthy mucosa allowing for re-epitheliasion
Greenlight laser:
- Aim/Principles: Similar to TURP
o Tissue effects with laser  vaporising, coagulating, cutting
o 60-80 W vaporize/20-40 W coag at beginning
o Then increase vaporization to 180W
o Side-fire (2 mm, 30o sweeps over 2 sec);
o Keep blue triangle in site.; Lateral grooves between median/lateral lobes;
o Then systematic BN to veru sweeps. Safety key
HOLEP:
- Aim/Principles: Similar to TURP with use of Holmium YAG, 2140nm, 100W laser
o Can also be used for stones, strictures, bladder tumours
o 0.4mm tissue penetration, 3-4mm tissue necrosis
 Tissue effects: Vaporising, Coagulation, Cutting
- Issues:
 o Need morcellator (risk of bladder injury), Resectoscope
o Significant learning curve. Takes twice as long – 1g/min
TURBT
- Aim: Diagnostic and therapeutic. Resection of bladder tumour to base ensuring adequate resection + haemostasis
- Pre-op: Review imaging and assess location/size of tumour (i.e dome, lateral wall +/- elderly female)
- Risks:
o Intra-op  Anaesthetic, Bleeding, infection, injury to surrounding structures (urethra, bladder), bladder perf
o Early  General (DVT/PE/IHD/pneumonia/atelectasis), pain, bleeding, UTI, urine leak
o Late  Malignant recurrence, delayed bleed
- Steps:
o Lithotomy position, pre-op clear urine, imaging present
o Clinical staging by EUA before and after procedure (i.e fixed T3/4)
o 30 +/- 70 degree cystoscopy (if difficult to visualise anterior bladder wall)
o 26Fr continuous flow resectoscope with 24Fr loop
o Complete systematic resection of bladder tumours. May require staged resection if significant
o Collection of specimen adequate for histopath diagnosis with Ellik evacuator
o Separate resection of muscle for initial staging. 22 3 way IDC placed.
- Issues/Complications
o Tumours near UO  resect with pure cutting. Minimise diathermy. Consider stenting in solitary functioning
kidney otherwise leave alone. May inc risk of UTUC
o If UO not visualised  use 70 degree, methylene blue + frusemide, monitor clinically, USS 48hrs, Neph if sx or
O
o Tumours in diverticulum  Need to be cautious with resection. Consider CCup Bx.Nil muscle, risk of T3 if perf.
o Obturator kick –
 Minimise with  pre-op planning, paralysis, staccato technique, no overfilling, bipolar, lower current
 Perf or bleeding (i.e EIV). Step-wise approach. Washout.. diathermy… (previously had EIV)
o Bladder perforation  intraP or extraP. Stop. Assess via cystogram
 IntraP  open repair, Extra-P  IDC for 10-14 days. Cystogram prior to removal
o Uncontrollable haemorrhage  stepwise approach. If unstable, may need embo or lower midline laparotomy

SPC (suprapubic catheter)

- Aim: To place SPC into bladder for patients with DU. Critical to do safely
- Pre-op: CT imaging prior. Establish high risk pts (i.e previous lap hernia, pelvic surgery, radiation)
- Risks: bleeding, infection, SPC infection/pain, major risk --> bowel injury (esp if previous surgery),
- Steps: GA, P& D, C/U, LA infiltration (2 FBs above pubis in midline, view needle, incision), trochar, SPC
Cystolithopaxy
- Review films/urine. Ensure up to date imaging to ensure stones amenable to endoscopic approach
- Steps:
o 22Fr rigid cystoscopy. Assess LUT --> exclude malignancy + stone burden
o 26Fr resectoscope (+ albarran deflector) --> 365 or 550nm laser fibres (dust on high frequency + low power)
Ureteroscopy + Pyeloscopy
- Aim: Clearance of stones safely, minimising risk of sepsis and ensuring safety wire in place throughout
- Pre-op: Pre-op urine, lithotomy, C/U, wire to renal pelvis, secured, semi-rigid 8Fr URS, 2nd wire
- Holmium 2140nm laser, basket with n-compass/circle in ureter, n-gage in kidney
- Complications during Viva
 Stuck basket:
o Simple maneuvers initially. Open basket and try dislodge stone with flushing
o Attempt to laser stone through basket
o Disassemble basket – remove sleeve and remove from scope (safety wire still present)
o Scope is then introduced adjacent to basket and cautious fragmentation – avoid damaging wire of basket.
Last resort is to laser basket
 Ureteroscope out of lumen and see fat
o Attempt to move scope back into lumen. Gentle RPG
o Ensure safety wire secure and place stent (they’ll say slips out)
o Re-attempt to place wire into kidney
o Failing that  nephrostomy placement +/- antegrade stent
 Avulsed ureter
o Trial to place stent
o Reconstruction per ureteric injury depending on location otherwise nephrostomy
 Cant get wire passed stone during stent
o Ureteric catheter + straight wire then trial with angled wire then trial Retropulsion: water, lubricant
 o Rigid ureteroscope: wire under vision
o Rigid ureteroscope + retropulsion
o Laser fragment to get wire passed (only if non-infected). Bail and nephrostomy as last resort
 Encrusted stent
o Rigid cystoscopy + wire to renal pelvis through stent.
 If unable, then place wire along side ureteric stent to renal pelvis as safety wire and ensure this is
secured
o Attempt to remove stent with safety wire secured. Gentle traction with caution to ensure ureter not
avulsed
o Use stent grasper to break off distal stone encrustation
o Attempt URS + laser lithotripsy of fragments using Ho-YAG laser on low settings (with safety wire
secured). Can also use lithoclast if available
o If unable to remove stent, may need to place stent and plan for percutaenous approach (likely later date if
prolonged endoscopic effort) to help prevent morbidity
o Percuatenous access and lasering of proximal coil + removal may be required in certain situations
(potentially even with combined retrograde approach if distal encrustation present)

ESWL
- Aim: Non-invasive method to clear stone. Needs to be careful selected pts.
o 4 components (Shockwave generator – i.e electromagnetic, focusing device, imaging, coupling)
o MOA: Shockwave --> direct (spallation, shearing, superfocusing), Indirect (cavitation bubble – mechanical wave
from shockwave retracting/reciding )
- Pre-op considerations: Ensure no CIs (Coagulopathy, Infection, Pregnancy, AAA >4cm, Distal obstruction, >10cm S-S)
- Risks:
o Intra-op: general, UTI, damage to surrounding structures (i.e kidney, spleen, liver, bowel), arrythmia
o Early: pain, sepsis, bleeding, steinestrasse, ureteric colic, haematoma
o Late: ureteric stricture, HTN
- Steps:
o Supine position, bed with cut-out. Attach coupling device
o Identify stone with USS or X-ray
o Fragment stone, rate of 60-90 per minutes. Maximum of 4000 shocks
o Ensure acceptable fragmentation

