Urologic Surgery

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Alternatives

Definition

Urologic surgery is the integration of surgical activities for the pelvis—the colon, urogenital, and gynecological organs—primarily for the treatment of obstructions, dysfunction, malignancies, and inflammatory diseases. Common urologic operations include:

• renal (kidney) surgery
• kidney removal (nephrectomy)
• surgery of the ureters, including ureterolithotomy or removal of calculus (stones) in the ureters
• bladder surgery
• pelvic lymph node dissection
• prostatic surgery, removal of the prostate
• testicular (scrotal) surgery
• urethra surgery
• surgery to the penis

Purpose

Conditions that commonly dictate a need for urologic surgery include neurogenic sources like spinal cord injury; injuries to the pelvic organs; chronic digestive and urinary diseases; and prostate infections and inflammations. There are many other common chronic and malignant diseases that can benefit from resection, surgical augmentation, or surgery to clear obstructions. These conditions impact the digestive, renal, and reproductive systems.

Most organs are susceptible to cancer in the form of tumors and invasion of the surrounding tissue. Urologic malignancies are on the rise. Other conditions that are seen more frequently include kidney stones, diseases and infections; pancreatic diseases;

KEY TERMS

Genitourinary reconstruction— Surgery that corrects birth defects or the results of disease that involve the genitals and urinary tract, including the kidneys, ureters, bladder, urethra, and the male and female genitals.

Nephrectomy— Surgical removal of a kidney.

Neurogenic bladder— Bladder dysfunction caused by neurological diseases that alter the brain’s messages to the bladder.

Prostatectomy— Prostate cancer surgery that includes partial or complete removal of the prostate.

ulcerative colitis; penile dysfunction; and infections of the genitourinary tract.

Urologic surgery has been revolutionized by striking advances in urodynamic diagnostic systems. Changes in these areas have been particularly beneficial for urologic surgery: laparoscopy, endoscopic examination for colon cancer, implantation procedures, and imaging techniques. These procedural and imaging advances have brought the field of urology to a highly active and innovative stage, with new surgical options created each year.

Demographics

According to the National Kidney Foundation, kidney and urologic diseases affect at least 5% of the American population, and cause over 260,000 deaths. As the population ages, these conditions are expected to increase, especially among ethnic minorities who have a disproportionate share of urologic diseases. Major urologic surgery includes radical and partial resections for malignant and benign conditions; and implantation and diversion surgeries.

Cancer

Prostate cancer is the most common cancer affecting males in the United States. One in six men will have the disease at some time in his life. It is, however, treated successfully with surgery.

According to the Urological Foundation, more than 63,200 new cases of bladder cancer are detected each year. In the United States, bladder cancer is the fourth most common cancer in men and the eighth most common for women.

Kidney cancer occurs in 51,190 new patients per year, with almost 13,000 deaths. It is the eighth most common cancer in men and the tenth most common cancer in women. Renal cell carcinoma makes up 85% of all kidney tumors. In adults ages 50–70 years, kidney cancer occurs twice as often in men as women. At the time of diagnosis, metastasis is present in 25–30% of patients with renal cell carcinoma.

Other conditions

Enlarged prostate (benign prostate hyperplasia, BPH) is very common, and often treated with surgery. Interstitial cystitis (bladder infection of unknown origin) often affects women with severe pain and incontinence. The condition, like other forms of severe incontinence, requires surgery.

Incontinence is increasingly diagnosed as a problem among the aging population in the United States, and is gaining recognition for its highly debilitating effects both in its fecal and urinary forms. According to the National Institute of Diabetes & Digestive & Kidney Diseases (NIDDK), more than 6.5 million Americans have fecal incontinence. Fecal incontinence affects people of all ages; many cases are never reported. Women are five times more likely than men to have fecal incontinence. This is primarily due to obstetric injury, especially with forceps delivery and anal sphincter laceration.

Urinary incontinence affects an estimated 38% of women aged 60 or older, and an estimated 17% of men aged 60 or older. According to one study published in the American Journal of Gastroenterology, only 34% of incontinent patients have ever mentioned their problem to a physician, even though 23% wear absorbent pads, 12% take medications, and 11% lead lives restricted by their incontinence.

Many surgical procedures are now available to correct both fecal and urinary incontinence. They include retropubic slings for urinary incontinence, artificial sphincter implants for urinary and fecal incontinence, and bladder and colon diversion surgeries for restoration of voiding and waste function with an outside appliance called an ostomy. Kidney surgery and transplantation account for a large segment of urologic surgery. Benign conditions include sexual dysfunction, kidney stones, and fertility issues.

Description

Until the late twentieth century, urological operations usually involved open abdominal surgery with full incision, lengthy hospital stays, and long recovery periods. Today, surgery is less traumatic, with shortened hospitalizations. Minimally invasive surgeries are the norm in many cases, with new laparoscopic procedures developed each year. Laparoscopic surgery is effective for many kidney tumors and kidney removal (nephrectomy ), lymph node excision, prostate and ureteral cancers, as well as incontinence, urological reconstruction, kidney stones, and some cases of bladder dysfunction.

Diagnosis/Preparation

Testing is often required to determine if a patient is better suited for open or laparoscopic surgery. Blood tests for some cancers, as well as function tests for the affected organs, will be required. Radiographic or ultrasound techniques are helpful in providing images of abnormalities.

