GENITOURINARY

Hernia: Abnormal protrusion of a viscus or part of a viscus through a defect either in

the containing wall or within the cavity of the viscus. Involves anterior & posterior muscle layers of the abdomen, diaphragm, and walls of the pelvis. Can be external or internal. External Hernia: Common, present as abnormal lump. (Inguinal most common in males, femoral more common in females) Richters Hernia: Part of the circumference of bowel trapped within hernial sac (Does not result in intestinal obstruction due to non-occlusion of lumen of bowel) Littres Hernia: A small bulge in the small intestine present at birth (Meckels diverticulum) lies within hernia sac, most common in femoral or inguinal hernia. Maydls Hernia: Hernial sac contains two loops of intestine that may become obstructed or strangulated. Not recognized unless hernia contents are inspected. Predisposing Factors: Congenital (i.e. present at birth) Acquired Increased Intra-abdominal pressure (Coughing/vomiting/ascites) Complications: Irreducibility (least serious): Adhesions between sac and its contents Fibrosis leading to narrowing of neck of the sac Sudden increase in IAP that causes permanent displacement of the sac Obstruction: Neck is sufficiently narrow to occlude the lumen of the intestine Nearly always irreducible and may become strangulated Urgent Presents with intestinal obstruction (abdominal colic, vomiting, constipation, abdominal distension) Strangulation (most serious): Compression at the hernial orifice cuts off blood supply Lymphatic and venous obstructed, leading to oedema and venous congestion Serious complication if intestine is involved Erythema of the overlying skin is a late sign Immediate operation needed

Reducible Hernia: Easy come, easy go Irreducible Hernia: Hard to be reduced Incarcerated Hernia: Retented and confined hernia Strangulated Hernia: Causes enteric necrosis

Inguinal Hernia:

Most common hernia, frequent in men.

Etiology: Inguinal canal passes through the abdominal wall between the deep (internal) and superficial (external) inguinal rings The canal is a site of weakness and therefore potential herniation Indirect Inguinal Hernia: The neck of the sac is situated lateral to the inferior epigastric artery Sac accompanies the spermatic cord along the inguinal canal towards the scrotum Sac lies in front of the cord, enclosed by the coverings of the cord Causes: Failure of the processus vaginalis to form the ligamentum vaginale Loss of integrity of the inguinal canal

Direct Inguinal Hernia: Rare in females, doesnt occur in children,

more common on right side after appendicectomy. Protrudes directly through posterior wall of inguinal canal, medial to the inferior epigastric artery. Causes: Main reason is weakness of the inguinal canal Herniation occurs at Hesselbachs triangle Neck of a DIH is usually larger than the body and so strangulation is rare Rarely reaches a large size or approaches the scrotum Features: Inguinal discomfort Pain Severe pain suggests obstruction or strangulation. Lump usually obvious, often precipitated by increasing IAP, reduce completely with rest and lying down. The patient initially is examined standing to demonstrate the lump and possible cough impulse Then lying down to allow the hernia to be reduced

Difference between IIH & DIH: IIH protrudes along the line of the inguinal canal towards the scrotum or labia DIH appears as a diffuse bulge at the medial end of the inguinal canal IIH is prevented from appearing by applying pressure over the deep inguinal ring (which lies just above the midpoint of the inguinal ligament) DIH protrudes through the posterior wall of the inguinal canal medial to the deep ring. IIH is controlled by pressure in the deep ring DIH appears medial to the examiners two fingers Accurate distinction may be impossible because of variation of the deep inguinal ring IIH are more likely to develop complications If the pulse lies laterally, it is indirect inguinal hernia. If the pulse lies medially, it is considered as direct inguinal hernia.

Treatment: Inguinal hernias are best treated surgically May under general, regional or local infiltration anaesthesia Principles of Operation: Any correctable aggravating factors be identified and treated In infants and young adults, repair usually be limited to high ligation Eliminate the hernia sac, reconstruct the inguinal floor Bilateral repair usually discouraged; Laparoscopic repair can be done with low risk

Traditional Repair (Herniorrhaphy): Repair posterior wall of the inguinal canal Repair the external oblique aponeurosis Strong non-absorbable sutures are used IMPORTANT: Bassini, Halsted, & McVay have higher chances of recurrence & is more painful, while Shouldice has lower chances of recurrence but isnt popular. Tension -Free Repair is MOST POPULAR NOW. Bassini Repair: Conjoint tendon is sutured onto the inguinal ligament Spermatic cord remains under the external oblique aponeurosis Halsted Repair: Resemble Bassini repair Except place the external oblique aponeurosis beneath the cord McVay Repair: Resemble Bassini repair Except suture the conjoined tendon onto the Coopers ligament