Ureterocele
- Know Weigert-Meyer rule
- Steps:
o Incision with collin’s knife over ureteric catheter
o Stent and then remove. Can consider resecting with loop.
Bladder/Prostate
Simple prostatectomy:
- Aim: Complete enucleation of prostate adenoma to improve bladder emptying. Transcapsular or transvesical approach.
- Pre-op:
 Indication: For patients who are not good candidates for TURP (i.e large prostate >120-140cc, large bladder
stones, concurrent divertic, complex urethral disease).
 Need to ensure DRE, PSA done prior + clear urine MCS
 Contraindication: small fibrous gland, prostate cancer, previous pelvic surgery, UTI
- Risks
 Intra-op: General (DVT/PE,anaphylaxis..)Bleeding, Damage to surrounding structures (bowel, UOs, sphincter)
 Early: Bleeding, Pain, Urine leak, Infection (UTI, pneumonia), General (DVT/PE, IHD, atelectasis)
 Late: RE (100%), SUI 1-2%, ED (5-15%), LUTS, recurrence of sx, BNC -5-10%, Epididymitis
- Principles: C/U 1st. Lower midline Incision/exposure, stay sutures with capsulotomy, enucleation of prostate with
A.commisure broken, haemostasis, closure. Important to prevent damage to UOs, sphincter and stop bleeding
- Millins/Transcapsular steps
 Lithotomy + C/U first  exclude bladder malignancy, assess stone burden + location of UOs
 Supine (break over ASIS). Lower midline laparotomy. Develop space of retziues, fixed table retraction, y blade
retractor,defat prostate, 0 vicryl sutures transverselly on prostatic capsule,
 Transcapsular (horizontal) incision with diathermy, 1-2cm below BN (on prostate side)
 Protect UOs, Enucleation of adenoma (plane between adenoma + capsule with Mettzes). Break ant comm.
 Work side to side blundtly. Use spong forceps to grasp adenoma for tracton or tenaculum
 Pack fossa, diathermy bleeders, Figure of 8 suture. Ensure haemostasis. Step-wise approach below
 Place sutures through BN mucosa and advance into prostatic fossa (trigonisation)
 Closure of capsule with 2x 0 vicryl in continuous fashion.
 24 3 way IDC with 30mls, SPC, Drain, close in layers
- Post-op
 IDC out day 3-5
 Drain out day 2-3 when minimal
- Freyers/Transvesical or suprapubic steps (for large stones, diverticulum)
 Vertical cystotomy (2cm from BN on bladder side) between stay sutures. Protect UOs
 Enucleate prostate as described above. Figure of 8 suture at 5 and 7 o’clock,
 Oversew bladder neck with continuous 2-0 vicryl, SPC, cystotomy closed in 2 layers
- Issues/complications:
 Bleeding:
 Pack fossa. Place catheter, fill balloon to 60mks and place on traction, haemostasic agent. Re-assess
 Suture ligation of lateral pedicles at pubovesical junction (postero-laterally)
 Complete control of dorsal venous complex (after open endopelvic fascia, suture ligate as per RRP)
 Failing that… pack and send to ICU for resuscitation/PRBC and re-look 24hrs
Transperineal biopsy of prostate
- Steps:
 Lithotomy, IV cefazolin, DRE, prep and drape, scrotum elevatewe
 TPB setup with Stepper. TRUS probe
 Brachytherapy grid
 Axial + Sagittal views
 R) Posterior, R) Ant, R) apex… repeat on left. (minimum 18 cores)
- Issues:
 Poor views
 Pre-op: Ensure rectum empty, biopsy posterior first then anterior (prevent haemoatoma distorting)
 Operative: Ensure no air in probe, more gel, legs higher
 Pubic arch  change angle of TPB. Consider free-hand/precision point
Open radical prostatectomy:
- Aim: Oncological resection of the entire prostate and seminal vesicles +/- lymph nodes for locoregional control of
prostate cancer with step-wise approach
- Risks:
 Intra-op: General (DVT/PE,anaphylaxis)Bleeding, Damage to surrounding structures (bowel, ureter, obturators)
 Early: Bleeding, Pain, Urine leak, Infection (UTI, pneumonia), General (DVT/PE, IHD, atelectasis)
 Late: SUI 10-15% at 1 year, ED ~30-50%, BNC -5-10%, recurrence - need for radiation/ADT
- Principles:
 o Incision, exposure, DVC control, urethra dissection, retrograde dissection to SVs, nerve spare, BN open and
specimen removed, BN recon and anastomosis over catheter, haemostasis
- Steps:
o Lower Midline incision, Space of Retzius, Identify Vas if possible
o Bilateral ePLND (if indicated), 2-0 vicryl, Green hemlocks or Metal liga-clips
o Defat prostate, Divide superficial diathermy
o Incise endopelvic fascia, Right angle with diathermy, Divide puboprostatics with scissors
o Bunch DVC with Allis clamp. distal & proximal – 0 vicryl CT1 x 2, Divide DVC
o Half-divide urethra with scalpel & place anterior sutures with IDC still in - 3-0 monocryl 1 & 11, 3 & 9;
o Divide completely – 5 & 7 o’clock and “Rocco stitch” at 6 o’clock
o Retrograde dissection. Attempt nerve spare if possible
 Nerve sparing: Avoid excessive traction, Avoid cautery, Incise lateral pelvic fascia down to capsule (i.e.
between pelvic & prostatic fascia), Peel off with peanut, blunt & sharp dissection
o Develop plane between Denovilliers & rectum (sharp & blunt). Lateral pedicles (clip stay side)
o SVs & vas – clip to artery to SV at tip
o Open bladder neck anteriorly and specimen removed.
o Reconstruct bladder neck – tennis racquet repair then eversion with 4.0 monocryl
o Anastomosis over catheter, Haemostasis, Leave drain, Washout catheter/Leak test
RALP (Robotic assisted prostatectomy)
- Positioning: Lower lithotomy, legs out, open hasson entry at umbilicus.. 4 ports 8cm across and assisting port 15mm
- Steps:
o Obliterated umbilicus identified and pulled down.
o Anterior approach:
 Identify pubic bone and defat prostate + identify endopelvics, release puboprostatics
 Bladder neck incision. Use catheter bounce. Make defect. i.e smiley face.
 Between bladder and prostate to SVs + Vas
o Posterior approach (antegrade dissection)
 Lift SVs and Vas. Antegrade dissection. Nerve spare.
 DVC + Apex. Urethra too. Dissect out Walsh’s pillars
o Anastamosis
 Specimen removed. 1st layer Rocco + 2nd layer Rocco.
 Anastomosis with V-lock
- Issues:
o Visy post in upper abdomen if significant adhesions
o Intra-op inguinal hernia: Do not do combined case. Mesh into an area.
 If asymptomatic  hernia done later.
Radical cystectomy
- Aims/principles:
o M - Radical cystectomy involves removal of the bladder and prostate, combined with urinary diversion and
PLND if performed for malignant disease in males (+ formation of ileal conduit with uretero-ileal anastomosis +
rose-bud stoma)
o F - Radical cystectomy in the female involves removal of the bladder along with the uterus, fallopian tubes and
ovaries. A vaginal sparing approach can be offered
- Pre-op considerations:
o Assess resectability + up to date staging  EUA. Intra-op  assess mobility of tumour + nodes
o Consider pt factors/disease factors.
o Pre-op NAC? Needs minimum 2/52 post NAC. Re-staged between cycles
o Clear consent process (30% morbidity, 3% mortality)
o High risk features  salvage case, adhesions, may need bowel prep/snr assistant
o Stoma nurse prior + marking of stoma site
o ERAS + ICU post-op bed booked
- Risks:
o Intra-op: General, Bleeding, Damage to surrounding structures (rectum, obturator nerve/A, vascular injury)
o Early: DVT/PE, Pneumonia, UTI, Wound infection, Bleeding, Urine leak, bowel leak/ileus/bowel obstruction,
stomal ischemia/stomal bleeding, lymphocele, stoma
o Late:
 Medical (ROAD-AIDS) – Renal failure, Osteoporosis, Acidosis, Diahrrea, Deficiency Vitamins
 Mechanical (Stenosis, Infection, Stones of uretero-ileal anastomosis + stomal prolapse/retraction)
 Malignant (Local recurrence, Upper tract Urothelial Tumour)
- M: steps
 Midline transperitoneal incision, Omnitract, Develop space of Retzius & divide vas
 Identify and lift Urachus up (median umbilical ligament). Develop peritoneal wings
 Assess resectability  i.e fixed pelvis mass, fixed nodes
 Isolate ureters – mobilise bowel, find ureter @ pelvic brim, trace to bladder. Ureter runs posterior to
superior vesica (water under bridge), ureters ligated and divided
 Posterior dissection  P.Peritoneum incised, Develop plane between bladder – rectum, Lat pedicles
running posterior laterally dissected and divdied with stapler/ligasure, bladder retracted up
 Anterior dissection  Prostate – Defat, Incise EPF, Divide puboprostatics, Bunch DVC with Allis distally
(pass vicryl suture, tie), Divide DVC with Harmonic, Divide urethra with diathermy
 Posterior pedicles with vascular stapler + prostate lateral with ligasure
 Remove specimen. Lymphadenectomy
 Form ileal conduit with U-I anastomosis + rose-bud stoma + drains
- F: steps
 Lithotomy, Midline transperitoneal incision, Omnitract, Develop space of Retzius, Divide R.Ligament
 Identify and lift Urachus up. Develop peritoneal wings
 Isolate ureters (mobilise bowel, trace to bladder, be weary of uterine vessels above ureter)
 Posterior dissection  Retract uterus anteriorly, develop plane between rectum and uterus, Divide
vaginal wall (sponge-stick), incise posterior fornix, Take anterior vag wall, Divide postero-lat pedicles
 Anterior dissection  Incise EPF, Divide PUL, DVC, Mobilise urethra, remove specimen
 Urethrectomy from below, Close vagina longitudinally (clam shell)
 Form ileal conduit with U-I anastomosis + rose-bud stoma, places drains
 Consider vaginal sparing approach  Neo-bladders + young pts sexually active
- Post-op : Drain, ERAS approach, LMWH 30 days, stents removed after 10-14 days
- Issues
o Rectal injury  CR team consult, assess if clean/small vs large/contaminated..
 Options  primary closure with 3.0 PDS + washout vs colostomy. Ensure Metronidazole post op
o Salvage Case/IBD/extensive mass  Consider bowel prep, sharp dissection, senior assistant, Abs, TPN
o See below for other issues…
Pelvic lymph node dissection
o Inferior: Node of Cloquet, Superior: Common iliac vessel bifurcation, Lateral: GF nerve, Medial: Bladder
Urethrectomy
- Aims/Principals: Oncological resection of urethra circumferentially, can be performed at time of cystectomy
- Steps:
• Perineal incision, fat, CF, BS, Circumferentially dissect bulbar urethra
• Dissect proximally to membranous urethra
 • Invert penis into wound to dissect urethra to navicular fossa
• Elliptical incision around urethral meatus. Separate spongiosum from cavernosum
• Use IDC to help define proximal limit, dissect urethra free, Closure
Urinary diversion
Ileal conduit:
- Aim/principles: Construct a well vascularised incontinent conduit with a pouting rosebud stoma for diversion of urine
following anastamotic principles + ensure Re-establishment of bowel continuity
- Pre-op;
o Same as cystectomy essentially (i.e ERAS, stoma nurse +/- ICU)
o Exclude contraindications (short gut, IBD, radiation)
- Steps:
o Bowel harvest
 (If not part of RC)  midline laparatomy, Mobilise left and right colon. Ureters isolated
 Harvest 15 cm terminal ileum, 15cm from IC valve. Mark proximal + distal ends.
 Divide mesentery and pedicles using transillumination with ligasure
 Divide bowel with GIA 80 stapler for bowel segment
 Side-to-side ‘trouser’ anastomosis with GIA stapler, Close Mesenteric window
o Uretero-ileal anastomosis: (Bricker’s)
 Choose best spot for ureters (Mosquito, scissors, 4-0 vicryl everting suture, Open ureter, Spatulate
ureter with Pott’s, Bricker (2 x continuous vicryl 4-0 from apex), Sucker to place Bander stent x 2, Tack
down periureteric fat
o Stoma: Excise circle of skin/fat (Allis), cruciate incision anterior rectus sheath (2 fingers), Ensure isoperistaltic,
End loop brought through with babcoks, fascia to seromuscular, 3-0 monocryl bowel to skin spout

Neobladder (studer technique)

- Aim/Principles: Create a Reservoir with low pressure that is continent, while preserving renal function and pertaining a
low risk of fluid & electrolyte imbalance
- Pre-op considerations:
 Pt factors: Pt compliance is most important factor, assess if cognitively ok, adequate renal function (eGFR >50),
adequate liver function, prior radiation, previous urethral stricture
 Disease factors: Ensure no urethral disease or disease at BN disease esp CIS, radiotherapy, no urethral
stricture, Pt must be consented for conduit!!)
- Risks:
 Intra-op: General, Bleeding, Damage to structures (rectum, obturator nerve/A, vascular injury)
 Early: DVT/PE, Pneumonia, UTI, Wound infection, Bleeding, Urine leak, bowel leak/ileus/obstruction/fistula,
pouch rupture, mucous plugging, metabolic acidosis, lymphocele, stoma
 Late:
 Medical (ROAD-AIDS) – Renal failure, Osteroporosis, Acidosis, Diahrrea, Deficiency Vitamins
 Mechanical (Stenosis, Infection, Stones, fistulas to bowel/skin/vagina, rupture of neo-bladder)
 Malignant (Local recurrence, Upper tract Urothelial Tumour)
 Pouch rupture, retention, mucous plugging, fistula, nocturnal enuresis, incontinence
- Steps:
 Midline laparatomy, fixted table retractor, mobilise bowel (cystectomy as previous)
 Harvest 55cm ileum around 25cm from IC valve with GIA 80 stapler. Ensure bowel continuity
 Cut off staple line to avoid stone formation (urine exposure)
 12-14 cm isoperistaltic long afferent limb for chimney
 Fold into a “U shape” with proximal 12-14 cm afferent limb chimney seperate; Open distal 40 to 44
cm along antimesenteric border; Close into spherical shape (2-0 vicryl)
 Uretero-ileal anastomosis (Brickers) with bander stents following anastamotic principles
 Anastomose to urethra (make 1cm hole in bladder. 6 sutures like RRP with 3.0 monocryl)
 Ureteric stents, 18FrSPC and urethral catheter. Flush to ensure nil clots and check for leakage
- Post-op:
 48hrs IV Abs, Daily clexane 40mg
 QID flushing 50mls through IDCS/SPC
 ERAS
 Remove stents day 7
 Remove SPC after cystogram Day 10
 Remove IDC 2 days later
 Sodibic 2-6g per day
 Voiding Training:
 Void Q2hrs during daytime, Gradually increase to 3 then 4 hrs to gain capacity of 500 mL
- Issues/Complications: (Neobladder specific)
  Vascular injury
 Positive urethral margin – perform conduit
 Part of neobladder looks dusky
 Initial manoeuvres
o Warm the bowel
o Check blood pressure
o Ensure not twisted
o Check mesentery not too tight
 Further manoeuvres
o Pin prick
o If proximal end (i.e. afferent limb)
 Consider excising and re-implanting ureters
o If distal end
 This end incorporated in neobladder
 Leave it and monitor closely
o If clearly avascular, perform ileal conduit
 Converting neobladder to ileal conduit
o Use afferent limb (approx. 15 to 20cm)

Troubleshooting for cystectomy/ileal conduit/Neobladder

- Stoma inadequate length?
 Unbreak table + release tension from retractors
 Ensure conduit towards feet and left ureter not kinked
 Mobilise distal small bowel mesentry – care to preserve mesenteric vessels
 Divide proximal small bowel mesentry
 Mobilise root of small bowel mesentry
 Consider turnbull loop stoma  close distal end, perform loop ileostomy with proximal end of loop (rose bud)
 Restart
- Dusky stoma at end
 Stepwise approach. Not uncommon. Full of extremes.
 Assess viability, Warm conduit, Check blood pressure
 Ensure: Not twisted, Below ileal-ileal anastomosis, Not strangled by mesenteric window closure and
Mesentery not strangled by fascia
 Construct new conduit if not salvageable
- Can’t place bander stent
 Ensure ureters are not kinked, Use different wire, Re-assess imaging (i.e obstructive cause?), Use flexible
ureteroscope, Suture stent/ureteric catheter across anastomosis – may not need to go up to the kidne
- Incise ureter and tumour spills
o Palpate ureter for proximal extent
o Excise additional ureter
 Send ureter for frozen section. If CIS  field change. Accept and proceed….
o Perform flexible ureteroscopy to assess proximal ureter
o Perform copious wash, Consider longer conduit
- Can’t find ureter
o Start at common iliacs
o Identify at bladder – may need to divide some lateral pedicles
o Perform cystoscopy and place stent/ureteric catheter
- Bowel injury during mobilisation
o Assess injury – clean vs diathermy, small vs large. Debride if necessary and wash. Likely call GS.
o If small  Repair injury – 3-0 PDS. 2 layered closure
 Assess water-tight closure (e.g. squeeze bowel)
o If large or contaminated. Call general surgeon. Diverting colostomg may be required
- Can’t use ileum  Consider colon conduit
- Complete duplex
o Carefully dissect both ureters
o Perform Wallace anastomosis – e.g. 66 Wallace and anastomose to proximal end of conduit
o Can also reimplant separately
- Why Bricker vs Wallace?
o Easier in my hands. Isolates the two ureters – in case of future recurrence
- Previous irradiated bowel  risk stomal stenosis
o Can reinforce with pedicled fascial flap. After rose budding, incise mucosa – forms V
o Suture pedicled flap to this. Reduces risk of contracture and has better vascularity
Colonic conduit.
- Aim: Alternative conduit option for pts with previous radiation or diseased small bowel
- Pre-op:
o Do with general surgeon. Based on middle colic artery blood supply (i.e usually use transverse colon)
 Can use sigmoid colon. Must preserve SRA for remaining rectum if so
o Bowel prep (pico prep + enema), stomal therapist to mark out site on R) and L) side
- Steps:
o Mobilise Transverse colon and splenic flexures.
o Mobilise ureters as per radical cystectomy. Take above RT field
o Transilluminate colonic mesentery. 15cm isolated on middle colic artery. Incise mesenteric windows with ligasure
o Restore colonic continuity (above conduit) with Hand-sewn with 3.0 maxon. 2 layers. Close mesenteric defect
o Uretero-colonic anastomosis following anastamotic principles with stent. Evert stoma

Continent cutaneous
- Aim/Principles:
o To create catheterisable supple tube with submucosal tunnel – continence mechanism (allowing reservoir
pressure to coapt channel)
o Exposure + mobilization of reservoir
o Harvesting of bowel for tube creation. Then cystotomy made.
o Stoma creation +Anastomosis with reservoir. Ensure submucosal tunnel 4:1 ratio
- Mitrofanoff  Harvest Appendix, cystotomy, tunnel distal tip into bladder (2cm tunnel), secure, mature stoma
- Yang Monti  4cm of terminal ileum detubularised,
- Indiana pouch (most common)  Ileo-caecal pouch. Pg 55 of Mahesha
o Steps:
 20 cm right colon & 10 cm TI (remove appendix)
 Open right colon longitudinally between taenia & close transversely (3-0 vicryl)
 Taper TI (12 Fr IDC) with GIA stapler along antimesenteric border
 Plicate IC valve with 2-0 silk (IDC after each suture, try a 14 Fr – should be mild resistance)
 Ureteric anastomosis
- Cutaenous ureterostomies  last line option. For pts with poor bowel quality or previous RT.