Cystoscopy is often used with bladder and urethra surgery. In this procedure, a thin telescope-like instrument is inserted directly into the bladder. Disorders of the colon may be studied with endoscopes, imaging instruments inserted directly into the colon. Urody-namic studies of the bladder and sphincter determine how the bladder fills and empties. Digital rectal exams diagnose prostatic disorders. In this procedure, the physician feels the prostate with a gloved, lubricated finger inserted into the rectum.

Aftercare

Hospital stays range from one day to one week, depending upon the level of organ involvement and type of urologic surgery (open versus laparoscopic). Major urologic surgeries may require stents (temporary diversion of urine or feces) and catheters that are removed after surgery. Some surgeries are staged in two parts to accommodate the removal of diseased tissue, and the augmentation or reconstruction to replace function. Laparoscopic surgery patients benefit from shorter hospital stays, more rapid recovery, and possibly lower morbidity rates than open surgery procedures. This is increasingly true for prostate cancer surgeries.

Risks

The risks of urologic surgery vary with the type of surgical procedure (open or laparoscopic), and the extent of organ involvement. According to one study of 2,407 urologic surgeries in four centers, the overall complication rate was 4.4%, with a mortality rate of 0.08%.

Open surgery poses the standard surgery and anesthetic risks associated with strain on the heart and lungs. Risks of infection at the wound site accompany all surgeries, open and laparoscopic. The risk of

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Urologic surgery is performed by surgeons who specialize in the treatment of urologic conditions. Surgery is performed in a general hospital, regional center, or clinic, depending upon the type of procedure.

injury to adjacent organs is higher in laparoscopic surgery. Kidney removal and transplantation have many risks because of the extent of the surgery, as do surgeries of the colon, bladder, and prostate.

Significant gains have been made in prostate surgery. Urinary control issues following prostate surgery, especially radical prostatectomy, have improved. However, postoperative urinary incontinence remains a significant risk, with 27% of patients in one study reporting the need for some kind of leakage protection. In the same study, only 14.2% of previously potent men reported the ability to achieve and maintain a postoperative erection that is sufficient for sexual intercourse. Urologic surgeons are well versed in the risks and benefits of the surgeries they perform, and they expect to be asked questions related to these issues.

Normal results

The expected surgery result is a topic that the urologic surgeon and patient should address prior to surgery. It is important that the patient understands the issues of recovery, rehabilitation, training or retraining, and the limitations surgery may offer for basic daily functions and enjoyment. Results of urologic surgery are individual, and depend upon the health of the patient and his or her motivation to deal with postoperative recovery issues and changes to organ function brought about by the surgery.

Alternatives

Many urological diseases can be dealt with through diet, weight loss, and lifestyle changes. These modifications are especially significant in preventing and treating conditions of the urinary tract. Obesity and nutrition play a significant role in urologic diseases, and impact many urologic cancers, inflammatory and ulcerative conditions, incontinence, and sexual dysfunction.

QUESTIONS TO ASK THE DOCTOR

• How many procedures does this physician and hospital perform compared to other facilities?
• What are the urination and sexual intercourse risks of this surgery?
• Does this condition offer alternatives to surgery without risks of exacerbating the condition?
• How often are patients dissatisfied with their outcomes?

Medical interventions are another form of treatment, particularly for infectious and inflammatory urologic conditions. They are particularly useful along with special adjunctive surgical procedures for the treatment of incontinence and painful bladder and kidney conditions. While many cancers must be treated surgically, prostate cancer is often treated with a “wait and see” approach due to its slow rate of growth. There is an increasing trend for men with slow-growing prostate cancers to have regular checkups instead of immediate treatment.

Resources

BOOKS

Khatri, V. P., and J. A. Asensio. Operative Surgery Manual, 1st ed. Philadelphia: Saunders, 2003.

Townsend, C. M., et al. Sabiston Textbook of Surgery, 17th ed. Philadelphia: Saunders, 2004.

Wein, A. J., et al. Campbell-Walsh Urology, 9th ed. Philadelphia: Saunders, 2007.

ORGANIZATIONS

American Society of Nephrology. 1725 Eye Street, NW Suite 510, Washington, DC 20006. (202) 659-0599. Fax: (202) 659–0709.

American Society of Transplantation. 236 Route 38 West, Suite 100, Moorestown, NJ 08057. (856) 608-1104. Fax: (856) 608-1103. http://www.a-s-t.org (accessed April 15, 2008).

National Institute of Diabetes and Digestive and Kidney Diseases. National Institutes of Health, Information Office. 31 Center Drive, MSC 2560, Building 31, Room 9A-04, Bethesda, MD 20892-2560. (800) 860-8747, (800) 891-5389, (800) 891-5390, (301) 496-3583. Fax: (301) 496-7422. http://www.niddk.nih.gov/ (accessed April 15, 2008).

National Kidney Foundation. Director of Communications, 30 East 33rd Street, New York, NY 10016. (800) 622-9010, (212) 889-2210. Fax: (212) 689-9261. http://www.kidney.org (accessed April 15, 2008).

OTHER

“Resource Guide: Prostate Cancer.” American Foundation for Urologic Diseases. http://www.auafoundation.org (accessed April 15, 2008).

Nancy McKenzie, PhD

Uterine fibroid removal seeMyomectomy