Shouldice Repair (GOLD STANDARD FOR HERNIORRHAPHY): Divide the transversalis fascia deep inguinal ring is closed around the cord conjoined tendon and internal oblique muscle are approximated in layers to the inguinal ligament Advantages & Disadvantages: cheap, easy to perform recurrence rate, pain, discomfort, ect. Hernioplasty Process: Insertion of a prosthetic mesh to cover and support posterior wall of the inguinal canal The mesh is cut to size and is then sutured to the posterior wall behind the cord Alternatively, the mesh can be placed deep in the defect of the posterior wall Most widely used Techniques include: Plug--insert the plug into the internal ring, with or without sheet of mesh Lichtenstein--use mesh to cover the entire inguinal floor Both Laparoscopic Hernia Repair: Performed under general anaesthesia, using either a transperitoneal or extraperitoneal approach Not appropriate for large or irreducible hernias Advantages of laparoscopic hernia repair include reduced post-operative pain and earlier return to work Disadvantages include increased risk of femoral nerve and spermatic cord damage, risk of developing Intra-peritoneal adhesions with the trans-peritoneal procedure, and greater cost and duration of the operation Includes Total Extra-peritoneal approach (TEP)/ Trans-abdominal pre-peritoneal approach (TAPP)/ Intra-peritoneal onlay Mesh (IPOM) TEP is preferable to TAPP because of its lower complication and recurrence rates TAPP should be reserved for patients with prior lower abdominal wall incisions that make the dissection of the peritoneum from the underside of the incision impossible. Patients who cannot tolerate general anesthesia or who have had extensive lower abdominal surgery should not undergo laparoscopic herniorrhaphy. Benefits of Biological Mesh: Safe Strong Least of infection and rejection Resists adhesions Fewer complications than synthetics

DIAGNOSIS OF URINARY DISEASES Classification of Pain:

Renal Pain: Located in the ipsilateral costovertebral angle just lateral to the sacrospinalis muscle and beneath the 12th rib. Caused by acute distention of the renal capsule, generally from inflammation or obstruction. May be associated with gastrointestinal symptoms; Renal pain may also be confused with pain resulting from irritation of the costal nerves, most commonly T10-T12.

Ureteral Pain: Usually acute and secondary to obstruction. Hyperperistalsis and spasm Vesical Pain: Inflammatory conditions of the bladder usually produce suprapubic discomfort Acute urinary retention Overdistention and inflammation Prostatic Pain: Usually secondary to inflammation with secondary edema and distention of the prostatic capsule; Poor localization Penile Pain: Usually secondary to inflammation in the bladder or urethra, pain at urethral meatus. Testicular Pain: Primary pain arises from within the scrotum, secondary to acute epididymitis Chronic scrotal pain is usually related to noninflammatory conditions The pain is generally characterized as a dull, heavy sensation that does not radiate.

HEMATURIA: 3 red cell per High-power field

IMPORTANT: Urinary infection is the most common cause of hematuria. Classification: Hematuria gross or microscopic Occurrence of hematuria during urination Pain association Specific shape of clots

Differences: Initial hematuria usually arises from the urethra; Total hematuria indicates bleeding is most likely from the bladder/UUT Terminal hematuria occurs at the end of micturition and is usually secondary to inflammation in the area of the bladder neck or prostatic urethra. Association with Pain: Pain in association with hematuria usually results from upper urinary tract hematuria with obstruction of the ureters with clots. Acute urinary infection (most common cause of hematuria) Shape of Clots: The presence of wormlike clots, particularly if associated with flank pain, identifies the hematuria as coming from the upper urinary tract Hematuria, particularly in the adult, should be regarded as a symptom of malignancy until proved otherwise and demands immediate urologic examination

ABNORMALITY OF VOIDING VOLUME

Classification: Polyuria: Greater than 2000ml per day with normal drinking Oliguria: Less than 400ml per day with normal drinking; Anuria: Less than 100ml per day (prerenal, renal and postrenal anuria) Pre-renal anuria (Inadequate renal irrigation) Renal anuria (Dysfunction of urinary production) Post-renal anuria (Obstruction of urinary tract) Symptoms: Irritative Frequency; Urgency Dysuria Obstructive: Decreased force of urination Urinary hesitancy Intermittency Postvoid dribbling Straining