Ureterosigmoidostomy
- Pre-op: Largely obsolete, can be considered a bail-out operation (ie. Patient unstable post cystectomy).
- Contraindication: Sigmoid diverticulitis, Pelvic irradiation, Incompetent anal sphincter
- Steps:
o Anterior sigmoid opened and ureter delivered posteriorly through taenia coli, submucosal tunnel for 3-4cm .
Anastomosis using reconstructive principals
- Complications specific for ureterosigmoidostomy
o Sigmoid carcinoma 2-10% (20 year lead-time bias), Fecal incontinence, Recurrent UTIs/ pyelonephritis, Upper
tract deterioration

**Simple rule for any intra-vesical approach  PC, Diverticulectomy, cystolithotomy… say ureteric stents to protect ureters
Partial cystectomy
- Aim: Bladder preserving operation for very select bladder malignancy (i.e single tumour, diverticulum, urachal)
o If for Urachal Adeno  entails removal of bladder + urachus to umbilicus + PLND
- Pre-op considerations:
o Ensure No CIS, -ve random biopsies, no prostate invasion, no variant histology
o Ensure at appropriate location (i.e dome away from UOs/BN), Ensure pt staged approriprately, clear urine
MCS.
o Contraindications:
 Absolute: CIS, multi-focal tumours
 Relative: HG tumours, tumours in trigone/BN
- Risks:
o Intra-op: General, bleeding, damage to surrounding structures (Ureters, vascular pedicles), tumour spillage,
+ve
o Early: General (DVT/PE, atelectasis), Infection (UTI, pneumonia, wound), Bleeding, Urine leak
o Late: Malignant Recurrence, UTI, reduce bladder capacity, fistula
- Principals: C.U + stents prior to protect UOs + mark out with bugbee, Lower midline incision (Ip or Ep) with Full
thickness excision of focal pathology with an appropriate margin (i.e 2cm) and closure in 2 layers of bladder
- Steps:
 o Cystoscopy first, mark out margin with Bugbee (2cm), assess relation of lesion to BN & UOs
o Lower midline laparotomy. Fill bladder with 22Fr way IDC
 Extra or intraperitoneal depending on location of mass (i.e posterior – intra-P usually)
 If extraP, stay sutures x 2 and ensure clear margin
 If intraperitoneal, mobilise urachus as per radical cystectomy & can divide lateral vascular
pedicle unilaterally if need better exposure to posterior bladder. Stay sutures
o Enter bladder away from tumour and vital structures (e.g. UO)
o En bloc resection of mass with 2cm margin, perivesical fat, adjacent peritoneum. Take care not to spill tumour
o Frozen section to check margins (Radical cystectomy if T3, unable to achieve negative margin)
o 2 layered bladder closure with 3.0 PDS (monofilament absorbable).
o Fill bladder with water after. IDC + drain
- Post-op: Drain out D2-3, cystogram D10-14 prior to TOV

Diverticulectomy
- Aim/Indications: Removal diverticulae causing sx (UTIs, Haematuria, malignancy).
- Pre-op
o Ensure underlying abnormality is addressed prior or during tx of diverticula. May need UDS
o Ensure careful pre-op planning. i.e C/U to assess location of UOs and stents prior + Ensure clear urine MCS
- Risks:
o Intra-op: General, bleeding, infection, damage to surrounding structures (Ureters, vascular pedicles)
o Early: General (DVT/PE, atelectasis), Infection (UTI, pneumonia, wound), Bleeding, Urine leak
o Late: Recurrence, UTI, fistula
- Principles:
o C/U prior and protection of UOs with stents, exposure with lower midline laparotomy, combined extraV +
intravesical approach with circumscribing of diverticular neck and sharp dissection, evert then circumscribe and
excise neck, close in 2 layers + cystotomy too, IDC + drain
- Steps:
o Cystoscopy prior to assess relation to UO. Placed ureteric stents prior for safety.
o Exposure as per simple prostatectomy (Lower midline, space of retzius, fixed table retractor)
o Intravesical approach (e.g. benign)
 Fill bladder with 22Fr IDC, Transverse Cystotomy between stay sutures. Identify ostium of
diverticulum
 Stay sutures on either side of diverticular neck (retraction)
 Evert mucosa of diverticulum with allies clamp. Circumscribe diverticulum neck (mucosa only)
 If peri-diverticular adhesions  sharply split the mucosa around diverticular orifice. Use
Mettzes + peanuts to dissect and free up peri-advential space, allowing diverticulum to be
pulled towards Bladder
 Excise diverticulum mucosa intact, Close bladder defect & vertical cystotomy in 2 layers
o Combined IV + EX approach may be required for larger Diverticulum
 Pack Diverticulum with sponge/finger to bolster and aid with dissection EV. Circumscribe neck
o Close bladder defect & vertical cystotomy in 2 layers, Leave 18 way 2 IDC, pelvic drain
- Post-op: Cystogram 10-14 days prior to TOV

Cystolithotomy
- Aim: Remove Large B.stone >5cm, failure of endoscopic approach, concomitant open with simple or Diverticulectomy
- Pre-op:
o C/U prior  identify position of UOs, exclude malignancy, ensure cause tx (i.e BOO) prior or during
- Steps:
o C/U first to exclude UC + protect ureters with stents. Reposition pt to Supine, insert 22Fr 3 way IDC, low
midline incision, fill bladder, vertical cystotomy through stay sutures, suction fluid and used rampleys/forceps
to grasp stone. Close bladder in 2 layers, leave drain
- Post-op: Cystogram prior to removal of IDC in 10 -14days

Augmentation – autoaugment, enterocystoplasty

- Aim: increase capacity of bladder using bowel harvest following anastamotic principles
- Steps:
o 20 cm segment ileum. Detubularised (anti-mesenteric border)
o Reconfigured into plate (U shaped) with 2-0 vicryl
o 2-0 continuous to suture ends together to complete the cup
o Bladder bivalved
- Post-op cares: SPC, regular N/S washes, cystogram day 7 prior to removal of SPC, then IDC following
Ureter
Ureteric injuries/ureteric strictures/ureterectomy:
 Aim: Restore continuity of urinary tract following reconstructive principals. Exclude other GU injuries
 Pre-op considerations:
o Bladder capacity (i.e previous radiation, neurogenic bladder), renal function, contralateral system
o Stability of patient (if intra-op)
 Risks:
o Intra-op: General, bleeding, infection, damage to surrounding structures
o Early: General (DVT/PE, etc) Urine leak, bleeding, infection, pain
o Late: reduced bladder capacity, division of vas, urinary obstruction,
 General Principals:
o 3 way IDC, Midline incision, fixed table retractor, Exposure of bladder and distal ureter
o Restore continuity of urinary tract following reconstructive principals
o Ensuring tension free, mucosa to mucosa, well vascularised, internal + external drain
- Ureteroureterostomy (2-3 cm)
o Identify healthy proximal and distal ends of ureters. Loop ends.
o Spatulate ends at 12 + 6 o clock. Anastomosis over stent with 3.0 PDS. Consieder omental wrap
o Concerns about variable blood supply of distal ureter
- Ureteroneocystotomy (<5cm) +/- Psoas hitch
o Supine, 3 way IDC placed with water
o Midline extraperitoneal, fixed table retractor, develop perivesical space + space of retzius
o Mobilise -->
 Contralateral peritoneal attachments, vas/round ligament + contralateral vascular pedicles (SVA,OUA)
 Assess if enough length present
 Oblique cystotomy (as if part of Boari) with two stay sutures
 Bladder dome to posas tendon with absorbable suture (3 x 0 vicryl) – longitudinal to avoid GF nerve
 Stay suture at 12 o’clock on ureter. Spatulate ureter with Potts
 Placed artery through, Deliver ureter intravesically, 4-0 monocryl interrupted – start posteriorly
 Ureteric stent up, finish anterior sutures, 2.0 vicryl to bladder, IDC + drain
 C/I: small contracted bladder, limited mobility, BOO, neurogenic
- Boari flap (10-15 cm)
o Steps:
 Midline extraperitoneal, Mobilise bladder (as above)
 Flap length = estimated ureteral defect. Flap width – apex ~3cm, base 6cm
 Flap made. Hitch back wall of flap to psoas
 Ensure enough length to follow anastamotic principles
 Ureter pulled through. ureteral anastomosis performed
 Flap tubularised anteriorly after ureteric anastamosis
 Stay sutures on flap
 Close the bladder, ensure Stent placed and drain
o Post-op
 Cystogram 10/7 prior to TOV
 Stent removed 6/52
 CT IVP 3/12

Mid/Proximal ureteric injuries

o If unstable/complex recon --> consider nephrostomy and planned definitive repair
o If stable -->
 Uretero-ureterostomy over stent
 Boari flap +/- nephrotosis (with good bladder capacity)
 Nephrotososis (mobilise kidney to gain extra 5-8 cm length)
 Ileal ureter replacement
 Transureteroureterostomy if bladder unsuitable
 Autotransplant
 - TTU/Ileal ureter
o Aim/Principals: Restore continuity of urinary upper tract following principals
o Exposure: Midline laparotomy, medialisation of bowel, ureters identified, tunnel in RP posterior to SB
mesentry but superior to IMA. Mobilise colon on recipient side to identify ureter. Minimal mobilisation of
ureter
o TUU --> spatulate transected ureter,2cm medial ureteromy, reconstruct with 4.0 monocryl following principals,
stents in, O.wrap.
 If need more length  divide gona vessels on donor side and swing it give more mobility
o Ileal ureter --> 20-25cm of ileum mobilised 20cm proximal to IC valve, bowel continuity, anastomosis with
renal pelvis + bladder following principals. Stent + drains

Bilateral Ureterolysis + Omental flaps

 Aim/Principles: To remove inflammatory tissue from ureter and disobstruct, Biopsy to exclude malignancy
 Pre-op consideration:
o Stenting prior, appropriate workup (FDG PET, Bx)
 Steps:
 Ensure C/U + bilateral ureteric stents. High risk. Senior colleague
 Supine, midline laparotomy
 Mobilise SB + colon; Incise posterior peritoneum from hilum to CIA; Identify ureter most normal ureter.
 Usually inferiorly (normal tissue, below RPF)
 Dissect ureter from RPF with sharp dissection. Use of right angles/mettzes
 Close small tears with 4-0 vicryl, Repeat on Left
 Omental wrapping (divide omentum in middle causeal to cranial, divide short gastrics if needed)
 Drains + stents
 Post-op
o 6/52 remove of stents
o F/U with CT IVP
 Issues:
o Difficult identification of ureters: Go to common illiacs, go proximally to hilum even
o Intra-op ureteric injuries:
 Small  repair primarily over stent + omental flap
 Large injury  as per ureteric injuries above
o Omental harvest technique and anatomy:

Pyeloplasty (open/lap)
 Aim/Principles:
o Perform a Dismembered pyeloplasty removing stenotic segment and forming an anastomosis that follows the
principles -->Widely patent/Spatulated, Watertight, Tension-free, Mucosa-to-mucosa, Over stent with drain
 Pre-op considerations:
o 2/3 features (i.e obstructed renogram, imaging, symptoms)
o RPG  assess length of stricture, exclude UTUC.
 Risks:
o Intra-op: General, bleeding, infection, damage to surrounding structures (ureter, liver, spleen, bowel),
o Early: General (DVT, PE), urine leak, bleeding, obstruction
o Late: Recurrence of stricture,
 Steps:
o Lithotomy initially. CE + RGP +/- stent define length of PUJO
o Positioning - lateral position for lap, supine for open
o Access:
 Lap  open hasson entry + 3 point triangulation
 Open  flank incision i.e subcostal/supra 12th or tip of 12th
o Mobilise bowel/viscera, open gerotas, Trace ureter on psoas to pelvis
o Preserve periureteral tissue to ensure adequate blood supply.
o Define renal pelvis, identify stenotic PUJ segment or crossing vessel presence
o Perform dismembered pyeloplasty. Stay suture on healthy ureter and renal pelvis(extra port and put to A.wall)
o Transect renal pelvis + ureter & Spatulate ureter laterally.
 Ensure inferior edge of pelvis will reach inferior spatulated ureter
 o 2 x continuous 4-0 vicryl (posterior wall, (re)place stent, anterior wall)
o Place penrose drain and ensure stent in
 Issues:
o Doesn’t reach/need more length? Maximally mobilise renal pelvis, ureter, kidney, consider Y-V or spiral flap
o Urine leak post-op
 Drain off suction… Shorten drain…IDC back in…. failing that…. May need nephrostomy
 Post-op:
o IDC out Day 1-2
o Drain out IDC and when outputs <30-50mls/day
o Stent out 4-6 weeks with MAG 3 at 3-6/12
 Alternatives:
o Foley Y-V Plasty: For high insertion of ureter.
 Technique: Free ureter and pull upwards with vesiloop, Y shaped incision, Anastomose as V
o Spiral Flap: For long low defect, Incise and create flap and swing caudally

Endopyelotomy (retrograde):
 Pre-op considerations: as above. More likely in patient not suitable for major surgery or not willing. 60-70% success
 Aim/Prinicpals:
o To endoscopically unobstruct adynamic segment of PUJ with minimal invasion
 Critical to ensure incise opposite side to blood supply
 Steps
o RGP to delineate anatomy, Safety wire
o Full thickness incision LATERALLY to fat using laser (273 fibre, 1.0 J, 10 Hz), 1 cm above & below area of
stricture +/- balloon dilate area post (PROXIMALLY)
o Avoid vessels – best spot to cut is laterally (relatively avascular)
o Pre-op imaging can help; Direct vision can help avoid obvious pulsatile areas
o Endopyelotomy stent (10/7 Fr) & IDC overnight

Endopyelotomy (antegrade)
o CU+ RGP + Ureteric catheter
o Position prone as per PCNL + Upper pole puncture
o X2 wires down, Balloon catheter to intussuscept PUJ. Can deal with stones
o Lateral incision with cold knife or laser down to fat
o 12Fr endopyelotomy stent

Ureterolithotomy – open, lap

 Aim: For removal of large stones not amenable to endoscopic approach
 Steps:
o Ensure Imaging on day of OT
o Subcostal/Supra-12 for upper vs. Pfannenstiel for lower or Lap (esp for mid/upper)
o Extraperitoneal. Avoid manipulating ureter
o Babcock above and below to prevent migration. 2 x 4-0 stays.
o Incise Vertically onto stone .
o Pott’s scissors > Remove stone. Check for distal stone/obstruction
o Close ureter over stent with drain following anastamotic principals
Pyelolithotomy
- Aim: Used for removal of calculi confined to the renal pelvis
- Steps:
o U-shaped incision. Apex at least 1 cm from PUJ
o +/- extend incision towards calcyes as needed
o Nephrotomy for retained stones

Nephrolithotomy
- Steps/principals
o As per PN approach. Supra 11/12 extraperitoneal. Anatrophic (Brodel line).
o Clamp posterior segmental artery & mark Brodel’s line, Ice & clamp, incision into collecting system
o renorrphay technique for closure

Nephro-U
 Aim/Principles:
o Transabdominal procedure for enbloc removal of kidney, ureter and cuff of bladder tissue in continuity
 o Similar approach for lap nephrectomy, early clipping of ureter and open end cuff for bottom end (can consider
for proximal/renal pelvis a pluck after TUR
 Steps:
o Laparoscopic or Open. Favour open if large, marked LN
o Complete nephrectomy as above
o Early clip to ureter to prevent seeding
o Leave kidney & ureter within body and close flank wounds
o Separate Pfannenstiel or Gibson incision for transvesical removal of bladder cuff
 Trace ureter down to insertion to bladder (superior vesical artery)
 Stay sutures. vertical cystotomy – circumscribe bladder cuff
 Place ureteric catheter into UO for traction
Kidney
Lap Nephrectomy
- Aim/Principles: Removal of Gerota’s fascia and its contents including the kidney, perirenal fat +/- adrenal gland
o L) radical Nx is an operation of the L) gonadal vein,
o R) is an operation of the IVC
o Meticulous pre-op workup critical  CL kidney, adrenal involvement, vessels, LNs, staging
o Involves  safe abdominal entry with 3 port triangulation, bowel mobilisation (liver on R), ureter + gonadal
vein identification on Psoas, dissection of hilum (window above or below), haemostasis, closure
- Steps:
o Positioning. True lateral position, bottom left flexed, table break at iliac crest, supports, pressure cares
o Transperitoneal open hasson port insertion, 3 port triangulation.
 Hasson port  12mm (half way between umbi + costal margin perpendicular), 5mm above, 15mm
towards ASIS on onlique
o Right: Liver retractor, mobilise bowel/duodenum/liver, Ureter on psoas to hilum, window above and below
hilum…EndoGIA stapler OR 3 x purple Haemolok to artery, 3 x gold Haemolok to vein, Spare adrenal, Mobilise
o Left: Mobilise bowel/pancreas/spleen, Ureter on psoas to hilum as above
Open nephrectomy
- Aim/Principles: Removal of Gerota’s fascia and its contents including the kidney, perirenal fat +/- adrenal gland
o Safe approach for large (>10cm tumours) or concerns with lap approach
- Principles: Early vascular control
o Subcostal incision or half chevron, through layers (EO, IO, TA, TF), fixed body wall retractor, exposure
o Mobilise bowel first, identify ureter. Workup to hilar structures
o Consider approaching renal vessels through posterior peritoneum
o On right side expose by Kocherising duodenum OR approach aorta between D4 & IMV, (Displace transverse
colon on chest, SB to right, incise posterior peritoneum, find left renal vein, artery on either side behind vein)
- Approach: Transabdominal
o Chevron/Half Chevron or subcostal from tip of 11th rib – for IVC thrombus, bilateral tumours
o Midline – for trauma, horseshoe, IVC thrombus, bilateral tumours
o Thoracoabdominal through 9th rib

Partial nephrectomy (Lap or Open)

 Indications: Absolute (single kidney, B/L tumours, familial), relative (risk of long-term renal failure), elective
 Aim/Principles: : Early vascular control after safe entry/bowel mobilisation/ureter + gonadal vein identification with
Removal of tumour with adequate margin and renorrphay technique

Lap PN (steps)
- Transperitoneal, Standard nephrectomy ports
- Mobilise bowel etc, Isolate hilum, Identify ureter, Fully mobilise kidney
- Intraoperative USS, Clear fat off tumour with hot scissors, Score margin around tumour
- Apply laparoscopic Bulldog, Cold scissors to excise tumour with macroscopic margin
- 2-0 V-lock continuous x 2 rows collecting system + tumour bed Then Remove clamp
- 0 vicryl through capsule/parenchyma with sliding clip Haemolok x2 (tighten)
- Floseal, Surgicel bolster (secured with extra length of 0 vicryl with Haemolok)
o Tack Gerotas in place over defect
Open PN (steps)
o Retroperitoneal, Supra 11 or Supra 12 or subcostal/modified Chevron
o Cut through muscle down (via Lats/SP to rib - posteriorly) &(skin, CS fat, EO, IO, TA - Anteriorly)
o Open above rib and place finger under transversus/transversalis to cut down onto
o Cut on upper surface of rib (expect pleura 1 inch back). Use right angle to free diaphragm
o Mobilise kidney off psoas muscle. Reflect peritoneum away medially
 o Mobilise abdominal wall from peritoneum (permit Finocetto or Omnitract)
o Open Gerota’s& Mobilise fat off kidney (right angle & diathermy). Sling ureter at lower pole, Identify hilar structures
o Mark kidney tumour (5 mm margin, keep fat attached) with intra-op USS
o Satinsky or Bulldog to renal artery (+/- renal vein if large)
o Scissors to excise tumour. 3-0 PDS to oversew vessels/collecting system in tumour bed
o Remove clamp. 0 PDS over Tisseal & Surgicel boolster. Close Gerota’s over tumour

IVC thrombectomy
- Pre-op workup critical.
o MDT approach (discussion at MDT. Anaesthesists, senior colleague, HPB, CTS, Vascular, allied health)
o Up to date image  ECHO, MRI, Staging
o Ensure not above diaphragm. Will require Cadiac bypass
- Principles:
o Incision and exposure (rooftop incision or Chevron incision)
o Early vascular control and superior IVC control
o Mobilise right colon, duodenum and small bowel
o Identify the renal vein and cava. Next step dependent on level.
o Ensure appropriate clamping for 2-3 onwards… specifically superior IVC control prior to manipulation of
tumour to prevent tumour embolus! And release in opposite manner (inferior first)
- Approach will depend on level:
o Level 0: Milk thrombus & ligate renal vein distal to thrombus with satinsky
o Level I: Milk thrombus & apply Satinsky to IVC  Close 4-0 prolene
o Level II: Control IVC proximal & distal (circumferential mobilisation, ligate lumbars); Occlude infrarenal IVC,
contralateral renal vein & suprarenal IVC; Cavotomy & remove thrombus; Flush with heparinised saline &
close; Release infrarenal IVC clamp upon tightening to flush out clot/debris/air
o Level III: Mobilise liver (triangular & coronary), Vascular control cephalad to thrombus (ideally by milking below
hepatic vein); Pringle manoeuvre if clamping of suprahepatic IVC needed; Sometimes CP bybass needed

Trauma nephrectomy
 Aim/Principles: Emergency, life threating situation to remove kidney. Would do in conjunction with Trauma Surgeon
and senior urology colleague. Key is to gain early vascular control
 Steps:
 Supine, Midline laparotomy with wide exposure, Incision from Xiphi to pubis.
 Mobilise + lift small bowel up and out to the right. Transverse colon on chest
 Early vascular control  incise retroperitoneum over aorta just above IMA. Guide access to left renal vein
 Isolate renal arteries (left renal vein is landmark). Sling vessels. Gain vascular control prior to access Gerotas
 Mobilise small bowel mesentry. Ligament of Treitz (suspensory ligament of D)
 Open Gerota’s. Evacuate clot and assess if kidney salvageable. Majority of time it’s not, may need nephrectomy.
o If salvageable  can consider renorrphary technique (from PN techniques). If not  nephrectomy.
 Close in layers, leave drain, IDC

Adrenalectomy
- Aim/Goals: Removal of adrenal gland for malignant or functional adrenal masses
- Pre-op:
o If Phaeo --> MDT approach (Endo), need 2/52 of alpha blocker (Phenoxybenzamine) +/- beta blocker, IV fluids
2/7 prior, staging, pre-op multiphase to assess anatomy (Arterial same but variable, Venous supply changes)
- Principals:
o With experienced colleague. “Dissection of the patient off the adrenal gland”
o Key is Early venous control with minimal minimisation to prevent systemic effects
o I ensure continued dialogue with anaesthesist and Clipping of arterial vessels to adrenal ensuring to minimise
adrenal manilpulation
- Steps:
o Lateral (similar to nephrectomy), ports positioned slightly more cranial, bowel medialisation
o Identify ureter + gonadal, work up to renal hilum. Use IVC on R), Gonadal on L).
o Early venous control with continued dialogue with anaesthesist
o Clipping of arterial vessels to adrenal ensuring to minimise adrenal manipulation
o Preservation of liver or spleen, cava and renal vessels