INCONTINENCE
Classification: Continuous Incontinence Stress Incontinence Urgency Incontinence Overflow Urinary Incontinence Enuresis Sexual Dysfunction: Loss of Libido Impotence Failure to Ejaculate Absence of Orgasm Premature Ejaculation Hematospermia Diagnosis: Physical Examination Urinalysis (Midstream urine sample preferred) Abdominal Plain Radiography Intravenous Urography (Requires normal renal function, Renal Parenchyma /Urolithiasis) CT Ultrasound MRI

Invasive Examination: Cystoscope/Ureteroscope/Nephronscope Retrograde Urography/ Urethrography (Performed by cystoscope/urethral meatus)

GENITOURINARY TRAUMA
General Considerations: 10% of E.R. trauma visits Often associated with multi-system trauma Subtle presentations, easily overlooked Diseased GU organs susceptible to injury Evaluation (Primary Survey): Airway with Cervical spine protection Breathing high-flow oxygen Circulation (Control of external bleeding) Disability (Assessment of neurologic status)

 Exposure / Environment

Renal Trauma:
General Considerations: Most commonly injured GU organ Often in association with multi-system organ injury Blunt >80% Penetrating <20% Types of Trauma: Blunt: Most common form of renal trauma Motor vehicle accidents Falls from heights Assaults High velocity impact (contusion / hematoma / laceration)

Penetrating: Uncommon form of renal trauma Gunshot wounds Stab wounds (Direct shearing force through renal tissue) Presentation: Hematuria (gross or microscopic) Microscopic = 5 RBCs/HPF Shock (hypotension, tachycardia, oliguria) Flank bruising/ palpable mass Flank pain/tenderness

Diagnosis: CT Classification (Using AAST): Grade I: Contusion, but no laceration Grade II: Superfical laceration < 1cm depth, does not involve the collecting system Grade III: Laceration > 1cm, without extension into the renal pelvis Grade IV: Laceration extends to renal pelvis Grade V: Shattered kidney

Non-operative management: Hemodynamic stable patient can usually be managed non-operatively 98% of renal injuries can be managed non-operatively (Bed rest/antibiotics/water) Grade IV &V injuries more often require surgical exploration

Surgical Indications:
Absolute: Persistent renal bleeding with hemodynamic instability Expanding perirenal hematoma Pulsatile perirenal hematoma Relative: Penetrating injuries Extensive urine extravasation Grade 5 injury Non-viable tissue (>20%) Arterial injury (main or segmental)

Methods: Partial Nephrectomy Total Nephrectomy IMPORTANT: TOTAL NEPHRECTOMY ONLY IF: Vasculature is completely avulsed The kidney is ischemic Life threatening Uncontrollable hemorrhage Principles of Renal Reconstruction: Complete renal exposure Debridement of non-viable tissue Hemostasis Suture ligature (Gelfoam, Surgicel/Argon beam coagulation) Water-tight closure of collecting system Approximation/coverage of parenchymal defect Complications: Early: Urine extravastion (most common) Hemorrhage, shock Urinoma formation Late: Infection Abscesses Loss of renal function Hypertension

Bladder Trauma:
General Considerations: Relatively uncommon Often in association with multi-system organ injury Significant mortality rate (10-20%) Have high index of suspicion of urethral disruption injury Bladder more susceptible to injury when full Types of Trauma: Blunt: Most common type of bladder injury Usually motor vehicle accidents 2/3 contusions, 1/3 ruptures 10-25% have associated bladder injury 85-90% of bladder injuries have associated pelvic #

Penetrating: Less common Often associated with major organ injuries Iatrogenic: Open or laparoscopic pelvic surgery Gynecologic, vascular, urologic or general surgery Spontaneous Rupture: Underlying pathology Cancer, obstruction, XRT, TB, sensory neurologic deficit Presentations: Gross hematuria (the classic finding) 95% blunt injuries have gross hematuria Inability to void Abdominal pain Abdominal bruising Pelvic mass Peritoneal signs Shock

Classification: Extraperitoneal Injury (Most common treatment by catheter drainage) Surgery in the case of bone fragment into bladder/Open pelvic Fracture/Rectal perforation/Poor catheter drainage Intraperitoneal Injury: Rapid raising intra-peritoneal pressure can cause rupture of bladder

 Surgery treatment

Complications: Intraperitoneal Urinary frequency Shock Peritonitis Extraperitoneal Shock Pelvic abscess