RPLND – including templates for primary, post chemo

- Aim/Goals: Aim to remove all LN tissue as per standard template from renal hilum superiorly, ureters laterally and
common iliac inferiorly.
 - Pre-op considerations:
o MDT discussion, pre-op imaging, Would do in tertiary centre with experienced RPLND colleague.
- Risks:

- Principals:
o Transverse abdominal incision 10th rib, Fixed table retractor, mobilisation of bowel
o Exposure of retroperitoneum and Identification of great vessels
o Removal of lymph nodes within standardized template (bilateral) using split + roll technique
- Paracaval, inter-aortocaval, paraoaortic. R goes to L too but rearely L to R.
- Steps:
o Transverse abdominal incision (10th rib across to 10th rib), divide falciform ligament, Fixed table retractor
o Medial gut mobilization (ascending and descending colon)
o Small bowel mobilization of mesentery from caecum to SMA and ligament of Treitz
o Mobilisation of bowel: Right colon and small bowel placed on chest, Consider IMA and IMV ligation to allow
lateral retraction of descending bowel
o Identify great vessels, renal vessels and lumbar vessels
o Harvest packets using split and roll technique
- Paracaval, inter-aortocaval, paraoaortic. R goes to L too but rearely L to R.
o Drain, Closure

PCNL
 PRONE:
o Aims/Goals: To clear large stone burden from kidney by gaining safe percutaneous access to collecting system
o Pre-op considerations: Ensure patient worked up, pre-op imaging, clear urine MCS, no contraindications (pt
factors/disease factors i.e retro-renal colon, anticoagulated, pregnant, extreme age etc)
o Risks:
 Intra-op: General, Bleeding, Infection, Damage to surrounding structures (lung/pleura, bowel, visceral
structures), inadequate clearance
 Early: General, bleeding, delayed bleed, infection, residual stones
 Late: Residual stones
o Principals:
 Initial lithotomy + placement of ureteric catheter, then Prone positioning with pressure area
protection (i.e bony prominents, pillows on chest + pelvis), safe puncture using Bullseye technique,
dilation using nephromax system, nephroscope, clear stone, nephrostomy placement. Monitor closely
for bleeding/visceral injury damage
o Steps:
 Initially lithotomy for cystoscopy + RPG, Ureteric catheter connected to contrast to allow injection of
methylene blue, prone position with pressure area support
 I’ll use Bull’s Eye technqiue: Align calyx end on (help miss interlobar arteries) 18G/15 cm diamond tip
needle through skin until methylene blue or resp movements with kidney
 C-arm 10-20 degrees towards surgeon to allow depth perception
 Aim to puncture in expiration
 Hydrophilic glidewire into kidney, JB1 catheter to direct down ureter, Replace with super stiff wire,
 Fascial dilator then used. Ensure cut made in skin + sheath to prevent scope getting stuck
 Nephromax balloon dilator to 14cmOR Amplatz sequential dilators (stainless coaxial)
 Nephromax 30 Fr sheath with a 24Fr nephroscope
 Use Ultrasonic-Suction or lithoclast to break down stone or Tri-radiant grasper or Laser
 Check at end of case with flexible scope – all calyces, ureter
 Leave nephrostomy tube in (no stent usually)
o Complications:
 Bleeding – 20 Fr neph tube, Clamp neph tube (clot)
 Colon injury – Withdraw nephrostomy tube into colonic lumen; Place ureteric stent; Remove
catheter draining bowel in 1 week if contrast studies satisfactory (no fistula)
 Pleural injury – leave drain, CXR, CTs consult, communication with anaesthesist
 Tumour within
 Renal pelvis perf  large tear = Nephrostomy and bail, small tear = complete
o Post-op:
 CT day 1 or X-ray post-op to ensure nil stones
 Clamp PCN… if nil issues remove 4hrs later. Nil stent
 OPD 3/12 with x-ray or CT KUB
o Supine (my preferred)
 Modified lithotomy, ipsiliateral leg flat. Ureteric catheter, 2x 1L normal saline bags
  Mark iliac crest + posterior axillary line + 12th Rib Aim just medial to PAL and under 12th rib (avoid
bowel). Will Use USS to exclude bowel presence
 Use paralaex technique with II (arterties used to line up kidney with II)
 Puncture with 18G diamond needle Wire to ureter. Fascial dilators then nephromax dilation
 Up 14cm H20. 30Fr sheath. Nephroscope 24-26Fr.

Testis/Scrotum
Orchidectomy (Inguinal) or Scrotal (total, subcapsular)
- Pre-op considerations
- Staging CT CAP
- Testicular tumour markers – AFP, bHCG, LDH
- Fertility considerations  Sperm banking. Consider testicular prosthesis
- Risks:
- Intra-op: General, Bleeding, Damage to Illioinguinal nerve, buttonhole scrotum, bowel (i.e hernia)
- Early: General (DVT,PE, etc), wound infection, bleeding,
Late: chronic pain, delayed bleed, subfertility (if contralateral testis poor), malignant recurrence
- Aim/Priciple:
- Oncological Excision of testis + spermatic cord to level of deep ring via an inguinal approach to limit
contamination between lymphatic drainage of testis.
- Steps:
- Oblique inguinal incision (4-8cm) over inguinal canal (PT to Asis), skin, CS, onto EO aponeurosis,
- Open canal, Identify and protect ilioinguinal nerve
- Blunt dissection to circumscribe spermatic cord -use peanut. Finger around then penrose around cord
- Deliver testis via external ring – reytec to free testicle. Dissect off gubernaculum.
- Suture ligation with 0 vicryl with Roberts x 2. Stitch tie 0 silk (for RPLND although I don’t do)
- Close 2-0 vicryl to external oblique, 2-0 vicryl to scarpa’s, subcut monocryl to skin
- Issues:
- Tumour invading scrotal wall: Scrotectomy. Aim to close primarily. Plastics input
- Post-operative bleeding
 Possibly from Gubernaculum, spermatic cord or cremastic muscle
 Re-open wound 
 assess scrotum for Gubernacular bleed
 Assess deep inguinal ring for spermatic cord vessels
o Pull on suture on retrieve vessels
o Consider incision on deep ring to identify vessels. Stay in RP
 If unable to access, pack wound and
- Illio-inguinal neuralgia:
- Scrotal approach (obese man): <3% risk of local recurrence, no worsening prog, excise scar
- Partial orchidectomy:
 Considered in extremely select cases. Bilateral tumours or solitary testis
 Intra-op frozen section after inguinal approach with intra-op USS

Orchidopexy (T.Torsion)
- Aim: To fix testis into scrotum in orthotopic position to prevent re-torsion
- Steps:
 Midline raphe incision though scrotal wall to deliver testis and cord
 Identify is torted and viable, detort and wrap in warm packs for 10mins if unsure
 Perform orchidectomy if non-viabe
 Perform 3 point orchidopexy with 3.0 vicryl being mindful of vessels in TA wall
 Perform on contralateral side and close dartos and skin
Epididymal cyst
- Aim: Removal of epididymis/cyst ensuring preservation of testis (ensure pt worked up + counselled)
- Risks:
 Intra-op: general, bleeding, damage to surrounding structures (testis, vas, epididymis)
 Early: Infection, Haematoma, DVT/PE
 Late: Testicular atrophy, Chronic pain, Recurrence,
- Steps (Epididymal cyst)
 Mid scrotal incision, Deliver tunica vaginalis intact, sharp dissection to avascular plane
 Mobilise epididymal cyst intact with sharp dissection on stalk
 Ligate stalk with 4-0 vicryl (or dissect epididymis off sharply)
 Close fascia over epididymal cyst bed
- Steps (Epididymectomy)
  Dissection from tail to head
 Sharp incision through TV – stay on epididymal side
 Ligate epididymal branch testicular artery. Note: preserve testicular artery – vessel is medial to epididymis
 Divide vas deferens
 Oversew head with 4-0 vicryl
 Closure of TV
Hydrocoele (modified Jaboulay)
- Aim:
- Reduce hydrocele and reduce risk of recurrence. Appropriately counselled.
- Alternatives: Sclerotherapy (highly select pts)
- Risks:
- Intra-op: general, bleeding, damage to surrounding structures (testis, vas, epididymis)
- Early: Infection, Haematoma, DVT/PE
- Late: Testicular atrophy, Chronic pain, Recurrence,
-
- Principles/steps:
- Midline scrotal incision dissecting down to hydocoele sac
- Dissect out laterally around hydrocoele sac, Deliver sac
- Decompress sac and open completely avoiding cord, epididymis and testis which can be splayed within the layers
of a large chronic hydrocele
- Inspect to ensure no communication with peritoneum
- Excise TV, closure of sac behind cord 2.0 vicryl (Lord: plication of hydrocele with interruoed sutures)
- Haemostasis, closure with 3.0 vicryl rapide
- Issues:
- Unfit pts/decline surgery  sclerotherapy
 Puncture in lower hydrocele, aspiration of hydrocele.
 Sclerosing agent  i.e Tetracycline, 95% alcohol, phenol, fibrovein

Varicocoele
 Aim: To occlude gonadal vein and its tributiaries, reducing flow in pampinform plexus
 Can be performed lap, open (microsurgical, inguinal), endovascular
 Pre-op considerations: Indicated for sx or specific infertility, consent, different options
 Risks:
o Intra-op: General, Bleeding, damage to surrounding structures
o Early: bleeding, infection, pain, loss of testis, hydrocele,
o Late: Recurrence, scrotal pain, hydrocele
 Principles: Exposure, Ligation of veins, preservation of arteries + lymphatics
 Steps:
o Laparoscopic –
 supine, IDC, lean to CL side, head down
 Umbilical hasson entry, 2x working ports (suprapubic + middle port on CL side)
 Identify cord below inguinal ring, dissect veins (usually 3), endoclips
 Prevese lymphatics, artery
o Microsurgical --> supine, incision inferior to deep ring, grasp cord with babcock, penrose drain for retraction,
under microscope x 10-12, identify veins, ligate, preserve lymphatics, close

Vasectomy
 Aim: Form of male contraception by occluding bilateral vas deference
 Pre-op considerations: Key consent process – irreversible, need to continue contraception 3/12
 Risks:
o Intra-op: General, Bleeding, damage to surrounding structures
o Early: bleeding, infection, pain, loss of testis, early failure – 1/200
o Late: Late failure, sperm granuloma, orchalgia, late failure – 1/2000, desire for reversal (5-10%)
 Steps:
o Bilateral scrotal incision. Palpate vas postero-laterally in cord
o Clamp with babock, incision over vas
o Resection of vas (2cm minimim)
o Intra-luminal diathermy, tie off ends, fascial interposition and repeat on other side
o Pt to remain on contraception for 3/12 + at least 20 ejaculates and then semen analysis to be done
 Issues:
o Can’t find vas  warm packs, relax scrotum then deliver testis, failing that inguinal incision + USS KUB
o Special clearance (at least 7 months + <100K non-motile sperm)
  Need repeat tests monthly with ongoing ejaculates (>20)
o Orchalgia  stepwise approach

Vas reversal
 Aim: Restore continuity of Vas following anastamotic principles. Microsurgical technique where applicable
o Factors determining success  time, length, previous technique
 Principals/Steps:
o Supine, Incison over vas, identification of vas ends
o Transect ends of vas to healthy lumen. Assess patency
o Stay sutures on each vas with 6-0 prolene
 10-0 nylon double armed suture
 9-0 sutures through muscularis and adventitia
o Reconstructive principals --> tension free, mucosa to mucosa, well vascularised
 Issues:
o If poor quality sperm --> perform VE
o Fertility rate: 80% improvement in sperm analysis, 50% conception.
 Post-op:
o Avoid ejaculation for 2-3/52 to prevent leak. Perform semen analysis 6-8/52
 VV --> sperm in >75%, pregnancy in 50% (motile sperm at 6/12 usually)
 VE --> sperm in 60%, pregnancy in 30% (motile sperm at 12/12 usually)

Penis
Partial penectomy
 Aim/Principles
o Removal of malignant penile cancer with resection of the glans, distal corpora and distal urethra with an clear
oncological margin (5-8mm)
o The key functional consideration is assess if enough length will be left
o to permit upright voiding. Requires minimum 3cm penile stump
 Pre-op
o Pre-op workup critical  biopsy proven, formal staging with CT + MRI, ensure minimum 3cm penile length,
LND staging for >T1b, consent may require total penectomy, DVT/Abs
 Risks:
o Intra-op: General, bleeding, infection, damage to surrounding structures
o Early: General (DVT/PE, atelectasis), Infection (UTI, pneumonia, wound), Bleeding, Urine leak
o Late: Recurrence, UTI, fistula, meatal stenosis, ED, poor cosmesis, too short a stump for upright voiding +
sexual performance
 Steps
o Supine, glove over distal tumour, torniquet at base of penis
o Incise skin with 1cm margin down to Buck’s fascia. Ligate and divide superficial dorsal veins
o Mobilise penile shaft skin. Divide Buck’s fascia.
o Ligate and divide deep dorsal arteries/veins arteries, Cut through cavernosal bodies,
o Keep 1 cm extra urethra, Spatulate urethra dorsally at 12
o Horizontal mattress to corpora, septum and back (2-0 PDS/Vicryl)
o Take tourniquet off and assess for bleeding, Close skin ventrally to urethra (4-0 vicryl)
o 18Fr IDC, gelonet + gause dressing
 Issues:
o Can lengthen stump by (dividing suspensory ligament, split IC muscle and free crura from P rami)
o Other Penile sparing options: Laser ablation, Circumcision, WLE, Glans resurfacing

Total penectomy and perineal urethrostomy

 Aim/Principles:
o For malignant penile disease where adequate margins does not allow for upright voiding or adequate sexual
function. Must attain clear oncological margin and creation of perineal urethrostomy
o Need to ensure biopsy proven disease prior + dynamic LN staging
 Risks:
o Intra-op: General, bleeding, infection, damage to surrounding structures
o Early: General (DVT/PE, atelectasis), Infection (UTI, pneumonia, wound), Bleeding, Urine leak
o Late: Recurrence, UTI, fistula, meatal stenosis, poor cosmesis
  Technique:
o Lithotomy, Glove over tumour, Elliptical incision around base of penis. Ensure clear margin (1cm)
o Diathermy down to Buck’s, divide superficial dorsal A/V. Divide suspensory and fundiform ligament
o Ligate and divide dorsal artery/nerves.
o Transect through corpora cavernosa and corpus spongiosum ensuring clear 1cm margin
o Oversew corpora cavernosa with 2-0 PDS. Mature to skin with interrupted 2-0 vicryl over IDC
Perineal urethrostomy
 Inverted U-shaped incision in perineum, develop flap (generous fat)
 Dissect through bulbospongiosus muscle (if not during penectomy, do it over metal sounds)
 4 cm incision in bulbar urethra. (If not during penectomy, stay sutures placed and do procedure)
 Spatulate urethra dorsally and secure apex to perineal incision. Interrupted sutures with 4.0 vicryl rapide. 18Fr IDC
through. Drain. Remove IDC 5/7
 Maintenance in continence with EUS

Invasive Lymph Node Staging

- DSLNB
 Aim: To help identify the SLN to determine if ILND is indicated in pts with Impalpable nodes in intermediate or high risk
(>T1b) penile SCC
o If DSNB not available options include: USS + FNAC OR Superficial modified template LND
 Steps
o Technium colloid injected adjacent to lesion prior to surgery (4-6hrs) + mapped with nuclear I
o Patent blue injected adjacent to lesion prior to surgery (just prior)
o Gama ray detection probe
o 5cm incision parallel to inguinal ligament, 2cm inferior and lateral to pubic tubercle
o Raise small skin flaps
o Identify and remove sentinel nod
o If positive proceed with radical LND in a separate sitting

- Modified inguinal LN dissection

 Aim:
o Invasive LN staging of penile cancer whilst minimising morbidity
o Borders: inguinal ligament superiorly, laterally to FEMORAL artery, medially to Abductor longus, inferiorly
fossa ovalis (preserves saphenous vein + sartorious)
 Advantages over full: Smaller skin incision, limited field of dissection, less lymphedema + flap necrosis
 Steps:
o Mark out inguinal ligament, fossa ovalis (2 finger breadths below and lateral to pubic tubercle). Where femoral
artery is felt (mid point between pubic symphysis and ASIS, 2cm below inguinal ligament
o Skin incision 2cm below groin crease for distance of 8-10cm (over femoral artery - fossa ovalis
o Raise skin flaps with campers on skin with skin hooks
o Dissect areola / lymphatic tissue superiorly until inguinal lig seen.
o Open fascia lata and femoral sheath on top of femoral artery.
o Take all tissue medial to this down to level of fossa ovalis. Saphenous vein preserved
o Deep lymphatics medial to femoral vein along the adductor longus fascia up to Cloquet’s node are removed
o Frozen section. If positive, proceed to radical inguinal LN
Radical Inguinal LND
o Primary role of ILND is in penile cancer and provides:
 Staging/prognostic info + Therapeutic effect  Improves survival but high
morbidity
 Borders  at ASIS to Pubic Tubercle (inguinal ligament)
 Medially - 15cm down from pubic tubercle
 Laterally – 20cm down from ASIS
 Inferiorly – joining the two lines above
 Boundaries of femoral triangle: Laterally sartorius, Medial aspect of adductor
longus, inguinal ligament, superiorly: floor is pectineus and ilacus, Roof is fascia lata
 Contents: nerve, artery , vein, nodal tissue. The nerve is outside the femoral sheath,
the rest is in it.
 Steps:
o Modified frog-leg position.
o From ASIS to pubic tubercle, from inguinal ligament to 15 cm below pubic tubercle
o Oblique incision ~ 3 cm below inguinal ligament. Incision sharply to Scarpa’s
o Raise flaps below level of Scarpa’s fascia
 o Longitudinal incision through fascia lata to expose underlying Sartorius & similar incision over adductor longus
(defines lateral & medial borders of lymphatic packet)
o Inferior portion of lymphatic packet dissected free & divided between ligatures
o Carry dissection from inferior to superior & from lateral to medial (superficial to femoral vessels), Transect
saphenous vein, Include tissue medial/inferior to femoral vein (deep packet – up to femoral canal)
o Then dissect Sartorius free & detach from ASIS, fix to inguinal ligament. Close in layers
o 2 x penrose drains
Circumcision (sleeve technique)
 Aim: To remove excess foreskin
 Pre-op: Screen for Cis
 Risks:
o Intra-op: General, bleeding, infection, damage to surrounding structures (dorsal nerve, urethra)
o Early: General (DVT/PE, atelectasis), Infection, Bleeding. Pain, too much length/too little
o Late: meatal stenosis, poor cosmesis, altered sensation, ED
 Steps:
o Penile block (adult 0.5% marcaine 20 ml plain). Mark. Circumferential incision is made in the outer penile skin
in 0.5-1 cm distal to sulcus
o Foreskin is retracted and a second circumferential incision is made 5mm proximal to the sulcus, depending on
penile length
o Make the two circumferential incisions. Then connect them by cutting the dorsal penile skin in the midline.
Foreskin is lifted and excised circumferentially off dartos
o Bleeding vessels gently cauterized with bipolar diathermy. Frenular artery suture ligated.
o Suture shaft skin to the distal mucosal skin with interrupted 4-0 vicryl rapide, using initial sutures for traction
(avoid tight sutures or inversion)
o Light dressing – jelonet, gauze and coban.
 Paeds (Plastibell)
o Dorsal slit after crushing with straight artery clip
o Plastibell is placed over the glans, foreskin is drawn up over the device. Should fit loosely
o heavy silk suture is then tied very tightly around the Plastibell in the groove
o foreskin is excised, Plastibell remains in place, until it eventually falls off in 3-10 days
o
Distal shunts
- Aim: Ischaemic priapism Not responding to aspiration, irrigation and injection of phenylephrine
- Pre-op: Patients must know that all shunts are assoc with risk of ED, this combined with duration of priapism.
- Risks:
o Intra-op: General, bleeding, infection, damage to surrounding structures (i.e urethra)
o Early: General (DVT/PE, atelectasis), Infection (UTI, pneumonia, wound), Bleeding, Urine leak
o Late: Recurrence, UTI, fistula, meatal stenosis, poor cosmesis, ED
 Often ED > 50%. For priapism > 48 hours – ED near 100%
- Types of distal shunt: Winters (tru-cut), Ebbehoj (scapel through glans to corpora, T-shunt (11-blade 90 deg, Al-Ghorab
(2cm transverse incision dorsal glans. Distal tunica albuginea excised from each corpus)
- T-Shunt steps:
o IDC, 11 blade through glans into distal tip of corpora
o Rotate blade 90 deg so sharp part face laterally, Remove blade
o Squeeze on shaft to milk out clot (need to squeeze quite firm)
o If doesn’t improve in 15 mins – repeat on the other side
o If still doesn’t work – need to tunnel the corpora – use 20 or 22F straight urethral sound or hegar dilator
through incision into corpora. Aim laterally
o Corpora dilated to the base of penis – peno-scrotal junction
o Squeeze again to milk clot out
- Penile fracture
o Aims:
o Steps:
 GA, supine, flexible cystoscopy (exclude urethral injury) + degloving incision of penis to bucks fascia
 Identify injury. Debride to viable tissue. Closure with 3-0 Ticron
 Closure of skin. Artificial erection to ensure no leak
 If urethral injury, close with 5-0 PDS over 18 Fr IDC
 Dressings/gauze

Plication for Peyronie’s operations (i.e Nesbitt)

- Indications: Stable disease (>6/12), Curvature >30 - <60 degrees, Adequate Penile length, bothered
 - Aims: ‘i.e shorten the long side’
o Correction of penile curvature in a patient with stable Peyronie’s disease and functional erections
o To allow to participate in penetrative intercourse + minimise side effects (ED, altered sensation, shortening)
- Risks:
o Intra-op: General, bleeding, infection, damage to surrounding structures (dorsal nerve, urethra)
o Early: General (DVT/PE, atelectasis), Infection, Bleeding. Pain, too much length/too little
o Late: meatal stenosis, poor cosmesis, altered sensation, ED
- Principles/steps:
o Circumcision degloving incision to Buck’s fascia
o Artificial erection. Tourniquet at base and Butterfly needle injected with N/Saline
o Incise Bucks fascia at point of maximal curvature on opposite side. Excise 1cm TA preserving Nerves/vessels
o 3.0 non-absorbable suture (prolene/Ticron) with buried knots after ensuring erection restored
o Complete closure of tunica and leak test performed, prior to closing in facial layers (Bucks with 5.0 PDS)
o Documentation of stretch penile length pre-and post op
- Other options:
 Lue-dot plication:
o Mark out 16 dots 5mm apart and 3mm lateral to spongiosum . Placed through albuginea.
o Use 2-0 Ti-Cron (Braided, Non-absorbable); Each suture = 4 dots. Rubber shod. Check if straight.
 Yachia
o 11 blade, cut parallel to shaft (longitudinal). Skin hooks, Close transversely with 2-0 prolene (KH)

Incision and grafting (dorsal plaque)

- Aim/Principals: ‘i.e lengthen the short side’ for Peyronie’s. Ensure appropriate workup
- Steps:
o Incison over plaque, Excise superficial dorsal vein. Elevate dorsal nerve
 Mobilise NVB laterally to 3 & 9 o’clock (elevate to palpably normal TA)
o Point of maximal curvature marked with suture at erection test
o H-shaped incision with middle strip at maximal curvature
o Flaps of H mobilised, Sutured with 4-0 PDS to create a square defect
o Graft tailored (oversized) & sutured with 4-0 PDS
o Close Buck’s fascia & skin
o Artificial erection to confirm straightening, 16Fr IDC
Penile prothesis:
 Aims: Placement of 3 piece inflatable prosthetic device to restore erections in a man with severe irreversible ED
 Pre-op considerations: Must have dexterity, libido. Consented appropriately with no CIs (UTI, skin infection, coags)
o Prevent infection via: 10 min scrub, IV ABs, shave, minimise theate movement, surgeon double G + balaclavas
 Risks:
o Intra-op: General, bleeding, infection, damage to surrounding structures (urethra, crossover, bladder)
o Early: General (DVT/PE, atelectasis), Infection, Bleeding, Pain, Cold glands, penile shortening,
o Late: Infection, necrosis, erosion, mechanical failure, buckling, altered sensation, revision rate 10% at 10 years
 Principles: `
 Steps:
o IV Cephazolin and Gentamicin, 10min scrub, Use Gent+Vanc wash, Minimal skin handling, glove changes
o Lonestar retractor (big circle up), Place IDC,Transverse penoscrotal incision, Finger sweep
o Pre-placed 2-0 vicryl sutures, Corporotomies bilaterally 1.5-2cm with stay sutures
o Corporal dilatation with brooks dilators proximally & distally (stay lateral to avoid urethra)
 Safety check: Field goal (same depth/same angle) & Distal fluid challenge to assess for urethral injury
o Place cylinder using Furlough, “Shoe horn” with Debakey proximally, then distally, Tie down sutures
o Place pump into scrotal pocket, Close dartos deeply, Connect pump to cylinders (crimp); Cycle device x 3
o Place reservoir into space of Retzius via external inguinal ring, Fill reservoir, Crimp connector between
reservoir and pump/device.
o Test and cycle device. Mummy wrap. Drain left in
o Post-op cares: overnight stay, TOV + Drain out day 1, OPD 4/52, education
o Complications:
 Corporal crossover  leave in CL side and place ipsilateral dilator i
 Urethral injury (distal or proximal)  repair and bail with urethrogram F/U
 Scrotal haematoma  take to theatre and washout. Can impacted integrity of scrotum