Ureteral Trauma:
Etiology: External trauma very rare <4% of penetrating trauma <1% of blunt trauma Usually surgical trauma (Gynecologic, vascular, urologic or general surgery/Open/Laparoscopic/Ureteroscopy)

Presentation: At time of external trauma If unrecognized intra-op, then: Low fever, ileus, Flank pain Hematuria may be absent Diagnostic Tests: Methylene blue IV or renal pelvic injection For suspected intra-op ureteral injury Allows localization of injury IVP CT scan Ureteropyelogram Retrograde Antegrade Surgical Indications: Ureteric injury during operation (Most common cause) Surgical trauma during hysterectomy or other pelvic surgery Preoperative catheterization of the ureters makes it easier to identify during surgery Injuries discovered at the time of surgery should be repaired immediately Injury not recognized at the time of operation

Unilateral Injury: (3 possibilities)

Asymptomatic (Ureter ligation leads to silent kidney atrophy) Loin pain and fever (Pyonephrosis) Urinary fistula (Through the abdominal/vaginal wound) Complications: Early: Hydronephrosis Urinoma Infection Late: Stricture Loss of renal function Stone formation

URINARY TRACT INFECTION

IMPORTANT DEFINITIONS:
Upper urinary tract infection: Infection occurs in kidney, pelvis and ureter Lower urinary tract infection: Infection occurs in bladder and urethra Cystitis: Infection occurs mainly in bladder, and usually with urethritis Urethritis: Infection occurs mainly in urethra Classification: Upper urinary tract infection or lower urinary tract infenction Pyelonephritis vs cystitis vs urethritis First Infection vs Recurrent infection Complicated vs Uncomplicated

Diagnosis: Location of infection: Upper or Lower Pathogen: From urine culture Any anatomic abnormalities in urinary tract

Pyelonpehritis:
Symptoms: Fever Flank pain Tenderness on flank Dysuria

 Urinary Urgency/Frequency

Cystitis:
Symptoms: Dysuria Urinary urgency Urinary frequency with Hematuria Suprapubic pain Foul-smelling urine No fever Management: Hydration Antibiotics (Trimethoprim & Fluoroquinolone for 3 days) Patients with complicated cystitis: Recurrence in recent three months History of abnormalities in urinary tract History with multiple antibiotics previously Pathogen diagnosis should be based on urine culture Management: Urine culture for recurrent UTI Ultrasound screening for any abnormalities of urinary tract CT scan or IVU for any abnormal finding from ultrasound screening Uroflowmetry with residual urine for patient with difficult voiding Control Diabetes Mellitus Antibiotics in initial stage Antibiotics should be based on urine culture The effective antibiotics should be maintained for over two weeks

Prostatitis:
Classification: Acute bacterial-Category I(Acute urinary symptoms with bacteremia) Chronic bacterial-Category II (Chronic urinary symptoms with bacteria in prostate) Nonbacterial-Category III (Chronic urinary symptoms without bacteria in prostate) Asymptomatic prostatitis-Category IV (inflammation in prostrate without symptoms)

Category 1:
Symptoms: UTI symptoms (dysuria, urgency, frequency, nocturia) Urinary hesitancy, fever, chills, malaise

 Enlarged, tender prostate on DRE Treatment: Bed resting (Anti-pyretics) Urine Culture Suprapubic drainage if patient were in urinary retention Treat with broad spectrum antibiotics Continuing oral antibiotics for 4 weeks after to eradicate bacteria in prostate

Category 2:
Symptoms: Episodes of dysuria, frequency, pelvic, perineal pain, usually without fever Prostate secretion test culture should be done for further treatment Treatment: Antibiotics option E coli present in 80% of cases TMP-SMX and fluoroquinolones orally for 4~6 weeks Option could be based on culture sensitivities when it is available -Blocker (Could relieve urinary symptoms) Analgesics (could relieve chronic pain) Cernilton (Pollen agents)

Orchitis:
Classification: Acute bacterial orchitis Secondary to UTI Secondary to STD Nonbacterial infectious orchitis Noninfectious orchitis Chronic Orchitis Chronic Orchialgia Symptoms: Unilateral testis pain and swollen Fever ( acute cases) abdominal discomfort, nausea, and vomiting The skin of the involved hemiscrotum is erythematous and edematous Most cause of bacteria is E.Coli and Pseudomonas

Treatment: Bed rest Scrotal support Hydration Antipyretics & Analgesics Antibiotic therapy (Same principle as acute or chronic bacterial prostatitis)