Urethroplasty
 Aims/Principals Definitive surgical tx of urethral stricture disease. Excision and primary anastomosis (<2cm) or incision
and substitution graft urethroplasty (>2cm or penile urethral strictures).
 o Must follow anastamotic principals --> Tension free, water tight, spatulated, well vascularised, MM
 Pre-op considerations:
o Retrograde urethrogram  assess length + location, pre-op clear urine
o no Cis for BMG harvest (i.e oral disease – leukoplakia)
 Risks:
o Intra-op: General, bleeding, infection, damage to surrounding structures (i.e urethra)
o Early: General (DVT/PE, atelectasis), Infection (UTI, pneumonia, wound), Bleeding, Urine leak, fistula,
numbness
o Late: Recurrence, UTI, fistula, meatal stenosis, poor cosmesis, ED 2%, cold glands, chordee, diverticulum, Graft
complications for substitution urethroplasy (i.e mouth bleeding, mouth pain)
Anastomotic urethroplasty
 Steps:
 Clear urine MCS, lithotomy, 17Fr C/U, IDC placed to stricture to allow palpation of distal end
 Perineal incision. Layers through skin, fat, colles, BS muscle and bulbar urethra.
 CS dissected circumferentially. Divide off central tendon. Divide urethra at distal end of stricture with scissors,
Excise scar tissue. Ensure sounds placed proximally and distally.
 Cystoscopy to ensure no proximal stricture. Spatulation (distal = ventral, proximal = dorsal), calibrate to 30 Fr
 Anastomosis 4-0 PDS interrupted over 16Fr IDC.
 Drain, Close muscle, fat, skin

Substitution urethroplasty (Ventral Onlay vs Dorsal Onlay)

Buccal mucosal graft urethroplasty
- Principals/steps
 Clear urine MCS, lithotomy, 17Fr C/U, IDC placed to stricture to allow palpation of distal end
 Perineal incision. Layers through skin, fat, colles, BS muscle and bulbar urethra.
 Mobilise bulbar urethra, rotate 180 degrees (if Dorsal onlay), open stricture along dorsal aspect, measure out
stricture, incise stricture
 Buccal graft – nasal intubation/cheek retractor; Mark parotid duct; Infiltrate/Hydrodissect with LA; Defat
 Tack graft to CC with quilting sutures, sew urethral edges to graft (DORSAL)
 Or tack graft into stricture site ventrally and close (VENTRAL)
 Anastomosis 4-0 PDS interrupted over 16Fr IDC. Drain, Close muscle, fat, skin

- Issues:
o To increase urethral length:
 Incise attachment to central tendon, Separate corporal bodies, Inferior pubectomy, Supra-crural re-
routing
o Good properties of buccal mucosa:
 Easily accessible, good healing, used to moist environment, hairless
o Contraindications to BMG:
 leukoplakia, tobacco chewing, oral Ca, systemic disease
o Alternatives to BMG:
 Rectal muscosa, FTSG (retro-auricular), Lingula mucosa
o Alternatives for very large defects (i.e >5cm)
 Longitudinal ventral penile skin flap (Orandi). However, hair bearing skin
 Distal penile circular fasciocutaneous flap (McAnich)

Longitudinal ventral penile skin flap (Orandi)

Disadvantage is that hair bearing skin may be included proximally
Expose urethra
 Incise parallel to urethra in region of stricture. Expose
urethra
 Incise urethra laterally contralateral to side of incision
Mobilise and place flap
 Mark out flap as longitudinal hexagon
 Incise down to dartos contralateral to initial incision
 Develop flap by mobilizing skin off dartos laterally
 Flip the flap into position
 Close with 5-0 absorbable monofilament over 16Fg IDC
Closure
 Close penile skin incison
Male Incontinence + Female
Male Sling (Advance)
• Aim: To reposition urethra to correct SUI (mild-moderate). UDS proven if possible
• Pre-op: Min 12/12 of conservative mx for SUI, flexible C/U to exclude stricture, UDS to confirm SUI
• Risks:
o Intra-op: General, bleeding, infection, damage to surrounding structures (B,U, rectum), Obturator NAV
o Early: General (DVT/PE, atelectasis), Infection, Bleeding, AUR, ?edema vs erosion vs too tight
o Late: Sling Erosion, Sling infection, recurrent UI, AUR , LUTS (OAB), sexual dysfunction (ED, anejaculation)
• Principles: Safe Placement of a sling to reposition membranous urethra after perineal incision to allow for bulbar
urethral exposure and safe placement with tensioning
• Steps:
o Lithotomy, place 14Fr IDC. Perineal incision, skin, fat, Colles, BS muscle, bulbar urethra
o Mobilise urethra, Release from central tendon and mark origin of CT on bulb with 3.0 PDS stay suture
o 2x vertical marking  1cm inferior to adductor longus tendon and just lateral to IP ramus
o Pop trochar into skin incision and rotate; Hold at 45 degree angle; Protect urethra with opposite hand
o After two “pops” (obturator MemB, O.Internus) drop handle towards midline to direct needle out.
o Place sling on tip of trochar and lift out. Do bilaterally
o Secure pad of sling with 3-0 PDS – proximally to where central tendon was
o Tension under vision of flexible CE (2-4 cm) to confirm coaption + ensure nil injury, 14 Fr IDC
 Post-op: TOV 1-2/7 as inpatient, IV Abs, F/U 4/52
 Alternative: ATOMS sling: sub urethral sling with transobturator anchor (ties around ischial ramus) and adjustable
suburethral patch. Fluid or AUS
• Complications/Difficulties:
o AUR (20%)  edema, too tight, constipation
 IDC and re-tov 1/52. >98% settle after this
 4-6/52 max time for edema to settle. Consider CISC. Remove sling results in worse SUI (Moon)

AUS (Artifical Urinary Sphincter)

 Aim: Definitive surgical treatment for SUI. Following meticulous sterility principles, exposure bulbar urethra with
placement sized cuff, suprapubic incision for placement of reservoir and pump, tubing connected + cycled
• Pre—op workup:
o Min 12/12 of conservative mx for SUI, flexible C/U to exclude stricture, UDS to confirm SUI
o Prevent infection via: -ve urine MCS, Ensure IV Abs (1g Ceftriaxone + Vancomycin 1g) + 10 mins scrub of
perineum with chlorhexidine alcohol prep, minimise traffic in and out
 Risks:
o Intra-op: General, bleeding, infection, damage to surrounding structures (urethra, bladder, rectum)
o Early: General (DVT/PE, atelectasis), Infection, Bleeding, AUR – ensure deactivated.
o Late: Erosion, infection of prosthesis, device failure (50% at 5 years), De-novo OAB, recurrence of sx
(U.atrophy)
 Principles: Meticulous sterility (clear urine, IV Abs (Ceft + Vanc, 10min scrub), lithotomy, Exposure bulbar urethra with
placement of sized cuff, suprapubic incision for placement of reservoir and pump, tubing connected + cycled
• Steps:
o 12 Fr IDC, Lonestar retractor, Midline perineal incision, Skin, Colles, BS muscle, bulbar urethra. Care taken
o Mobilise urethra circumferentially, Sharp dissection (keep Buck’s on dorsal urethra), pass right angle (no
spreading), Place vesiloop for traction, Dissect under vision
o Measure and place appropriately sized cuff (4.5-5cm)
o Place pressure regulating balloon into space of Retzius via transverse suprapubic incision
 Fill reservoir with 23mls normal saline
o Place pump in scrotum using Rampley’s tunnelled subcutaneously from abdominal wound to scrotum
o Tubing from cuff tunnelled from perineum subcutaneously & connected to balloon
 Trim tubes + Ensure no air bubbles (using arteries to clamp) + cycle the device to ensure it works
o Ensure cuff DEACTIVTED, Flexi CE, Close perineal wound in layers.
• Post-op: IV Abs, Catheter out day 1, 1/52 oral Abs (Norfloxacin), 1/52 wound review, leave de-activated for 4 weeks,
manipulate pump into place daily/ Avoid cycling + medi-alart bracelet so AUS deactivated prior to any IDC placement
• Complications/difficulties: (Tse  device, external or LUT factors)
o Urethral atrophy (10%)- Replace cuff in new urethra
 If radiation or can’t use proximal urethra  Downsize cuff or Consider TCC placement via penoscrotal
o TC cuff: Pass through dorsal wall of corpora to minimise erosion
o Erosion: Explant all parts of AUS device. Repair urethra. IDC out after pericatheter urethrogram.
  Consider: Ensure Cuff upsized, deactivate overnight, less pressure on perineum, transcorporal.
o Urethral injury  Bail and close primarily over IDC. Peri-catheter urethrogram 2/52
o Persistence incontinence  Cuff too large or malpositioned? Pre-existing DO? Urethral atrophy? UTI/BOO?

Slings (TVT – mid urethral – Retropbuc sling via BOTTOM-UP approach)

 Aims: The placement of a polypropylene mesh to Stabilise the mid urethra.
 Pre-op:
o Indicated for UD proven SUI. Ensure pt has had bladder diary, CU + UDS.
o CIs: pelvic radiation, further pregnancies, chronic pelvic pain, poor detrusor function
o TVT  higher rate of bladder perf/vaginal bleeding but less chronic groin pain
 Risks:
o Intra-op: General, bleeding, infection, damage to surrounding structures (B,U, rectum), Obturator NAV
o Early: General (DVT/PE, atelectasis), Infection, Bleeding, AUR –?edema vs erosion
o Late: Mesh Erosion (BUV), Mesh infection, recurrent UI, AUR , LUTS (OAB)
 Principles: Principles involve inverted U vaginal incision exposing mid-urethra and then a retropubic approach to allow
placement of sling with appropriate tensioning and ensuring no urinary tract organ injury
 Steps
o Lithotomy, 14Fr IDC, Hydrodissection of vaginal mucosa with LA,
o 2 suprapubic markings  2 cm lateral from midline over pubic symphysis
o Inverted U Vaginal incision to raise flaps + develop peri-urethral + mid urethra
o Dissect lateral towards ipsilateral shoulder with Mettzes through EP fascia
o Trochar needle placement along pubic bone to avoid bladder/urethra onto suprapubic marking
 Too medial  bladder, too lateral  vaginal fornix)
o Cystoscopic evaluation for iatrogenic injury after each pass of trocar
o Placement of polypropylene mesh (click sling onto end of passes)
o Tensioning b/w tape and urethra with sounds/mayo scissors inbetween
o Tack in mid urethra. Snip off abdominal ends. Close vaginal flaps
o Leave IDC + Vagina pack
 Post-op: IV Abs 24hrs, Vaginal pack out and TOV day 1, OPD 4/52
• Complications/Issues: (p69-75 of Mahesha’s)
o Fails TOV: repeat TOV 1/52. Up to 4-6/52 (for edema)…then trial CISC till 3/12..then incise and loosen or if
extremely tight, consider sling loosening at 1/52
o Erosion into vagina  small (estrogen cream +/- trim exposed edges) vs large (excison of mesh)
o Erosion into urethra  endoscopic mx with laser or mesh excision +/- martius flap with specialist
o Erosion into bladder  small (endoscopic incision of mesh with laser) vs mesh excision (TV or RP approach.
Like VVF). i.e inverted U, excision of mesh till tension relived, non-overlapping suture lines, tissue interpositon

Pubovaginal sling/rectus fascial sling (Top down approach)