GENITOURINARY TUBERCULOSIS
Definition: Tuberculosis involving kidney, ureter, bladder and male genitals, cause is Tubercle bacillus. Clinical Manifestation: Frequency, urgency and dysuria Hematuria Pyuria Lumbago Systemic Symptoms Diagnosis: Urine Rate (Important) Acid Fast Staining Urine Culture US KUB+IVP CT & MRI Cystoscopy Treatment: Systemic Therapy Chemotherapy Surgical Treatment (Nephrectomy/Reconstructive Surgery) Postoperative Chemotherapy Bladder Contracture (Only considered after cure of TB)

URINARY TRACT OBSTRUCTION

Classification: Congenital or Acquired Mechanical or Dynamical Upper urinary tract or Lower urinary tract Disorders of the tract or other systems

 Upper Urinary (Kidney/Ureter/Multifactoral) or Lower Urinary (Prostate/Urethra) Tract

Congenital UPJ Obstruction

Causes: Congenital (Aperistaltic segment of ureter) Acquired (Compression from bands) Results of UTO: Lowered GFR Lowered Renal Blood Flow Complications: Renal Parenchymal Atrophy (Renal Failure) Urosepsis (Bacteria in circulatory system)

Hydronephrosis: Blockage in urine drainage from pelvis, leading to elevated

pelvic pressure and dilated calyces, resulting in renal parenchyma atrophy (Renal failure). Severity depends on: Duration Degree (Complete or Incomplete) Site Symptoms: Congenital (Asymptomatic to abdominal mass) Acquired (Symptoms of primary disease) Complete Obstruction (Renal Colic) Intermittent (Persistent and complete obstruction)

Diagnosis: Confirmation Severity & Renal Function Clinical Findings: Laboratory: Infection (Urinalysis/Leukocytosis) Renal Function (Azotemia/Electrolyte Imbalance) Imaging: Sonography (Thin renal parenchyma) KUB Excretory Urography (Reveals entire cause unless severely impaired renal function) Retrograde Uropathy (Percutaneous Urography in case of failure)

 CT & MRI (Differentiate from solid tumors)

Treatment: Treating primary disease Relief of obstruction (JJ-Drainage/Nephrostomy) Nephrectomy (ONLY in Irreversible kidney damage)

BENIGN PROSTATIC HYPERPLASIA

Definition: Hyperplasia of prostatic epithelial cells that leads to formation of large nodules in periurethral region, why may eventually cause complete obstruction of the urethra. General factors: Mostly occurs in peripheral zone Most common benign tumor in men Symptoms: Men > 50yrs. Prostate size has poor correlation with symptoms (Middle lobe causes severe symptoms) Severity based on obstruction, progressive speed, and associated infection Urination frequency, urgency, nocturia & dysuria Symptoms of Complications: UTI Odynuria Bladder stone Hematuria Renal failure (Hydronephrosis)

IPSS: International-Prostate Symptom Score, used to determine severity. Mild: 0-7 Moderate: 8-19 Severe: 20-35 IMPORTANT: BPH determined by Digital Rectal Examination (DRE). Tone of anal sphincter Prostate size & consistency Nodules Diagnosis: DRE Uroflowmetry/Urodynamic Study Ultrasonography Prostate Specific Antigen (Marker for Prostate Cancer)

 Cystoscopes (When Transitional Cell Carcinoma suspected)

Treatment: Watching waiting Medical therapy (Alpha-blockers/Finasteride) Phytotherapy (Plant extracts) Surgical Treatment: Transurethral Resection of Prostate (TURP) (95% perfomed endoscopically) Open Prostatectomy (When too large for endoscopic resection) (Suprapubic/Retropubic)

URINARY STONES
Definition: Aggregation of dietary minerals from the urine that forms in the kidney. 95% form in Upper Urinary Tract, 5% in Lower Urinary Tract. General Considerations: Third most common disease Etiology still unknown Recurrence rate at 50% within 5 years Factors for formation: Urine stagnation UTI Food/Drugs Abnormal Metabolism/Endocrine Dysfunction Sites of formation: Renal Ureteral Vesical Prostatic & Seminal vesicle Urethral & Prepuce

Renal
Symptoms: Pain Hematuria Nausea/Vomitting Diagnosis: X-Ray Ultrasonography

 Spiral CT

Complications: Infection Hydronephrosis Renal tissue destruction Treatment: Conservative: Drugs Water Invasive: Extracorprela Shockwave Lithtripsy (ESWL) (Using shock waves) Percuaneous Nephrolithotomy (PCNL) Trnasurethral Lithotripsy (TUL) Laparoscopy