 Aims: The placement of an autologous fascia to Stabilise the proximal urethra.
 Pre-op: Indicated for UD proven SUI. Ensure pt has had bladder diary, CU + UDS. Can be done for ISD/radiation pts
 Risks:
o Intra-op: General, bleeding, infection, damage to surrounding structures (B,U, V rectum), graft issues
o Early: General (DVT/PE, atelectasis), Infection, Bleeding, AUR, graft complications (wound dehiscence)
o Late: Graft complications, recurrent SUI, AUR , LUTS (OAB)
 Principles: Rectus fascia harvest with pfannensteil with subsequent inverted U vaginal incision exposing proximal
urethra with a retropubic approach to allow placement of rectus fascial sling with appropriate tensioning and ensuring
no urinary tract organ injury
 Steps:
o Lithotomy. Pfannenstiel in skin crease. IDC to empty bladder.
o Harvest: 2cm wide x 8 cm long. Stay suture in either end.Develop retropubic space, can feel either side of
urethra
o Hydrodissection with LA. Inverted U Vaginal incision to raise flaps + develop peri-urethral + proximal urethra
o Dissect lateral towards ipsilateral shoulder through EP fascia to RP space
o Stamey needle placed from top to bottom whilst protecting urethra with singer
 Retireve sling via suture.
 Secure sling to periurethral tissue. Close fascia (before sling tightening)
 Ensure no tension, 2 fingers; Right angle between sling & urethra
o 30 + 70 degree Cystoscopy to check bladder
 Post-op: IV Abs 24hrs, Vaginal pack out and TOV day 1, OPD 4/52
 Alternatives:
 o Fascia lata graft (autologous)
o P.Mesh (synthetic), Xenograft (porcine, bovine pericardium)
 Complications:
o Graft too short: re-harvest)
o Unable to close fascia defect: mobilise fascia, graft with mesh

Injection of Bulking Agents

- Aim/Principal: Injection of urethral bulking agent to increase outlet resistance + contribute to caption and continence
- Risks:
o Intra-op: General, bleeding, infection, damage to surrounding structures (B,U)
o Early: General (DVT/PE, atelectasis), Infection, Bleeding, AUR
o Late: Failure – SUI Recurrence,
- Steps:
o Cystoscopy. Ensure entire urethral length viewed
o Williams needle to inject bulking agent (i.e Macroplastique) at 3 + 9 o’clock
 Avoid BN or distal injection

Urethral diverticulum:
 Aim: To completely excise symptomatic diverticulae while preserving continence
 Pre-op: MRI for pre-op planning. Assess location, size. C/U prior. 3 Ds – Dysuria, Dyspareunia, PV Dribbling
 Risks:
o Intra-op: General, bleeding, infection, damage to surrounding structures (B,U,V)
o Early: General (DVT/PE, atelectasis), Infection, Bleeding, AUR, De Novo SUI
o Late: Recurrence, urethral stricture, UV fistula, urethral necrosis, vaginal scarring
 Principles: Mobilisation of well vascularised vaginal flap, dissection of peri-urethral fascia, dissection + removal of neck
of UD sac and ensuring watertight closure of urethra/vaginal + peri-urethral fascia that follows principles of
multilayered, non-overlapping closure with absorbable suture. Consider martial labial flap to close dead space
 Steps:
o Place 14Fr IDC, Retract with weighted speculum, 3-0 silk to retract labia laterally/cephalad, Lonestar
o Local anaesthetic with adrenaline
o Inverted U-shape incision to mobilise flap so entire diverticulum can be dissected out
o Incise periurethral fascia transversely. Dissect urethral diverticulum down to neck.
o Open diverticulm to facilitate identification of ostium/connection to urethra and Remove diverticulum
 Inject saline alongside IDC to identify urethral defect.
o Closed in layers (4-0 vicryl) – urethra, periurethral fascia, vagina. Follows principles of multilayered, non-
overlapping closure with absorbable suture. Consider martial labial flap to close dead space
 Alternatives:
o Martius flap: Interpositional tissue to help with vascularity and close dead space
 Vertical incision over labia & mobilise fat pad
 Post-op:
o IV Abs 24hrs, Vaginal pack out,
o Pericatheter urethrogram 10/7, prior to TOV

Vesico-vaginal fistula
o Principles:
 Excision of fistula tract, Non-overlapping suture lines
 Interposition; Control of infection; Avoidance of post-op bladder distension
o Vaginal – U-shaped incision, +/- excise fistulous tract (aided by Foley in tract, dilate tract if does not accommodate
Foley), Close in layers interrupted (bladder horizontal, perivesical tissue transversely, vaginal mucosa +/- Martius)
o Abdominal: CE+ureteric catheters + IDC + catheter in fistula; Start extraperitoneal if possible; Bivalve bladder to level
of fistula; Excise fistula through to vaginal wall; Separate bladder/vagina, Close vagina; Close bladder; Interpose
omentum

Rectourethral fistula
• Principles:
o Follow SNAP principles  sepsis control, nutrition, anatomy, plan surgery
 Adequate fecal and urinary diversion
 Maintain infection free environment
 Adequate drainage. Exposure of operative field
 Tension free, watertight, mucosa-mucosa non-opposiing suture lines
 Transfer of healthy vascular tissue transposition
 • Techinque
o York-Mason (transrectal, transphincteric)
o Principles: Excision of fistula tract, Non-overlapping suture lines; Interposition; Control of infection;
o Steps:
 Lithotomy + C/U
 Prone jack-knife, Full thickness incision through posterior anus and dorsal rectal wall to level of
coccyx; Fistula in anterior rectal wall is excised; Urethra and Anterior rectal wall + Mucosa closed (3
layer). Consider interpositional tissue (gracillis muscle flap)
 Gracillus harvest  with plastics. Detach from medial malleolus. Blood supply from femoral aryery
Bladder Botox
- Aim: Invasive therapy for NDO or DO. UDS proven.
- Pre-op:
o CIs: infection, pregnancy, coagulopathy. Know MOA
o 100 units non neurogenic, 300 units neurogenic
- Steps:
o C/U, injection 100 units in 1ml alliquots in grid formation
throughout bladder
o Avoid trigone + UOs
SNM (Sacral Nerve Neuromodulation)
- Aim:
o Aim to place electrodes in nerve root of S3, to modulate
neural input to bladder
o Multiple stage approach, with testing with trial electrodes
(50% improvement in symptoms prior to definitive device)
- FIRST STAGE
o Prone position, pillows under chest and legs
o 2cm lateral, 10cm above tip of coccyx (surface markings of S3), under II guidance
o Place electrode in S3 until needle drops into foramen – under II. Angle of 60degrees
 S3: pelvic floor bellows + great toe plantar flexion
 S2: anal wink + great toe plantar flexion
 S4: pelvic floor bellows + great toe dorsi flexion
o Tip is placed through the bone, lead should face lateral and caudal
o Stylet is removed and replaced with tined wire – testing to confirm
position – least voltage required to result in effect
o Remove needle to deploy tines
o Tunnel the lead to other side of the body
- SECOND STAGE
o Repeat as above with tined wire and subcutaneous pocket for device

PTNS (Percuatenous Tibial Nerve Stimulation)

- Aim:
o Direct electrical stimulation of S3 afferent nerve.
o Inaffective if damage to S3 nerve (e.g. pelvic surgery or tibial nerve)
o Improves urgency, frequency and UUI in 60%
- Pre-op:
o CIs: PPM, bleeding risk, pregnancy
- Steps:
o Percutaneous needle electrode inserted 5cm cephalad and 2cm posterior to medial malleolus
o Correct position causes flexion or fanning of toes
o 30mins each week for 12 weeks
o 1 maintenance treatment per month
Paediatric:

Reimplantation for VUR:

- Aims/Principals:
 Exposure of bladder and distal ureter
 Reconstruct VUJ complex to ensure non refluxing VUJ mechanism – by means of submucosal tunnel in 5:1 ratio
 Reconstruct using reconstructive principals
 Ensure non obstructing
 Intravesical:
 Cohen: Cross-trigonal reimplantation technique
 Leadbetter-Politano: recreates the new UO in normal anatomical position, allowing URS procedures
 Glenn-Anderson: ureter moblised and advanced beneath new submucosal tunnel
 Extravesical: Lisch-Gregoire (submucosal flap created with no entering of bladder)

Hypospadias surgeries
- Aims/principals: Reconstruction with orthotopic urethral meatus, correction of chordee
 Acceptable long term sexual and urinary function
 Good cosmesis with Correct curvature with dorsal plication
 Hypospadias repair --> Urethroplasty +/- meatoplasty
 Choice of procedure depends on meatal location, glans configuration, urethral plate, skin
 Distal
 TIP (tubularised incised plate a.k.a. Snodgrass)
 Midline incision to plate to reduce tension on tubulsarisation. Dartos
 Primary tubularisation – GAP, Thiersch-Duplay
 MAGPI (meatal advancement and granuloplasty)
 Proximal
 Urethral plate preserved (TIP) or Urethral plate cut (Tube onlay (Koyanagi) or Two-stage (6 months)

Urachal remnants
 Partial cystectomy with Excision of urachus in continity with abdominal wall + PLND

Vesicostomy
- Indications
o Useful in neonates with PUV where urethra cannot accommodate cystoscope
o Rising Cr despite valve ablation / resection.
Key Procedural Steps – Natalie Webb
- 2cm transverse incision 2 finger breadths above pubic symphysis
- 2x2cm cruciate incision in rectus fascia. Fill bladder
- Rectus retracted laterally. 3-0 vicryl placed near the dome of bladder for stay suture and traction
- Full thickness incision of bladder wall.
- Suture rectus fascial edges to bladder wall muscle using 3-0 or 4-0 vicryl 1cm from the cut edge of the bladder.
- Suture bladder mucosa to skin with 4-0 monocryl
- Vesicostomy should be about 20-24Fr (little finger) in size. Leave IDC in bladder for a few days
Undescended testis:
- Step-wise approach as previously discuscsed. Palpable (80%) vs non-palpable (20%)
- Non-palpable  diagnostic lap
- Blind ending spermatic cord
- Spermatic cord into inguinal canal
 - Atrophic testis

Fowler Stephen’s operation (abdominal testis)

- Aim: Locate testis with examination +/- laparoscopy
 If intra-abdominal + long-looped vas perform Fowler-stephens one or two stage (one if good
vasculature and length, 2 if needs to form collaterals)
 Always consent for orchidectomy

Inguinal cryptorchidism
- Steps:
- 4cm incision over inguinal canal, dissection to EOA
- Incision of EOA to deep ring. Identify and protect ilioinguinal. Mobilise cord to deep ring
- Resection
- Identify and divide cremaster. Transect gubernaculum
- Ligate + Close patent processus vaginalis. Scrotal incision, create subdartos pouch
- Place testis in datos pouch without tension. Consider fixation suture through TV to dartos
- Complications/Issues:
- Not enough length/too much tension
 Incise transversalis fascia at internal ring
 Transect lateral fascial bands along cord
 Prentiss manoevre: transpose cord medial to inferior epigastric vessels

Female
Transabdominal Sacro-colpopexy
 Aim: The key aspect of abdominal sacrocolpopexy is the suspension of the vaginal apex to the sacral
promontory in a manner that recreates the natural anatomic support provided by the uterosacral and cardinal
ligament
 Risks: Damage to surrounding structures, Mesh erosion, damage to BUNV, Chronic pain,
 Steps:
 Trendelenberg. Low midline or pfanensteil incision into peritoneal cavity
 Plane developed posterior to bladder and vagina . Ureters identified and sacral promentry between
 Presacral peritoneum incised and areolar tissue dissected down to longitudinal ligament of sacrum
 Attention turned to vaginal apex, swab stick placed in vagina and anterior/posterior dissection of
vagina performed (dissect free from bladder (vesico-uterine pouch) and rectum (recto-uterine pouch
of Douglas))
 Y-shaped polyprolene mesh placed and attached from vagina ant + post surfaces to sacral promentry
 Presacral peritoneum returned to cover as much mesh as
possible
 Cystoscopy to ensure no inadvertent bladder injury
 Post-op
 IDC removed POD2
 No heavy lifting 6 weeks

Burch colposuspension
 Stress incontinence – usually performed in the setting of other abdominal surgery
 Coopers ligament = extension of lacunar ligament on the pectineal line of the pubic bone
 PRINCIPALS:
 o Non-absorbable suture placement between bladder
neck/endopelvic fascia and Coopers ligament (x2 on
each side)
o Cystoscopy to ensure no bladder injury
 Worsens POP