Ureteral Stones
infection) Symptoms: Pain Nausea/Vomiting Hematuria Infection Diagnosis: Laboratory (Same as Renal) Imaging: CT B Ultrasonography KUB Complications: Renal Damage Anuria Infection

(Originates from kidney and may result in complicating

Treatment: Passes spontaneously if < 0.5cm in diameter Large stones require ureteral stent

 ESWL & PCNL (When stones in upper two-third of ureter)

Vesical Stone:

Stones containing calcium, present in lower urinary tract. More frequent in males than females (90%) Symptoms: Bladder neck obstruction Hematuria Vesical distention Urethral stricture Urethral pain & urine interruption Diagnosis: Laboratory: Hematuria Imaging: X-Ray US/CT/Endoscope Treatment: Small stones pass spontaneously Large stones require TUL or Vesicolithotomy

GENITOURINARY TUMOR
Kidney Cancer:
Any cancer arising in kidney or renal pelvis, but most are RCC, which arise from proximal convoluted tubules. General Facts: Renal Cell Carcinoma (RCC) accounts for 3% of malignancies MOST LETHAL urologic cancer More in male than female (3:1) Etiology: Lifestyle factors (Smoking/Obesity) Preexisting renal conditions (Polycystic renal disease/Chronic renal failure) Symptoms: Asymptomatic & nonpalpable Detected accidentally using non-invasive imaging Weight loss/fever/anemia/night sweat (COMMON SYMPTOMS) Paraneoplastic syndromes (Only found in 30% of symptomatic patients) Diagnosis:

Laboratory findings: Anemia Hematuria Imaging: X-Ray CT Ultrasonography Staging: Stage I: Tumor < 7cm, remains in kidney, 95% of 5-year survival Stage II: Tumor > 7cm, remains in kidney, 88% of 5-year survival Stage III: Tumor in major veins, 1 regional lymph node involved, 59% 5-year survival Stage IV: Tumor beyond Gerotas fascia, >1 lymph node involved, 20% 5-year survival

Treatment: Radical Nephrectomy (For stages I, II, IIIa) Partial Nephrectomy (Solitary tumor < 4cm)

Bladder Cancer:
General Considerations: Most common GUT cancer in China More than 90% are Transitional Cell Carcinomas Superficial & Invasive Stages: Tis (Pre-invasive carcinoma/in situ carcinoma) Ta (Non-invasive papillary carcinoma) T1 (Tumor does not extend beyond lamina propria) T2 (Tumor invades muscle) T3 (Tumor invades perivesical tissue) T4 (Tumor invading neighboring structures) (T4a invading prostate/vagina) (T4b tumor fixed to pelvic wall)

Symptoms: 85% present painless hematuria 20% present irritative bladder symptoms (Dysuria/urgency/frequency) Diagnosis: Laboratory:

 Testing for hematuria Cystoscopy (GOLDEN STANDARD) Imaging: Intravenous Urography (IVU) US CT Treatment: Principle: Based on tumor stage, patient age and general health TURBT + Instillation (Non-muscle invasive tumor) Cyestectomy (Muscle invasive tumor) (Partial or radical) Radiotherapy & Chemotherapy Intravesical Chemotherapy (Used to prevent tumor recurrence)

LAPAROSCOPIC ADRENAL SURGERY

Contraindications:
Large carcinoma with local invasion Tumors > 12cm Uncorrected coagulopathy

Transperitoneal Vs. Retroperitoneal:

Longer vs. shorter operative time Higher vs lower analgesic requirement Higher vs lower complication rate

Right Adrenalectomy:
Retraction of liver Peritoneal Incision Exposure of IVC Adrenal vein ligation Adrenal gland mobilization Specimen extraction

Left Adrenalectomy:
Trocar Insertion Mobilization of splenic flexure, spleen & tail Adrenal vein ligation Adrenal mobilization Colonic mobilization

Advantages of retroperitoneal approach:

Avoiding potential peritoneal adhesions from previous injuries Avoid potential visceral injury Avoid bowel complications

Bilateral & Partial Adrenalectomy Indications:

Cushings Syndrome Bilateral pheochromocytomas Bilateral aldosterone-producing tumors

Conclusions:
LA is ideal for all benign tumors < 12cm Transperitoneal approach recommended for most patients